Application of a protocol for enhanced recovery after radical cystectomy: a before-and-after cohort study.

PURPOSE: Radical cystectomy with urinary diversion is a major urological surgery burdened both by a high rate of short- and long-term complications and by a high emotional and psychological impact. Post-operative recovery is extremely important and the application of ERAS protocols can facilitate the return to functional autonomy. The aim of the present study was to verify the efficacy of our ERAS programme on outcomes of recovery after surgery of patients undergoing radical cystectomy with various urinary diversions. METHODS: This is a before-after study comparing the historical group (n. 77) of radical cystectomies following a peri-operative standard of care with the prospective observational group (n. 83) following our ERAS programme. Recovery after surgery outcomes evaluated were length of stay, re-admission rate at 30-90/days and post-operative complications. RESULTS: Patients treated following the ERAS protocol presented less intra-operative blood loss (p < 0.001) and less intra-operative fluid infusions (p < 0.001). Time of first flatus was shorter in the ERAS group, though no difference was found in timing of nasogastric tube removal and defecation. Removal of drainage was done significantly earlier in the ERAS group. The median length of stay decreased from 12 to 9 days (p = 0.003) with a significant reduction also in re-admission rates at 30 and long-term complications at 90 days from surgery. CONCLUSION: The application of an opioid-free ERAS protocol to patients undergoing open radical cystectomy was associated, as compared with prior traditional care, with significant reductions of recovery time and length of stay, number of total in-hospital complications, in particular functional ileus and re-admissions by 30 and 90 days after surgery.

Developing a five-step training model for transperineal prostate biopsies in a naïve residents' group: a prospective observational randomised study of two different techniques.

PURPOSE: To evaluate a five-step training model for transperineal prostate biopsies (TPPB) and the differences in terms of the detection rate (DR) and the ease of execution when using either the "fan technique" (FT) or the use of a Free Hand technique (FH). METHODS: A prospective observational randomised study was conducted from September 2015 to November 2017. Six naïve residents, who underwent the same five-steps training model, were randomly subdivided into two different groups of three residents based on the selected TPPB technique: A (FT) and B (FH). Patient characteristics (age, PSA, prostatic volume, DRE, MRI), intraoperative (operative time, number of samples) and postoperative parameters (histologic, pain) were evaluated in the 2 groups. The overall and stratified DR for PSA ranges and prostate volume (PV), operative time and complications were compared. RESULTS: The overall detection rate was very high in both groups (FT 58.2% vs FH 59.6%) and not statistically different between the two techniques. There were no differences in terms of complication rates and pain. The FH showed a better detection rate in prostates smaller than 40 cc (p = 0.023) and a faster operative time (p = 0.025) compared to FT. CONCLUSIONS: Within the TPPB, FH is associated with a higher detection rate in patients with prostate < 40 cc compared to an FT when performed by inexperienced trainees. Standardised training organised in consecutive steps seems to contribute to the achievement of overall high detection rates with both methods.

Perioperative Renal Ultrasonography of Arterio-to-Venous Coupling Predicts Postoperative Complications after Major Laparoscopic Urologic Surgery.

Point-of-care ultrasonography (POCUS) with concomitant venous and arterial Doppler assessment enables clinicians to assess organ-specific blood supply. To date, no studies have investigated the usefulness of including a comprehensive perioperative POCUS assessment of patients undergoing major laparoscopic surgery. The primary aim of the present study was to evaluate whether the combined venous and arterial renal flow evaluation, measured at different time points of perioperative period, may represent a clinically useful non-invasive method to predict postoperative acute kidney injury (AKI) after major laparoscopic urologic surgery. The secondary outcome was represented by the development of any postoperative complication at day 7. We included 173 patients, subsequently divided for analysis depending on whether they did (n = 55) or did not (n = 118) develop postoperative AKI or any complications within the first 7 days. The main results of the present study were that: (1) the combination of arterial hypoperfusion and moderate-to-severe venous congestion inferred by POCUS were associated with worst outcomes (respectively, HR: 2.993, 95% CI: 1.522-5.884 and HR: 8.124, 95% CI: 3.542-18, p < 0.001); (2) high intra-operative abdominal pressure represents the only independent determinant of postoperative severe venous congestion (OR: 1.354, 95% CI: 1.017-1.804, p = 0.038); (3) the overall number of complications relies on the balance between arterial inflow and venous outflow in order to ensure the adequacy of peripheral perfusion; and (4) the overall reliability of splanchnic perfusion assessment by Doppler is high with a strong inter-rater reliability (ICC: 0.844, 95% CI: 0.792-0.844). The concomitant assessment of arterial and venous Doppler patterns predicts postoperative complications after major laparoscopic urologic surgery and may be considered a useful ultrasonographic biomarker to stratify vulnerable patients at risk for development of postoperative complications.

