The use of Versius CMR for pelvic surgery: a multicentric analysis of surgical setup and early outcomes.

INTRODUCTION: Versius CMR is a novel robotic system characterized by an open surgical console and independent bedside units. The system has potentials of flexibility and versatility, and has been used in urological, gynecological, and general surgical procedure. The aim is to depict a comprehensive analysis of the Versius system for pelvic surgery. METHODS: This is a study involving two Institutions, ASST Santi Paolo and Carlo, Milan, and Apuane Hospital, Massa, Italy. All interventions performed in the pelvic area with the Versius were included. Data about indications, intra-, and post-operative course were prospectively collected and analyzed. RESULTS: A total of 171 interventions were performed with the Versius. Forty-two of them involved pelvic procedures. Twenty-two had an oncological indication (localized prostate cancer), the remaining had a non-oncological or functional purpose. The mostly performed pelvic procedure was radical prostatectomy (22) followed by annexectomy (9). No intra-operative complication nor conversion to other approaches occurred. A Clavien II complication and one Clavien IIIb were reported. Malfunctioning/alarms requiring a power cycle of the system occurred in 2 different cases. An adjustment in trocar placement according to patients' height was required in 2 patients undergoing prostatectomy, in which the trocar was moved caudally. In two cases, a pelvic prolapse was repaired concomitant with other gynecological procedures. CONCLUSIONS: Pelvic surgery with the Versius is feasible without major complications; either dissection and reconstructive steps could be accomplished, provided a proper OR setup and trocar placement are pursued. Versius can be easily adopted by surgeons of different disciplines and backgrounds; a further multi-specialty implementation is presumed and long-term oncological and functional outcomes are awaited.

Reproducibility of a modified posterior reconstruction during robotic intracorporeal neobladder reconfiguration.

OBJECTIVE: Robotic intracorporeal neobladder reconstruction is a complex procedure in which the approximation of the reservoir to the urethral stump can be a demanding step. The aim of the study is to evaluate the reproducibility of a modified posterior reconstruction (PR) during the reconfiguration of intracorporeal neobladder after robot assisted radical cystectomy (RARC). MATERIALS AND METHODS: From July 2021 to July 2022, 35 RARC were performed, and 17 patients underwent intracorporeal neobladder reconstruction. A PR was planned in males (14). Intra- and peri-operative data were collected. SURGICAL TECHNIQUE: RARC and node dissection are performed. Afterwards, 40-cm ileal segment is isolated; the portion with the more adequate mesenteric length is brought down to the pelvis. A modified PR is performed with a double-armed barbed suture: a first layer connects the Denonvillier's fascia to the rhabdosphincter in a running fashion; the second layer is created with the other arm and approximates the posterior side of the ileal segment towards the urethral stump. In the anterior caudal part of the ileum, a 1.5-cm incision is made to realize the neobladder neck; the neovesical-urethral anastomosis is performed with a second bidirectional suture. RESULTS: Anastomotic and PR time were 14 (range 7-20) and 5 minutes (4-8), respectively. A single Clavien IIIa complication was recorded in a patient who underwent NAC and had a C. albicans superinfection in the post-operative course. All patients were discharged with complete or acceptable bladder voiding. Twelve patients with follow-up >90-days reported a satisfying daytime continence. CONCLUSIONS: PR represents a simple technical refinement that improves neobladder-urethral anastomosis by favoring ileal approximation to the urethral stump and decreasing anastomotic tension.

