A proposed mathematical model to help preoperative planning between RIRS and MiniPerc for renal stones between 10 and 20 mm using holmium:Yag laser (Cyber Ho): the stone management according to size-hardness (SMASH) score

To evaluate the performance of a mathematical model to drive preoperative planning between RIRS and MiniPerc (MP) for the treatment of renal stones between 10 and 20 mm. Patients with a renal stone between 10 and 20 mm were enrolled. A mathematical model named Stone Management According to Size-Hardness (SMASH) score was calculated: hounsfield units (HU) χ stone maximum size (cm)/100. Patients were divided into 4 groups: RIRS with score < 15 (Group A), RIRS with score ≥ 15 (Group B), MP with score < 15 (Group C), MP with score ≥ 15 (Group D). Cyber Ho device was always used. Stone free rate (SFR) was assessed after 3 months. Complication rate and need for auxiliary procedures were evaluated. Between January 2019 and December 2021, 350 patients were enrolled (87, 88, 82 and 93 in Groups A, B, C and D). Mean stone size was 13.1 vs 13.3 mm in Group A vs B (p = 0.18) and 16.2 vs 18.1 mm in Group C vs D (p = 0.12). SFR was 82%, 61%, 75% and 85% for Groups A, B, C and D. SFR was comparable between Groups C and D (p = 0.32) and Groups A and C (p = 0.22). SFR was significantly higher in Group A over B (p = 0.03) and in Group D over B (p = 0.02). Complication rate was 2.2%, 3.4%, 12.1%, 12.9% for Groups A, B, C, D. RIRS and MP are both safe and effective. The mathematical model with the proposed cut-off allowed a proper allocation of patients between endoscopic and percutaneous approaches.Registration number of the study ISRCTN55546280.

Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study

INTRODUCTION

The optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n = 30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee.

METHODS

This is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1-10; 11-20; 21-30) for both trainee and expert and LC variables were compared.

RESULTS

Overall, mean OTA insertion time was 56 s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33 s respectively, P = .01). For cases 11-20 and 21-30, time advantage of the senior surgeon is less evident (P = .05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum.

CONCLUSIONS

OTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC.

Pulsed-wave vs Continuous-wave Thulium Fiber Laser Enucleation of the Prostate (ThuFLEP): A Comparison of Perioperative Outcomes

OBJECTIVE

To compare intra and early postoperative outcomes between pulsed-wave and continuous-wave Thulium Fiber Laser Enucleation of the Prostate (PW-ThuFLEP vs CW-ThuFLEP) for the treatment of benign prostatic hyperplasia.

METHODS

238 patients with lower urinary tract symptoms due to benign prostatic hyperplasia underwent PW-ThuFLEP (118 patients) vs CW-ThuFLEP (120 patients). Preoperative prostate volume, adenoma volume, prostate-specific antigen (PSA), and hemoglobin values were recorded. International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual volume, and International Index of Erectile Function-5 score (IIEF-5) were assessed. Operative time, enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin drop, and postoperative complications were recorded. Micturition improvements and sexual outcomes were evaluated 3months after surgery.

RESULTS

CW-ThuFLEP showed shorter operative time (61.5 vs 67.4 minutes, P = .04). Enucleation time (50.2 vs 53.3 minutes, P = .12), enucleation efficiency (0.8 vs 0.7 g/min, P = .38), catheterization time (2.2 vs 2.1days, P = .29), irrigation volume (32.9 vs 32.8L, P = .71), hospital stay (2.8 vs 2.6days, P = .29) and hemoglobin drop (0.38 vs 0.39 g/dL, P = .53) were comparable. No significant difference in complication rate was observed. At 3-month follow-up, the procedures did not show any significant difference in IPSS, Qmax, post-void residual volume, IIEF-5, and PSA value.

CONCLUSION

PW-ThuFLEP and CW-ThuFLEP both relieve lower urinary tract symptoms equally, with high efficacy and safety. Operative time was significantly shorter with CW-ThuFLEP, but with a small difference with low clinical impact. Enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin and PSA drop, complication rate, and sexual outcomes showed no differences.

Transcutaneous electrical nerve stimulation for pelvic pain: A scoping review of treatment protocols, practical indications, and caveats

BACKGROUND

Neuromodulation (NM) is a family of therapies based on electrical stimulation to target specific nerves that control LUTS (Lower Urinary Tract Symptoms) and pain. The aim is to modulate what is happening within the nervous system to achieve therapeutic effects. A particular type of neuromodulation, called TENS (Transcutaneous Electrical Nerve Stimulation), has proven effective for treating pelvic pain. The available evidence provides indications regarding the many aspects of TENS that influence therapeutic effects, but a comprehensive review has yet to be conducted.

METHODS

Scoping review on Pubmed, CINAHL, Embase, Scopus, and Web of Science, including clinical trials, reviews, case studies or series, and other descriptive studies, according to the Joanna Briggs and PRISMA methodology.

RESULTS

The 31 papers retrieved allowed the formulation of precise indications about the DOs and DON'Ts of electrode placement, waveform, pulse duration, pulse frequency, amplitude, session duration, and frequency of sessions. This paper also discusses the biochemical and neuro urological mechanisms of TENS.

CONCLUSION

TENS effectiveness is influenced by many factors, some self-evident, others subtle, which this paper elucidates. Pelvic pain requires a multimodal approach, of which TENS is just a part. TENS should therefore be viewed as one of the components of the rehabilitation program in the frame of thorough and continuous patient assessment.

