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Background: Hemorrhagic and infectious events represent severe complications after percutaneous nephrolithotomy (PCNLs). Existing nephrolithometric nomograms have been introduced but their reliability in predicting complications is debated. We present a newly designed nomogram with intention to predict hemorrhagic/infectious events after PCNLs., Methods: We conducted a multicentric prospective study on adult patients undergoing standard (24 Fr) or mini (18 Fr) PCNL. Dataset was derived from previous RCT, where patients have been assigned to mini-PCNL or standard-PCNL to treat renal stones up to 40 mm. Aim of the study was to identify preoperative risk factors for early postoperative infectious/hemorrhagic complications including fever, septic shock, transfusion or angioembolization., Results: A total of 1980 patients were finally included. 992 patients (50.1%) received mini-PCNL and 848 standard PCNL (49.9%). The overall SFR was 86.1% with a mean maximum stone diameter of 29 mm (SD 25.0-35.0). 178 patients (8.9%) had fever,14 (0.7%) urosepsis, 24 patients (1.2%) required transfusion and 18 (0.9%) angioembolization. The overall complication was (11.7%). After multivariable analysis, the included elements in the nomogram were age (P=0.041), BMI (P=0.018), maximum stone diameter (P<0.001), preoperative hemoglobin (P=0.005), type 1/2 diabetes (P=0.05), eGFR<30 (P=0.0032), hypertension (>135/85 mmHg, P=0.001), previous PCNL or pyelo/nephrolithotomy (P=0.0018), severe hydronephrosis (P=0.002). After internal validation, the AUC of the model was 0.73., Conclusions: This is the first nomogram predicting infections and bleedings after PCNLs, it shows a good accuracy and can support clinicians in their patients' peri-operative workout and management.

Introduction: A Doppler ultrasound (US) of the scrotum is commonly used to improve the diagnostic confidence for testicular torsion in an emergency setting. However, the sensitivity of this investigation to identify torsion varies largely. This is due, in part, to a lack of guidelines on how-to perform the US and therefore training is necessary., Evidence Acquisition: The Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) and the Section of Urological Imaging of the European Association of Urology (ESUI) established a joint panel of experts to standardize Doppler US investigation of patients with testicular torsion. The panel reviewed the available literature, identified accumulated knowledge and limitations, and released recommendations on how-to perform Doppler US in patients with acute scrotal pain., Evidence Synthesis: Diagnosis of testicular torsion is based on clinical evaluation and investigation of the cord, the testis, and the paratesticular structures. A preliminary clinical evaluation, including history and palpation, is necessary. Grey scale US, color Doppler US and spectral analysis must be performed by a sonologist with at least level 2 competence. Modern equipment with adequate grey-scale and Doppler capabilities are required., Conclusions: Standardization of Doppler US in suspicious testicular torsion is presented, with the aim to obtain comparable results among different centres, prevent unnecessary operations, and improve patient management.

Background: In literature, the reports of outcomes after percutaneous nephrolithotomies are rather heterogeneous. This may influence studies comparison, it may also render difficult to evaluate surgical adequacy, perioperative morbidity, and patient's Quality of Life between studies. For this reason, we propose to introduce PNL-Trifecta as composite measure to standardize data reporting outcomes after percutaneous nephrolithotomies., Methods: We performed a prospective multicentric study on consecutive patients undergone PNL to treat renal stones between 2018 and 2020. Successful PNL-trifecta was considered achieved when procedures obtained the three following results: no residual fragments >2 mm at unenhanced CT scan at 3 months postop, no complications (defined as Clavien-Dindo Score 0) and operation carried out without placing a nephrostomy tube (tubeless or totally tubeless). We compared results of standard versus mini-PNL and between stones of different complexity (evaluated with Guy's Stone Score and S.T.O.N.E. Nephrolithometry Score). Univariate analysis was utilized to identify other factors influencing achievement of PNL-Trifecta., Results: Two hundred forty-five patients fulfilled inclusion/exclusion criteria and have been enrolled in the study (median age: 56, IQR 48-57). The overall PNL-Trifecta achievement rate was 22.85% (28.66% in the mini-PNL group and 13.68% in the standard-PNL group, P=0.010). The stone free rate, CD 0 rate and tubeless/totally tubeless rate in the mini-PNL group were 60.66%, 89.33% and 51.33% respectively. In the standard-PNL group they were 44.21%, 40.00% and 15.78% respectively. At the univariate analysis, differences between Guy's Stone Score groups in achieving PNL-Trifecta were significant (P=0.001). Also, the level of upper puncture (P=0.010) and utilization of device with active suction (P=0.002) showed statistically significant differences. Furthermore, the length of stay in the patient's group achieving Trifecta was 2.28 versus a mean length of stay of 4.64 days in the group of patients not achieving Trifecta (P=0.046)., Conclusions: We present Trifecta for PNLs as a potential tool to evaluate quality of percutaneous nephrolithotomies and to provide an instrument for an adequate standard data reporting. It can represent a valid way to assess and monitor surgeon's learning curves. It will require further external validation and studies to evaluate its correlation with mid- and long-term results and patient's health related Quality of Life outcomes.

