External validation of a nomogram for outcome prediction in management of medium-sized (1-2 cm) kidney stones.

BACKGROUND: Stone nomogram by Micali et al., able topredict treatment failure of shock-wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PNL) in the management of single 1-2 cm renal stones, was developed on 2605 patients and showed a high predictive accuracy, with an area under ROC curve of 0.793 at internal validation. The aim of the present study is to externally validate the model to assess whether it displayed a satisfactory predictive performance if applied to different populations. METHODS: External validation was retrospectively performed on 3025 patients who underwent an active stone treatment from December 2010 to June 2021 in 26 centers from four countries (Italy, USA, Spain, Argentina). Collected variables included: age, gender, previous renal surgery, preoperative urine culture, hydronephrosis, stone side, site, density, skin-to-stone distance. Treatment failure was the defined outcome (residual fragments >4 mm at three months CT-scan). RESULTS: Model discrimination in external validation datasets showed an area under ROC curve of 0.66 (95% 0.59-0.68) with adequate calibration. The retrospective fashion of the study and the lack of generalizability of the tool towards populations from Asia, Africa or Oceania represent limitations of the current analysis. CONCLUSIONS: According to the current findings, Micali's nomogram can be used for treatment prediction after SWL, RIRS and PNL; however, a lower discrimination performance than the one at internal validation should be acknowledged, reflecting geographical, temporal and domain limitation of external validation studies. Further prospective evaluation is required to refine and improve the nomogram findings and to validate its clinical value.

Robot-assisted radical cystectomy with intracorporeal reconstruction of urinary diversion by mechanical stapler: prospective evaluation of early and late complications.

Introduction: Radical cystectomy with pelvic lymph node dissection is the gold standard treatment for non-metastatic muscle-invasive bladder cancer and high-risk non-muscle-invasive bladder cancer. For years, the traditional open surgery approach was the only viable option. The widespread of robotic surgery led to its employment also in radical cystectomy to reduce complication rates and improve functional outcomes. Regardless of the type of approach, radical cystectomy is a procedure with high morbidity and not negligible mortality. Data available in the literature show how the use of staplers can offer valid functional outcomes, with an acceptable rate of complications shortening the operative time. The aim of our study was to describe the perioperative outcomes and complications associated with robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) using a mechanical stapler. Material and methods: From January 2015 to May 2021, we enrolled patients who underwent RARC with pelvic node dissection and stapled ICUD (ileal conduit or ileal Y-shaped neobladder according to the Perugia ileal neobladder) in our high-volume center. Demographic features, perioperative outcomes and early (≤30 days) and late (>90 days) post-operative complications according to the Clavien-Dindo classification, were recorded for each patient. We also analyzed the potential linear correlation between demographic, pre-operative as well as operative features and the risk of post-operative complications. Results: Overall, 112 patients who underwent RARC with ICUD were included with a minimum follow-up of 12 months. Intracorporeal Perugia ileal neobladder was performed in 74.1% of cases while ileal conduit was performed in 25.9%. The mean operative time, estimated intraoperative blood loss, and LOS were 289.1 ± 59.7 min, 390.6 ± 186.2 ml, and 17.5 ± 9.8 days, respectively. Early minor and major complications accounted for 26.7% and 10.8%, respectively. Overall late complications were 40.2%. The late most common complications were hydronephrosis (11.6%) and urinary tract infections (20.5%). Stone reservoir formation occurred in 2.7% of patients. Major complications occurred in 5.4%. In the sub-analysis, the mean operative time and the estimated blood loss improved significantly from the first 56 procedures to the last ones. Conclusion: RARC with ICUD performed by mechanical stapler is a safe and effective technique. Stapled Y-shaped neobladder did not increase the complication rate.

Complications of extraperitoneal robot-assisted radical prostatectomy in high-risk prostate cancer: A single high-volume center experience.