Radical prostatectomy represents an effective treatment in patients with specimen-confined high pathological Gleason score prostate cancer.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: To date, only a few studies have addressed the long-term oncological outcomes of radical prostatectomy (RP) in patients with pathological Gleason score ≥ 8 prostate cancer. According to these reports, some individuals with pathological Gleason score ≥ 8 may benefit from RP, with cancer-control outcomes comparable with those of patients with low- and intermediate-risk prostate cancer. The presence of pathological Gleason score 8-10 represents a poor prognostic factor in the outcome of men with prostate cancer. However, in patients with specimen-confined disease, RP and bilateral PLND provided long-term cancer-control outcomes similar to those of patients with more favourable disease characteristics. OBJECTIVES: To evaluate the outcomes of patients with pathological Gleason score 8-10 prostate cancer subjected to radical prostatectomy (RP). To determine the prognostic factors associated with cancer-specific survival (CSS) in this subset of patients. PATIENTS AND METHODS: The study included 580 consecutive patients with pathological Gleason sum 8-10 prostate cancer treated with RP and pelvic lymph node dissection (PLND) at a single European institution between July 1988 and April 2010. All patients had detailed pathological and follow-up data. Pathological Gleason score was determined by a single expert genitourinary pathologist. Biochemical recurrence (BCR) was defined PSA concentration of ≥ 0.2 ng/mL and rising. Kaplan-Meier plots were used to graphically explore BCR-free survival as well as CSS and overall survival (OS) rates. Moreover, univariable and multivariable Cox regression models were fitted to test the predictors of CSS. RESULTS: The mean (median, range) age at surgery was 66.1 (66.4, 41-85) years. The mean (median, range) total PSA concentration was 29.6 (11.1, 0.5-1710) ng/mL. Pathological Gleason score was 8 in 238 (41.0%), 9 in 330 (56.9%) and 10 in 12 (2.1%) patients. Overall, 119 (20.5%), 124 (21.4%), 281 (48.4%) and 56 (9.7%) patients had pT2, pT3a, pT3b and pT4 prostate cancer, respectively. Overall, 275 (47.4%) had LN invasion, while 150 (25.1%) patients had specimen-confined disease (defined as pT2cR0 pN0 or pT3aR0 pN0 prostate cancer). The mean (median, range) follow-up was 53 (47, 1-226) months. At 5 and 10 years after RP, BCR-free survival was 76.7% and 49.6%, respectively. Similarly, the 5- and 10-year CSS rates were 87.3% and 69.5%, respectively. Patients with specimen-confined disease (P < 0.001) and patients with negative LNs (P = 0.012) had significantly better CSS rates than their counterparts with less favourable pathological characteristics. In multivariable Cox regression models, only the presence of specimen-confined disease achieved independent predictor status (P = 0.001). CONCLUSION: Presence of high Gleason score at RP represents a poor prognostic factor in the outcome of patients with prostate cancer. However, RP provides excellent long-term cancer control outcomes in the subset of patients with specimen-confined disease.

Urethral lift for benign prostatic hyperplasia: a comprehensive review of the literature.

Current treatments for benign prostatic hyperplasia (BPH) include watchful waiting, medical therapy, and interventional procedures. The post-surgical complication profile and the early discontinuation of medical therapy are significant drawbacks of the established approach and stimulate the search for less-invasive approaches. Our aim is to provide a comprehensive review all available literature on prostatic urethral lift (PUL), presenting an overview of safety, indications, surgical technique and results of the procedure, and to evaluate the potential role it could play in the treatment of BPH. A comprehensive search was conduct on PubMed and Scopus database to identify original articles in English dealing with PUL without any limit to publication date. Keywords used were prostatic urethral lift, urethral lifting, Urolift, benign prostatic hyperplasia and minimally invasive therapy. The PUL seems to offer a better IPSS improvement when compared to medical therapy, but the result is inferior when compared to surgical therapy. Published studies report an absence of degradation of erectile or ejaculatory function after treatment, which appears a noteworthy benefit of PUL. Additional advantages of the PUL are a better complication profile in comparison to other surgical therapies and the use of a local anesthesia, sometimes without postoperative catheterization. The PUL, a novel, minimally invasive treatment option for men affected by BPH, presents a promising potential although it is clear that PUL is not a substitute for traditional ablative surgical approach, as this procedure requires a scrupulous selection of the patient.

Robot-Assisted Radical Cystectomy: A Single-Center Experience and a Narrative Review of Recent Evidence.

Radical cystectomy represents one of the most challenging surgical procedures, exhibiting a high morbidity rate. The transition to minimally invasive surgery in the field has been steep, due to either the technical complexity and prior concerns of atypical recurrences and/or peritoneal spread. More recently, a larger series of RCTs has proven the oncological safety of robot-assisted radical cystectomy (RARC). Beyond survival outcomes, the comparison between RARC and open surgery in terms of peri-operative morbidity is still ongoing. We present a single-center experience of RARC with intracorporeal urinary diversion. Overall, 50% of patients had an intracorporeal neobladder reconstruction. The series confirms a low rate of complications (Clavien Dindo ≥ IIIa 7.5%) and wound infections (2.5%) and the absence of thromboembolic events. No atypical recurrences were found. To discuss these outcomes, we reviewed the literature related to RARC including level-1 evidence. PubMed and Web of Science searches were performed using the medical subject terms "robotic radical cystectomy" and "randomized controlled trial (RCT)". Six unique RCTs comparing robot and open surgery were found. Two clinical trials dealt with RARC with an intracorporeal reconstruction of UD. Pertinent clinical outcomes are summarized and discussed. In conclusion, RARC is a complex but feasible procedure. The transition from extracorporeal urinary diversion (UD) to a complete intracorporeal reconstruction could be the key to improving peri-operative outcomes and reducing the whole morbidity of the procedure.