Perioperative Intravenous Amino Acid Infusion in Major Urologic Surgery.

Post-operative acute kidney injury (PO-AKI) is a serious complication that may occur after major abdominal surgery. The administration of intravenous perioperative amino acids (AAs) has been proven to increase kidney function and has some beneficial effects to prevent PO-AKI. The aim of this study was to establish if the perioperative infusion of AAs may reduce the incidence of PO-AKI in patients undergoing major urological minimally invasive surgery. From a total of 331 patients, the first 169 received perioperative crystalloid fluids and the following 162 received perioperative AA infusions. PO-AKIs were much higher in the crystalloid group compared to the AA group (34 vs. 17, p = 0.022) due to a lower incidence of KDIGO I and II in the AA group (14 vs. 30 p = 0.016). The AA group patients who developed a PO-AKI presented more risk factors compared to those who did not (2 (2-4) vs. 1 (1-2), p = 0.031) with a cut-off of 3 risk factors in the ROC curve (p = 0.007, sensitivity 47%, specificity 83%). The hospital length of stay was higher in the crystalloid group (p < 0.05) with a consequent saving in hospital costs. Perioperative AA infusion may help reduce the incidence of PO-AKI after major urological minimally invasive surgery.

Low Intra-Abdominal Pressure with Complete Neuromuscular Blockage Reduces Post-Operative Complications in Major Laparoscopic Urologic Surgery: A before-after Study.

Most urological interventions are now performed with minimally invasive surgery techniques such as laparoscopic surgery. Combining ERAS protocols with minimally invasive surgery techniques may be the best option to reduce hospital length-of-stay and post-operative complications. We designed this study to test the hypothesis that using low intra-abdominal pressures (IAP) during laparoscopy may reduce post-operative complications, especially those related to reduced intra-operative splanchnic perfusion or increased splanchnic congestion. We applied a complete neuromuscular blockade (NMB) to maintain an optimal space and surgical view. We compared 115 patients treated with standard IAP and moderate NMB with 148 patients treated with low IAP and complete NMB undergoing major urologic surgery. Low IAP in combination with complete NMB was associated with fewer total post-operative complications than standard IAP with moderate NMB (22.3% vs. 41.2%, p < 0.001), with a reduction in all medical post-operative complications (17 vs. 34, p < 0.001). The post-operative complications mostly reduced were acute kidney injury (15.5% vs. 30.4%, p = 0.004), anemia (6.8% vs. 16.5%, p = 0.049) and reoperation (2% vs. 7.8%, p = 0.035). The intra-operative management of laparoscopic interventions for major urologic surgeries with low IAP and complete NMB is feasible without hindering surgical conditions and might reduce most medical post-operative complications.

Correlation Between Long-Term Acetylsalicylic Acid Use and Prostate Cancer Screening with PSA. Should We Reduce the PSA Cut-off for Patients in Chronic Therapy? A Multicenter Study.

