Role of increasing leukocyturia for detecting the transition from asymptomatic bacteriuria to symptomatic infection in women with recurrent urinary tract infections: A new tool for improving antibiotic stewardship.

OBJECTIVES: To evaluate the importance of leukocyturia in detecting the transition from asymptomatic bacteriuria to symptomatic infection in women with recurrent urinary tract infections. METHODS: In this cross-sectional study, we evaluated all women with recurrent urinary tract infection and asymptomatic bacteriuria who had been enrolled in two previous studies. Data from urological visits, urine analyses and microbiological evaluations were collected. Patients were divided into two groups: patients with symptomatic recurrence (group A) and patients without recurrence (group B), with a mean follow-up period of 38.8 months. Data on leukocyturia and clinical data were compared. Logistic regression analyses were carried out and areas under the receiver operating characteristic curves were calculated. RESULTS: A total of 301 women with symptomatic urinary tract infection were included in group A, whereas 249 women without clinical infection were included in group B. Group A showed a higher level of leukocytes in the urinary analysis taken at the moment of recurrence when compared with the baseline value (mean leukocytes per high power field 54 ± 5 vs 19 ± 6 at baseline; P < 0.0001). When an increase of leukocytes/mm3 of >150% from baseline was used for logistic regression, the area under the receiver operating characteristic of the model was 0.82 (95% CI 0.78-0.94; P = 0.01). An increase of leukocytes/mm3 of >150% from baseline had a sensitivity of 90.1% and a specificity of 91.2% for symptomatic urinary tract infection. CONCLUSIONS: This study shows that an increase of leukocyturia of >150% from baseline has a predictive role for the transition from asymptomatic bacteriuria to symptomatic urinary tract infection in women with recurrent urinary tract infections.

Unusual case of locally advanced and metastatic paratesticular liposarcoma: a case report and review of the literature.

Liposarcoma accounts for 20% of all sarcomas and is a rare occurrence in the paratesticular region. We present the case of a 66-year-old man with a massive liposarcoma of the right scrotum invading the lower limb and the abdominal wall skin. The case concerns an unusually large and aggressive liposarcoma (25 cm), presenting with multiple lung and nodal metastases. The patient had an unfavourable evolution with rapid progression of metastases, although there were no signs of local disease. In this case, a wide local excision was performed in order to obtain local control of the disease. Even though paratesticular sarcomas might have a more favourable evolution, the association with lung involvement carries an ominous prognosis. Diagnosis of paratesticular sarcoma should be kept in mind in case of irregular necrotic masses in the inguinal and scrotal region.

Is retrograde intrarenal surgery for the treatment of renal stones with diameters exceeding 2 cm still a hazard?

INTRODUCTION: Major kidney stones have traditionally been treated with percutaneous nephrolithotomy. However, retrograde intrarenal surgery (RIRS), which until a few years ago was considered inappropriate for this purpose, is becoming a viable, attractive alternative. The aim of the current study was to assess the efficacy and safety of RIRS combined with holmium laser lithotripsy for the treatment of stones > 2 cm in diameter in a large series of patients, reporting complications according to the Clavien-Dindo classification. MATERIALS AND METHODS: By retrospective analysis, we identified a total of 162 patients who were affected by stones greater than 2 cm in diameter and who had undergone RIRS. We reviewed demographic and stone characteristics, intraoperative and postoperative outcomes, and complications. RESULTS: The mean stone size was 2.7 cm +/- 0.6 cm. The primary, secondary, and tertiary stone-free rates were 66%, 80.9%, and 87.7%, respectively. The mean number of procedures per patient was 1.48. The complication rates according to the Clavien-Dindo classification were Clavien I in 20.4% of patients, Clavien II in 0%, Clavien III in 4.9%, Clavien IV in 0.6%, and Clavien V in 0%. CONCLUSIONS: As an alternative to standard procedures for the treatment of renal calculi greater than 2 cm in diameter, RIRS is safe and effective, with a low complication rate.

A Novel Nomogram Based on Initial Features to Predict BPH Progression.