Introduction: The role of robot-assisted radical prostatectomy (RARP) in high-risk prostate cancer (PCa) has been debated over the years, but it appears safe and effective in selected patients. While the outcomes of transperitoneal RARP for high-risk PCa have been already widely investigated, data on the extraperitoneal approach are scarcely available. The primary aim of this study is to evaluate intra- and postoperative complications in a series of patients with high-risk PCa treated by extraperitoneal RARP (eRARP) and pelvic lymph node dissection. The secondary aim is to report oncological and functional outcomes. Methods: Data of patients who underwent eRARP for high-risk PCa were prospectively collected from January 2013 to September 2021. Intraoperative and postoperative complications were recorded, as also perioperative, functional, and oncological outcomes. Intraoperative and postoperative complications were classified by employing Intraoperative Adverse Incident Classification by the European Association of Urology and the Clavien-Dindo classification, respectively. Univariate and multivariate analyses were performed to evaluate a potential association between clinical and pathological features and the risk of complications. Results: A total of 108 patients were included. The mean operative time and estimated blood loss were 183.5 ± 44 min and 115.2 ± 72.4 mL, respectively. Only two intraoperative complications were recorded, both grade 3. Early complications were recorded in 15 patients, of which 14 were of minor grade, and 1 was grade IIIa. Late complications were diagnosed in four patients, all of grade III. Body mass index (BMI) > 30 kg/m2, Prostate-Specific Antigen (PSA) > 20 ng/mL, PSA density >0.15 ng/mL2, and pN1 significantly correlated with a higher rate of overall postoperative complications. Moreover, BMI >30 kg/m2, PSA >20 ng/mL, and pN1 significantly correlated with a higher rate of early complications, while PSA >20 ng/mL, prostate volume <30 mL, and pT3 were significantly associated with a higher risk of late complications. In multivariate regression analysis, PSA >20 ng/mL significantly correlated with overall postoperative complications, while PSA > 20 and pN1 correlated with early complications. Urinary continence and sexual potency were restored in 49.1%, 66.7%, and 79.6% of patients and in 19.1%, 29.9%, and 36.2% of patients at 3, 6, and 12 months, respectively. Conclusions: eRARP with pelvic lymph node dissection in patients with high-risk PCa is a feasible and safe technique, resulting in only a few intra- and postoperative complications, mostly of low grade.

Ureteroiliac fistula after oncological surgery: Case report and review of the literature.

Fistulas arising between ureters and iliac arteries (UAF) are rare pathological events and frequently require emergency treatment, as they are associated with massive haematuria and haemorrhagic shock. The medical history plays a key role in the diagnostic and therapeutic process, as it allows to include UAF among the differential diagnoses of gross haematuria. The emergency treatments of fistulas arising between the urinary system and the vascular system include the open repairing surgery or the endovascular grafting, the latter generally better tolerated by patients suffering from multiple comorbidities or not eligible for traditional surgery. Nephrostomy or ureteral stent can be used to drain the affected upper urinary tract temporarily or permanently. Herein, we reported two cases of oncological patients affected by UAF and treated successfully by endovascular procedures. Furthermore, we performed a narrative review of the literature concerning UAF and its diagnostic and therapeutic management. Although our study did not allow us to state definitive conclusion about the diagnostic and therapeutic management of UAF due to small sample size, our findings support previous experiences in favour of the treatment of fistulas with an endovascular approach.

Simultaneous treatment of a pubovesical fistula and lymph node metastasis secondary to multimodal treatment for prostate cancer: Case report and review of the literature.

Pubovesical fistula (PVF) is a rare complication of radical treatments for prostate cancer (PCa), especially when a multimodal approach is performed. We present a case of PVF with extensive communication between the bladder and the pubic bones, and lymph node metastases of PCa treated by cystectomy and salvage lymphadenectomy. We describe a case of a 65-year old male patient who, after radical prostatectomy and adjuvant radiation therapy, suffered from suprapubic and perineal pain, ambulation difficulties and recurrent urinary tract infections. Cystoscopy, cystography and contrast-enhanced magnetic resonance imaging diagnosed a PVF. Choline positron emission tomography/computed tomography scan demonstrated PCa lymph node metastases. After the failure of conservative treatment, open radical cystectomy with ureterocutaneostomy diversion and salvage lymphadenectomy were performed with resolution of symptoms. At 3-month follow-up, the pelvic and perineal pain was completely regressed and 1-year later the patient was still asymptomatic. This clinical case shows efficacy and safety of combined salvage lymphadenectomy and cystectomy with urinary diversion for the treatment of late PCa node metastasis and PVF.

