Safety and efficacy of vacuum-assisted mini-percutaneous nephrolithotomy for the treatment of renal stone disease: an analysis of stone free status and postoperative infectious complications.

PURPOSE: Vacuum-assisted mini-percutaneous nephrolithotomy (vmPCNL) is being increasingly adopted due to its faster operating times and lower incidence of postoperative infectious complications (IC), however, studies have been limited by small sample sizes. We hypothesize that vmPCNL is an efficacious treatment for renal stone disease with acceptable stone-free rates (SFR) and low incidence of IC. The objectives of this study were to measure SFR three months after surgery, determine the factors influencing SFR, and determine the rates of postoperative IC after vmPCNL. MATERIALS AND METHODS: Seven hundred and sixty seven patients underwent vmPCNL for the treatment of renal stones > 20 mm at a single institution. Patients underwent postoperative computed tomography at three months to assess SFR. Postoperative fever and SIRS/Sepsis were recorded for individual patients. Multivariate logistics regression was performed to assess predictors of SFR. RESULTS: The SFR was found to be 73.7% at three months. Stone burden (OR 0.39, 95% CI [0.33-0.46]) and age (OR 1.03, 95% CI [1.01-1.04]) emerged as statistically significant predictors of SFR on multivariate analysis. 5.5% of patients experienced postoperative fever, while 2.9% experienced SIRS/Sepsis. CONCLUSIONS: This is the largest continuous cohort of patients to undergo vmPCNL for stone disease and demonstrates that vmPCNL is safe and efficacious, with an SFR of 74% at three months. The incidence of postoperative fever and SIRS/Sepsis is 5.5% and 2.9% respectively. Further randomized studies with large sample sizes are required to ascertain the rates of these complications in comparison to conventional approaches.

Urotensin II receptor expression in prostate cancer patients: A new possible marker.

BACKGROUND: Urotensin II receptor has been poorly studied in prostate cancer. To evaluate the expression of urotensin II receptor (UII-R) in patients undergoing radical prostatectomy. METHODS: Overall, we identified 140 patients treated with retropubic radical prostatectomy (RP) in one center. UII-R was evaluated in prostate biopsies with immunohistochemical staining, resulting in a granular cytoplasmic positivity, through automated system using the kit Urotensin II Receptor Detection System provided by Pharmabullet srl. Immunostained slides were independently and blindly evaluated by ten uro-pathologists. To evaluate UTII-R expression three different parameters were considered: localization, granules dimensions and intensity of expression. A score from 0 to 3 was applied to each parameter to obtain a score from 0 to 9. Each parameter and the total score were evaluated as predictors of high grade disease on surgical pathology and of advanced stage disease. Accuracy of total score for the prediction of upgrading and upstaging was analyzed using receiver operator characteristics curve and decision curve analysis (DCA). RESULTS: On radical prostatectomy 92/140 (66%) presented high grade disease on surgical pathology. Patients with high grade disease presented an apical distribution of the receptor, larger granules and a more intense expression when compared to patients with low grade disease. A well they presented a higher total score. Subscores and total scores were found to be predictors of upgrading and upstaging. On ROC analysis total score presented an AUC of 0.72 and 0.70, respectively, for the prediction of upgrading and upstaging. On DCA total score showed a clinical benefit in the prediction of adverse pathological outcomes. CONCLUSION: Urotensin II receptor is a potential marker of adverse pathological outcomes. Further studies should confirm our data and evaluate its role as a prognostic marker.

Anterior colporrhaphy plus inside-out tension-free vaginal tape for associated stress urinary incontinence and cystocele: 10-year follow up results.

