Three-dimensional virtual model for robot-assisted partial nephrectomy: a propensity-score matching analysis with a contemporary control group.

PURPOSE: To compare two cohorts of patients submitted to robot-assisted partial nephrectomy (RAPN) with vs without the use of three-dimensional virtual models (3DVMs). METHODS: We screened a prospective consecutive cohort of 152 patients submitted to RAPN with 3DVM and 1264 patients submitted to RAPN without 3DVM between 2019 and 2022. Propensity score matching analysis (PSMA) was applied. Primary endpoint was to evaluate whereas RAPNs with 3DVM were superior in terms of functional outcomes at 12-month. Secondary endopoints were to compare perioperative and oncological outcomes. Multivariable logistic regression analyses (MVA) tested the associations of clinically significant eGFR drop and 3DVMs. Subgroups analysis was performed for PAUDA-risk categories. RESULTS: 100 patients for each group were analyzed after PSMA. RAPN with 3DVM presented a higher rate of selective/no clamping procedure (32% vs 16%, p = 0.03) and a higher enucleation rate (40% vs 29%, p = 0.04). As concern to primary endopoint, 12-month functional preservation performed better within 3DVM group in terms of creatinine serum level (median 1.2 [IQR 1.1-1.4] vs 1.6 [IQR 1.1-1.8], p = 0.03) and eGFR (median 64.6 [IQR 56.2-74.1] vs 52.3 [IQR 49.2-74.1], p = 0.03). However, this result was confirmed only in the PADUA ≥ 10 renal masses. Regarding secondary endpoints, no significative difference emerged between the two cohorts. MVA confirmed 3DVM as a protective factor for clinically significant eGFR drop only in high-risk (PADUA ≥ 10) masses. CONCLUSIONS: RAPN performed with the use of 3DVM assistance resulted in lower incidence of global ischemia and higher rate of enucleations. The positive impact of such technology was found at 12-month only in high-risk renal masses.

Efficacy and safety profile of GreenLight laser photoselective vaporization of the prostate in ≥ 75 years old patients: results from the Italian GreenLight Laser Study Group.

BACKGROUND: Benign Prostatic Obstruction (BPO) is the most common non-malignant urological condition among men and its incidence rise with age. Among prostate treatments, GreenLight laser seems to reduce bleeding and would be safer in the aging population. AIMS: We aimed to compare the functional outcomes and safety profile of < 75 years old (Group A) and ≥ 75 years old (Group B) patients. METHODS: In a multicenter setting, we retrospectively analyzed all the patients treated with GreenLight Laser vaporization of the prostate (PVP). RESULTS: 1077 patients were eligible for this study. 757 belonged to Group A (median age 66 years) and 320 to Group B (median age 78 years). No differences were present between the two groups in terms of prostate volume, operative time, hospital stay, PSA decrease over time after surgery, complications and re-intervention rate with a median follow-up period of 18 months (IQR 12-26). Nevertheless, focusing on complications, GreenLight laser PVP demonstrated an excellent safety profile in terms of hospital stay, re-intervention and complications, with an overall 29.6% complication rate in older patients and only two cases of Clavien III. Functional outcomes were similar at 12 month and became in favor of Group A over time. These data are satisfactory with a Qmax improvement of 111.7% and an IPSS reduction of 69.5% in older patients. DISCUSSION AND CONCLUSIONS: GreenLight laser photoselective vaporization of the prostate is a safe and efficient procedure for all patients, despite their age, with comparable outcomes and an equal safety profile.

Predictors of early catheter replacement after HoLEP. Results from a high-volume laser center.