The Challenges of Patient Selection for Prostate Cancer Focal Therapy: A Retrospective Observational Multicentre Study.

Increased diagnoses of silent prostate cancer (PCa) have led to overtreatment and consequent functional side effects. Focal therapy (FT) applies energy to a prostatic index lesion treating only the clinically significant PCa focus. We analysed the potential predictive factors of FT failure. We collected data from patients who underwent robot-assisted radical prostatectomy (RARP) in two high-volume hospitals from January 2017 to January 2020. The inclusion criteria were: one MRI-detected lesion with a Gleason Score (GS) of ≤7, ≤cT2a, PSA of ≤10 ng/mL, and GS 6 on a random biopsy with ≤2 positive foci out of 12. Potential oncological safety of FT was defined as the respect of clinicopathological inclusion criteria on histology specimens, no extracapsular extension, and no biochemical, local, or metastatic recurrence within 12 months. To predict FT failure, we performed uni- and multivariate logistic regression. Sixty-seven patients were enrolled. The MRI index lesion median size was 11 mm; target lesions were ISUP grade 1 in 27 patients and ISUP grade 2 in 40. Potential FT failure occurred in 32 patients, and only the PSA value resulted as a predictive parameter (p < 0.05). The main issue for FT is patient selection, mainly because of multifocal csPCa foci. Nevertheless, FT could represent a therapeutic alternative for highly selected low-risk PCa patients.

Robotic versus open simple prostatectomy for benign prostatic hyperplasia in large glands: single-centre study.

PURPOSE: Robot-assisted simple prostatectomy (RASP) for benign prostatic hyperplasia (BPH) is a recently described surgical approach, but comparison with open simple prostatectomy (OSP) lack in the literature. We compared perioperative outcomes of OSP versus RASP. METHODS: Patients who underwent simple prostatectomy between 2017 and 2020 were included in this retrospective study. OSP was performed by the transvesical technique and RASP was performed with a DaVinci Xi robot, using the transvesical extraperitoneal approach. Perioperative and postoperative data were compared and complications risk factors for complications were identified. RESULTS: and limitations. Overall, 103 patients were included (median age 72 years [IQR = 67-76]). Forty-seven underwent RASP and 56 OSP. The median volume of the prostate gland was 130 mL [IQR = 100-180] in the RASP group and 126 mL [IQR = 100-160] in the OSP group. RASP was associated with a significant reduction in blood loss (median 200 vs. 400 mL; p < 0.001), shorter hospital stay (5 vs. 10 days; p < 0.001) and median catheterisation time (4 vs. 9 days; p < 0.001). In the RASP group, there were fewer grade ≥ 2 complications (2 (4.3%) vs. 13 (23.2%); p = 0.005) and less need for transfusions (0 vs. 6 (11%), p = 0.005). Preoperative prostate volume was a risk factor for complications (OR = 1.2 [95% CI 1.1-1.5]; p = 0.01) while robot-assisted surgery was a protective factor (OR 0.3 [95% CI 0.05-0.9]; p = 0.05). Functional outcomes between the two groups were identical at 12 months follow up. CONCLUSION: RASP is a safe and effective procedure. When compared with OSP, RASP was associated with decreased morbidity as well as reduced hospital stay and catheterisation time. Functional outcomes were comparable to the open approach.

Management of Fournier's gangrene during the Covid-19 pandemic era: make a virtue out of necessity.

