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Objective: To report the outcomes of intra- and extra-peritoneal robot-assisted radical prostatectomy (RARP) and robot-assisted radical cystectomy (RARC) with Hugo™ robot-assisted surgery (RAS) system (Medtronic, Minneapolis, MN, USA). Methods: Data of twenty patients who underwent RARP and one RARC at our institution between February 2022 and January 2023 were reported. The primary endpoint of the study was to report the surgical setting of Hugo™ RAS system to perform RARP and RARC. The secondary endpoint was to assess the feasibility of RARP and RARC with this novel robotic platform and report the outcomes. Results: Seventeen patients underwent RARP with a transperitoneal approach, and three with an extraperitoneal approach; and one patient underwent RARC with intracorporeal ileal conduit. No intraoperative complications occurred. Median docking and console time were 12 (interquartile range [IQR] 7–16) min and 185 (IQR 177–192) min for transperitoneal RARP, 15 (IQR 12–17) min and 170 (IQR 162–185) min for extraperitoneal RARP. No intraoperative complications occurred. One patient submitted to extraperitoneal RARP had a urinary tract infection in the postoperative period that required an antibiotic treatment (Clavien-Dindo Grade 2). In case of transperitoneal RARP, two minor complications occurred (one pelvic hematoma and one urinary tract infection; both Clavien-Dindo Grade 2). Conclusion: Hugo™ RAS system is a novel promising robotic platform that allows to perform major oncological pelvic surgery. We showed the feasibility of RARP both intra- and extra-peritoneally and RARC with intracorporeal ileal conduit with this novel platform.

Background: Adverse events induced by intravesical bacillus Calmette-Guérin (BCG) to treat high-grade non–muscle-invasive bladder cancer (NMIBC) often lead to treatment discontinuation. The EAU-RF NIMBUS trial found a reduced number of standard-dose BCG instillations to be inferior with the standard regimen. Nonetheless, it remains important to evaluate whether patients in the reduced BCG treatment arm had better quality of life (QoL) due to a possible reduction in toxicity or burden. Objective: To evaluate whether patients in the EAU-RF NIMBUS trial experienced better QoL after a reduced BCG instillation frequency. Design, setting, and participants: A total of 359 patients from 51 European sites were randomized to one of two treatment arms between December 2013 and July 2019. The standard frequency arm (n = 182) was 6 weeks of BCG induction followed by 3 weeks of maintenance at months 3, 6, and 12. The reduced frequency arm (n = 177) was BCG induction at weeks 1, 2, and 6, followed by maintenance instillations at weeks 1 and 3 of months 3, 6, and 12. Outcome measurements and statistical analysis: Analyses were performed using an intention-to-treat analysis and a per-protocol analysis. QoL was measured using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 version 3.0 (QLQ-C30 v.03) prior to the first and last instillations of each BCG cycle. Group differences were determined using linear regression corrected for QoL at baseline. Differences in QoL over time were tested for significance using a linear mixed model. Side effects were recorded by the treating physician using a standardized form. Chi-square tests were used to compare the side-effect frequency between the arms. Results and limitations: There were no significant differences in the means of each QoL scale between the two arms. There were also no significant changes over time in all QoL domains for both arms. However, differences in the incidence of general malaise at T1 (before the last induction instillation), frequency, urgency, and dysuria at T7 (before the last maintenance instillation) were detected in favor of the reduced frequency arm. Conclusions: Reducing the BCG instillation frequency does not improve the QoL in NMIBC patients despite lower storage symptoms. Patient summary: In this study, we evaluated whether a reduction in the number of received bacillus Calmette-Guérin instillations led to better quality of life in patients with high-grade non–muscle-invasive bladder cancer. We found no difference in the quality of life between the standard and the reduced bacillus Calmette-Guérin instillation frequency. We conclude that reducing the number of instillations does not lead to better quality of life in patients with high-grade non–muscle-invasive bladder cancer.