Asymptomatic bacteriuria in candidates for active treatment of renal stones: results from an international multicentric study on more than 2600 patients

The occurrence of asymptomatic bacteriuria concomitant to urolithiasis is an issue for patients undergoing renal stone treatment. Disposing of a preoperative urine culture is essential to reduce the risk of septic events. The endpoint of the study is to report which characteristics of candidates for renal stone treatment are frequently associated with positive urine culture. 2605 patients were retrospectively enrolled from 14 centers; inclusion criteria were age > 18 and presence of a single renal stone 1-2 cm in size. The variables collected included age, gender, previous renal surgery, comorbidities, skin-to-stone distance, stone size, location, density, presence of hydronephrosis. After a descriptive analysis, the association between continuous and categorical variables and the presence of positive urine culture was assessed using a logistic regression model. Overall, 240/2605 patients (9%) had preoperative bacteriuria. Positive urine culture was more frequent in females, patients with previous renal interventions, chronic kidney disease, congenital anomalies, larger stones, increased density. Multivariate analysis demonstrated that previous renal interventions (OR 2.6; 95% CI 1.9-3.4; p < 0.001), renal-related comorbidities (OR 1.31; 95% CI 1.19-1.4; p < 0.001), higher stone size (OR 1.06; 95% CI 1.02-1.1; p = 0.01) and density (OR 1.00; 95% CI 1.0-1.00; p = 0.02) were associated with bacteriuria; male gender and lower caliceal location were inversely related to it. Beyond expected risk factors, such as female gender, other parameters are seemingly favoring the presence of positive urine culture. The awareness of variables associated with bacteriuria allows to assess which individuals are at increased risk of presenting bacteriuria and reduce the rate of septic complications.

Pelvic lymph node dissection in prostate and bladder cancers

Prostate cancer and bladder cancer accounts for approximately 13.5% and 3% of all male cancers and all newly diagnosed cancers (regardless sex), respectively. Thus, these cancers represent a major health and economic burden globally. The knowledge of lymph node status is an integral part of the management of any solid tumor. In the urological field, pelvic lymph node dissection (PLND) is of paramount importance in the diagnosis, management, and prognosis of prostate and bladder cancers. However, PLND may be associated with several comorbidities. In this narrative review, the most recent updates concerning the patterns and incidence of lymph node metastasis, the role of different imaging studies and nomograms in determining patients' eligibility for PLND, and the anatomical templates of PLND in urologic patients with bladder or prostate cancer will be discussed.

Ureteral access sheath-related injuries vs. post-operative infections. Is sheath insertion always needed? A prospective randomized study to understand the lights and shadows of this practice

OBJECTIVE

To compare intraoperative ureteral injuries in RIRS with UAS insertion with the rate of postoperative infections after RIRS without UAS insertion.

PATIENTS AND METHODS

In this randomized trial, patients who received an indication for RIRS between January 2017 and December 2017 were divided into two groups. Group A had no UAS insertion and Group B had UAS insertion. Post-Ureteroscopic Lesion Scale (PULS) grading was performed after UAS or flexible ureteroscope removal. Proximal, middle and distal ureteral lesions were evaluated and compared according to the PULS scale. Additionally, patients in both groups were followed postoperatively to assess any infective complication.

RESULTS

The evaluation comprised 181 patients, 89 for group A and 92 for group B. Overall stone-free rate, clinically insignificant residual fragments, and final stone-free rate were 41.4%, 53.5%, and 95%, respectively. There were 33 (37.1%) patients with ureteral lesions in group A while 42 (45.6%) patients had ureteral lesions in group B, with no significant difference. On the other hand, the overall presence of postoperative infection rate was much higher for Group A (37.1% vs 16.3% P = 0.03).

CONCLUSIONS

UAS insertion does not result in a higher number of ureteral injuries. UAS insertion during RIRS allows a lower rate of postoperative infections.

CLINICAL TRIAL REGISTRATION NUMBER (ISRCTN REGISTRY NUMBER)

55546280.

Ureteral access sheath-related injuries vs. post-operative infections. Is sheath insertion always needed? A prospective randomized study to understand the lights and shadows of this practice

OBJECTIVE

To compare intraoperative ureteral injuries in RIRS with UAS insertion with the rate of postoperative infections after RIRS without UAS insertion.

PATIENTS AND METHODS

In this randomized trial, patients who received an indication for RIRS between January 2017 and December 2017 were divided into two groups. Group A had no UAS insertion and Group B had UAS insertion. Post-Ureteroscopic Lesion Scale (PULS) grading was performed after UAS or flexible ureteroscope removal. Proximal, middle and distal ureteral lesions were evaluated and compared according to the PULS scale. Additionally, patients in both groups were followed postoperatively to assess any infective complication.

RESULTS

The evaluation comprised 181 patients, 89 for group A and 92 for group B. Overall stone-free rate, clinically insignificant residual fragments, and final stone-free rate were 41.4%, 53.5%, and 95%, respectively. There were 33 (37.1%) patients with ureteral lesions in group A while 42 (45.6%) patients had ureteral lesions in group B, with no significant difference. On the other hand, the overall presence of postoperative infection rate was much higher for Group A (37.1% vs 16.3% P=.03).

CONCLUSIONS

UAS insertion does not result in a higher number of ureteral injuries. UAS insertion during RIRS allows a lower rate of postoperative infections. Clinical Trial Registration Number (ISRCTN registry number): 55546280.

A new urinary catheter design reduces in-vitro biofilm formation by influencing hydrodynamics

AIM

To evaluate the performance of a new catheter design based on different hydrodynamics aiming to reduce the development of biofilm, and compare it with a conventional Foley catheter (FC).