Corrigendum to "Rectal Perforation During Pelvic Surgery" [Eur Urol Open Sci 44 (2022) 54-59].

[This corrects the article DOI: 10.1016/j.euros.2022.04.006.].

First case of robot-assisted radical cystectomy and intracorporeal neobladder reconstruction with the Hugo RAS system: step-by-step surgical setup and technique.

Robotic assisted radical cystectomy (RARC) is a standard option for the treatment of bladder cancer. Currently, novel platforms are entering the market and the Hugo RAS (Medtronic, Minneapolis, MN, USA) is a new system consisting of an open console with 3D-HD screen and a multi-modular fashion. Even if several series are already available for radical prostatectomy, to now a full description of RARC performed with Hugo RAS is still lacking. We report the first case of RARC with intracorporeal neobladder performed with the Hugo RAS-and another case of RARC with ureterostomy. Both patients were affected by MIBC. Case 1 was a 61-year-old patient without comorbidities (CCI 4), in which a Bordeaux ileal neobladder was scheduled after previous NAC. The second was the case of a 70-year-old one with CCI 7 and BMI 35; in this case, a ureterostomy was planned. Details of the robotic system: one 11 mm endoscope port was placed on the midline 2 cm above the umbilicus. Another two 8 mm robotic ports were symmetrically placed under vision on a transversal line-located 1 cm below the umbilicus. A third robotic port was positioned on the left side in a W configuration. All ports were located at least 9 cm between each other. Finally, two assistant ports were positioned in the right abdominal site. All arm-carts were parked 45-60 cm from the operative bed, before the docking process begins. Three arm-carts were parked on the left side, the assistant and the scrub nurse worked on the right side, while the energy tower stayed at the foot of the bed, according to the previous description of Hugo RAS robotic radical prostatectomy. The endoscope arm-cart is docked first, then the adjacent left carts are docked; finally, the surgeon's right-hand cart is docked from the right side of the bed. The docking angles and tilt we applied were: endoscope: 175°; minus 45°; surgeon left hand 140°; minus 30°; surgeon right hand 225°; minus 30°; fourth arm 125°; plus 15°. The instruments we used were those fitting our conventional four-instrument setup for RARC: monopolar shears, Maryland forceps, needle driver and Cadiere as the fourth arm. The procedures were completed without technical errors or technological failures-requiring a change in surgical strategy. Docking time was approximately 35 min; console time up to urethral dissection was 150 and 140 min in Case 1 and 2. The time for pelvic nodal dissection was approximately 37 min for both. The multi-modularity fashion of the Hugo RAS allowed an easy management of the bowel in Case 1; the absence of robotic staplers required the use of the laparoscopic ones, managed by an adjunctive assistant with room within the cart. In conclusion, RARC with the Hugo RAS is a feasible procedure able to reproduce all surgical steps without critical errors or complications requiring a change in surgical planning. Urinary diversion with intracorporeal reconstruction is feasible as well, with adequate preliminary outcomes.

Three-Dimensional Customized Imaging Reconstruction for Urological Surgery: Diffusion and Role in Real-Life Practice from an International Survey.

Despite the arising interest in three-dimensional (3D) reconstruction models from 2D imaging, their diffusion and perception among urologists have been scarcely explored. The aim of the study is to report the results of an international survey investigating the use of such tools among urologists of different backgrounds and origins. Beyond demographics, the survey explored the degree to which 3D models are perceived to improve surgical outcomes, the procedures mostly making use of them, the settings in which those tools are mostly applied, the surgical steps benefiting from 3D reconstructions and future perspectives of improvement. One hundred responders fully completed the survey. All levels of expertise were allowed; more than half (53%) were first surgeons, and 59% had already completed their training. Their main application was partial nephrectomy (85%), followed by radical nephrectomy and radical prostatectomy. Three-dimensional models are mostly used for preoperative planning (75%), intraoperative consultation and tailoring. More than half recognized that 3D models may highly improve surgical outcomes. Despite their recognized usefulness, 77% of responders use 3D models in less than 25% of their major operations due to costs or the extra time taken to perform the reconstruction. Technical improvements and a higher availability of the 3D models will further increase their role in surgical and clinical daily practice.