ABSTRACT Introduction: Robotic approach has shown its feasibility and safety with respect to open approach for radical cystectomy (1). The performances of Hugo™ RAS system (Medtronic, Minneapolis, USA) have been demonstrated in several clinical scenarios (2-5). We report the feasibility and surgical settings of the first series of robot-assisted radical cystectomy (RARC) with intracorporeal ileal-conduit performed with Hugo™ RAS system. Methods: Two patients were submitted to RARC with ileal conduit at our institution. The trocar placement scheme and the operating room setting with docking angles of the four arms were already described (6). A 12-mm and a 5-mm trocar for the assistant were placed. In both cases, an ileal-conduit with a Wallace type-1 uretero-enteric derivation was performed intra-corporeally. Results: The first patient was a 71-year-old male with a very-high risk non-muscle invasive bladder cancer(BC), and the second patient was a 64-year-old male with a diagnosis of T2 high-grade BC. Operative times were 360 and 420 minutes with a docking time of 12 and 9 minutes, respectively. No intraoperative complications occurred. The estimated blood loss was 200ml and 400ml, respectively. The second patient developed an ileus on postoperative day 4 (Clavien-Dindo grade 2). No positive surgical margins were recorded. No recurrence nor progression occurred during follow-up. Conclusion: RARC with intracorporeal ileal conduit urinary diversion is feasible with Hugo™ RAS system. We provided insight into the surgical setting using this novel robotic platform to help new adopters to face this challenging procedure. These findings may help a wider distribution of robotic programs for BC treatment.

Background: Grade of non–muscle-invasive bladder cancer (NMIBC) is an important prognostic factor for progression. Currently, two World Health Organization (WHO) classification systems (WHO1973, categories: grade 1–3, and WHO2004 categories: papillary urothelial neoplasm of low malignant potential [PUNLMP], low-grade [LG], high-grade [HG] carcinoma) are used. Objective: To ask the European Association of Urology (EAU) and International Society of Urological Pathology (ISUP) members regarding their current practice and preferences of grading systems. Design, setting, and participants: A web-based, anonymous questionnaire with ten questions on grading of NMIBC was created. The members of EAU and ISUP were invited to complete an online survey by the end of 2021. Thirteen experts had previously answered the same questions. Outcome measurements and statistical analysis: The submitted answers from 214 ISUP members, 191 EAU members, and 13 experts were analyzed. Results and limitations: Currently, 53% use only the WHO2004 system and 40% use both systems. According to most respondents, PUNLMP is a rare diagnosis with management similar to Ta-LG carcinoma. The majority (72%) would consider reverting back to WHO1973 if grading criteria were more detailed. Separate reporting of WHO1973-G3 within WHO2004-HG would influence clinical decisions for Ta and/or T1 tumors according the majority (55%). Most respondents preferred a two-tier (41%) or a three-tier (41%) grading system. The current WHO2004 grading system is supported by a minority (20%), whereas nearly half (48%) supported a hybrid three- or four-tier grading system composed of both WHO1973 and WHO2004. The survey results of the experts were comparable with ISUP and EAU respondents. Conclusions: Both the WHO1973 and the WHO2004 grading system are still widely used. Even though opinions on the future of bladder cancer grading were strongly divided, there was limited support for WHO1973 and WHO2004 in their current formats, while the hybrid (three-tier) grading system with LG, HG-G2, and HG-G3 as categories could be considered the most promising alternative. Patient summary: Grading of non–muscle-invasive bladder cancer (NMIBC) is a matter of ongoing debate and lacks international consensus. We surveyed urologists and pathologists of European Association of Urology and International Society of Urological Pathology on their preferences regarding NMIBC grading to generate a multidisciplinary dialogue. Both the “old” World Health Organization (WHO) 1973 and the “new” WHO2004 grading schemes are still used widely. However, continuation of both the WHO1973 and the WHO2004 system showed limited support, while a hybrid grading system composed of both the WHO1973 and the WHO2004 classification system may be considered a promising alternative.

Several randomized controlled trials (RCTs) comparing en bloc resection of bladder tumor (ERBT) to conventional transurethral resection of bladder tumor (cTURBT) have reported controversial results. In particular, the 1-yr recurrence rate ranged from 5% to 40% for ERBT and from 11% to 31% for cTURBT. We provide an updated analysis of an RCT comparing the 1-yr recurrence rate for ERBT versus cTURBT for a cohort of 219 patients comprising 123 (56.2%) in the ERBT group and 96 (43.8%) in the cTURBT group. At 1 yr, 11 patients in the ERBT group and 12 in the cTURBT group experienced recurrence. The heterogeneity in recurrence observed in other RCTs could be explained by the scarce and heterogeneous adoption of tools and techniques that have been proved to lower the recurrence rate, supporting the need for implementation of a TURBT checklist. This prompted us to create a checklist of items for RCTs to standardize how TURBT is performed in trials, facilitate comparison between studies, assess the applicability of results in real-life practice, and provide a push towards high-quality resections to improve oncological outcomes. The checklist could have utility as a user-friendly guide for reporting TURBT procedures to improve our understanding of trials involving this procedure. Patient summary: We compared the recurrence rate at 1 year for bladder cancer treated with two different approaches to remove bladder tumors in our center. The rates were comparable for the two groups. Other studies have found widely differing recurrence rates, so we propose use of a checklist to standardize these procedures and provide more consistent outcomes for patients.