METHODS

The new proposed design (NPD) catheter is a modification of the FC, based on asymmetric positioning of the balloon and additional drainage holes allowing continuous urine drainage and complete voiding of the bladder. A first experiment was undertaken to assess drainage capability, and a second experiment was performed using a bioreactor with a set-up simulating the bladder and using the test catheter as a flow-through system. The biofilm formation of five bacterial species associated with catheter-associated urinary tract infection (CAUTI) was determined after 24 h of incubation using an MTT assay. Morphological evaluation was performed using scanning electron microscopy. In-vitro determination of residual fluid, and quantitative and morphological data on biofilm formation on the intravesical and intraluminal parts of the tested catheters were assessed.

RESULTS

Residual fluid was significantly higher in the FC (5.60 ± 0.43 mL) compared with the NPD catheter (0.2 ± 0.03 mL). The NPD catheter showed significantly less biofilm formation (P<0.0001) than the FC. Catheter design had a variable effect on biofilm formation depending on the bacterial strain tested. There was significantly less intraluminal biomass compared with intravesical biomass in both catheters (P<0.0001). Multi-layered biofilms that covered the FC surfaces completely were seen for all tested strains, while the NPD catheter surfaces showed reduced biofilm formation.

CONCLUSIONS

Modifications of the hydrodynamic characteristics of a catheter can significantly reduce bacterial colonization. Integrated design approaches combining chemical, mechanical and topographical elements can help to reduce the occurrence of CAUTI.

The surgical learning curve for salvage robot-assisted radical prostatectomy: a prospective single-surgeon study

BACKGROUND

The aim of this study was to report the overall results and the learning curve (LC) in salvage robot-assisted radical prostatectomy (sRARP) patients, in terms of morbidity, oncological and functional outcomes in a single surgeon tertiary-referral center.

METHODS

One hundred and twenty patients underwent sRARP by a single surgeon (V.P.) from 2008 to 2018. To assess the trends in the learning experience they were sub-divided in 4 groups of 30 consecutive patients based on date of surgery. The Kaplan-Meier method and regression models were used to identify survival estimations and predictors of potency, continence and biochemical failure (BCF) at 12 months.

RESULTS

As the learning experience for sRALP increased operative time (OT) was significantly shorter (from 139.5 to 121 minutes) and the amount of nerve-sparing (NS) undertaken increased (from 46% to 80%). While complications rate remained stable, estimated blood loss (EBL) and radiographic anastomotic leaks (RAL) decreased through the groups (from 124 to 69 ml and 40% to 16,7%, respectively). BCF and continence rates at 12 months after sRARP were similar among groups (23-36% and 36,7-50%, respectively) and chance of potency rates tended to increase (from 3.3% to 16-23%) but was not statistically significant. In a multivariate analysis, predictors for BCF were PSM and GS 8-10. Non-radiation primary treatment was the unique predictor of continence at 12 months after sRARP.

CONCLUSIONS

Our data may suggest a decreasing trend in terms of OT and EBL through the sRARP learning curve. While morbidity remained stable through the time, RAL trended towards a decline. A higher degree of NS was observed through the groups and there was a slight correlation trend between surgical expertise and potency recovery. PSM and GS 8-10 were predictors of BCF and non-radiation primary treatment predicted a better continence after sRARP.

Applications of the da Vinci single port (SP) robotic platform in urology: a systematic literature review

INTRODUCTION

Robotic surgical technology has evolved to include a new platform specifically designed for the single-port (SP) approach. Benefits of the da Vinci SP are still under investigation. This study aimed to review the urological literature since the first report of the use of the platform.

EVIDENCE ACQUISITION

We performed a systematic literature review of PubMed, Medline, and Web of Science databases on June 15, 2020 searching for all available articles of da Vinci SP use from December 2014 (date of the first clinical report of da Vinci SP in the urology) until June 1, 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines.

EVIDENCE SYNTHESIS

A total of 43 articles were eligible for inclusion. Ten studies reported different surgeries and techniques on cadavers while the rest described the clinical experience of different groups. We divided our article and tables into preclinical experience with surgery on cadavers, radical prostatectomy (RP) approach, and multiple types of procedures described in the same study.

CONCLUSIONS

The application of da Vinci SP in urologic procedures after five years of the first clinical investigation is feasible and safe. Radical prostatectomy is the most common intervention performed with this robot. Some groups described benefits in terms of less postoperative pain and early discharge, especially with the extraperitoneal approach. However, further studies with larger sample sizes and longer follow-up are awaited.

Applications of the da Vinci single port (SP) robotic platform in urology: a systematic literature review

INTRODUCTION

Robotic surgical technology has evolved to include a new platform specifically designed for the single-port (SP) approach. Benefits of the da Vinci SP are still under investigation. This study aimed to review the urological literature since the first report of the use of the platform.

EVIDENCE ACQUISITION

We performed a systematic literature review of PubMed, Medline, and Web of Science databases on June 15, 2020 searching for all available articles of da Vinci SP use from December 2014 (date of the first clinical report of da Vinci SP in the urology) until June 1, 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines.

EVIDENCE SYNTHESIS

A total of 43 articles were eligible for inclusion. Ten studies reported different surgeries and techniques on cadavers while the rest described the clinical experience of different groups. We divided our article and tables into preclinical experience with surgery on cadavers, radical prostatectomy (RP) approach, and multiple types of procedures described in the same study.

CONCLUSIONS

The application of da Vinci SP in urologic procedures after five years of the first clinical investigation is feasible and safe. Radical prostatectomy is the most common intervention performed with this robot. Some groups described benefits in terms of less postoperative pain and early discharge, especially with the extraperitoneal approach. However, further studies with larger sample sizes and longer follow-up are awaited.

COVID-19 and dermatology: a comprehensive guide for dermatologists

Linked articles: COVID‐19 SPECIAL FORUM. J Eur Acad Dermatol Venereol 2020; 34: e291–e310.