BACKGROUND: Fournier's gangrene (FG) is a necrotizing fasciitis caused by aerobic and anaerobic bacterial infection that involves genitalia and perineum. Males, in their 60 s, are more affected with 1.6 new cases/100.000/year. Main risk factors are diabetes, malignancy, inflammatory bowel disease. FG is a potentially lethal disease with a rapid and progressive involvement of subcutaneous and fascial plane. A multimodal approach with surgical debridement, antibiotic therapy, intensive support care, and hyperbaric oxygen therapy (HBOT) is often needed. We present the inpatient management of an FG case during the Covid-19 pandemic period. A narrative review of the Literature searching "Fournier's gangrene", "necrotizing fasciitis" on PubMed and Scopus was performed. CASE PRESENTATION: A 60 years old man affected by diabetes mellitus, with ileostomy after colectomy for ulcerative colitis, was admitted to our Emergency Department with fever and acute pain, edema, dyschromia of right hemiscrotum, penis, and perineal region. Computed tomography revealed air-gas content and fluid-edematous thickening of these regions. Fournier's Gangrene Severity Index was 9. A prompt broad-spectrum antibiotic therapy with Piperacillin/Tazobactam, Imipenem and Daptomycin, surgical debridement of genitalia and perineal region with vital tissue exposure, were performed. Bedside daily surgical wound medications with fibrine debridement, normal saline and povidone-iodine solutions irrigation, iodoform and fatty gauze application, were performed until discharge on the 40th postoperative day. Every 3 days office-based medication with silver dressing, after normal saline and povidone-iodine irrigation and fibrinous tissue debridement, was performed until complete re-epithelialization of the scrotum on the 60th postoperative day. CONCLUSIONS: FG is burdened by a high mortality rate, up to 30%. In the literature, HBOT could improve wound restoration and disease-specific survival. Unfortunately, in our center, we do not have HBOT. Moreover, one of the pandemic period problems was the patient's displacement and outpatient hospital management. For all these reasons we decided for a conservative inpatient management. Daily cleaning of the surgical wound allowed to obtain its complete restoration avoiding surgical graft and hyperbaric oxygen chamber therapy, without foregoing optimal outcomes.

RéSUMé: CONTEXTE: La gangrène de Fournier (GF) est une fasciite nécrosante causée par une infection bactérienne aérobie et anaérobie qui implique les organes génitaux et le périnée. Les hommes, dans la soixantaine, sont plus touchés avec 1,6 nouveau cas/100 000/an. Les principaux facteurs de risque sont le diabète, les tumeurs malignes, et les maladies inflammatoires de l'intestin. La GF est une maladie potentiellement mortelle avec une atteinte rapide et progressive du plan sous-cutané et fascial. Une approche multimodale, avec débridement chirurgical, antibiothérapie, soins de soutien intensif et oxygénothérapie hyperbare (OHB), est souvent nécessaire. Nous présentons la prise en charge en milieu hospitalier d'un cas de GF pendant la période de pandémie de Covid-19. Une revue narrative de la littérature, recherchant «gangrène de Fournier¼, «fasciite nécrosante¼ sur PubMed et Scopus, a été réalisée. CAS CLINQUE: Un homme de 60 ans, atteint d'un diabète sucré et porteur d'une iléostomie après colectomie pour colite ulcéreuse, a été admis dans notre service d'urgences, avec fièvre et des douleurs aiguës, œdème et dyschromie de l'hémiscrotum droit, du pénis et de la région périnéale. La tomodensitométrie a révélé une teneur en air-gaz et un épaississement fluide-œdémateux de ces régions. L'indice de gravité de la gangrène de Fournier était de 9. Une antibiothérapie rapide à large spectre avec Pipéracilline/tazobactam, imipénème et daptomycine, et un débridement chirurgical des organes génitaux et de la région périnéale avec exposition des tissus vitaux, ont été effectués. Ont été réalisés au chevet du patient, un traitement quotidien des plaies chirurgicales, avec débridement de la fibrine, irrigation par solution saline normale et solution de povidone-iode, et application de gaze iodoforme et grasse, jusqu'à la décharge au 40èmejour postopératoire. Tous les 3 jours, un traitement à base de médicaments d'officine avec pansement à l'argent a été réalisé après irrigation par solution saline normale et solution de povidone-iode, et débridement de la fibrine des tissus, jusqu'à la ré-épithélialisation complète du scrotum au 60ème jour postopératoire. CONCLUSIONS: La GF est grevée d'un taux de mortalité élevé, jusqu'à 30%. Dans la littérature, l'OHB pourrait améliorer la restauration des plaies et la survie spécifique de la maladie. Malheureusement, dans notre centre, nous n'avons pas d'OHB. En outre, l'un des problèmes de la période pandémique était le déplacement du patient et la prise en charge ambulatoire des hôpitaux. Pour toutes ces raisons, nous avons opté pour une prise en charge conservatrice en milieu hospitalier. Le nettoyage quotidien de la plaie chirurgicale a permis d'obtenir sa restauration complète en évitant la greffe chirurgicale et la thérapie en chambre à oxygène hyperbare, sans renoncer à des résultats optimaux. MOTS-CLéS: Gangrène de Fournier, fasciite nécrosante, urgence urologique, débridement chirurgical.