There is a critical need to establish reference response rates following bladder-sparing therapies administered in the setting of bacillus Calmete-Guerin (BCG)-unresponsive non–muscle-invasive bladder cancer (NMIBC). We sought to determine the efficacy of different interventions in recent trials accruing patients fulfilling the strict BCG-unresponsive definition established by the US Food and Drug Administration. We performed a systematic review and meta-analysis for clinical trials in the BCG-unresponsive disease space to include published and presented results. The primary endpoints were complete response rate for CIS±Ta/T1 tumors, recurrence-free rate for patients with papillary-only disease, and disease-free rate in studies enrolling both papillary CIS tumors (Ta/T1/CIS). I2 was used for assessing heterogeneity. Eleven studies using 9 different therapeutic agents in a total of 909 patients with BCG-unresponsive NMIBC were identified. The resulting outcomes at 3, 6, and 12 months were 44%, 38%, and 25% complete response rate in CIS±Ta/T1 tumors; 73%, 58%, and 48% recurrence-free rate in papillary-only; and 48%, 22%, and 43% disease-free rate in combined Ta/T1/CIS, respectively. Relatively low levels of heterogeneity were observed amongst studies restricted to papillary-only or CIS±Ta/T1 tumors. Future randomized controlled studies are needed and will likely require stratification between papillary-only and CIS±Ta/T1 tumors.

PURPOSETo assess the effect of clinical and pathological variables on cancer-specific and overall survival (OS) in de novo metastatic patients from a collaborative of primarily Latin American countries.PATIENTS AND METHODSOf 4,060 patients with renal cell carcinoma diagnosed between 1990 and 2015, a total of 530 (14.5%) had metastasis at clinical presentation. Relationships between clinical and pathological parameters and treatment-related outcomes were analyzed by Cox regression and the log-rank method.RESULTSOf 530 patients, 184 (90.6%) had died of renal cell carcinoma. The median OS of the entire cohort was 24 months. American Society of Anesthesiology classification 3-4 (hazard ratio [HR]: 1.64), perirenal fat invasion (HR: 2.02), and ≥ 2 metastatic organ sites (HR: 2.19) were independent prognostic factors for 5-year OS in multivariable analyses. We created a risk group stratification with these variables: no adverse risk factors (favorable group), median OS not reached; one adverse factor (intermediate group), median OS 33 months (HR: 2.04); and two or three adverse factors (poor risk group), median OS 14 months (HR: 3.58).CONCLUSIONOur study defines novel prognostic factors that are relevant to a Latin American cohort. With external validation, these easily discerned clinical variables can be used to offer prognostic information across low- and middle-income countries.

Background: The burden of urological diseases is rising as the worldwide population ages. Although specialist urological provision is needed, a large proportion of these conditions will be managed in primary care. The importance of including urology in medical education currently remains unclear. Objective: To provide recommendations on undergraduate medical education for urology in Europe. Design, setting, and participants: A three-round Delphi process to reach consensus on standardising the undergraduate urology curriculum in Europe was endorsed by the European School of Urology. Outcome measurements and statistical analysis: The levels of agreement were set using a nine-point scale according to the GRADE grid: 1–3, disagree; 4–6, uncertain; and 7–9, agree. Consensus was defined as at least 70% of the participants scoring within the same 3-point grouping. Results and limitations: Overall, consensus was reached for 20 of 34 statements (70.5%) across the three Delphi rounds, with agreement for 75% (n = 15) and disagreement for 25% (n = 5). The following main points were agreed. Urological teaching should be introduced before year 5 of medical school, with at least 20 h of theoretical activities and at least 30 h of practical activities. Urology should be taught as a stand-alone subject rather than combined with another surgical specialty or a nephrology programme. The participants agreed that urology should be taught according to symptoms. A urology programme should include the anatomy and physiology of the urinary tract, and students should know how to clinically assess a urological patient. Conclusions: Our recommended urology pathway will allow European medical schools to provide a more comprehensive undergraduate urology curriculum. It will also help to improve and maintain standards of urology undergraduate teaching across Europe. Patient summary: Our survey showed that urology in universities should have, at minimum, time for theoretical and practical activities and should be taught as a stand-alone subject on the basis of symptoms. Students should give feedback to facilitate constant improvement and evolution of the teaching programme.