INTRODUCTION: The aim of the study was to investigate clinical and surgical factors associated with early catheter replacement in patients treated with Holmium Laser Enucleation of the Prostate (HoLEP). MATERIALS AND METHODS: Data of patients treated with HoLEP at our Institution by a single surgeon from March 2017 to January 2021 were collected. Preoperative variables, including non-invasive uroflowmetry and abdominal ultrasonography (US), were recorded. Bladder wall modifications (BWM) at preoperative US were defined as the presence of single or multiple bladder diverticula or bladder wall thickening 5 mm. Clinical symptoms were assessed using validated questionnaires. Only events occurred within the first week after catheter removal were considered. RESULTS: Overall, 305 patients were included, of which 46 (15.1%) experienced early catheter replacement. Maintenance of anticoagulants/antiplatelets (AC/AP) therapy at surgery (p=0.001), indwelling urinary catheter (p=0.02) and the presence of BWM (p=0.001) were more frequently reported in patients needing postoperative re-catheterization. Intraoperative complications (p=0.02) and median lasing time (p=0.02) were significantly higher in this group. At univariate analysis, indwelling urinary catheter (p=0.02), BWM (p=0.01), ongoing AC/AP therapy (p=0.01) and intraoperative complications (p=0.01) were significantly associated with early catheter replacement. At multivariate analysis, indwelling urinary catheter (OR: 1.28; p=0.02), BWM (OR: 2.87; p=0.001), and AC/AP therapy (OR: 2.21; p=0.01) were confirmed as independent predictors of catheter replacement. CONCLUSIONS: In our experience the presence of indwelling urinary catheter before surgery, BWM and the maintenance of AC/AP therapy were shown to be independent predictors of early catheter replacement after HoLEP.

Holmium laser enucleation of the prostate (HoLEP) is safe and effective in patients with high comorbidity burden.

INTRODUCTION: We assessed the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) in patients with high comorbidity burden. MATERIALS AND METHODS: Data from patients treated with HoLEP at our academic referral center from March 2017 to January 2021 were prospectively collected. Patients were divided according to their CCI (Charlson Comorbidity Index). Perioperative surgical data and 3-month functional outcomes were collected. RESULTS: Out of 305 patients included, 107 (35.1%) and 198 (64.9%) were classified as CCI ≥ 3 and < 3, respectively. The groups were comparable in terms of baseline prostate size, symptoms severity, post-void residue and Qmax. The amount of energy delivered during HoLEP (141.3 vs. 118.0 KJ, p=0.01) and lasing time (38 vs 31 minutes, p=0.01) were significantly higher in patients with CCI ≥ 3. However, median enucleation, morcellation and overall surgical time were comparable between the two groups (all p>0.05). Intraoperative complications rate (9.3% vs. 9.5%, p=0.77), median time to catheter removal and hospital stay were comparable between the two cohorts. Similarly, early (30 days) and delayed (>30 days) surgical complications rates were not significantly different between the two groups. At 3-month follow up, functional outcomes using validated questionnaires did not differ between the two groups (all p>0.05). CONCLUSIONS: HoLEP represents a safe and effective treatment option for BPH also in patients with high comorbidity burden.

Robotic treatment for urinary tract endometriosis: preliminary results and surgical details in a high-volume single-Institutional cohort study.

BACKGROUND: Aim of the study was to present the surgical techniques and the postoperative outcomes in women treated with robotic excision for deep endometriosis involving the urinary tract. MATERIALS AND METHODS: We retrospectively reviewed the prospectively recorded clinical data of women consecutively undergoing minimally invasive treatment for complex endometriosis involving urinary tract in our center between January 2012 and June 2018. All the patients received a preoperative multidisciplinary evaluation with the general surgeon, the gynecologist and the urologist due to the frequent concomitant involvement of bowel and genital system. Patients undergoing robotic surgery were treated with the Si or Xi da Vinci surgical system. RESULTS: A total of 74 consecutive patients were enrolled. Twenty-eight (37.8%) patients underwent conventional laparoscopy and 46 (62.2%) robotic surgery. Only patients treated with robotic approach were considered for the final analyses. Overall, 17 (36.9%) patients were treated with partial cystectomy, 13 (28.3%) with ureteral reimplantation, 10 (21.7%) patients were treated with ureteral lysis, 4 (8.7%) with removal of bladder endometrial node without opening the mucosa layer and 2 (4.3%) with ureteral end-to-end anastomosis. Concomitant involvement of bowel and genital system was registered in 14 (30.4%) and 32 (69.5%) patients, respectively. No conversions to laparotomy were recorded. Overall, 5 (10.9%) patients experienced postoperative complications, of which only one was a major complication (Clavien 3b). At a median follow-up of 31.3 (IQR 17.6-43.3) months, 4 (8.7%) patients experienced disease recurrence at the level of urinary tract. CONCLUSIONS: Robotic excision of urological endometriosis represents a safe and effective treatment option, since a limited rate of surgical complications was recorded even in cases of multi-organ disease.