Validation in an Independent Cohort of MiR-122, MiR-1271, and MiR-15b as Urinary Biomarkers for the Potential Early Diagnosis of Clear Cell Renal Cell Carcinoma.

Clear cell renal cell carcinoma (ccRCC) is the most common type of renal cell carcinoma, and the absence of symptoms in the early stages makes metastasis more likely and reduces survival. To aid in the early diagnosis of ccRCC, we recently developed a method based on urinary miR-122-5p, miR-1271-5p, and miR-15b-5p levels and three controls. The study here presented aimed to validate the previously published method through its application on an independent cohort. The expression of miRNAs in urine specimens from 28 ccRCC patients and 28 healthy subjects (HSs) of the same sex and age was evaluated by RT-qPCR. Statistical analyses were performed, including the preparation of receiver operating characteristic (ROC) curves. The mean ccRCC diameter in ccRCC patients was 4.2 ± 2.4 mm. Urinary miRNA levels were higher in patients than in HSs. The data were processed using the previously developed algorithm (7p-urinary score), and the area under the curve (AUC) of the algorithm's ROC curve was 0.81 (p-value = 0.0003), with a sensitivity of 96% and specificity of 65%. Therefore, the 7p-urinary score is a potential tool for the early diagnosis of ccRCC.

Mid-term functional outcomes of extraperitoneal robot-assisted simple prostatectomy: a single centre experience.

For large prostate volume, open simple prostatectomy (OSP) or holmium laser enucleation are the gold standard surgical treatment medical therapy failure. Robot-assisted simple prostatectomy (RASP) has recently been proposed as an alternative to OSP and endoscopic techniques. Our objective was to describe our extraperitoneal RASP technique for patients with benign prostate obstruction (BPO), and to report on perioperative and mid-term functional outcomes. Data were collected prospectively for all consecutive patients who underwent RASP in our high-volume tertiary hospital over a 6-year period. International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5) and uroflow findings were compared before and after surgery. Intraoperative and postoperative outcomes were also assessed. Forty-seven patients were included in the study. There was no intraoperative incident and no blood transfusion was needed after surgery. Median time to bladder catheter removal was 4 days and patients were discharged the day after. Within 90 postoperative days, 6 patients (12%) experienced at least one complication, all low-grade except one (2.1%) which was Clavien IIIa grade. By univariate analysis, the only risk factor for postoperative complications was the Charlson comorbidity index (OR = 2.1, 95% CI = [1.1-4.7], p = 0.04). At 12 months, a significant improvement IPSS and uroflow rate was observed. No patient reported stress urinary incontinence. Extraperitoneal RASP appears to be a safe and effective technique for men with LUTS related to large BPO. RASP is less invasive than OSP and wide diffusion of the robot-system could lead to the rapid implementation of RASP as a treatment for large prostate.

Diagnostic performance of the Bladder EpiCheck methylation test and photodynamic diagnosis-guided cystoscopy in the surveillance of high-risk non-muscle invasive bladder cancer: A single centre, prospective, blinded clinical trial.