AIMS: We report the success rate and complications rate of combined ultralateral anterior Colporrhaphy plus Tension-free Vaginal Tape (TVT-O) in a long-term (10 year) follow-up prospective survey. METHODS: Patients previously treated for associated stress urinary incontinence (SUI) and cystocele were subjected to annual follow-up for 10 year with a complete urogynecologic evaluation. Furthermore, an urodynamic assessment and a quality of life questionnaire (ICIQ-UI SF) were recorded at the 5th and 10th year of follow up. RESULTS: Fifty patients treated between June 2004 and May 2006 were included in the analysis. Five patients did not return to 5-yr follow-up: two patients developed a median tape erosion and three patients withdraw. At 10-yr follow-up two more patients withdraw for a total of seven patients lost to follow-up. After 10 years patients objectively cured from cystocele were 41 (95%) while patients objectively cured from SUI were 39 (91%). At 10th year follow-up 38 patients (89%) result cured from both SUI and cystocele, 3 (7%) patients result cured only from prolapse, 1 (2%) patient only from SUI, and 1 (2%) patient result objectively failed for both SUI and cystocele. The ICIQ-UI SF scores at 10th year follow-up was 6.2 ± 3.7. The late complication rate at 10th year follow-up was 32% (OAB symptoms 20%; Mixed incontinence 2%; Bladder outlet obstruction 0%; Dyspareunia 6%; Chronic pelvic pain 0%; Vaginal tape erosion 4%; Detrusor hyperactivity 0%). CONCLUSIONS: The combined procedures shown proved to be an effective and safe procedure to treat concomitant SUI and cystocele.

Primary Malignant Melanoma of the Bladder.

A 81-year-old man was admitted to our university for a second opinion after diagnosis of bladder melanoma in December 2014. His medical history included arterial hypertension, hypothyroidism, peripheral arterial disease treated with a bypass, and corneal transplantation. His medical history was negative for malignant melanoma. He experienced gross hematuria in the absence of any other clinical manifestations, and urine cytology identified atypical cells. The patient underwent transurethral resection of the bladder with diagnosis of melanoma.

Can re-cTURBT be useful in pT1HG disease as a risk indicator of recurrence and progression? A single centre experience.

INTRODUCTION: Understaging after initial transurethral resection is common in patients with high-risk non muscle infiltrating bladder cancer (NMIBC) and can delay accurate diagnosis and definitive treatment. The rate of upstaging from T1 to T2 disease after repeated transurethral resection ranges from 0 to 28%, although the rate of upstaging may be even higher up to 49% when muscularis propria is absent in the first specimen. A restaging classic transurethral resection of bladder tumour (re-cTURBT) is the better predictor of early stage progression. According to some reports, the rate of positivity for tumor in re-cTURBT performed within eight weeks after initial cTURBT was as high as 18-77%, and in about 40% of the patients a change in tumor stage was reported. We aimed to investigate, in high risk group, the presence of residual tumor following white light classical transurethral resection of bladder tumor (WLre-cTURBT) and the different recurrence and progression rate between patients with persistent or negative (pT0) oncological disease after WLre-cTURBT. MATERIALS AND METHODS: A cohort of 285 patients presenting with primitive bladder cancer underwent to WLcTURBT from January 2011 to December 2015; out of them 92 (32.28%) were T1HG. In according to EAU guidelines 2011, after 4-6 weeks all HG bladder cancer patients underwent a WL recTURBT . All patients were submitted to a subsequent followup including cystoscopy every 3 months with multiple biopsies, randomly and in the previous zone of resection; urinary citology on 3 specimens and kidney/bladder ultrasound every 6 months. The average follow-up was 48 months. RESULTS: Following WLre-cTURBT we observed a persistent disease in 18 (15.2%) patients: 14 (77.7%) with a HG-NMIBC and 4 (22.2%) with a high grade (HG) muscle invasive bladder cancer (pT2HG). After follow up of all 92 patients according to the guidelines EAU, we observed recurrence in 36/92 (39.1%) and progression in 14/92 (15.2%). Of 14 NMIBC with persistent disease, 10 patients (71.4%) showed recurrence: 4 patients (40%) were pT1HG with concomitant carcinoma in situ (CIS), 3 patients (30%) multifocal pTaHG, 2 (20%) patients CIS and one patient (10%) a muscle invasive neoplasm (pT2HG). Instead of the group of 48 patients pT0 following WL recTURBT, we observed recurrence in 26 patients (54.1%) and in two patients (4.1%) progressions, who presented after 3 months in association with CIS. The remaining 22 patients (45.9%) with initial pT1HG are still progression free. Multivariate analysis showed that the most important variable of early progression were persistent neoplasm and histopathological findings at WLre-cTURBt (p = 0.01), followed by the Summary No conflict of interest declared. INTRODUCTION Bladder cancer is a common genito-urinary malignancy, with transitional cell carcinoma comprising nearly 90% of all primary bladder tumours. At the first diagnosis 70% to 80% of urothelial tumours are confined to the epithelium, the remainder is characterized by muscle invasion. A significant number of patients with high risk non-muscle invasive bladder tumours (HG-NMIBT) treated with white light classic transurethral resection of bladder tumours (WLcTURBT) and intravesical BCG will progress to invasive disease (1-3). Progression to muscle invasion (pT2) mandates immediate radical cystectomy (4). WLcTURBT is the standard initial therapy for NMIBT, but the high percentage of recurrence after surgery is still an unresolved problem (5). High grade pT1 bladder neoplasm (pT1HG) really represents a therapeutic challenge due to the high risk of progression (about 15-30%) to muscle-invasive disease, usually within 5 years (6). However, no consensus exists regarding the treatment of patients with recurrent bladder tumours that invade the lamina propria (pT1) (7-9). Recent studies suggested that the first cTURBT may be incomplete in a significant number of cases (10). Understaging at the time of the initial transurethral resection is common for patients with high-risk NMIBC and can delay accurate diagnosis and definitive treatment. It is therefore recommended for patients with high-risk disease and in those with large or multiple tumors or when the initial transurethral resection is incomplete, to repeat WLre-cTURBT within 2-6 DOI: 10.4081/aiua.2017.4.272 result of the first cystoscopy (p = 0.002) and presence of CIS (p = 0.02). DISCUSSION: Following WLre-cTURBt in HG-NMIBC patients we identified in 15% of cases a persistent disease with a 4.3% of MIBC. In the high risk persistent bladder neoplasms group we observed recurrent and progression rate higher than in T0 bladder tumours group (Δ = + 17.3% and = Δ + 62.5%, p < 0.05.