Multimodular robotic systems (Hugo RAS and Versius CMR) for pelvic surgery: tasks and perspectives from the bed-side assistant.

The Hugo RAS and Versius are new robotic systems with a multimodular configuration, requiring a dedicated positioning of units, arms and trocars. While promising flexibility and multiquadrant opportunities-with an enhanced range of motion-the presence of multiple units around the patient should be effectively managed by the assistant and requires a new background of tasks. The article represents a practical guide while providing an overview on assistants' perspectives.

Impact of hands-on practice with HugoRAS and Versius System simulators on the attractiveness of robotic surgery among medical and nurse undergraduate students.

The scenario of robotic surgery is rapidly evolving with the introduction of new robotic systems. A structured learning program in robotic surgery during academic education is often lacking, especially for undergraduates; as a result, many students may be unaware of indications to robotic surgery and technological progress. The aim of the study is to evaluate the knowledge and interest toward robotic surgery of medical and nurse students, and to analyze how the attractiveness may change after a hand-on training course with new simulators of Hugo RAS and Versius System. We performed a cross-sectional study involving medical and nurse students recruited on a voluntary basis at ASST Santi Paolo and Carlo, Milan; participants were invited to join a hands-on practice simulation with the Hugo RAS and/or Versius Trainer Simulator. Before the hand-on exercise, students were asked to fulfill an online anonymous questionnaire addressing knowledge and interest toward robotic surgery. After a 2-h hands-on exercises at the Hugo RAS and/or at the Versius Trainer simulator (preceded by a brief lecture on robotic surgery and new systems), participants were asked to complete a second-round questionnaire to evaluate changes in attractiveness toward robotic surgery. Data were recorded in a database; after a descriptive analysis of the variables, median values were compared with the Mann-Whitney U test, frequencies with the Fisher's exact test and in the case of paired observations (before and after the simulation), the Mc Nemar test was used. Forty-one undergraduates agreed to participate. Twenty-three nursing students and 18 medical students were recruited. Some of them had a basic knowledge in robotic surgery and were able to figure out some surgical indications, given the presence of a robotic program already settled up at the institution. Before the hands-on course, 44.0% nurse students and 36.6% of medical students were interested in surgical disciplines and robotic surgery. After the simulation, all students (100%) reported a high level of interest in robotic surgery and some of them required for a dedicated internship (p < 0.001). The students provided also feedback on the perceived ease-of-use of the robotic simulators (on a scale 0-10); overall, the median score was 8, IQR [7-8], with no differences between nursing and medical students (p = 0.482). In conclusion, the study demonstrates a great interest toward robotic surgery as a part of medical and nurse education. A hands-on simulation further improved the interest of undergraduates from both backgrounds. The technological progress with the availability of new surgical systems will be the future challenge of training programs and should be considered at all levels of education.

Prior Robotic Console Expertise May Improve Basic Skills at the New Hugo RAS Simulator: Results from a Cohort Trial and Implications for Skill Transference Across Platforms.