PURPOSE: Currently, bladder cancer (BC) surveillance consists of periodic white light cystoscopy and urinary cytology (UC). However, both diagnostic tools have limitations. Therefore, to improve the management of recurrent BC, novel, innovative diagnostic tests are needed. The primary aim of this study was to determine the diagnostic performance of Bladder EpiCheck (BE) and photodynamic diagnosis (PDD) guided cystoscopy in the surveillance of high-risk BC. A secondary aim was to compare Bladder EpiCheck (BE) and PDD-guided cystoscopy findings with whose of UC to design a diagnostic algorithm that facilitates clinical decision making. PATIENTS AND METHODS: This was a prospective, blinded, single-arm, single-visit cohort study. All patients were under surveillance for high-risk non-muscle-invasive bladder cancer, and underwent cystoscopy with PDD and a BE test. Those who received a histological diagnosis were used as a reference population. Receiver operating characteristic curve analysis was performed to evaluate the diagnostic performance of BE, PDD-guided cystoscopy, and UC for identifying biopsy-confirmed BC lesions. The diagnostic power of the test was assessed by determining the area under the curve (AUC). RESULTS: Forty patients were enrolled. For BE, the AUC was 0.95, and BC recurrence was detected at a sensitivity of 100% and specificity of 90.9%. For PDD, the AUC was 0.51, with a sensitivity and specificity of 61% and 41%, respectively. BE was combined with UC to create a decision-making algorithm capable of reducing the number of follow-up cystoscopies needed. CONCLUSION: BE is a very accurate diagnostic tool that has the potential to be useful in the surveillance of high-risk BC patients. Especially when combined with UC, it may be used to reduce the number of cystoscopies needed throughout follow-up. Conversely, the use of PDD as a diagnostic tool in such patients should be reconsidered. However, due to the small sample size of this study, a larger prospective clinical trial should be performed to confirm findings.

Holmium:YAG Laser for the Treatment of Genital and urethral Warts: Multicentre Prospective Evaluation of Safety and Efficacy.

Introduction: Genital condylomatosis is a highly contagious disease caused by the human papilloma virus (HPV). The aim of this prospective multicentre study was to evaluate the safety and efficacy of the Holmium:YAG (yttrium-aluminium-garnet) laser in the treatment of genital and intra-urethral warts; the secondary aim was to assess the patients' postoperative satisfaction and cosmetic results. Methods: From December 2016 to March 2019, patients with genital warts were prospectively enrolled in three hospitals. The inclusion criteria were male gender, age over 18 years-old and treatment-naïve. External and urethral genitalia warts were treated by the Holmium YAG laser. The follow-up analysis consisted of physical examination, flexible urethro-cystoscopy in case of meatal lesions, and administration of Dermatology Quality of Life Index (DLQI) and Patient Global Impression of Improvement (PGI-I) questionnaires at 1, 3, 6 and 12 months after surgery and subsequently yearly. Results: Sixty patients were enrolled. The single treatment was effective in 57/60 patients (95%). At a mean follow-up of 26 months, recurrences occurred in 8 patients (13.3%). No peri- or post-operative complication occurred. An improvement in pre-operative condition was highlighted with PGI-I and DLQI questionnaires. Conclusion: Our prospective multicentre study showed that holmium laser surgery seems to be a safe and effective treatment for external genital and urethral warts. Good dermatological outcomes aid to further improve patient satisfaction.

Metastatic renal Ewing's sarcoma in adult woman: Case report and review of the literature.

Primary renal extra-skeletal Ewing sarcoma is a rare neoplasm, often metastatic at diagnosis, and with a poor outcome. A multimodal approach is often the treatment of choice in this aggressive neoplasm. We present a case of primary renal extra-skeletal sarcoma in a 45-year-old woman who underwent tumor resection without clear margins. After no response to the first cycle of chemotherapy, we documented an early onset of local recurrence. The patient refused any other treatment and died four months after surgery.

Endoscopic Combined Intrarenal Surgery for Stone Formation After Previous Laparoscopic and Open Renal Surgery.

Background: Nonabsorbable sutures used during renal surgery represent a known substratum for stone growth. We hereby describe two cases of nephrolithiasis secondary to permanent suture material, originally placed during conservative renal surgical procedures and afterward migrated into the caliceal system, managed with endoscopic combined intrarenal surgery (ECIRS) with subsequent complete renal clearance. Case Presentation: Case 1. A 54-year-old male, with history of laparoscopic excision of a left parapelvic cyst, presenting with left inferior caliceal stone. Case 2. A 79-year-old female, who underwent open enucleation of a left renal pelvis tumor 15 years before. She presented with bilateral lithiasis, including a staghorn stone in the left renal pelvis. Both patients underwent left ECIRS by two surgeons, revealing the presence of suture devices, which were completely removed. Abdominal CT at 1 month after surgery did not show residual lithiasic fragments in both cases. Conclusion: To prevent the risk of stone formation, it is mandatory to use nonabsorbable suture agents sparingly during conservative renal surgery and furthermore to remove all foreign material from the collecting system because they have the potential for calculi growth. In this sense, ECIRS technique may also avoid further open or minimally invasive surgery and the use of suture instruments.