Correction to: The diagnosis and treatment of urogenital schistosomiasis in Italy in a retrospective cohort of immigrants from Sub-Saharan Africa.

The original version of this article unfortunately contained a mistake. The given name and family name of Filippo Parretti was transposed in the original publication. The correct name is as shown above.

The diagnosis and treatment of urogenital schistosomiasis in Italy in a retrospective cohort of immigrants from Sub-Saharan Africa.

OBJECTIVES: To evaluate ultrasound and praziquantel to, respectively, assess and reduce urogenital schistosomiasis (UGS)-associated morbidity in migrants from Sub-Saharan Africa (SSA). METHODS: Migrants from SSA with UGS attending three Italian centres for tropical diseases during 2011-2016 were retrospectively enrolled. Data on clinical symptoms, routine laboratory, parasitological tests, and ultrasound reported as per the WHO-Niamey protocol were collected at baseline and at available follow-up visits after treatment with praziquantel 40 mg/kg/day for 3 days. RESULTS: One hundred and seventy patients with UGS were enrolled and treated with praziquantel. Baseline ultrasonography showed urinary tract abnormalities in 115/169 patients (68%); the mean global Schistosoma haematobium score was 2.29 (SD 2.84, IQR 0-2), the mean urinary bladder intermediate score 1.75 (SD 1.73, IQR 0-2), and the mean upper urinary tract intermediate score 0.54 (SD 2.37, IQR 1-10). Abnormalities were more common among the 111 (65%) who were symptomatic (p < 0.02; OR 2.53; 95% CI 1.19-5.35). Symptoms started in 94/111 (85%) before arriving (median 63 months, IQR 12-119). At follow-up, we observed a significant reduction in the prevalence of UGS-related symptoms, blood, urine, and ultrasound abnormalities. CONCLUSIONS: Our study results support the use of ultrasound and praziquantel for assessing and reducing UGS-associated morbidity in migrants. Health-seeking behaviour, diagnostic, and treatment delays contribute to the advanced pathology and qualified treatment success. To ensure earlier treatment, based on our findings, clinical experience, and available literature, we propose an algorithm for the diagnosis and clinical management of UGS. Multicentre studies are needed to improve the management of subjects with UGS in non-endemic countries.

Florence robotic intracorporeal neobladder (FloRIN): a new reconfiguration strategy developed following the IDEAL guidelines.

OBJECTIVE: To describe our step-by-step technique for robotic intracorporeal neobladder configuration, including the stages of conception, development and exploration of this surgical innovation, according to the Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) Collaboration guidelines. PATIENTS AND METHODS: The Florence robotic intracorporeal neobladder (FloRIN) was performed employing the following main surgical steps: isolation of 50 cm of ileum; bowel anastomosis; urethro-ileal anastomosis creating an asymmetrical 'U'-shape (30 cm distally and 20 cm proximally to anastomosis), ileum detubularisation; posterior wall reconfiguration as an 'L'; bladder neck reconstruction; anterior folding of the posterior plate to reach the 12 o'clock position; uretero-enteral 'orthotopic' bilateral anastomosis. The conception and development of the FloRIN followed the IDEAL guidelines recommended stages: Phase 1 (simulation) involved the neobladder robotic configuration using silicone models. Phase 2a (development) aimed to reproduce the configuration in an open fashion in one patient, and then in the first three robotic procedures. Phase 2b (exploration) consisted of the technique standardisation in 15 consecutive robotic approaches. Phase 2a and 2b included urodynamics and imaging assessment of the patients treated. RESULTS: From February 2016 to September 2017 FloRIN was performed in 18 patients. Comparing the first three (Phase 2a) with the subsequent 15 patients (Phase 2b), the median (interquartile range [IQR]) reconstruction operating time was 260 (220-340) vs 160 (150-210) min, respectively. Postoperative surgical complications occurred in four of the 18 patients (22.1%), including one surgical Clavien-Dindo Grade III and three Grade I, postoperative medical Clavien-Dindo Grade II complications occurred in three (16.7%) patients. On urodynamic examination (available in nine [50%] patients) the median (IQR) reservoir cystometric capacity, compliance, and post-void residual were 240 (220-267) mL, 18 (12.5-19.8) mL/cmH2 O, and 0 (0-50) mL, respectively. Ultrasonography showed no Grade ≥2 vesico-ureteric reflux. CONCLUSION: We describe the FloRIN configuration, showing its technical feasibility with acceptable time efficiency. The first cases studied had good reservoir capacity, low pressure with no reflux, and complete voiding.