Urology in the Time of Coronavirus: Reduced Access to Urgent and Emergent Urological Care during the Coronavirus Disease 2019 Outbreak in Italy

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic has put a substantial burden on the Italian healthcare system, resulting in the restructuring of hospitals to care for COVID-19 patients. However, this has likely impacted access to care for patients experiencing other conditions. We aimed to quantify the impact of COVID-19 on access to care for patients with urgent/emergent urological conditions throughout Italy.

MATERIALS AND METHODS

A questionnaire was sent to 33 urological units in the AGILE consortium, asking clinicians to report on the number of urgent/emergent urological patients seen and/or undergoing surgery over a 3-week period during the peak of the COVID-19 outbreak and a reference week prior to the outbreak. ANOVA and linear regression models were used to quantify these changes.

RESULTS

Data from 27 urological centres in Italy showed a decrease from 956 patients/week seen just prior to the outbreak to 291 patients/week seen by the end of the study period. There was a difference in the number of patients with urgent/emergent urological disease seen within/during the different weeks (all p values < 0.05). A significant decrease in the number of patients presenting with haematuria, urinary retention, urinary tract infection, scrotal pain, renal colic, or trauma and urgent/emergent cases that required surgery was reported (all p values < 0.05).

CONCLUSION

In Italy, during the COVID-19 outbreak there has been a decrease in patients seeking help for urgent/emergent urological conditions. Restructuring of hospitals and clinics is mandatory to cope with the COVID-19 pandemic; however, the healthcare system should continue to provide adequate levels of care also to patients with other conditions.

Urology in the Time of Coronavirus: Reduced Access to Urgent and Emergent Urological Care during the Coronavirus Disease 2019 Outbreak in Italy

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic has put a substantial burden on the Italian healthcare system, resulting in the restructuring of hospitals to care for COVID-19 patients. However, this has likely impacted access to care for patients experiencing other conditions. We aimed to quantify the impact of COVID-19 on access to care for patients with urgent/emergent urological conditions throughout Italy.

MATERIALS AND METHODS

A questionnaire was sent to 33 urological units in the AGILE consortium, asking clinicians to report on the number of urgent/emergent urological patients seen and/or undergoing surgery over a 3-week period during the peak of the COVID-19 outbreak and a reference week prior to the outbreak. ANOVA and linear regression models were used to quantify these changes.

RESULTS

Data from 27 urological centres in Italy showed a decrease from 956 patients/week seen just prior to the outbreak to 291 patients/week seen by the end of the study period. There was a difference in the number of patients with urgent/emergent urological disease seen within/during the different weeks (all p values < 0.05). A significant decrease in the number of patients presenting with haematuria, urinary retention, urinary tract infection, scrotal pain, renal colic, or trauma and urgent/emergent cases that required surgery was reported (all p values < 0.05).

CONCLUSION

In Italy, during the COVID-19 outbreak there has been a decrease in patients seeking help for urgent/emergent urological conditions. Restructuring of hospitals and clinics is mandatory to cope with the COVID-19 pandemic; however, the healthcare system should continue to provide adequate levels of care also to patients with other conditions.

Thulium-laser retrograde intra renal ablation of upper urinary tract transitional cell carcinoma: an ESUT Study

BACKGROUND

Radical nephroureterectomy (RNU) is the gold standard treatment for upper urinary tract urothelial carcinoma (UTUC); however, patients presenting with small low-grade UTUC have been treated by flexible ureteroscopic laser ablation with good outcomes. Different types of laser have been discussed in the literature including Holmium and Neodymium lasers. We aimed to assess the safety and efficacy of Thulium laser (Tm:YAG) in the ureteroscopic ablation of UTUC.

METHODS

A retrospective observational multicentre study of patients diagnosed with papillary UTUC between January 2015 and December 2016 was carried out. All patients underwent ureteroscopic biopsy of the UTUC followed by Tm:YAG ablation. Based on the histopathological grade of the tumor, patients were counseled to undergo either RNU (high- grade tumors) or conservative management and follow-up (low-grade tumor).

RESULTS

RNU was performed in 31 patients, while the remaining 47 patients (undergone Tm:YAG ablation only) were followed up for a mean of 11.7 months with only 19.2% of patients showing upper tract recurrence and no patients showed postoperative ureteral strictures. Limitations include the short follow-up and retrospective nature of the study.

CONCLUSIONS

On the short term, thulium Laser ablation of UTUC is safe and feasible especially in low-grade UTUC.

Thulium-laser retrograde intra renal ablation of upper urinary tract transitional cell carcinoma: an ESUT Study

BACKGROUND

Radical nephroureterectomy (RNU) is the gold standard treatment for upper urinary tract urothelial carcinoma (UTUC); however, patients presenting with small low-grade UTUC have been treated by flexible ureteroscopic laser ablation with good outcomes. Different types of laser have been discussed in the literature including Holmium and Neodymium lasers. We aimed to assess the safety and efficacy of Thulium laser (Tm:YAG) in the ureteroscopic ablation of UTUC.

METHODS

A retrospective observational multicentre study of patients diagnosed with papillary UTUC between January 2015 and December 2016 was carried out. All patients underwent ureteroscopic biopsy of the UTUC followed by Tm:YAG ablation. Based on the histopathological grade of the tumor, patients were counseled to undergo either RNU (high- grade tumors) or conservative management and follow-up (low-grade tumor).

RESULTS

RNU was performed in 31 patients, while the remaining 47 patients (undergone Tm:YAG ablation only) were followed up for a mean of 11.7 months with only 19.2% of patients showing upper tract recurrence and no patients showed postoperative ureteral strictures. Limitations include the short follow-up and retrospective nature of the study.