Background: Robot-assisted surgery ensures minimal invasiveness; since the expiry of the Da Vinci patent, new robotic systems have entered the market. Recently, the Hugo RAS received CE approval for several surgical procedures. However, more is needed to know about skill acquisition at the new simulator. Objective: This study aims to analyse the factors impacting basic surgical skills at the Hugo RAS simulator. Design setting and participants: We present a cross-sectional study involving 71 participants of different backgrounds invited to a hands-on session with the Hugo RAS simulator voluntarily. All of them had no prior expertise with the system. Participants were recruited among medical/nurse students, residents, and laparoscopic and robotic surgeons. Intervention: All participants underwent a hands-on "pick and place" exercise at the Hugo RAS simulator; the metrics of a second-round pick and place exercise were recorded. Outcome measurements and statistical analysis: Metrics were analysed with regard to the following variables: demographics, videogame use, and prior surgical experience (no surgical expertise, experience with laparoscopy, and experience with robotic console). Results and limitations: All participants completed the test. Of them, 77.5% were naïve to surgery, 8.5% had prior laparoscopic expertise, and 14.1% had prior robotic console experience. The time to complete the pick and place exercise was significantly lower (p < 0.001) among prior robotic surgeons (38 s, interquartile range [IQR] 34-45) compared with both naïve participants (61 s, IQR 53-71) and laparoscopists (93 s, IQR 53-162). The overall score of the exercise decreased with age (p = 0.046); however, the overall scores were significantly and steadily higher among surgeons experienced in robotic consoles across all age groups (p = 0.006). Neither gender (p = 0.7) nor videogame use (p = 0.9) correlated significantly with the metrics. Conclusions: This is the first study analysing factors impacting basic skill acquisition at a new robotic simulator. Experience with robotic consoles may represent a major factor, raising the hypothesis of the transferability of basic robotic skills across different robotic systems. Further studies are required to explore this issue. Patient summary: In the present study, we analysed which characteristics may affect the basic surgical skills at a novel robotic platform.

The relationship between continence and perineal body tone before and after radical prostatectomy: a pilot study.

INTRODUCTION: Recent preliminary studies showed that tonic-trophic characteristics of the pelvic muscles are related to postoperative male urinary incontinence. The aim of the current study was to test whether perineal body tone (PBT), evaluated using the Beco perineometer (Perineocaliper), is related to urinary continence recovery after robot-assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: The study population consisted of 48 patients who underwent RALP between January and July 2009. Surgical interventions were performed by a single surgeon and patients were evaluated by a single physiotherapist. All patients were taught pelvic floor muscle exercises (PFME). PBT was evaluated in each patient preoperatively, as well 30 days and 3 months after surgery. In addition, patients were evaluated with a 24-hr pad-test and the International Consultation on Incontinence-questionnaire (ICI-Q). RESULTS: Mean age at surgery was 65.5 years (range 46-63). Twenty-four patients underwent a bilateral nerve-sparing procedure (50%). One-month after surgery, 25 (52.1%) patients were continent while 23 (47.9%) patients were still incontinent. A statistically significant difference in preoperative perineometric measures was observed between continent and incontinent patients (mean 1.36 cm vs. 0.80 cm; P < 0.001). This difference was even more pronounced when comparing postoperative perineometric measures (mean 1.24 cm vs. 0.43 cm; P < 0.001). Evaluation of patients 3 months after surgery showed an increase in perineometric measures (mean increase 0.76 cm). The increase was significantly higher in patients who became continent after 3 months relative to patients who were still incontinent despite PFME (mean perineometric measures 1.45 cm vs. 1.00 cm; P = 0.021). CONCLUSIONS: Our results demonstrate that urinary continence recovery is related to PBT recovery. Further studies are needed to confirm whether perineometric measures may be used as a predictive tool for the risk-stratification of postoperative UI.

Low-intensity Extracorporeal Shockwave Therapy for the Management of Postprostatectomy Erectile Dysfunction: A Systematic Review of the Literature.

Context: Erectile dysfunction (ED) following radical prostatectomy is a concern for patients and their partners. Low-intensity extracorporeal shockwave therapy (LI-ESWT) can potentially enhance tissue repair and regeneration. The aim of the current study was to systematically review the literature to assess the role of LI-ESWT in the management of patients with postprostatectomy ED. Evidence acquisition: Two authors independently performed a systematic search of the PubMed and Web of Science databases to identify all relevant articles. Non-English reports, case reports, reviews, letters, and editorials were excluded. Risk of bias was assessed according to the GRADE guidelines. Evidence synthesis: Nine articles met the inclusion criteria and were included in the qualitative analysis. All the studies included were published between 2015 and 2022 and the majority of them compared phosphodiesterase type 5 inhibitors (PDE5Is) alone versus a combination of LI-ESWT and PDE5Is. Only three studies were randomized controlled trials (RCTs). In general, there is no standardized protocol for LI-ESWT for postprostatectomy ED. In comparisons of LI-ESWT + PDE5Is versus PDE5Is alone, some authors found a statistically significant improvement in erectile function with LI-ESWT + PDE5Is. The starting time for LI-ESWT differed among the studies, ranging from 3 d to 6 mo after surgery. The main limitations of the review are the scarcity of studies, small sample sizes, high risk of bias, and high heterogeneity among studies. Conclusions: There is currently limited evidence on the use of LI-ESWT either alone or in combination with PDE5Is in penile rehabilitation protocols after prostatectomy. However, small clinical trials with short follow-up show that LI-ESWT could potentially play a role in the management of postprostatectomy ED in the future. Further RCTs with larger sample sizes are needed. Patient summary: Despite limited reports in the literature, low-intensity shockwave therapy after removal of the prostate is a promising noninvasive treatment for dealing with erectile dysfunction after surgery.