Background: The impact of warm ischemia time (WIT) on renal functional recovery remains controversial. We examined the length of WIT>30 min on the long-term renal function following on-clamp partial nephrectomy (PN)., Methods: Data from 23 centers for patients undergoing on-clamp PN between 2000 and 2018 were analyzed. We included patients with two kidneys, single tumor, cT1, minimum 1-year follow-up, and preoperative eGFR≥60 mL/min/1.73m 2 . Patients were divided into two groups according to WIT length: group I "WIT≤30 min" and group II "WIT>30 min." A propensity-score matched analysis (1:1 match) was performed to eliminate potential confounding factors between groups. We compared eGFR values, eGFR (%) preservation, eGFR decline, events of chronic kidney disease (CKD) upgrading, and CKD-free progression rates between both groups. Cox regression analysis evaluated WIT impact on upgrading of CKD stages., Results: The primary cohort consisted of 3526 patients: group I (N.=2868) and group II (N.=658). After matching the final cohort consisted of 344 patients in each group. At last follow-up, there were no significant differences in median eGFR values at 1, 3, 5, and 10 years (P>0.05) between the matched groups. In addition, the median eGFR (%) preservation and absolute eGFR change were similar (89% in group I vs. 87% in group II, P=0.638) and (-10 in group I vs. -11 in group II, P=0.577), respectively. The 5 years new-onset CKD-free progression rates were comparable in the non-matched groups (79% in group I vs. 81% in group II, log-rank, P=0.763) and the matched groups (78.8% in group I vs. 76.3% in group II, log-rank, P=0.905). Univariable Cox regression analysis showed that WIT>30 min was not a predictor of overall CKD upgrading (HR:0.953, 95%CI 0.829-1.094, P=0.764) nor upgrading into CKD stage ≥III (HR:0.972, 95%CI 0.805-1.173, P=0.764). Retrospective design is a limitation of our study., Conclusions: Our analysis based on a large multicenter international cohort study suggests that WIT length during PN has no effect on the long-term renal function outcomes in patients having two kidneys and preoperative eGFR≥60 mL/min/1.73m 2 .