CONCLUSIONS

On the short term, thulium Laser ablation of UTUC is safe and feasible especially in low-grade UTUC.

En-bloc resection of bladder tumors for pathological staging: the value of lateral margins analysis

BACKGROUND

In endoscopic resection of colorectal tumors, the pathological assessment of the lateral margins is a strong predictor of tumor recurrence after resection. The aim of the current study is to evaluate the value of the peritumoral margins assessment in ERBT on tumor recurrence.

METHODS

We retrospectively analyzed the data of 50 consecutive patients with NMIBC and treated by ERBT between January and December 2017.

RESULTS

The lateral margins showed dysplasia in 16 patients and malignancy in three patients. Local recurrence occurred in 14 (28%) patients. It was noted that 57% of patients with recurrence showed some degree of dysplasia or malignancy in the lateral margin; however, on multivariate logistic regression lateral margins lesions were not significantly associated with recurrence (OR 2.175, 95% CI: 0.430-10.996, P=0.35).

CONCLUSIONS

ERBT may improve the pathological report of bladder tumor. There was a trend toward increased rate of recurrence in patients with dysplasia or malignancy in their lateral margins; however, this was not statistically significant on multivariate analysis. Further studies with larger sample sizes are required to assess the value of lateral margin analysis.

Ex vivo fluorescence confocal microscopy: the first application for real-time pathological examination of prostatic tissue

OBJECTIVE

To report the first application of ex vivo fluorescence confocal microscopy (FCM) - a novel optical technology that is capable of providing fast microscopic imaging of unfixed tissue specimens- in the urological field assessing its diagnostic accuracy for non neoplastic and cancerous prostate tissue (prostatic adenocarcinoma) compared to the 'gold standard' histopathological diagnoses.

PATIENTS AND METHODS

In all, 89 specimens from 13 patients with clinically localised prostate cancer were enrolled into the study. All patients underwent robot-assisted laparoscopic radical prostatectomy with fresh prostatic tissue biopsies taken at the end of each intervention using an 18-G biopsy punch. Specimens were randomly assigned to the three collaborating pathologists for evaluation. Intra- and inter-observer agreement was tested by the means of Cohen's κ. The diagnostic performance was evaluated on receiver operating characteristic curve analysis.

RESULTS

The overall diagnostic agreement between FCM and histopathological diagnoses was substantial with a 91% correct diagnosis (κ = 0.75) and an area under the curve of 0.884 (95% confidence interval 0.840-0.920), 83.33% sensitivity, and 93.53% specificity.

CONCLUSION

FCM seems to be a promising tool for enhanced specimens' reporting performance, given its simple application and very rapid microscopic image generation (<5 min/specimen). This technique may potentially be used for intraoperative pathological specimens' analysis.

Macroscopic locoregional relapse from prostate cancer: which role for salvage radiotherapy?

INTRODUCTION

Salvage radiotherapy (SRT) after radical prostatectomy for prostate cancer (PCa) is recommended as soon as PSA rises above 0.20 ng/ml, but many patients (pts) still experience local macroscopic relapse. The aim of this multicentric retrospective analysis was to evaluate the role of SRT in pts with macroscopic relapse.

MATERIALS AND METHODS

From 2001 to 2016, 105 consecutive pts with macroscopic PCa relapse underwent SRT ± androgen deprivation therapy (ADT). Mean age was 72 years. At time of relapse, 29 pts had a PSA value < 1.0 ng/mL, 50 from 1.1 to 5, and 25 pts > 5. Before SRT, 23 pts had undergone 18F-choline PET and 15 pts pelvic MRI. Ninety-four pts had prostatic bed relapse only, and four nodal involvement. Fifty-one pts were previously submitted to first-line ADT, while 6 pts received ≥ 2 lines.

RESULTS

At a median follow-up of 52 months, 89 pts were alive, while 16 were dead. Total RT dose to macroscopic lesions was > 70 Gy in 58 pts, 66-70 Gy in 43, and < 66 Gy in 4 pts. In 72 pts, target volume encompassed only the prostatic bed with sequential boost to macroscopic site; 33 pts received prophylactic pelvic RT. Ten-year overall survival was 76.1%, while distant metastasis-free survival was 73.3%. No grade 4-5 toxicities were found.

CONCLUSIONS

SRT ± ADT for macroscopic relapse showed a favorable oncological outcome supporting its important role in this scenario. Data from this series suggest that SRT may either postpone ADT or improve results over ADT alone in appropriately selected pts.

Advantages of the supine transgluteal approach for distal ureteral stone extracorporeal shock wave lithotripsy: outcomes based on CT characteristics

BACKGROUND

Extracorporeal shock wave lithotripsy (ESWL) for distal ureteral stones can be performed in prone or supine position. The aim of this study was to investigate the advantages brought by the supine transgluteal ESWL approach for distal ureteral stones treatment using real-time ultrasound (US), and to show how computerized tomography (CT) scan parameters may be related to the outcomes.

METHODS

Seventy consecutive supine transgluteal ESWL of distal ureteral stones were performed. All patients had a pre-treatment CT scan. The following parameter were evaluated: stone size, Hounsfield Units, skin-to-stone distance, sciaticum majus foramen width, stone to ureteral ostium distance, fragmentation and expulsion perception during the treatment, and the stone-free status. Stone focusing was obtained US, which allows a real-time visualization of stone location and fragmentation. Follow-up included a kidney ureter bladder (KUB) film and US examination at 2-3 weeks after treatment (median time: 18 days). Stone-free condition was defined as the complete absence of stone fragments. A linear regression analysis was used to assess the possible variables mostly related to stone-free status. P<0.05 was considered as significant.