Experimental Nephrectomies Using a Novel Telesurgical System: (The Telelap ALF-X)-A Pilot Study.

PURPOSE: The SOFAR® Telelap Alf-X (Milan, Italy) is a novel telesurgical system which combines the advantages of both laparoscopy and open surgery. It offers some new features like tactile perception, open site view, eye-tracking control of the camera, and optimal ergonomics. OBJECTIVE: The aim of this study is to examine the feasibility and the safety of nephrectomy using a novel telesurgical system with haptic sensation: the Telelap Alf-X. MATERIALS AND METHODS: Twelve female swine underwent nephrectomies using the Telelap Alf-X system. Data regarding operative times, estimated blood loss (EBL), surgical methodology, and intraoperative complications are presented. RESULTS: The Telelap Alf-X's docking took less than one minute, the system was versatile during each step of the nephrectomy and the operative times have reduced dramatically along the learning curve. One intraoperative complication was recorded (Vena Cava injury-repaired using the robotic system) and the estimated blood loss was minimal. CONCLUSIONS: The Telelap Alf-X proved to be safe and reliable and can be easily used by the surgeon. The porcine model nephrectomies proved to be an excellent way to gain experience and avoid future complications.

Preoperative Computed Tomography Imaging Accurately Identifies Adrenal Gland Involvement In Patients With Renal Masses.

OBJECTIVE: To determine the frequency of adrenal gland involvement (AGI) in patients with renal cell carcinoma (RCC) and assess the ability of preoperative computed tomography (CT) imaging to predict AGI prior to radical nephrectomy (RN). METHODS: We retrospectively identified 90 patients who underwent RN with concomitant ipsilateral adrenalectomy (CIA) between 2019 and 2021 at our institution. We reviewed the preoperative CT findings and final pathology reports to assess AGI and determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preoperative CT imaging. RESULTS: Five patients (5.5%) had AGI on pathological analysis. On preoperative CT, 8 patients had CT findings suspicious of AGI. All 5 patients with pathological AGI were identified preoperatively yielding a sensitivity of 100%. Pathological analysis in all patients who did not demonstrate AGI on imaging showed no adrenal invasion, yielding a negative predictive value of 100%. High-grade tumors were significantly associated with AGI (84.4% vs 33.6%, P = .02). Patients with AGI had larger tumor size when compared with those without AGI on final pathology (10 cm vs 6.89 cm, P = .07). CONCLUSION: The overall incidence of AGI in patients with RCC is low. Preoperative CT can accurately identify those with AGI and can thus prevent unnecessary CIA during RN.