Construct, content and face validity of the camera handling trainer (CHT): a new E-BLUS training task for 30° laparoscope navigation skills.

PURPOSE: Assessing construct, face and content validity of the camera handling trainer (CHT), a novel low-fidelity training device for 30° laparoscope navigation skills. METHODS: We developed a custom-designed box trainer with clinically based graphic targets. A total of 117 participants, stratified according to their previous experience (novice, competent, expert), took part to a CHT session and subsequently were asked to fill out a survey to assess the impact of the CHT on their 30° laparoscope navigation skills. Sixty of them were also studied for task performance during a 1-h session, with multiple time measurements. RESULTS: All participants, regardless of the previous experience, significantly improved their performance after the CHT session. Regarding construct validity, the mean task performance on the last measurement for novice group was found to be comparable to the mean first attempt of both competent (p = 0.12) and expert (p = 0.24) participants. All participants agreed that "the CHT is a valid training tool" and that "the CHT should be part of the regular dry laboratory training sessions", assessing both face and content validity. Limitations include the need for assessment of predictive validity. CONCLUSIONS: The CHT is a valid training tool for 30° laparoscope navigation and thus should be considered as one of the fundamental exercises during basic laparoscopic hands-on training sessions for urologists.

Patient's satisfaction after 2-piece inflatable penile prosthesis implantation: An Italian multicentric study.

INTRODUCTION: Penile prosthesis implant represents a valuable solution for pts with severe erectile dysfunction (ED), non-responders to medical management. The aim of our study was to evaluate the satisfaction of patients (pts) after 2-pieces inflatable penile prosthesis (IPP). AIM OF THE STUDY: to evaluate safety, reliability and post-operative patient's satisfaction after implantation of two-pieces IPP. MATERIALS AND METHODS: This retrospective multicentric analysis concerns a group of 42 patients undergone 2-pieces IPP implantation from November 2005 to November 2013, in four Centers of proven experience. As a first step, a detailed review of all clinical reports was performed. Secondly, every patient was asked to fill the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) specifically modified, in order to assess their own satisfaction after surgery and, its impact on patient's quality of sexual life. RESULTS: 42 pts were evaluated (AMS-Ambicor: 28; Coloplast-Excell: 14); mean age, at time of operation: 60,7 years; mean follow up: 27,6 months; etiology of ED: vascular 23,8%, diabetes 19%, La Peyronie D. 7,1%, consequence of radical prostatectomy 31%, consequence of other pelvic surgery 11,9%, spinal trauma 7%. Mean operative time: 117 ± 58 min, mean postoperative hospital stay 3 ± 1,6 days. Post operative short-term complications: 4 pts (9,5%). Post operative long-term complications: 4 pts (9,5%). Long-term functional results (Questionnaire): 71% of pts (30) reported regular use of the prosthesis, at least 1 time/week, the satisfaction was good in 42% of pts (18), quite good in 33,3% (14), quite bad in 2,4% (1), very bad in 7,1% (3), 6 pts (14,4%) didn't answer. CONCLUSIONS: 2 pieces IPP appears to be associated with a low complication rate and good satisfaction of pts especially in the elderly. It also assures satisfactory rates of aesthetics and functional results.

Endoscopic robot-assisted simple enucleation (ERASE) for clinical T1 renal masses: description of the technique and early postoperative results.