RESULTS

Median number of SWL sessions for patient was 1 (IQR: 1-1), mean 1.2±0.5. The re-treatment rate for stone-free patients was 18.3%. Stone-free rate was 85.7%. A clear and real time US stone fragmentation was perceived by the surgeon during the treatment in 42/70 (60%) of patients and correlated to the definitive stone-free status (P=0.04). Stone to ureteral ostium distance was the only variable affecting the stone-free condition (P=0.01).

CONCLUSIONS

Supine transgluteal SWL of distal ureteral stones provide satisfactory outcomes in terms of stone-free rate. The distance of the stone to the ureteral ostium, measured by CT, appeared to be the only significant variable connected to SWL success.

Testicular metastasis of signet ring cell tumour of unknown origin: diagnostic features of a tricky case

We introduce the diagnostic complexity of a testicular metastasis by signet ring cell adenocarcinoma of unknown origin. Testicular metastases are a rare event but, particular after 50 years of age, a testicular mass could represent a metastasis.

Giant genital cavernous haemangioma: case description and surgical management

Giant genital haemangiomas are rare occurrences. Once properly diagnosed, they should be managed by surgery with wide and deep margins. We present a clinical case and provide suggestions for diagnosis and treatment of this unusual pathology.

Knotted ureteral catheter in an 83-year-old man: case presentation and urological non-invasive management in the elderly

Ureteral catheters are important devices in the management of upper urinary tract obstruction; severe complications due to insertion or stent permanence are unusual. We report the clinical case and management of a knotted ureteral stent in an 83-year-old man.

Urological concerns: Should trans-urethral catheter be located over or under the thigh?

INTRODUCTION

Bladder catheterization is a common practice after several surgical procedures; a wrong trans-urethral catheter position can affect the outcomes of some urological maneuvers. We assess with a physical model the variation of intra-vesical pressures due to different locations of the catheter.

MATERIALS AND METHODS

Using a plastic bag fulfilled with 5l of normal saline, we try to reproduce bladder condition assessing pressures in case of catheter located over or under the thigh.

RESULTS

In case of catheter over the thigh, the flow of liquid is not allowed, and only a pressure of 23 cm of water induces the passage of fluid.

CONCLUSION

A wrong catheter position may adversely affect intravesical pressures; this finding has to be taken into consideration, especially when dealing with post-urological surgery catheterization.

Well-differentiated giant scrotal liposarcoma: case presentation and management

Scrotal liposarcoma is an uncommon disease, usually found after the fifth decade. We describe the case of a well-differentiated scrotal liposarcoma associated with a considerable inflammatory reaction, treated with surgical ablation.

Indwelling Ureteral Stents and Sexual Health: A Prospective, Multivariate Analysis

PURPOSE

Ureteral stents are common devices in urological practice. However, a stent may provoke lower urinary tract symptoms that severely affect quality of life. We evaluated the relationship between ureteral stents and male erection/female sexuality.

MATERIALS AND METHODS

A total of 30 men and 20 women undergoing ureteral stent positioning were considered. Patients affected by risk factors for erectile dysfunction or hormonal and metabolic alterations were excluded. Hystero-ovariectomy and menopause were considered exclusion criteria. Three questionnaires were administered before stenting and 45 to 60 days after stent positioning, including the International Prostate Symptom Score, the International Index of Erectile Function-5 for men and the Female Sexual Function Index for women.

RESULTS

Mean age was 45 years in men and 39 years in women. The mean+/-SD International Index of Erectile Function-5 score was 23.2+/-1.27 and the mean Female Sexual Function Index score was 32.15+/-2.71 before stent positioning. No lower urinary tract symptoms were reported before the procedure. After the ureteral stent was indwelling the mean International Index of Erectile Function-5 score was 13.5+/-4.01 and the mean Female Sexual Function Index score was 23.6+/-14.66 (p=0.000 and 0.007, respectively). Of 30 men 25 reported a pathological International Index of Erectile Function-5 score and 6 of 20 women denied any sexual activity due to stent related anxiety, resulting in the minimum Female Sexual Function Index score. In the remaining 14 women sexual life was not significantly impaired by the ureteral stent (p=0.08).

CONCLUSIONS

Ureteral stents impaired the quality of sexual life in male and female subjects. In men the most important distress was in regard to erectile function, probably related to lower urinary tract symptoms. Conversely female sexuality appeared to be severely impaired due to stent related psychological concerns.

Bacille Calmette-Guérin intravesical instillation and erectile function: is there a concern?

The aim of our study was to evaluate the effect of bacille Calmette-Guérin (BCG) therapy on erectile function in a cohort of male patients affected by non-muscle invasive bladder cancer. Thirty male patients undergoing BCG treatment for non-muscle invasive bladder cancer were enrolled in the study. Their mean age was 60.4 years. None of the patients had risk factors for erectile dysfunction (ED). All subjects underwent a BCG standard schedule therapy (once weekly instillation for 6 weeks). International Index of Erectile Function (IIEF-5) and International Prostate Symptom score (I-PSS) were addressed to the patients during the treatment schedule (at fourth or fifth instillation) and 1 month after the last instillation. The mean IIEF-5 score was 17.6 +/- 6.7 during therapy and 21.7 +/- 2.92 a month after the last instillation (P=0.008). Baseline ED and the association with lower urinary tract symptoms are variables significantly connected with post-treatment results (P=0.016 and 0.00 respectively) whereas the age seems not to be related to ED (P=0.256). No major side effects were recorded. It is concluded that BCG treatment is effective for prophylaxis of non-muscle invasive bladder cancer; however, it may induce a high incidence of ED. Although this effect is transient and reversible, erectile failure is another source of psychological distress that adversely affects the quality of life of men undergoing BCG treatment.