Refining Penile Trauma Management: Introduction of the Penile Trauma Score.

OBJECTIVE: To introduce the Penile Trauma Score (PTS), a new statistically driven classification system aimed at enhancing the management of penile trauma by providing clinically relevant treatment protocols. METHODS: A retrospective review was conducted of 34 men with penetrating penile injuries at the Elvis Presley Level 1 Trauma Center, Memphis, from January 2014 to December 2016. Variables assessed included injury mechanism, location, depth, and follow-up outcomes related to voiding and erectile function. Odds ratios were calculated using superficial penile injury as the control group. RESULTS: Based on physical examination findings and odds ratios calculated, the PTS was developed. Results indicated that higher PTS scores necessitated surgical intervention, while lower scores could be managed nonoperatively. Follow-up showed no missed injuries or reported dysfunctions, validating the PTS's effectiveness. CONCLUSION: The PTS represents an important modification in the classification and management of penile trauma. By integrating practical, easily identifiable injury characteristics, the PTS facilitates more streamlined surgical decision-making and potentially reduces unnecessary diagnostic procedures. However, further prospective studies with larger sample sizes and longer follow-up are needed to fully validate the PTS's clinical utility.

Analysis of early perioperative outcomes of robot-assisted radical cystectomy and colonic diversion.

Studies of right colon pouch urinary diversion have widely varying estimates of the risk of perioperative complications, reoperation, and readmission. We sought to describe the association between specific risk factors and complication, readmission, and reoperation rates following right colon pouch urinary diversion. Patients undergoing robot-assisted right colon pouch urinary diversion from July 2013 to December 2022 were analyzed. Outcome measures include high-grade (Clavien-Dindo grade ≥ 3) complications within 90 days, readmission within 90 days, and reoperation at any time during follow-up. Specific risk factors such as age, gender, body mass index (BMI), diabetes, Charlson comorbidity index (CCI), and prior radiation were analyzed to establish an association with these outcomes. During the study period, 77 patients underwent the procedure and were eligible to study. The average follow-up was 88.7 (SD 14) months. 90-day high-grade complications were 24.67%, and 90-day readmission was 33.76%. The cumulative rate of any reoperation was 40.2%, and major reoperation was 24.67%. Female gender (OR 3.3, p = 0.015), 1 kg/m2 increase in BMI (OR 3.77, p = 0.014), diabetes (OR 3.49, p = 0.021), higher CCI (OR 1.59, p = 0.034), prior radiation (OR 1.97, p = 0.026), lower eGFR (OR 0.99, p = 0.032) and BMI ≥ 25 kg/m2  (OR 3.9, p value 0.02) was associated with Clavien III-IV complications. Female gender (OR 3.3, p = 0.015), diabetes (OR 3.97, p = 0.029), higher Charlson Comorbidity Index (OR 1.73, p = 0.031), prior radiation (OR 1.45, p = 0.029), lower eGFR (OR 0.87, p = 0.037) and BMI ≥ 25 kg/m2 (OR 3.86, p = 0.031) were predictive of reoperation. Overall, the rate of postoperative complications, readmissions, and reoperation was high but consistent with other studies. This study helps further characterize surgical outcomes after right colon pouch urinary diversion and highlights patients who may benefit from enhanced preoperative management for minimising complications.

Zoledronic acid induces a significant decrease of circulating endothelial cells and circulating endothelial precursor cells in the early prostate cancer neoadjuvant setting.