Abstract In a subset analysis of data from a 6-month, multicenter, non-interventional study, we compared change in symptoms and quality of life (QoL), and treatment tolerability, in men with moderate to severe lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) receiving tamsulosin (TAM, 0.4 mg/day) or the hexanic extract of Serenoa repens (HESr, 320 mg/day) as monotherapy. Symptoms and QoL were assessed using the IPSS and BII questionnaires, respectively. Patients in the treatment groups were matched using two statistical approaches (iterative and propensity score matching). Within the iterative matching approach, data was available from a total of 737 patients (353 TAM, 384 HESr). After 6 months, IPSS scores improved by a mean (SD) of 5.0 (4.3) points in the TAM group and 4.5 (4.7) points in the HESr group (p = 0.117, not significant). Improvements in QoL were equivalent in the two groups. TAM patients reported significantly more adverse effects than HESr patients (14.7% vs 2.1%; p

Background: Late onset of radiation-induced haemorrhagic cystitis (RHC) after radiation therapy (RT) for prostate cancer (PCa) may present or evolve severely, requiring hospitalization with invasive interventions. In the present study, we have analysed the prevalence and risk factors associated with the onset of RHC. Methods: From January 2002 to May 2017, 1421 patients undertook RT for PCa as a primary, adjuvant, or salvage treatment option. RHC presented in 5.6% (n = 80) of the patients; the diagnosis was based on clinical and endoscopic characteristics. Variables in observation included patients, tumours, and RT-dosimetry characteristics. Patients with a previous history of bladder cancer were excluded. Univariate (Student t/Chi square) and uni-/multivariate Cox regression analysis were performed; the events and time-points were hospitalization and time-to-event, respectively. Results: There were 80 patients with a mean age at RT of 70.1 years (SD 6.4), mean time lag to RHC of 43.9 months (SD 37.5). Median Emergency attendance was two and three times for patients without/with hospitalization, respectively. There were in total 64 admissions with invasive treatment required in 26/36 (72.2%) of the patients hospitalised, including transurethral fulguration in 22 and radical cystectomy in 5. Patients at higher risk of hospitalization were those undertaking antiplatelet/anticoagulant treatment (HR:3.30; CI 95%:1.53–3.30; p = 0.002) and those treated with salvage RT with higher bladder volume receiving >70 Gy (bladder V70) (HR:1.03; CI 95%:1.01–1.05; p = 0.027). At receiving operating characteristic analysis, the cutoff for bladder V70 was 29%. Conclusion: Nearly half of patients presenting RHC may require invasive treatment including cystectomy. Risk factors associated with hospitalization are patients undertaking antiplatelet/coagulant treatment and bladder V70 > 29% in salvage RT patients.

Abstract Background The Female Sexual Function Index (FSFI) is a commonly used scale for the assessment of female sexual function. Our aim was to develop and validate a Spanish short version of the FSFI. Methods A parallel exploratory, sequential mixed-methods approach was used, involving 2 sites. The process consisted of 2 steps: (1) cognitive and content validation of the previously translated FSFI in the Spanish population, both through a focus group; and item selection based on the difficulty and discrimination parameters using item response theory (IRT), thereby obtaining a short version of the scale (sFSFI-sv); (2) assessment of test–retest reliability (intraclass correlation coefficient, ICC) of the sFSFI-sv. The presence or absence of a sexual disorder variable based on clinical interview was used on the Receiver Operating Characteristic (ROC) to establish the cut off point whose Area Under the Curve (AUC) based on sensibility and specificity was maximum. Results Specific modifications of the FSFI were made according to the focus group results. 114 women were included for IRT analysis. The initial IRT model pointed to the exclusion of items 1, 2, 5, 11, 18, and 19 (S-χ2 p

Abstract Background To evaluate demographic, clinical and pathological characteristics of small renal masses (SRM) (≤ 4 cm) in a Latin-American population provided by LARCG (Latin-American Renal Cancer Group) and analyze predictors of survival, recurrence and metastasis. Methods A multi-institutional retrospective cohort study of 1523 patients submitted to surgical treatment for non-metastatic SRM from 1979 to 2016. Comparisons between radical (RN) or partial nephrectomy (PN) and young or elderly patients were performed. Kaplan-Meier curves and log-rank tests estimated 10-year overall survival. Predictors of local recurrence or metastasis were analyzed by a multivariable logistic regression model. Results PN and RN were performed in 897 (66%) and 461 (34%) patients. A proportional increase of PN cases from 48.5% (1979–2009) to 75% (after 2009) was evidenced. Stratifying by age, elderly patients (≥ 65 years) had better 10-year OS rates when submitted to PN (83.5%), than RN (54.5%), p = 0.044. This disparity was not evidenced in younger patients. On multivariable model, bilaterality, extracapsular extension and ASA (American Society of Anesthesiologists) classification ≥3 were predictors of local recurrence. We did not identify significant predictors for distant metastasis in our series. Conclusions PN is performed in Latin-America in a similar proportion to developed areas and it has been increasing in the last years. Even in elderly individuals, if good functional status, sufficiently fit to surgery, and favorable tumor characteristics, they should be encouraged to perform PN. Intending to an earlier diagnosis of recurrence or distant metastasis, SRM cases with unfavorable characteristics should have a more rigorous follow-up routine.