Purpose: To evaluate the prostate cancer (PCa) detection rate in men with chronic use of Aspirin and to compare it with the detection rate of non-users. Patients and Methods: Prospectively maintained database regarding patients undergoing prostate biopsy over the last 10 years in five institutions. Patients were divided into two groups according to their exposure to Aspirin. We relied on multivariable linear and logistic regression models to test whether Aspirin administration was associated with lower PSA values at prostate biopsy, higher PCa diagnosis, and higher Gleason Grade Grouping (GGG) at biopsy. Results: Were identified 1059 patients, of whom 803 (76%) did not take Aspirin vs 256 (24%) were taking it. In multivariable log-linear regression analysis, Aspirin administration was associated with lower PSA levels (OR 0.83, 95% CI 0.71-0.97, p = 0.01), after controlling for age, prostate volume, smoking history, associated inflammation at prostate biopsy, presence of PCa at biopsy, and GGG. In multivariable logistic regression analysis, Aspirin administration was not found to be a predictor of PCa at prostate biopsy (OR 1.40, 95% CI 0.82-2.40, p = 0.21) after controlling for age, PSA, smoking history, prostate volume, findings at digital rectal examination and the number of biopsy cores. In patients with PCa at prostate biopsy (n = 516), Aspirin administration was found to predict higher GGG (OR 2.24, 95% CI 1.01-4.87, p = 0.04). Conclusion: Aspirin administration was found to be a predictor of more aggressive GGG. These findings suggest that a lower PSA threshold should be considered in patients taking Aspirin, as, despite low PSA levels, they might harbour aggressive PCa.

Two-stage functional and aesthetic reconstructive surgery in melanoma in situ of the glans penis and urethra.

Melanoma in situ including glans penis and fossa navicularis is unique and represents a challenging dilemma since surgery should not be very aggressive. We present a case of melanoma in situ treated with a two-stage penile and urethral reconstructive surgery, with emphasis on functional and aesthetic results. At the first-stage surgery an anatomic glansectomy was perfomed, and combined preputial and full-thickness skin grafts were used to prepare the urethral plate and restore the aesthetic aspect of the corpora cavernosa. After 6 months, the distal urethra was repaired including the configuration of an orthotopic meatus and a neo-glans.

Age above 70 years and Charlson Comorbidity Index higher than 3 are associated with reduced survival probabilities after radical cystectomy for bladder cancer. Data from a contemporary series of 334 consecutive patients.

OBJECTIVE: To assess the joint effect of age and comorbidities on clinical outcomes of radical cystectomy (RC). METHODS: 334 consecutive patients undergoing open RC for bladder cancer (BC) during the years 2005-2015 were analyzed. Pre-, peri- and post-operative parameters, including age at RC (ARC) and Charlson Comorbidity Index (CCI), were evaluated. Overall and cancer-specific survivals (OS, CSS) were assessed by univariate and multivariate modelling. Furthermore, a three-knot restricted cubic spline (RCS) was fitted to survival data to detect dependency between death-rate ratio (HR) and ARC. RESULTS: Median follow-up time was 3.8 years (IQR = 1.3-7.5) while median OS was 5.9 years (95%CL = 3.8-9.1). Globally, 180 patients died in our cohort (53.8%), 112 of which (62.2%) from BC and 68 patients (37.8%) for unrelated causes. After adjusting for preoperative, pathological and perioperative parameters, patients with CCI > 3 showed significantly higher death rates (HR = 1.61; p = 0.022). The highest death rate was recorded in ARC = 71-76 years (HR = 2.25; p = 0.034). After fitting an RCS to both OS and CSS rates, two overlapping nonlinear trends, with common highest risk values included in ARC = 70-75 years, were observed. CONCLUSIONS: Age over 70 years and CCI > 3 were significant factors limiting the survival of RC and should both be considered when comparing current RC outcomes.

Urology apps: overview of current types and use.

INTRODUCTION: In recent years numerous applications have been developed with different purposes, aimed both at simplifying the lives of doctors and patients also within the urological field. MATERIAL AND METHODS: In January 2020 we conducted a search in the Apple App Store and Google Play Store. RESULTS: A total of 521 apps were reviewed, an increase of 8 times as compared to the last complete available review of eight years ago. Most of the urological apps are geared towards the patient and provide information and services to improve the understanding and treatment of different diseases. Some of these apps also get the patient directly in touch with healthcare staff allowing for an improvement in doctor-patient communication. CONCLUSIONS: Although the usefulness of many of these tools is undoubted, the problem of scientific validation, content control and privacy are not yet solved.

Risk factors for the delay in the diagnosis of penile lesions: results from a single center in Italy.