BACKGROUND: Simple enucleation (SE) has proven to be oncologically safe. We describe the surgical steps and report the results of the Endoscopic Robotic-Assisted Simple Enucleation (ERASE) technique. METHODS: Data were gathered prospectively from 130 consecutive patients undergone ERASE for intracapsular kidney cancer, between 2010 and 2013. ERASE was performed using the 4S Da Vinci surgical system, (Intuitive Surgical, Sunnyvale, CA, USA) in a three-arm configuration. Patients' characteristics and surgical outcomes of ERASE in cT1 were analyzed and the results in cT1a tumors were compared to those of pure laparoscopic SE performed in the same institution in the same time period. RESULTS: The mean (range) preoperative tumor size was 3.2 cm (0.8-10.0 cm), and clinical stage was T1a for 101 patients, T1b for 28, and T2a for 1. Median PADUA score was 8 (IQR 7-9). In 33.9% of patients, ERASE was done without pedicle clamping. Mean (±SD) warm ischemia time (WIT) was 18 ± 6 min. According to Clavien system, 1 grade 1 (0.8%), 5 grade 2 (3.1%), 4 grade 3 (3.8%), and 1 grade 4 (0.8%) surgical complications occurred. Positive surgical margin (PSM) rate was 2.8%. ERASE in cT1a tumors was associated with a significantly lower need for pedicle clamping, shorter WIT, and lower estimated blood loss (EBL) along with similar operative time and intra and postoperative complication rates but with a significantly lower incidence of urinary fistulas requiring stent insertion compared to laparoscopic SE. Also mean time to drainage removal and length of hospital stay (LOS) were significantly lower in for ERASE. The two groups had comparable PSM rate. CONCLUSIONS: ERASE has proven to be a feasible technique for the minimal invasive treatment of clinical stage T1 renal masses. The robotic approach can achieve surgical results superior to those of pure laparoscopy by reducing the need for clamping, WIT, EBL, and LOS.

Sutureless hemostatic control during laparoscopic NSS for the treatment of small renal masses.

BACKGROUND: This study aimed to evaluate the safety and efficacy of a sutureless hemostatic control during laparoscopic nephron sparing surgery (LNSS) for the treatment of small renal masses. METHODS: Between November 2007 and August 2010, 245 patients underwent nephron sparing surgery. Overall, 100 patients (41%) had LNSS. Hemostasis was controlled either by a knot-tying suture repair (standard-LNSS) or by a sutureless technique (s-LNSS). The s-LNSS was done using a bipolar cauterization of the resection bed, followed by Floseal apposition. Operative and warm ischemia time (WIT), intraoperative blood loss, hospital stay, blood tests, and perioperative complications were recorded. RESULTS: In 32 cases (32%) hemostasis was controlled by the sutureless technique. The s-LNSS was the treatment of choice for small tumors ≤1.5 cm, and it was also used for the treatment of tumors between 1.6 and 2.5 cm, aside from their spatial extension. Indeed, the mean (range; interquartile range) clinical dimension of the tumors in the s-LNSS group was 1.9 (1-3.5; 1.5-2.1) cm. On the contrary, the vast majority of tumors >2.5 cm were treated with standard-LNSS. Mean (range; interquartile range) WIT in the s-LNSS group was 16 (8-22; 12-16) minutes. The mean (range) intraoperative blood loss in the s-LNSS group was 107 cc (25-205). No postoperative early and late bleeding were reported in the s-LNSS group, and the mean (range) time to drainage removal and time to discharge were 3 (2-5) and 4 (3-7) days, respectively. CONCLUSIONS: The sutureless technique with bipolar cauterization of the surgical bed and Floseal apposition is safe and effective for the hemostatic control in the treatment of small cortical masses. It can be always used for tumors ≤1.5 cm and can be a valid option also for tumors between 1.6 and 2.5 cm, aside from their spatial extension.

3D virtual model for robot-assisted partial nephrectomy in highly-complex cases (PADUA ⩾ 10).