Combined Robotic Surgery for Double Renal Masses and Prostate Cancer: Myth or Reality?

With the widespread use of imaging modalities performed for the staging of prostate cancer, the incidental detection of synchronous tumors is increasing in frequency. Robotic surgery represents a technical evolution in the treatment of solid tumors of the urinary tract, and it can be a valid option in the case of multi-organ involvement. We reported a case of synchronous prostate cancer and bifocal renal carcinoma in a 66-year-old male. We performed the first case of a combined upper- and lower-tract robotic surgery for a double-left-partial nephrectomy associated with radical prostatectomy by the transperitoneal approach. A comprehensive literature review in this field has also been carried out. Total operative time was 265 min. Renal hypotension time was 25 min. Blood loss was 250 mL. The patient had an uneventful postoperative course. No recurrence occurred after 12 months. In the literature, 10 cases of robotic, radical, or partial nephrectomy and simultaneous radical prostatectomy have been described. Robotic surgery provides less invasiveness than open surgery with comparable oncological efficacy, overcoming the limitations of the traditional laparoscopy. During robotic combined surgery for synchronous tumors, the planning of the trocars' positioning is crucial to obtain good surgical results, reducing the abdominal trauma, the convalescence, and the length of hospitalization with a consequent cost reduction. Rare complications can be related to prolonged pneumoperitoneum. Simultaneous robotic prostatectomy and partial nephrectomy appears to be a safe and feasible surgical option in patients with synchronous prostate cancer and renal cell carcinoma.

Role of miRNAs in prostate cancer: Do we really know everything?

Many different genetic alterations, as well as complex epigenetic interactions, are the basis of the genesis and progression of prostate cancer (CaP). This is the reason why until now the molecular pathways related to development of this cancer were only partly known, and even less those that determine aggressive or indolent tumour behaviour. MicroRNAs (miRNAs) represent a class of about 22 nucleotides long, small non-coding RNAs, which are involved in gene expression regulation at the post-transcriptional level. MiRNAs play a crucial role in regulating several biological functions and preserving homeostasis, as they carry out a wide modulatory activity on various molecular signalling pathways. MiRNA genes are placed in cancer-related genomic regions or in fragile sites, and they have been proven to be involved in the main steps of carcinogenesis as oncogenes or oncosuppressors in many types of cancer, including CaP. We performed a narrative review to describe the relationship between miRNAs and the crucial steps of development and progression of CaP. The aims of this study were to improve the knowledge regarding the mechanisms underlying miRNA expression and their target genes, and to contribute to understanding the relationship between miRNA expression profiles and CaP.

Renal Artery Embolization Before Radical Nephrectomy for Complex Renal Tumour: Which are the True Advantages?

INTRODUCTION: Renal artery embolization is performed before radical nephrectomy (RN) for renal mass in order to induce preoperative infarction and to facilitate surgical intervention through decrease of intraoperative bleeding. Moreover, in metastatic renal cancer it seems to stimulate tumour-specific antibodies, even if no established benefits in clinical response or survival have been reported. The role of preoperative renal artery embolization (PRAE) in management of renal masses has been often debated and its real benefits are still unclear. Nevertheless, in huge and complex renal masses, which are often characterized by a high and anarchic blood supply and rapid local invasion, radical nephrectomy can be challenging even for skilled surgeons. The aim of this prospective randomized study was to evaluate the effectiveness and safety of PRAE in complex masses by comparing perioperative outcomes of RN with and without PRAE. MATERIALS AND METHODS: From December 2015 to May 2018 we enrolled prospectively 64 patients who underwent RN for localized (T2a-b) or locally advanced (T3 and T4) or advanced (N+, M+) renal cancers. Patients were divided in two groups. The first group included 30 patients who underwent PRAE; in the second group we enrolled 34 patients who did not undergo RN without PRAE. Perioperative outcomes in terms of operative time, blood loss, transfusion rate and length of hospitalization were evaluated. Statistical analysis was performed using GraphPad Prism 6.0 software. RESULTS: Median blood loss was 250 ml (50-500) and 400 ml (50-1000) in the first and second group, respectively, with a statistically significant difference (p=0.0066). Median surgical time was 200 min (90-390) and 240 min (130-390) in PRAE and No-PRAE group (p=0.06), respectively. No major complications occurred after embolization. Overall complication rate in Group 1 and 2 was 46.7% (14/30) and 50% (17/34), respectively (p=0.34). No major complications occurred in both groups. The mean follow up was 21,5 months. CONCLUSIONS: Our results prove PRAE to be a safe procedure with low complications rate. To our experience, PRAE seems to be a useful tool in surgical management of a large mass and advanced disease.