PURPOSE: Published data demonstrated that zoledronic acid (ZOL) exhibits antiangiogenetic effects. A promising tool for monitoring antiangiogenic therapies is the measurement of circulating endothelial cells (CECs) and circulating endothelial precursor cells (CEPs) in the peripheral blood of patients. Our aim was to investigate the effects of ZOL on levels of CECs and CEPs in localized prostate cancer. METHODS: Ten consecutive patients with a histologic diagnosis of low-risk prostate adenocarcinoma were enrolled and received an intravenous infusion of ZOL at baseline (T0), 28 days (T28) and 56 days (T56). Blood samples were collected at the following times: T0 (before the first infusion of ZOL), T3 (72 h after the first dose), T28, T56 (both just before the ZOL infusion) and T84 (28 days after the last infusion of ZOL) and CEC/CEP levels were directly quantified by flow cytometry at all these time points. RESULTS: Our analyses highlighted a significant reduction of mean percentage of CECs and CEPs after initiation of ZOL treatment [p = 0.014 (at day 3) and p = 0.012 (at day 84), respectively]. CONCLUSION: These preliminary results demonstrate that ZOL could exert an antiangiogenic effect in early prostate cancer through CEP and CEC modulation.

York Mason procedure to repair iatrogenic rectourinary fistula: our experience.

BACKGROUND: Rectourinary fistula (RUF) is an uncommon but devastating condition in men. It usually occurs as a complication of prostatic cancer treatment, whether this is by radiation therapy or surgery. It can also occur in patients with benign pathology of the prostate, inflammatory bowel disease, or Fournier's gangrene, and following pelvic trauma. RUF represents a challenge for the surgeon because spontaneous closure is a rare event. Several techniques have been described for surgical repair of fistula. The goal of the present study was to demonstrate that the York Mason posterior, transrectal correction of an iatrogenic RUF is a reliable approach that offers good postoperative outcomes. METHODS: We retrospectively reviewed the medical records of 39 patients who underwent York Mason repair from 1998 to 2012 at the University of Southern California (USC) and Campus Bio-Medico University of Rome (UCBM). The most frequent common causes of RUF were itemized, and statistical analysis was performed to determine correlations between the fistula's etiology and surgical outcome. Patients were then divided into two different cohorts: those who had undergone only one previous procedure (group 1) and those who had undergone two or more surgeries (group 2). We performed a statistical analysis between the two groups and calculated the percentage of fistula repair by means of the posterior trans-sphincteric approach with the York Mason technique in each groups We evaluated the presence of comorbidities (diabetes and infection) and their influence on the surgical outcome. Finally, we reported patient outcomes during follow-up. RESULTS: In the present series, the RUF was iatrogenic in every case. The onset of the fistula followed prostate cancer treatment, most commonly after laparoscopic procedures. The success rate of fistula repair was found to be independent of the fistula's etiology. Diabetes and infections did not influence the surgical outcome. Overall, more than 50 % of patients treated with the York Mason posterior, transanal, transrectal approach remained free of fistula during follow-up. Almost 90 % of those who were previously operated only once remained free of fistula. CONCLUSIONS: The posterior trans-sphincteric approach of the York Mason technique is effective in treating RUF.

Use of nonabsorbable staples for urinary diversion: a step in the wrong direction.

BACKGROUND: The use of bowel segments incorporated into the urinary tract is well established in urological surgery. OBJECTIVE: To describe and compare the use of absorbable and nonabsorbable staples for creation of a urine reservoir after radical cystectomy. MATERIALS AND METHODS: This review is based on a systematic Medline search assessing the period 1950-2010. RESULTS: Use of the autosuture stapling device for the construction of the urinary diversion significantly reduces operating time. Johnson and Fuerst reported its use for the first time to construct a ureteroileocutaneous urinary diversion in 1973. However, many studies demonstrated that exposed metal staples represent a nidus for stone formation when they are in direct contact with urine, particularly in urinary diversions such as Kock pouch and ileal conduit. Stone formation has been attributed in part to the use of nonabsorbable artificial materials, such as metal staples and Marlex mesh, strictures of the pouch and accumulation of mucus. The treatment options for pouch calculi include observation for spontaneous passage, extracorporeal shockwave lithotripsy, percutaneous or endoscopic lithotripsy/lithotomy. CONCLUSIONS: Historically, the mean time to stone formation with nonabsorbable material (staples, Marlex mesh) is 34 months. None of the studies on use of nonabsorbable staples in urinary diversion has such a long follow-up. Until further studies with more appropriate observation time are completed, the use of nonabsorbable staples for continent and noncontinent urinary diversion should be discouraged.

Renal cell carcinoma with tumor thrombus: A review of relevant anatomy and surgical techniques for the general urologist.