Total intracorporeal robot-assisted laparoscopic ileal conduit (Bricker) urinary diversion: technique and outcomes.

OBJECTIVE: Several recent preliminary reports have demonstrated that Robot-Assisted Cystectomy with total intracorporeal Ileal Conduit (RACIC) is a feasible option over the open technique. We report our stepwise surgical procedure of robotic total intracorporeal ileal conduit urinary diversion, technical consideration, development, refinements and initial experience. Only the ileal conduit urinary diversion is described with no emphasis on the cystectomy's steps. METHODS: Between February 2008 and September 2009, nine patients underwent RACIC for muscle invasive transitional cell carcinoma (TCC). The entire procedure, including radical cystoprostatectomy, extended pelvic node dissection (ePLND), ileal conduit urinary diversion (Bricker) including isolation of the ileal loop (20 cm ileal segment) 15 cm away from the ileocecal junction, restoration of bowel continuity with stapled side-to-side ileo-ileal anastomosis, retroperitoneal transfer of the left ureter to the right side, and bilateral stented (8 F feeding tube) ileo-ureteral anastomoses in a Wallace faction were all performed exclusively intracorporeally using the da Vinci Si surgical robot and finally the conduit stoma was fashioned. RESULTS: The RACIC was technically successful in all nine patients (three females and six males. Mean age 74.1; 57 to 87) without open conversion. The mean operative time including extended pelvic lymphadenectomy and urinary diversion was 346.2 minutes (210 to 480). Mean operative time of diversion is 72 minutes (52-113) mean estimated blood loss 258 mL (200 to 500) and the median hospital stay were 14 days (10 to 27). In all three female patients, the specimen was extracted through the vagina. There were no intraoperative complications and only one major postoperative complication: one postoperative iatrogenous necrosis of the ileal conduit caused by uncareful retraction of the organ bag and thereby probably injuring the conduit pedicle, as the ileal conduit was well vascularised at the end of the operation, requiring an open revision (in male patient extracted through the suprapubic incision). A clear liquid diet was started on the third postoperative day. All patients returned to normal activity within 2 weeks (from date of surgery). Postoperative renal function was normal with mean postoperative creatine 0.99 mg/dL) and excretory urography revealed unobstructed upper tracts in all cases. CONCLUSION: Robot-assisted radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion for the treatment of high risk or invasive bladder cancer with urinary diversion is technically feasible. The robotic system aids in performing a meticulous dissection and all operative steps of the open procedure are replicated precisely while adhering to the sound oncologic principles of traditional radical cystectomy. Robotics brings an unprecedented control of surgical instruments, shorten the learning curve, and allow open surgeons to apply more easily their technical skill in a minimal invasive fashion. Robotic cystectomy with total intracorporeal ileal conduit urinary diversion offers operative and perioperative benefits and functional outcome. In our hands results comparable to open experience with further reduced perioperative morbidity, early recovery, resumption of normal activities, excellent cosmesis and increased quality of life (QOL). In addition, minimal blood loss, fluid shifts, and electrolyte loss considerably reduce systemic and cardiovascular stress in these older groups of patients.

Initial extended transrectal prostate biopsy--are more prostate cancers detected with 18 cores than with 12 cores?