Evaluation of Surgical Site Infection in Mini-invasive Urological Surgery.

Surgical Site Infection (SSI) is the most frequent source of infection in surgical patients and the second most frequent cause of hospital-acquired infection. The primary aim of this prospective study was to compare SSI occurrences between minimally invasive surgery (MIS) and open urological surgery. Secondly, perioperative outcomes were evaluated in two different approaches. A consecutive group of 60 patients undergoing urological surgery were prospectively enrolled in a single high-volume center between May and October 2018. We included procedures that were performed by minimally invasive or traditional techniques. We evaluated and compared the incidence of SSI and perioperative outcomes in terms of intraoperative bleeding, post-operative complications, postoperative pain, patient satisfaction with the analgesic treatment, time to flatus, time of oral intake and mobilization, and length of hospital stay. The two groups were homogeneous with regard to demographic data. Superficial incisional SSIs were diagnosed in 10% of cases (3/30) in the second group and 0% in the first (p<0.05); space/organ SSIs developed in 4 patients, which were diagnosed by ultrasound scan and confirmed by abdominal CT: 1 patient (3.3%) in group 1 showed an infected lymphocele, whereas 1 case of infected lymphocele and 2 cases of pelvic abscess were detected in group 2 (10%, p<0.05). All the perioperative outcomes as well as were overall complication rate favored MIS (p<0.05). The use of minimally invasive techniques in urological surgery reduced the risk of SSI by comparison with a traditional approach. In addition, MIS was associated with better perioperative outcomes and a lower overall complication rate.

Robotic treatment of giant adrenal myelolipoma: A case report and review of the literature.

Adrenal myelolipoma is a rare mesenchymal tumour with benign biological behaviour that is mainly composed of mature adipose and myeloid tissue. Both sexes are equally affected, most commonly between the fifth and seventh decades of life. The diagnosis of adrenal myelolipoma is mostly incidental. Although it may occasionally be associated with necrosis, rupture and haemorrhage, causing abdominal pain, this tumour is usually asymptomatic. Consequently, management is conservative, while surgical treatment is reserved for symptomatic cases, or for masses growing quickly or to a size >6 cm. Giant myelolipomas (sized >10 cm) are rare. Open radical adrenalectomy is the standard treatment for giant myelolipomas, while the minimally invasive approach has been used in only few cases. We herein report the case of a patient with a giant adrenal myelolipoma who underwent robotic partial adrenalectomy. To the best of our knowledge, this is the largest giant adrenal myelolipoma treated with robotic surgery reported in the literature to date. A 55-year-old male patient underwent an abdominal computed tomography scan during follow-up after radical prostatectomy for prostate cancer Gleason Score 6 (ISUP 1) due to biochemical recurrence. The examination revealed a right hypodense adrenal mass, sized 16×13 cm. Abdominal magnetic resonance imaging confirmed the presence of characteristics suggestive of a myelolipoma. The patient did not report any symptoms. Due to the benign characteristics of the mass, robotic partial adrenalectomy and enucleation of the mass were performed. The operative time and estimated blood loss were 205 min and 100 ml, respectively. No intra- or postoperative complications occurred. The patient was mobilized on the first postoperative day and the time to flatus was 36 h; the length of hospitalization was 4 days. Histological examination confirmed the diagnosis of adrenal myelolipoma, sized 18×11.5×6 cm. No tumour recurrence occurred over a follow-up period of 12 months. In conclusion, robotic surgery allows performing partial adrenalectomy with a lower risk of bleeding and with preservation of healthy adrenal tissue, which is of paramount importance for the patient as it reduces recovery time and the need for medical substitution therapy.