Abstract Background Although pathological factors remain the main determinate of survival for patients with bladder cancer, quality of surgical care is crucial for satisfactory outcomes. Using a validated quality score, we investigated the impact of surgical factors on the overall survival (OS), recurrence-free survival (RFS) and disease-specific survival (DSS) in patients with locally advanced and organ-confined disease (OCD). Retrospective review of IRCC database includes 2460 patients from 29 institutions across 11 countries. The final cohort included 1343 patients who underwent RARCs between 2005 and 2016. Patients with locally advanced disease (LAD) (> pT2 and/or N +) were compared with OCD (≤ pT2/N0). Validated Quality Cystectomy Score (QCS) based on four sets of quality metrics was used to compare surgical performance. Kaplan–Meier method was used to compute RFS, CSS and OS rates. Multivariable stepwise logistic regression was used to evaluate variables associated with RFS, DSS and OS. Results 48% had LAD. When compared to patients with OCD, they received neobladders less frequently (17% vs. 28%, p

Background: Car-dependent city planning has resulted in high levels of environmental pollution, sedentary lifestyles and increased vulnerability to the effects of climate change. The Barcelona Superblock model is an innovative urban and transport planning strategy that aims to reclaim public space for people, reduce motorized transport, promote sustainable mobility and active lifestyles, provide urban greening and mitigate effects of climate change. We estimated the health impacts of implementing this urban model across Barcelona. Methods: We carried out a quantitative health impact assessment (HIA) study for Barcelona residents ≥20 years (N = 1,301,827) on the projected Superblock area level (N = 503), following the comparative risk assessment methodology. We 1) estimated expected changes in (a) transport-related physical activity (PA), (b) air pollution (NO2), (c) road traffic noise, (d) green space, and (e) reduction of the urban heat island (UHI) effect through heat reductions; 2) scaled available risk estimates; and 3) calculated attributable health impact fractions. Estimated endpoints were preventable premature mortality, changes in life expectancy and economic impacts. Results: We estimated that 667 premature deaths (95% CI: 235–1,098) could be prevented annually through implementing the 503 Superblocks. The greatest number of preventable deaths could be attributed to reductions in NO2 (291, 95% PI: 0–838), followed by noise (163, 95% CI: 83–246), heat (117, 95% CI: 101–137), and green space development (60, 95% CI: 0–119). Increased PA for an estimated 65,000 persons shifting car/motorcycle trips to public and active transport resulted in 36 preventable deaths (95% CI: 26–50). The Superblocks were estimated to result in an average increase in life expectancy for the Barcelona adult population of almost 200 days (95% CI: 99–297), and result in an annual economic impact of 1.7 billion EUR (95% CI: 0.6–2.8). Discussion: The Barcelona Superblocks were estimated to help reduce harmful environmental exposures (i.e. air pollution, noise, and heat) while simultaneously increase PA levels and access to green space, and thereby provide substantial health benefits. For an equitable distribution of health benefits, the Superblocks should be implemented consistently across the entire city. Similar health benefits are expected for other cities that face similar challenges of environmental pollution, climate change vulnerability and low PA levels, by adopting the Barcelona Superblock model. Keywords: Active transport, Health impact assessment, Public space, Sustainability, Transport planning, Urban planning

Abstract Objective We performed a cohort study in seven hospitals in Spain to determine the clinical characteristics of incident patients with bladder cancer, the diagnostic process, and the conditions that might affect health care interval times. Results 314 patients with bladder cancer were included, 70.3 (Standard Deviation [SD] 11.2) years old and 85.0% male. Clinical stage was T1 in 45.9% of patients. The median interval time between first consultation and diagnosis was of 104.0 days (Inter quartile range [IQR]:112.0; range from 0 to 986), being shorter for those patients who attended a hospital for their first consultation. The median interval time between diagnosis and first treatment was of 0.0 days (IQR: 0.0; range from 0 to 366), being longer when the patient had a pathologic tumor stage ≥ T2a.