PURPOSE: We retrospectively investigated the detection rates of prostate cancer, high grade prostatic intraepithelial neoplasia and atypical glands suggestive of carcinoma by initial 18 and 12-core prostate biopsy. MATERIALS AND METHODS: A total of 3,460 consecutive patients with prostate specific antigen between 2.5 and 15 ng/ml underwent 12 (1,684) or 18 (1,776) core prostate biopsy under local anesthesia at 2 departments that adopted the same indications for performing biopsy. Biopsies were evenly distributed throughout the prostate in 6 sectors. In the 12-core prostate biopsy group 2 samples were obtained from each sector and in the 18-core prostate biopsy group 1 additional core was taken from each sector. RESULTS: The cancer detection rate in patients who underwent 18-core prostate biopsy was not different from the rate in those who underwent 12-core prostate biopsy (39.9% and 38.4%, p = 0.37), nor did the detection of atypical glands suggestive of carcinoma differ significantly between the 2 groups (2.9% and 3.3%, respectively, p = 0.33). However, 18-core prostate biopsy detected a significantly higher percent of cases of high grade prostatic intraepithelial neoplasia (20.0% vs 12.9%, p = 0.001). The cancer detection rate was higher with 18 than with 12-core prostate biopsy in patients with a prostate volume of 55 cc or greater (31.5% vs 24.8%, p = 0.01) but not in those with a prostate volume of less than 55 cc (54.3% and 53.0%, respectively, p = 0.7). Moreover, we determined that patients with positive digital rectal examination findings do not need 18-core prostate biopsy as opposed to 12-core prostate biopsy. CONCLUSIONS: Compared with 12-core prostate biopsy, 18-core prostate biopsy detects significantly more cases of high grade prostatic intraepithelial neoplasia. However, 18-core prostate biopsy detects a significantly higher number of cancer only in patients with a prostate volume of 55 cc or greater.

Ischemia of the glans 24 hours after circumcision: A case report and therapeutic solution.

INTRODUCTION:: Circumcision is a common surgical procedure, typically performed under local anesthesia and somehow also as outpatient clinic. Although complications are rare and most frequently related to the procedure itself, ischemia of the glans may occur as a major complication and can be related to local ischemia following dorsal penile nerve block. CASE DESCRIPTION:: We describe the case of a 33-year-old patient who underwent circumcision at our institution and, 24 h after the procedure, developed an acute ischemia of the glans; a re-intervention was performed in emergency setting to ensure a large, not-tightened circular suture under the glans, and low-molecular-weight heparin and antiplatelet therapy was introduced to achieve anti-coagulative/antiaggregant effects. After 48 h, the skin returned to its normal color and in 7 days the penile glans achieved complete remission of the ischemic aspect. A 6-month follow-up confirmed regular outcomes with normal erectile functions. CONCLUSION:: The treatment we proposed to treat acute post-circumcision ischemia of the glans is a simple and effective one, with a perfect aesthetic and functional outcome observed within 4 weeks and confirmed at 6-month follow-up.

Reproducibility of a modified posterior reconstruction during robotic intracorporeal neobladder reconfiguration

ABSTRACT Objective: Robotic intracorporeal neobladder reconstruction is a complex procedure in which the approximation of the reservoir to the urethral stump can be a demanding step. The aim of the study is to evaluate the reproducibility of a modified posterior reconstruction (PR) during the reconfiguration of intracorporeal neobladder after robot assisted radical cystectomy (RARC). Materials and Methods: From July 2021 to July 2022, 35 RARC were performed, and 17 patients underwent intracorporeal neobladder reconstruction. A PR was planned in males (14). Intra- and peri-operative data were collected. Surgical technique: RARC and node dissection are performed. Afterwards, 40-cm ileal segment is isolated; the portion with the more adequate mesenteric length is brought down to the pelvis. A modified PR is performed with a double-armed barbed suture: a first layer connects the Denonvillier's fascia to the rhabdosphincter in a running fashion; the second layer is created with the other arm and approximates the posterior side of the ileal segment towards the urethral stump. In the anterior caudal part of the ileum, a 1.5-cm incision is made to realize the neobladder neck; the neovesical-urethral anastomosis is performed with a second bidirectional suture. Results: Anastomotic and PR time were 14 (range 7-20) and 5 minutes (4-8), respectively. A single Clavien IIIa complication was recorded in a patient who underwent NAC and had a C. albicans superinfection in the post-operative course. All patients were discharged with complete or acceptable bladder voiding. Twelve patients with follow-up >90-days reported a satisfying daytime continence. Conclusions: PR represents a simple technical refinement that improves neobladder-urethral anastomosis by favoring ileal approximation to the urethral stump and decreasing anastomotic tension.