Efficacy of expulsive therapy using nifedipine or tamsulosin, both associated with ketoprofene, after shock wave lithotripsy of ureteral stones

Extracorporeal shock wave lithotripsy (ESWL) is currently considered one of the main treatments for ureteral stones. Some studies have reported the effectiveness of pharmacologic therapies (calcium antagonists or alpha-blockers) in facilitating ureteral stone expulsion after ESWL. We prospectively evaluated the efficacy, after ESWL, of nifedipine on upper-middle ureteral stones, and tamsulosin on lower ureteral stones, both associated to ketoprofene as anti-edema agent. From January 2003 to March 2005 we prospectively evaluated 113 patients affected by radiopaque or radiolucent ureteral stones. Average stone size was 10.16 +/- 2.00 mm (range 6-14 mm). Thirty-seven stones were located in the upper ureter, 27 in the middle ureter, and 49 in the lower ureter. All patients received a single session of ESWL (mean number of shock waves: 3,500) by means of a Dornier Lithotripter S (mean energy power for each treatment: 84%). Both ultrasound and X-ray were used for stone scanning. After treatment, 63 of 113 patients were submitted to medical therapy to aid stone expulsion: nifedipine 30 mg/day for 14 days administered to 35 patients with upper-middle ureteral stones (group A1) and tamsulosin 0.4 mg/day for 14 days administered to 28 patients with stones located in the distal ureter (group A2). The remaining 50 patients were used as a control group (29 upper-middle ureteral stones-B1-and 21 lower ureteral stones-B2-), receiving only pain-relieving therapy. No significant difference in stone size between the groups defined was observed. Stone clearance was assessed 1 and 2 months after ESWL by means of KUB, ultrasound scan and/or excretory urography. A stone-free condition was defined as complete stone clearance or the presence of residual fragments smaller than 3 mm in diameter. The stone-free rates in the expulsive medical therapy group were 85.7 and 82.1% for the nifedipine (A1) and tamsulosin (A2) groups respectively; stone-free rates in the control groups were 51.7 and 57.1% (B1 and B2, respectively). Five patients (14.3%) in group A1, 5 (17.8%) in group A2, 14 (48.3%) in group B1 and 9 (42.8%) in group B2 were not stone-free after a single ESWL session and required ESWL re-treatment or an endoscopic treatment. Medical therapy following ESWL to facilitate ureteral stone expulsion results in increased 1- and 2-month stone-free rates and in a lower percentage of those needing re-treatment. The efficacy of nifedipine for the upper-mid ureteral tract associated with ketoprofene makes expulsive medical therapy suitable for improving overall outcomes of ESWL treatment for ureteral stones.

Laparoscopic radical cystectomy: an Italian survey

BACKGROUND

Radical cystectomy with urinary diversion is the current gold standard procedure for muscle-invasive bladder cancer. However, laparoscopic radical cystectomy (LRC) has evolved rapidly worldwide during the past decade, despite its complexity due to both the demolitive step with management of a highly aggressive cancer and the reconstructive step. The authors performed a survey to assess the Italian experience with LRC and urinary diversion in an effort to point out the volume of the procedure in their country, providing some surgical details.

METHODS

A total of 10 Italian urologic departments with experts in laparoscopic urologic surgery were contacted and asked to participate in a two-page survey concerning indications for cystectomy, laparoscopic technique, intra- and postoperative complications, and follow-up evaluation of the procedure when available.

RESULTS

Five sites elected to participate, and a total of 83 LRCs were collected. All centers used five trocar ports. The mean operative time was 8 h and 40 min, and the estimated blood loss was 376 ml. In two cases, the procedure was converted to open surgery. Postoperative complications consisted of one urinary leakage, one fistula, and one atrium rupture. A retrieval sac was used in all cases. Urinary diversions consisted of 43 ileal conduits, 26 orthotopic diversions, and 14 other techniques. The mean follow-up period was 9 months (range, 1-36 months). No tumor seeding was recorded.

CONCLUSIONS

The LRC procedure is feasible although technically demanding. The morbidity of this procedure is evident, but may be reduced with further experience. Bowel management and reconstruction remain the most challenging part of the procedure.

Immediate Improvement in Penile Hemodynamics after Cessation of Smoking: Previous Results

OBJECTIVES

To assess the chronologic relationship between the cessation of smoking and the restoration of erectile function. Smoking is associated with an increased risk of erectile dysfunction.

METHODS

Twenty active smokers (20 to 40 cigarettes/day) affected by erectile dysfunction (International Index of Erectile Function 5-item score less than 21) were enrolled in the study. The mean age was 40 years. All the patients underwent penile color Doppler ultrasonography during the basic and dynamic phases (10 microg prostaglandin E1). A second Doppler evaluation was performed 24 to 36 hours after cessation of smoking. The peak systolic velocity (PSV) and end-diastolic velocity (EDV) were recorded. The PSV and EDV cutoff value was 30 cm/s and 5 cm/s, respectively.

RESULTS

Of the 20 patients, 10 (50%) had normal PSV values but only 5 (25%) had normal EDV values at the baseline Doppler evaluation. All the patients (100%) had normal PSV values at the second penile Doppler evaluation after smoking withdrawal, and 17 (85%) also had normal EDV values. The average PSV was 40.1 and 50.3 cm/s (P = 0.09) and the mean EDV was 6.8 and 2.4 cm/s (P <0.01) at the baseline penile Doppler examination and after smoking withdrawal, respectively.