BACKGROUND: Early diagnosis is fundamental for the investigation and treatment of penile lesions. There is an unfortunate documented delayed in presentation and diagnosis of penile lesions. Literature is scant regarding the risk factors contributing to this delay in a Mediterranean population. Few previous reports are published in entirely different homogeneous populations. The objective of this study was to provide an analysis of the causes and risk factors related to the delay of the first medical visit in a North Italian population subgroup. METHODS: From September 2004 to September 2017, 184 consecutive patients were treated at our institute with a surgical approach for a penile lesion. The epidemiological factors and reasons for the delay to diagnosis were recorded during personal or telephonic interviews. Univariate logistic regression models were performed to screen for an effect of the clinical and demographic variables on the delay in diagnosis. Variables with a P value <0.05 were entered into multivariate analysis, where the delay in diagnosis was the dependent variable. RESULTS: One hundred and thirteen patients were enrolled. The average patient age was fifty-eight. The average delay between the appearance of the lesion and the first medical consultation was fifty-three days. The principal cause of delay was the lack of knowledge of penile lesions and secondly, the feeling of embarrassment of having to visit a doctor. The multivariate analysis reported a significant correlation between the level of education, sexual activity and extramarital affairs on the delay in presentation (P values respectively: 0.01, 0.009 and 0.04). CONCLUSIONS: Patients education regarding this pathology and its potential danger is inadequate and thus it is necessary to implement a campaign of information and prevention in order to reduce delayed diagnosis.

Clinical and histopathological features of carcinosarcoma of the renal pelvis: a systematic review of a rare tumor.

INTRODUCTION: Carcinosarcoma of the kidney pelvis (CRP) is a rare but not exceptionally unique tumor in which in literature are reported almost only case studies and small series. We aim to provide a comprehensive overview of the disease, examining epidemiology, symptoms, pathological features, treatment and outcomes which are still missing, in order to offer a landmark paper to urologists which have to manage patients with this type of disease. EVIDENCE ACQUISITION: A review of the current literature was conducted through the NCBI PubMed database in June 2017 following the updated PRISMA guidelines. The filters used for the research were: "carcinosarcoma renal pelvis," "carcinosarcoma kidney pelvis," and "urinary tract carcinosarcoma." Only studies with confirmed histological diagnosis of CRP and a description of patient characteristics (demographics and/or pathological) were included in the review. EVIDENCE SYNTHESIS: Only 15 studies fulfilled the inclusion criteria. The main symptom at presentation was macroscopic hematuria, followed by abdominal pain. The carcinomatous pattern made of transitional cell carcinoma in 73.3% of patients and squamous carcinoma in 33%, while the sarcomatoid was spindle cells in 40% of patients, chondrosarcoma and undifferentiated in 33.3%. Despite radical surgical treatment was performed in all patients, there are no articles reporting a survival rate of more than two years. CONCLUSIONS: Carcinosarcoma of the kidney is a rare tumor of which little is known, especially about pathogenesis and oncological outcomes in the different therapeutic approaches described. Current literature is almost exclusively a case report that does not provide adequate information especially about survival and progression free survival. The creation of a shared database could in a matter of years lead us to increase the information about the oncological outcomes of the various possible treatments.

Development of a photographic handbook to improve cystoscopy findings during resident's training: A randomised prospective study.

Objectives: To evaluate if the use of a photographic handbook (PH) can be a useful tool to improve the detection of disorders during cystoscopy training, as several hands-on tools have been proposed to improve technical skills but very few aim to improve specificity and sensitivity. Subjects and methods: Eight junior residents (JRs) were divided into two groups: Group A, comprised four JRs with previous limited experience of performing cystoscopies; and Group B, including four inexperienced JRs who were asked to study a specific PH before performing cystoscopies. The findings of the two groups were compared using the chi-squared test. Results: A total of 401 consecutive cystoscopies, of which 214 (53.4%) were performed by Group A and 187 (46.6%) by Group B, were considered. Group B showed superior ability in detecting uncommon findings (i.e., carcinoma in situ, bullous oedema, interstitial cystitis, etc.) with 24/46 (52.2%) detected vs eight of 32 (25%) in Group A (P = 0.016). Conclusions: The PH was a useful tool for improving identification of pathological conditions, which could be used to enhance hands-on simulator and practical tutored training. Abbreviations: CIS: carcinoma in situ; JR: junior resident; PH: photographic handbook; VR: virtual reality Classification: Stones/Endourology.