Objectives: The aim of this study was to establish a tool to identify patients at risk for pharmaceutical and surgical interventions for benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS) over a 10 year follow-up. Methods: The data of patients with mild to moderate male LUTS undergoing phytotherapy from January to December 2010 were reviewed. Patients were followed for 10 years through medical visits and telephone consultations. The outcomes were (1) treatment switch from phytotherapy or no therapy to alpha-blockers or 5α-reductase inhibitors (5-ARI), and (2) clinical progression (acute urinary retention or need for surgery). Two calibrated nomograms (one for each outcome) were constructed on significant predictors at multivariate analysis. Results: A total of 107 patients with a median age of 55 years at presentation were included; 47% stopped or continued phytotherapy, while 53% switched to alpha-blockers and/or 5-ARI after a median time of 24 months. One-third in the second group experienced clinical progression after a median time of 54 months. Age, symptom score, peak flow rate (Qmax), prostate-specific antigen (PSA), and post-void residual volume were significantly associated with the outcomes. According to our nomograms, patients switching therapy or progressing clinically had average scores of 75% and 40% in the dedicated nomograms, respectively, as compared to 25% and <5% in patients who did not reach any outcome. Conclusions: We developed a nomogram to predict the risk of pharmaceutical or surgical interventions for BPH-related LUTS at 10 years from presentation. On the basis of our models, thresholds of >75% and >40% for high risk and <25% and <5% for low risk of pharmaceutical or surgical interventions, respectively, can be proposed.

Robotic-assisted radical prostatectomy following colo-rectal surgery: a user's guide.

To assess the feasibility and operative outcomes of RARP following colo-rectal surgery. A prospective database of patients undergoing RARP is maintained at our Institution since January 2015. We reviewed all patients undergoing RARP after previous colo-rectal surgery. Overall, 49 (7.4%) of 658 RARPs were performed after previous pelvic surgery, 14 (2.1%) of which following colo-rectal surgery after an interval of 5 years. (a) Colo-rectal surgery. Previous colo-rectal surgery included resection of the left colon (n = 6), and right colon (n = 4), and rectum (n = 4). Histopathology showed pT0-T2N0 in 5, pT3N0-1 in 3, and benign conditions in 4. Prostate-specific antigen (PSA) was elevated (4 ng/ml or greater) or slightly elevated (3.5-4 ng/ml) in 9 (65%) of 14 cases at the time of colo-rectal surgery. (b) Prostatectomy. Overall prostatectomy and adhesiolysis median operative times were 235 and 42 min, respectively. A robotic approach was accomplished in 11 cases with previous uncomplicated colo-rectal surgery; open conversion occurred in 3 cases. Risk factors for open conversion during RARP were: history of multiple or complicated abdominal surgery, previous open conversion, and hospital stay > 10 days. Postoperative complications included: anemization (n = 2), persistent drain output (n = 1), and urinary tract infection (n = 1). The robotic approach was successful in the case of previous uncomplicated colo-rectal surgery. The risk of intestinal injury during conversion might suggest a direct retropubic approach in case of previous multiple or complicated abdominal surgery. A planned elective colo-rectal surgery should include a thorough urologic evaluation, considering the risk of a subsequent prostate surgery.

Is Hypertension Associated with Worse Renal Functional Outcomes after Minimally Invasive Partial Nephrectomy? Results from a Multi-Institutional Cohort.

BACKGROUND: Hypertension (HTN) is a global public health issue. There are limited data regarding the effects of HTN in patients undergoing partial nephrectomy (PN) for renal tumors. To address this void, we tested the association between HTN and renal function after minimally invasive PN (MIPN). METHODS: Using a multi-institutional database (2007-2017), we identified patients aged ≥ 18 years with a diagnosis of cT1 renal tumors treated with MIPN. Kaplan-Meier plots and Cox regression models addressed newly-onset CKD stage ≥ 3b or higher (sCKD). All analyses were repeated after 1:1 propensity score matching (PSM). RESULTS: Overall, 2144 patients were identified. Of those, 35% (n = 759) were yes-HTN. Yes-HTN patients were older, more frequently male and more often presented with diabetes. Yes-HTN patients harbored higher RENAL nephrometry scores and higher cT stages than no-HTN patients. Conversely, yes-HTN patients exhibited lower preoperative eGFRs. In the overall cohort, five-year sCKD-free survival was 86% vs. 94% for yes-HTN vs. no-HTN, which translated into a multivariable HR of 1.67 (95% CI: 1.06-2.63, p = 0.026). After 1:1 PSM, virtually the same results were observed (HR 1.86, 95% CI: 1.07-3.23, p = 0.027). CONCLUSIONS: Yes-HTN patients exhibited worse renal function after MIPN when compared to their no-HTN counterparts. However, these observations need to be further tested in a prospective cohort study.

Posterior reconstruction during robotic-assisted radical cystectomy with intracorporeal orthotopic ileal neobladder: description and outcomes of a simple step.