CONCLUSIONS

Within 24 to 36 hours of the cessation of cigarette smoking, the color Doppler parameters demonstrated a significant improvement in EDV and a trend toward an increase in PSV. Additional clinical evaluation is required to further characterize the expeditious improvement in erectile function after the cessation of smoking.

Medical Therapy of Urolithiasis

Nephrolithiasis treatment has become easier and less invasive with the development of extracorporeal shockwave lithotripsy (SWL) and endourologic techniques. However, medical therapy represents a well-established and complementary approach that can improve the efficacy of SWL and endourology. During recent decades, pharmacologic intervention has become more effective in stone disease: drugs can control the pain of renal colic, interfere at various levels in lithogenesis, and contribute to the expulsion of stones. It is well known that lithogenesis is a multifactorial process influenced by environmental-nutritional factors (low urinary volume, diet rich in animal protein, etc) and metabolic alterations; i.e., hypercalciuria, hyperuricosuria, and deficiency of stone-inhibiting factors (citrate, magnesium, glycosaminoglycans [GAGs]). Specific drugs such as citrate, allopurinol, and thiazide represent highly effective treatments for the promoting factors. Furthermore, recent findings suggest an interesting role for a phytotherapeutic agent, Phillantus niruri, and its inhibitory action on calcium oxalate crystallization related to the higher incorporation of GAGs into the calculi. Another step forward in medical management of stone disease is expulsive therapy. Many studies have proven the efficacy of medical expulsive therapy with nifedipine and alpha-blockers: their specific action on ureteral smooth muscle in association with anti-edema drugs accounts for their efficacy in expelling ureteral stones. In this paper, we provide an update on the medical treatment of stone disease, focusing our attention on what is known and what is new in renal colic and litholithic and expulsive medical therapy.

Can Phyllanthus niruri Affect the Efficacy of Extracorporeal Shock Wave Lithotripsy for Renal Stones? A Randomized, Prospective, Long-Term Study

PURPOSE

Phyllanthus niruri is a plant used in Brazilian folk medicine for the treatment of urolithiasis. We assessed the efficacy of P. niruri after extracorporeal shock wave lithotripsy for renal stones.

MATERIALS AND METHODS

We prospectively evaluated 150 patients with renal stones that were as large as 25 mm and composed of calcium oxalate. All patients received 1 to 3 extracorporeal shock wave lithotripsy sessions by Dornier Lithotriptor S. After treatment 78 of 150 patients (52%) underwent therapy with Uriston, a P. niruri extract (2 gm daily) for at least 3 months (group 1). Otherwise 72 of 150 patients (48%) were used as a control group (group 2). No significant difference in stone size between the 2 groups was found. Stone clearance was assessed after 30, 60, 90 and 180 days by abdominal x-ray and ultrasound scan.

RESULTS

Stone-free rate (stone-free defined as the absence of any stone or residual fragments less than 3 mm) was 93.5% in group 1 and 83.3% in group 2 (p = 0.48) at the end point of the followup (180 days). For lower caliceal stones (56 patients) the stone-free rate was 93.7% in the treatment group and 70.8% in the control group (p = 0.01). Re-treatment need for group 1 was 39.7% and for group 2 it was 43.3% (p = 0.2). No side effects were recorded with extracorporeal shock wave lithotripsy or P. niruri therapy.

CONCLUSIONS

Regular self-administration of P. niruri after extracorporeal shock wave lithotripsy for renal stones results in an increased stone-free rate that appears statistically significant for lower caliceal location. Its efficacy and the absolute lack of side effects make this therapy suitable to improve overall outcomes after extracorporeal shock wave lithotripsy for lower pole stones.

Changes in peak systolic velocity induced by chronic therapy with phosphodiesterase type-5 inhibitor

The aim of this study was to assess the influence of chronic therapy with phosphodiesterase type-5 inhibitor on penile haemodynamics at colour Doppler ultrasound. Thirty patients affected by erectile dysfunction (ED) of different aetiology tested with the International Index of Erectile Function (IIEF-5) were evaluated with penile colour Doppler ultrasound during basic and dynamic phases (10 microg PGE1) before and after chronic self-administration of sildenafil citrate (dosage: 100 mg as required, two to three times a week) for a period of 5-20 months (mean: 12.3). Treatment was interrupted 14-21 days before the second ultrasound evaluation. Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were recorded by means of colour Doppler; cut off values were 25 and 5 cm s(-1) respectively. Data were compared by nonparametric tests. Twenty-two of the 30 patients showed normal pre-treatment PSV, while eight of 30 had an insufficient arterial flow. Mean pre-treatment EDV was 4.7 +/- 0.5. After chronic therapy with sildenafil, a global improvement of 10.5% on PSV was seen (P < 0.001), without any statistical difference between patients with normal pre-treatment peak and those with a borderline one. No statistically significant changes were found for EDV (P = 0.98). It is concluded that chronic therapy with phosphodiesterase-5 inhibitor results in a significant improvement in PSV values, probably due to a penile chronic vasoactive enhancement.

Experience with fibrin glue in bulbar urethral reconstruction using dorsal buccal mucosa graft

Buccal mucosa dorsal onlay graft urethroplasty represents a widespread method for bulbar urethral stricture repair. We describe a modified procedure with the use of fibrin glue applied on the receiving bed before graft location.

Transrectal contrast-enhanced (Levovist) ultrasonography in evaluation of urinary leakage after radical prostatectomy: A preliminary report

Quick postoperative catheter removal remains one of the main goals of radical prostatectomy, but it leads to a greater risk of urinary leakage. Transrectal ultrasonography with enhancing contrast medium (Levovist) is a simple, effective, and minimally invasive examination to evaluate vesicourethral integrity.