Renal cell carcinoma (RCC) is estimated to account for 4.1% of all new cancer diagnoses and 2.4% of all cancer deaths in 2020 according to the National Cancer Institute SEER database. This will likely total 73,000 new cases and 15,000 deaths. RCC is one of the most lethal of the common cancers urologists will encounter with a 5-year relative survival of 75.2%. Renal cell carcinoma is one of a small subset of malignancies that are associated with tumor thrombus formation, which is tumor extension into a blood vessel. An estimated 4% to 10% of patients with RCC will have some degree of tumor thrombus extending into the renal vein or inferior vena cava at the time of diagnosis. Tumor thrombi change the staging of RCC and therefore are an important part of initial patient workup. It is known that such tumors are more aggressive with higher Fuhrman grades, N+ or M+ at time of surgery and have higher probability of recurrence with lower cancer-specific survival. Aggressive surgical intervention with radical nephrectomy and thrombectomy can be performed with survival benefits. Classifying the level of the tumor thrombus becomes vitally important in surgical planning as it will dictate the surgical approach. Level 0 thrombi may be amenable to simple renal vein ligation while level 4 can require thoracotomy and possible open-heart surgery with coordination of many surgical teams. Here we will review the anatomy associated with each level of tumor thrombus and attempt to construct an outline for surgical techniques that may be used. We aim to give a concise overview so that general urologists may use it to understand these potentially complicated cases.

Oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma: a literature review.

Background and Objective: Radical nephroureterectomy (RNU) represents the gold standard treatment for non-metastatic upper tract urothelial cancer. We sought to provide a comprehensive review of reported oncologic outcomes of the RNU procedure and of factors that might impact these outcomes. Methods: A non-systematic review of the literature was conducted by performing an electronic literature search using PubMed with "radical nephroureterectomy" and "oncologic outcomes" as free text search terms. Both original articles and systematic reviews were considered. Search was limited to articles in English that were published in the last 20 years. Key Content and Findings: Open and laparoscopic RNU offer comparable oncologic outcomes. In more recent years, the discussion has de facto shifted towards the "oncological safety" of robotic RNU, which also seems to offer comparable oncologic outcomes. Several studies have looked at the impact of different treatment-, patient- and tumor-related factors. Among treatment-related factors, attention has been given to diagnostic ureteroscopy and the risk of intravesical recurrence. Surgical wait time and perioperative blood transfusion have also been studied. Perioperative chemotherapy, specifically adjuvant therapy, was shown to improve survival. Among patient-related factors, baseline chronic kidney disease, diabetes mellitus, body mass index, and systemic inflammation have gained recent attention. Some tumor related factors, such as stage, grade, location, and multifocality may negatively impact survival outcomes. Lymphovascular invasion and histologic variants are clinically significant pathological findings. Conclusions: RNU is a procedure with measured long-term oncologic outcomes. Minimally invasive techniques have gained an established role as they seem to offer comparable oncologic "safety", although special attention is needed in relation to the method of bladder cuff excision. Robotic RNU is gaining popularity, and while evidence remains limited, the current literature supports the oncologic safety of this procedure. Several factors, which can be categorized as treatment-related, patient-related, and tumor-related, might impact the oncologic outcomes of UTUC patients undergoing RNU. These factors can provide crucial information to stratify patients based on their relative risk of disease recurrence and mortality which may guide clinical decision-making.

Telelap Alf-X: a novel telesurgical system for the 21st century.

OBJECTIVE: To introduce a new telesurgical concept and system, we describe the TELELAP Alf-X system and report the results of the preliminary laboratory experiments on dry lab skill exercises. METHODS: The TELELAP Alf-X system offers a novel approach to remotely operated 3-dimension endoscopy by adding haptic sensation, an eye-tracking system, and a high degree of configuration versatility. The Alf-X system consists of a remote control unit, manipulator arms, connection node, and reusable endoscopic instruments. To test the hand-eye coordination, manual dexterity, depth offield, and ability to make optimal sutures and knots, the Alf-X system was used in a laparoscopic trainer utilizing specific tools by a single surgeon (SG) who repeated three different exercises ten times. The time and accuracy of the exercises were recorded. RESULTS: By using the TELELAP Alf-X system, the surgeon was able to work repeatedly and to perform all the exercises scheduled. In all exercises, the best results were achieved after the first five cases. CONCLUSION: The TELELAP Alf-X system shows excellent stability, easy-to-use interface, and ability to perform essential endoscopic skills. Further experimentation, especially in live tissue, could identify the role of this new technology for the surgical repertoire.