A posterior reconstruction (PR) might improve the fluidity and delicacy of the maneuvers related to the neovesico-urethral anastomosis during robotic-assisted radical cystectomy (RARC). Our objective is to describe in detail the surgical steps of PR and to assess its feasibility and functional outcomes. The data regarding patients undergoing a totally intracorporeal RARC with neobladder and PR for high-grade and/or muscle-invasive urothelial cancer of the bladder at Karolinska University Hospital between October 2015 and November 2016 by a single surgeon (PW) were reviewed. Prior to the anastomosis, a modified posterior Rocco's repair involving the Denonvillier's fascia, the rhabdosphincter, and the posterior side of the ileal neobladder neck was performed. The steps are shown in a video at https://doi.org/10.1089/vid.2019.0029 . The primary outcome was urinary continence; the secondary outcomes were urinary leakage, intermittent catheterization, and complications related to the reconstructive steps. Eleven male patients with a median age and BMI of 67 years and 24, respectively, underwent RARC with PR associated to the neovesico-urethral anastomosis. Overall and posterior reconstruction time were 300' (195-320) and 6' (4-7), respectively. The daytime and nighttime continence rates were 100% and 44% at 12 months, respectively; the median pad weight was 3.5 g and 108 g at daytime and nighttime, respectively. One urinary leakage from the urethrovesical anastomosis was treated conservatively. Two patients perform intermittent catheterization. The posterior reconstruction during RARC is safe and feasible, providing good continence rates. It supported a careful suturing of the anastomosis as well as an uncomplicated catheter placement.

Guess Who's Coming to Dinner: COVID-19 in a COVID-free Unit.

OBJECTIVE: To assess the impact of the pandemic on surgical activity and the occurrence and features of Covid-19 in a Covid-free urologic unit in a regional hospital in Northern Italy. MATERIALS AND METHODS: Our Department is the only urologic service in the Trento Province, near Lombardy, the epicenter of Covid-19 in our Country. We reviewed the surgical and ward activities during the 4 weeks following the national lockdown (March 9 to April 5, 2020). The following outcomes were investigated: surgical load, rate of admissions and bed occupation, and the rate and characteristics of unrecognized Covid-positive patients. Data were compared with that of the same period of 2019 (March 11 to April 7). RESULTS AND CONCLUSION: About 63%, 70%, 64%, and 71%, decline in surgery, endoscopy, bed occupation, and admission, respectively, occurred during the 4 weeks after the lockdown, as compared to 2019. Urgent procedures also declined by 32%. Three (8%) of 39 admissions regarded unrecognized Covid-19 overlapping or misinterpreted with urgent urologic conditions such as fever-associated urinary stones or hematuria. In spite of a significant reduction of activity, a non-negligible portion of admissions to our Covid-free unit regarded unrecognized Covid-19. In order to preserve its integrity, we propose an enhanced triage prior to the admission to a Covid-free unit including not only routine questions on fever and respiratory symptoms but also nonrespiratory symptoms, history of exposure, and a survey about the social and geographic origin of the patient.

Robotic-assisted partial nephrectomy provides better operative outcomes as compared to the laparoscopic and open approaches: results from a prospective cohort study.

The objective of this is to compare the surgical outcomes of partial nephrectomy (PN), performed via three different approaches: robot-assisted (RAPN), laparoscopic (LPN), and open (OPN), in a single non-academic regional center. The data of patients undergoing PN at our Department from 2005 to 2016 were prospectively collected. A logistic regression model adjusted for preoperative variables (age, tumor size, creatinine and hemoglobin, ASA and Padua scores) was performed to evaluate whether transfusion, conversion, and postoperative complication rate were influenced by the surgical approach. Overall 270 patients underwent PN: analysis included 253 cases (RAPN = 110, LPN = 70, OPN = 73). Preoperative variables did not differ significantly among the three groups. Shorter operative (130 vs 180 and 200') and ischaemia (12 vs 23 and 22') times and longer hospital stay (8 vs 7 and 6 days) were found in the OPN group as compared to LPN and RAPN, respectively. The RAPN group included a higher rate of pT1b (31.8 vs 14.2 and 15%) and malignant histotype (90 vs 82.9 and 68.5%) as compared to LPN and OPN, respectively. Clavien Grade III-IV complications were lower in the RAPN (7.2%) as compared to OPN (12.3%) and LPN (17.1%) groups. Multivariate analysis showed a lower risk for conversion, transfusion and overall complications in the RAPN group versus LPN and OPN. The surgical approach affects the perioperative outcomes in a regional setting. The advantages of RAPN over OPN (lower risk of conversion, transfusion, and overall complications) are extended over LPN as well, although OPN offered faster operative and ischemia times at the expense of greater blood loss and hospital stay.