PURPOSE: To compare two cohorts of patients submitted to robot-assisted partial nephrectomy (RAPN) for highly-complex renal masses (PADUA ⩾ 10) with versus without the use of 3DVMs. MATERIALS AND METHODS: We screened a prospective consecutive cohort of 152 patients submitted to RAPN with 3DVM and 1264 patients submitted to RAPN without 3DVM between 2019 and 2022. Only PADUA ⩾ 10 cases were considered eligible for analysis. Propensity score matching (PSM) analysis was applied. Primary endpoint was to evaluate whereas RAPNs with 3DVM were superior in terms of functional outcomes at 12-month. Secondary outcomes were to compare perioperative and oncological outcomes. Multivariable logistic regression analyses (MVA) tested the associations of clinically significant eGFR drop and 3DVMs. Subgroups analysis was performed for PAUDA-risk categories. RESULTS: Thirty seven patients for each group were analyzed after PSM. RAPN with 3DVM presented a higher rate of selective/no clamping procedure (32.5% vs 16.2%, p = 0.03) and a higher enucleation rate (43.2% vs 29.8%, p = 0.04). Twelve-month functional preservation performed better within 3DVM group in terms of creatinine serum level (median 1.2 [IQR 1.1-1.4] vs 1.6 [IQR 1.1-1.8], p = 0.03) and eGFR (median 64.6 [IQR 56.2-74.1] vs 52.3 [IQR 49.2-74.1], p = 0.03). MVA confirmed 3DVM as a protective factor for clinically significant eGFR drop in this subgroup of patients. CONCLUSIONS: RAPN performed with the use of 3DVM assistance for PADUA ⩾ 10 cases resulted in lower incidence of global ischemia and higher rate of enucleations. The positive impact of such technology was found at 12-month follow-up.

Stentless florence robotic intracorporeal neobladder (FloRIN), a feasibility prospective randomized clinical trial.

INTRODUCTION: Aim of the study was to evaluate perioperative, postoperative and mid-term functional outcomes of Florence intracorporeal neobladder (FloRIN) configuration technique performed with stentless procedure. MATERIALS AND METHODS: This single institution randomized 1:1 prospective series included consecutive patients treated with Robot-Assisted Radical Cystectomy (RARC) and FloRIN reconfiguration from January 2021 to February 2022. Postoperative complications were graded according to Clavien Dindo classification and divided in early (<30 days from discharge) and delayed (>30 days). RESULTS: Overall, 63 patients were included in the analysis. Among these 32 (50.8 %) were treated with RARC + stentless FloRIN while 31 (49.2 %) underwent stent placement procedure. No differences were found in terms of baseline characteristics between the two groups. Stentless procedure was associated with significant shorter console time 328 vs 374 min (p = 0.04) and lower estimated blood loss (EBL) 330 vs 350 ml (p = 0.04) comparing to stent group. As regards perioperative features, no significant differences were recorded in terms of canalization (p = 0.58) and time to drainage removal (p = 0.11) while a shorter length of hospital stay was found in case of stentless procedure (p = 0.04). Early postoperative complications Clavien ≥ 3a occurred in 9.3 % and 12.9 % of patients while delayed major complications were recorded in the 3.1 % and 9.6 % of patients treated with stentless and stent FloRIN, respectively (p = 0.09). As regards the mid-term functional outcomes, no differences were found in terms of kidney function loss in both 3rd and 6th month assessment (p = 0.13 and p = 0.14, respectively). CONCLUSIONS: In conclusion, Stentless FloRIN is a feasible and safe IntraCorporeal Neobladder technique, as confirmed by the worthy functional and perioperative outcomes achieved in comparison with the standard FloRIN ureteral management strategy.

Is it safe to defer prostate cancer treatment? Assessing the impact of surgical delay on the risk of pathological upstaging after robot-assisted radical prostatectomy.

INTRODUCTION: We sought to investigate whether surgical delay may be associated with pathological upstaging in patients treated with robot assisted radical prostatectomy (RARP) for localized and locally advanced prostate cancer (PCa). MATERIALS AND METHODS: Consecutive firstly-diagnosed PCa patients starting from March 2020 have been enrolled. All the patients were categorized according to EAU risk categories for PCa risk. Uni- and multivariate analysis were fitted to explore clinical and surgical predictors of pathological upstaging to locally advanced disease (pT3/pT4 - pN1 disease). RESULTS: Overall 2017 patients entered the study. Median age at surgery was 68 (IQR 63-73) years. Overall low risk, intermediate risk, localized high risk and locally advanced disease were recorded in 368 (18.2 %), 1071 (53.1 %), 388 (19.2 %) and 190 (9.4 %), respectively. Median time from to diagnosis to treatment was 51 (IQR 29-70) days. Time to surgery was 56 (IQR 32-75), 52 (IQR 30-70), 45 (IQR 24-60) and 41 (IQR 22-57) days for localized low, intermediate and high risk and locally advanced disease, respectively. Considering 1827 patients with localized PCa, at multivariate analysis ISUP grade group ≥4 on prostate biopsy (HR: 1.30; 95 % CI 1.07-1.86; p = 0.02) and surgical delay only in localized high-risk disease (HR: 1.02; 95 % CI 1.01-1.54; p = 0.02) were confirmed as independent predictors of pathological upstaging to pT3-T4/pN1 disease at final histopathological examination. CONCLUSIONS: In localized high-risk disease surgical delay could be associated with a higher risk of adverse pathologic findings.