Urodynamics investigation on children with vesicoureteral reflux identifies overactive bladder and poor compliance in those with voiding dysfunction.

BACKGROUND: Up to 50% of children with vesicoureteral reflux (VUR) may have associated voiding dysfunction. It is thought to be an important determinate of the severity and resolution of VUR; however, to date there has been no objective measurement defining the impact of voiding dysfunction in children with VUR. The purpose of this study is to compare the urodynamic parameters of children with VUR who have and do not have symptomatic voiding dysfunction. METHODS: We performed a retrospective study of 138 children with a diagnosis of primary VUR who underwent urodynamic investigations. Information regarding patient demographics, grade and laterality of VUR and clinical history of bladder dysfunction were assessed. Urodynamic parameters recorded included detrusor overactivity, early and late compliance, voiding pressure, post-void residual volume and functional bladder capacity. Statistical analysis was performed using t Student analysis, Pearson's χ(2) test or Fischer's exact test, with a p < 0.05 as being significant. RESULTS: The mean age of the patients at the time of urodynamic evaluation was 5.8 years (SD 4.4). 30% had symptomatic voiding dysfunction based on the clinical history. Children without a history of voiding dysfunction had higher grades of VUR as compared to those with it (p = 0.002). Bladder hypertone, detrusor overactivity, detrusor hypereflexia and poor late bladder compliance presented a statistically significant higher incidence the incidence of bladder overactivity and poor late bladder compliance was higher in children with bladder dysfunction than those without it. CONCLUSION: Our findings suggest that voiding dysfunction does have objective and quantifiable effects on bladder dynamics. Urodynamic evaluation may play a role in the management of children with VUR by identifying those with bladder dysfunction secondary to abnormal voiding habits.

Salvage Robot-assisted Renal Surgery for Local Recurrence After Surgical Resection or Renal Mass Ablation: Classification, Techniques, and Clinical Outcomes.

BACKGROUND: Salvage treatment for local recurrence after prior partial nephrectomy (PN) or local tumor ablation (LTA) for kidney cancer is, as of yet, poorly investigated. OBJECTIVE: To classify the treatments and standardize the nomenclature of salvage robot-assisted renal surgery, to describe the surgical technique for each scenario, and to investigate complications, renal function, and oncologic outcomes. DESIGN, SETTING, AND PARTICIPANTS: Sixty-seven patients underwent salvage robot-assisted renal surgery from October 2010 to December 2020 at nine tertiary referral centers. SURGICAL PROCEDURE: Salvage robot-assisted renal surgery classified according to treatment type as salvage robot-assisted partial or radical nephrectomy (sRAPN or sRARN) and according to previous primary treatment (PN or LTA). MEASUREMENTS: Postoperative complications, renal function, and oncologic outcomes were assessed. RESULTS AND LIMITATIONS: A total of 32 and 35 patients underwent salvage robotic surgery following PN and LTA, respectively. After prior PN, two patients underwent sRAPN, while ten underwent sRARN for a metachronous recurrence in the same kidney. No intra- or perioperative complication occurred. For local recurrence in the resection bed, six patients underwent sRAPN, while 14 underwent sRARN. For sRAPN, the intraoperative complication rate was 33%; there was no postoperative complication. For sRARN, there was no intraoperative complication and the postoperative complication rate was 7%. At 3 yr, the local recurrence-free rates were 64% and 82% for sRAPN and sRARN, respectively, while the 3-yr metastasis-free rates were 80% and 79%, respectively. At 33 mo, the median estimated glomerular filtration rates (eGFRs) were 57 and 45 ml/min/1.73 m2 for sRAPN and sRARN, respectively. After prior LTA, 35 patients underwent sRAPN and no patient underwent sRARN. There was no intraoperative complication; the overall postoperative complications rate was 20%. No local recurrence occurred. The 3-yr metastasis-free rate was 90%. At 43 mo, the median eGFR was 38 ml/min/1.73 m2. The main limitations are the relatively small population and the noncomparative design of the study. CONCLUSIONS: Salvage robot-assisted surgery has a safe complication profile in the hands of experienced surgeons at high-volume institutions, but the risk of local recurrence in this setting is non-negligible. PATIENT SUMMARY: Patients with local recurrence after partial nephrectomy or local tumor ablation should be aware that further treatment with robot-assisted surgery is not associated with a worrisome complication profile, but also that they are at risk of further recurrence.

Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy.

BACKGROUND: Over the years, several techniques for performing robot-assisted prostatectomy have been implemented in an effort to achieve optimal oncological and functional outcomes. OBJECTIVE: To provide an evidence-based description and video-based illustration of currently available dissection techniques for robotic prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: A literature search was performed to retrieve articles describing different surgical approaches and techniques for robot-assisted radical prostatectomy (RARP) and to analyze data supporting their use. Video material was provided by experts in the field to illustrate these approaches and techniques. SURGICAL PROCEDURE: Multiple surgical approaches are available: extraperitoneal, transvesical, transperitoneal posterior, transperitoneal anterior, Retzius sparing, and transperineal. Surgical techniques for prostatic dissection sensu strictu are the following: omission of the endopelvic fascia dissection, bladder neck preservation, incremental nerve sparing by means of an antegrade or retrograde approach, and preservation of the puboprostatic ligaments and dorsal venous complex. Recently, techniques for total or partial prostatectomy have been described. MEASUREMENTS: Different surgical approaches and techniques for robotic prostatectomy have been analyzed. RESULTS AND LIMITATIONS: Two randomized controlled trials evaluating the extraperitoneal versus the transperitoneal approach have demonstrated similar results. Level I evidence on the Retzius-sparing approach demonstrated earlier return to continence than the traditional anterior approach. The question whether Retzius-sparing RARP is associated with a higher rate of positive surgical margins is still open due to the intrinsic bias in terms of surgical expertise in the available comparative studies. This technique also offers an advantage in patients who have received kidney transplantation. Retrospective evidence suggests that the more the anatomical dissection (eg., more periprostatic tissue is preserved), the better the functional outcome in terms of continence. Yet, two randomized controlled trials evaluating the different techniques of dissection have so far been produced. Partial prostatectomies should not be offered outside clinical trials. CONCLUSIONS: Several techniques and approaches are available for prostate dissection during RARP. While the Retzius-sparing approach seems to provide earlier return to continence than the traditional anterior transperitoneal approach, no technique has been proved to be superior to other(s) in terms of long-term outcomes in randomized studies. PATIENT SUMMARY: We have summarized available approaches for the surgical treatment of prostate cancer. Specifically, we described the different techniques that can be adopted for the surgical removal of the prostate using robotic technology.

Training the urologic oncologist of the future: where are the challenges?

OBJECTIVE: Training the new generation of urologic oncologist from a surgical perspective poses unique challenges. The advent of minimally invasive surgical procedures coupled with the need to perform open surgical procedures has significantly increased the demands upon both the trainer and trainee. The learning and practice of complex procedures demand continuous improvements in surgical training programs. This review discusses some theoretical and practical issues to be considered for the successful and safe transmission of surgical skills in an era of increasing regulations. FINDINGS: Few systematic studies address this topic, leaving ample margin for research and improvement in this endeavor. It is the authors' opinion that mentorship remains the most significant and important component to successful surgical training today. The advent of simulation, virtual reality, and modular teaching represent (novel and important) advances in the field of surgical education. While some residency programs have incorporated these changes into their surgical training curriculum, this has not become widespread and the available literature remains at best sporadic. CONCLUSIONS: Mentorship remains an integral if not the most critical component to surgical training today. Other novel approaches to surgical training have developed and should be incorporated into the traditional concepts of mentorship training. This may become even more important with the advent of minimally invasive approaches to surgery. The vast majority of the studies published concur that the traditional model of "see one, do one, teach one" is not an optimal approach for training surgical skills. Socioeconomic changes are forcing the surgical community to rethink how they train residents and absorb new technologies. Adapting to the new demands posed on surgical educators represents a great challenge for the upcoming years.