Early impact of robot-assisted partial nephrectomy on renal function as assessed by renal scintigraphy.

To measure the early impact of robot-assisted partial nephrectomy (RAPN) on renal function as assessed by renal scan (Tc 99m-DTPA), addressing the issue of risk factors for ischemic damage to the kidney. All patients undergoing RAPN for cT1 renal masses between June 2013 and May 2014 were included in this prospective study. Renal function as expressed by glomerular filtration rate (GFR) was assessed by Technetium 99m-diethylenetriaminepentaacetic acid (Tc 99m-DTPA) renal scan preoperatively and postoperatively at 1 month in every patient. A multivariable analysis was used for the determination of independent factors predictive of GFR decrease of the operated kidney. Overall, 32 patients underwent RAPN in the time interval. Median tumor size, blood loss, and ischemia time were 4 cm, 200 mL, and 24 min, respectively. Two grade III complications occurred (postoperative bleeding in the renal fossa, urinoma). The GFR of the operated kidney decreased significantly from 51.7 ± 15.1 mL/min per 1.73 m(2) preoperatively to 40, 12 ± 12.4 mL/min per 1.73 m(2) 1 month postoperatively (p = 0.001) with a decrease of 22.4 %. On multivariable analysis, only tumor size (p = 0.05) was a predictor of GFR decrease of the operated kidney. Robotic-assisted partial nephrectomy had a detectable impact on early renal function in a series of relatively large tumors and prevailing intermediate nephrometric risk. A mean decrease of 22 % of GFR as assessed by renal scan in the operated kidney was found at 1 month postoperatively. In multivariable analysis, tumor size only was a significant predictor of renal function loss.

Role of risk factors for erectile dysfunction in patients undergoing transurethral resection of the prostate: early impact on sexual function.

INTRODUCTION: Transurethral resection of the prostate (TURP) has been long debated as a possible cause of erectile dysfunction (ED). We investigated the role of common risk factors for ED in patients aged 60 to 70 undergoing TURP Factors related to the treatment were also considered. MATERIALS AND METHODS: Ninety patients underwent TURP for benign prostate hyperplasia (BPH) from June 2002 to February 2003. Fourty-two of them, sexually active aged 60 to 70, were administered preoperatively and 3-month postoperatively the International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) questionnaires. A complete assessment of risk factors for ED was performed in the preoperative setting (treated hypertension, diabetes, cigarette smoking, hypercolesterolemy, cardiovascular disease). IIEF score was related to age, comorbidities, operative time, resected tissue weight, retrograde ejaculation, IPSS score. RESULTS: Nine (21.4%) patients reported worsened IIEF-5 score after TURP, and 33 (78.6%) unchanged/improved score. Cardiovascular disease was present in 56% of patients with worsened IIEF-5 score and in 12% of patients with improved/unchanged IIEF-5 score; it was the only factor that correlated significantly in the regression model. CONCLUSION: In general, most patients report a stable sexual function after TURP. Patients with known cardiovascular disease undergoing TURP had an increased risk of sexual impairment after this procedure.

Early surgical repair of penile fractures: our experience.

OBJECTIVE: Fracture of the penis is a relatively rare condition, defined as the rupture of the tumescent corpora cavernosa. The fracture is quite easily recognized, whereas its management remains controversial. Our experience regarding the early treatment of penile fractures is herein reported. MATERIALS AND METHODS: In a 7-year period (1997-2004) 10 patients aged 23 to 42 years, presented with a penile fracture, occurred during coitus. All patients were admitted to the hospital 1 to 10 hours after injury. Diagnosis was made on clinical examination. Six patients referred a snapping sound at the time of injury. Common clinical features included sudden penile pain, detumescence and penile deviation. All patients showed penile haematoma; 3 had scrotal and perineal haematoma as well. None of the patients had urethral bleeding. RESULTS: all patients were surgically treated; at the time of surgery unilateral albuginea rupture was found in all cases. With a mean follow-up of 37 months (range 1-78) all cases were able to achieve an adequate erection. No complications, such as deformations, penile plaque, urethral fistula or erectile dysfunction were reported. CONCLUSION: Immediate surgical repair in case of penile fracture is recommended in order to obtain better functional outcome and to avoid potential complications.

Operative safety and oncologic outcome of laparoscopic radical nephrectomy for renal cell carcinoma >7 cm: a multicenter study of 222 patients.