Analysis of surgical complications of renal tumor enucleation with standardized instruments and external validation of PADUA classification.

PURPOSE: To assess surgical results and morbidity of tumor enucleation (TE), and to evaluate their correlation with PADUA nephrometric score. METHODS: We prospectively gathered data, including accurate analysis of tumor nephrometry, from 244 consecutive patients treated with TE for clinically localized renal cell carcinoma. All surgical results were collected, and perioperative complications were stratified for severity according to Clavien system. Correlation between preoperative variables and surgical results/complications was assessed with uni- and multivariate analysis. RESULTS: Mean (range) tumor size was 3.6 (0.8-10.0) cm, and mean (range) warm ischemia time was 16.8 (5-35) min. Overall, perioperative complications occurred in 45 patients (18.4 %), and of those 8 were medical and 37 were surgical (4 Clavien grade 1, 25 grade 2, and 8 grade 3) complications. Urine leakage rate was 2.0 %. No grade 4/5 complications occurred in this series. At univariate analysis PADUA score, endophytic tumor growth, tumor diameter, involvement of UCS and renal sinus resulted associated with warm ischemia time (p < 0.0001 each) and surgical complications (p = 0.0007, p = 0.049, p = 0.021, p = 0.036, and p = 0.029, respectively). At logistic regression, nephrometry score resulted independently associated with overall complications (related risk for each increased point 1.54; p = 0.017), surgical complications (related risk 1.58; p = 0.016), and Clavien grade 3 surgical complications (related risk 2.99; p = 0.008). CONCLUSIONS: The TE technique was associated with a 15.2 % surgical complication rate with a 3.3 % reintervention rate (including ureteral stenting and superselective renal artery embolization). Tumor nephrometry and surgical indication resulted independent predictors of Clavien grade 3 complications. The PADUA score is a reliable tool to predict surgical results and morbidity of TE.

Patterns and Predictors of Optimal Surgical and Functional Outcomes after Holmium Laser Enucleation of the Prostate (HoLEP): Introducing the Concept of "Trifecta".

PURPOSE: The present study sought to provide reproducible and patient-oriented metrics to assess the rate of "successful" outcomes (Trifecta) following holmium laser enucleation of the prostate (HoLEP). Clinical and surgical predictors of failure to achieve Trifecta were investigated. MATERIALS AND METHODS: We queried our prospectively collected database of all patients treated with HoLEP between March 2017 and January 2021. Trifecta was defined as the contemporary presence of: (1) no postoperative complication within 3 months; (2) no urinary incontinence at 3-months follow-up; and (3) 3-month postoperative max flow-rate >15 mL/s. Cases were grouped according to Trifecta achievement. All surgical procedures were carried out by a single surgeon. Surgical experience was divided into two different eras according to the number of procedures conducted (surgical era). Multivariate logistic regression analysis was performed to assess predictors of Trifecta failure. RESULTS: Overall 305 patients were included. Of these, 192 patients (63.0%) achieved Trifecta. Preoperative patient-related features were comparable between the two groups, except for a higher post-void residual (PVR) in non-Trifecta patients (median 180 vs. 130 mL, p=0.003). A significant proportion of Trifecta patients (88.5%) were treated in the second surgical era and in 126 (65.6%) cases an en-bloc enucleation was performed. Multivariate analysis confirmed PVR ≥250 mL, first surgical era and standard three-lobes enucleation technique as independent predictors of Trifecta failure. CONCLUSIONS: In our experience the rate of "successful" HoLEP, defined according to our newly introduced Trifecta metric, was 63.0%. We demonstrated that surgical strategy together with rising experience and baseline PVR are key elements to forecast the outcomes.