OBJECTIVE: To evaluate the safety of laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) >7 cm, addressing the issue of modality and risk factors for complications and open conversion, and to assess the oncologic outcome. METHODS: The data of 222 patients undergoing LRN for RCC >7 cm prospectively enrolled from 2002 to 2010 at 5 urologic centers were reviewed. Transperitoneal LRN was performed by 5 experienced laparoscopic surgeons. The Clavien-Dindo classification was used to assess complications. Multivariable analysis of factors predictive of conversions was performed. Oncologic outcomes for survival were estimated using the Kaplan-Meier method. RESULTS: Median tumor size was 8.5 cm, operative time was 180 minutes, and blood loss was 280 mL. Forty-two patients (19%) received a blood transfusion. Six (2.7%) patients had grade III-IV complications: 2 with postoperative bleeding requiring abdominal re-exploration and 1 each with adrenal injury, splenic injury, wound diastasis, and respiratory insufficiency. Twelve patients (5.4%) were converted to open surgery. The diameter was 11.9 in converted groups and 8.5 cm in nonconverted groups (P = .001). Multivariable analysis revealed that pathologic stage was the only independent predictor of conversion (P = .002). The 5-year overall (OS), cancer-specific (CSS), and progression-free (PFS) survival was 74%, 78%, and 66%, respectively. The 5-year stage-adjusted CSS was 89% in pT2 and 40% in pT3 patients (P <.0001). Limitations of this study were its retrospective nature and the relatively short follow-up period for oncologic outcome. CONCLUSION: LRN for large RCC is a safe operation. Stage pT3 is a risk factor for open conversion and is associated to significantly lower cancer-specific survival compared with pT2 stage.

Role of transperineal six-core prostate biopsy in patients with prostate-specific antigen level greater than 10 ng/mL and abnormal digital rectal examination findings.

OBJECTIVES: To define whether six-core biopsies still have a role in patients presenting with prostate-specific antigen (PSA) levels greater than 10 ng/mL and abnormal digital rectal examination (DRE) findings. Recent studies have suggested that the six-core biopsy is inadequate for the diagnosis of prostate cancer; however, it remains controversial whether an increased number of cores is justified in all patients. METHODS: From June 2002 to February 2005, 122 (18.8%) of 650 patients underwent prostate biopsy because of a PSA level greater than 10 ng/mL and abnormal DRE findings. All patients underwent transperineal ultrasound-guided prostate biopsy in a standardized fashion: a six-core biopsy was performed first, followed by six additional cores during the same session, four in the peripheral and two in the transition zone. RESULTS: The detection rate in patients with a PSA level greater than 10 ng/mL and abnormal DRE findings was 72.1% (88 of 122) and 75.4% (92 of 122) using the 6-core and 12-core biopsy, respectively. One case of tumor was missed by the six-core biopsy among patients with a PSA level greater than 15 ng/mL and abnormal DRE findings. No cases of tumor were missed by six-core biopsy in the group with a PSA level greater than 20 ng/mL and abnormal DRE findings. CONCLUSIONS: Six-core biopsy provided a similar cancer detection rate compared with 12-core biopsy in patients with PSA levels greater than 10 ng/mL and abnormal DRE findings. An initial approach with 6-core biopsy is reasonable in patients with a PSA level greater than 10 ng/mL and abnormal DRE findings and is advocated in those with PSA greater than 20 ng/mL and abnormal DRE findings.

Renal cysts: can percutaneous ethanol injections be considered an alternative to surgery?

AIM: To evaluate the efficacy of a new sclerotization technique with pure ethanol in the treatment of symptomatic renal cysts. PATIENTS AND METHODS: Fourteen patients having renal cysts with a meant diameter of 10 (range 5-15) cm were treated. Our technique includes: ultrasound-guided percutaneous puncture with an 18-gauge needle, positioning of a 5-Fr catheter, complete cyst fluid aspiration, injection of pure alcohol equal to 15% of the initial cyst volume, and alcohol aspiration after 90 min. The procedure was repeated eight times within 5 days. The patients were followed up by ultrasound and/or CT scan for 1 year. RESULTS: All patients became symptom free. Follow-up showed a progressive reduction of the cyst diameter in all cases. Three cysts only (in 2 patients; cyst diameter <2 cm) persisted after 12 months. No significant complications were observed. CONCLUSIONS: In our experience, injections of pure ethanol in renal cysts, repeated after some days, were effective in eliminating recurrences and related symptoms. The procedure was not associated with significant complications. Our findings suggest that it be considered the first-choice procedure in the treatment of renal cysts, due to the good results and the low cost of ethanol.