Introduction: Frailty has been recognized as a major risk factor for adverse perioperative and oncological outcomes in patients with genitourinary malignancies. Yet, the evidence supporting such an association in patients with renal cell carcinoma (RCC) is still sparse. Herein we provide an updated comprehensive overview of the impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for RCC., Evidence Acquisition: A systematic review of the English-language literature was conducted using the MEDLINE (via PubMed), Web of Science and the Cochrane Library databases according to the principles highlighted by the EAU Guidelines Office and the PRISMA statement recommendations. The review protocol was registered on PROSPERO (CRD42021242516). The overall quality of evidence was assessed according to GRADE recommendations., Evidence Synthesis: Overall, 18 studies were included in the qualitative analysis. Most of these were retrospective single-center series including patients undergoing surgery for non-metastatic RCC. The overall quality of evidence was low. A variety of measures were used for frailty assessment, including the Canadian Study of Health and Aging Frailty Index, the five-item frailty index, the Modified Rockwood's Clinical Frailty Scale Score, the Hopkins Frailty score, the Groningen Frailty Index, and the Geriatric nutritional risk index. Sarcopenia was defined based on the Lumbar skeletal muscle mass at cross-sectional imaging, the skeletal muscle index, the total psoas area, or the Psoas Muscle Index. Overall, available studies point to frailty and sarcopenia as potential independent risk factors for worse perioperative and oncological outcomes after surgery or ablation for different RCC stages. Increased patient's frailty was indeed associated with higher risk of perioperative complications, healthcare resources utilization, readmission rates and longer hospitalization periods, as well as potentially lower cancer specific or overall survival., Conclusions: Frailty has been consistently associated with worse outcomes after surgery for RCC, reinforcing the value of preoperative frailty assessment in carefully selected patients. Given the low quality of the available evidence (especially in the setting of tumor ablation), prospective studies are needed to standardize frailty assessments and to identify patients who are expected to benefit most from preoperative geriatric evaluation, aiming to optimize decision-making and postoperative outcomes in patients with RCC.

Background: The aim of the study was to test the effect of active surveillance (AS) versus primary intervention (PI) on overall mortality (OM) in elderly patients diagnosed with SRM., Methods: Elderly patients (75 years or older) diagnosed with SRMs (<4 cm) and treated with either PI (i.e. partial nephrectomy or kidney ablation) or AS between 2009 and 2018 were abstracted from the renal surgery in the elderly (RESURGE) and Delayed Intervention and Surveillance for small Renal Masses (DISSRM) datasets, respectively. OM rates were estimated among groups with Kaplan Meier method and Cox proportional hazards regression models after applying inverse probability of treatment weighting (IPTW). Multivariable logistic regression model was used to estimate IPTW. Covariates of interest were those unbalanced and/or significantly correlated with the treatment choice or with OM., Results: A total of 483 patients were included; 121 (25.1%) underwent AS. Sixty patients (12.4%) died. Overall, 6.7% of all deaths were related to cancer. IPTW-Kaplan Meier curves showed a 5-year overall survival rates of 70.0±3.5% and 73.2±4.8% in AS and PI groups, respectively (IPTW-Log-rank P value=0.308). IPTW-Cox regression model did not show meaningfully increased OM rates in AS group (HR: 1.31, 95% CI: 0.69-2.49)., Conclusions: AS represents an appealing treatment option for very elderly patients presenting with SRM, as it avoids the risks of a PI while not compromising the survival outcomes of these patients.

Background: During the past two decades cryoablation (CA) has become a therapeutic option for the management of localized cT1 renal masses in comorbid patients. We analyzed the mid-term functional and oncological outcomes of CA in the treatment of cT1 renal masses which were classified as high-complexity masses according to the PADUA system., Methods: A total of 299 patients underwent percutaneous CA between November 2007 and December 2018 in 4 institutions for cT1N0M0 renal masses. All patients with high-complexity (PADUA≥10) renal tumors were included. Technical failure of CA was considered an exclusion criterion., Results: Inclusion criteria were met by 45 patients. Median Charlson Comorbidity Index (CCI) was 6.0 (IQR: 5.0-7.0), median age was 74 years (IQR: 64.5-79.5). Seven Clavien 1 and 1 Clavien 2 procedure-related complications were reported. Median eGFR at baseline was 64.3mL/min (IQR: 52.0-82.3) while at the 1-year follow-up was 61.4 mL/min (IQR: 44.0-74.5). The median follow-up was 32 months (IQR: 13.25-47.5). Local recurrences were detected in 6 patients; 3 of them underwent re-cryoablation while the others started active surveillance. Median time to recurrence was 17.5 months (IQR: 7.8-27.3). Cancer-specific survival and metastasis-free survival were 100%, while overall survival was 86.7%., Conclusions: CA proved to be a valuable therapeutic option for the management of patients with cT1 high-complexity PADUA≥10 renal tumors as it provides a low rate of procedural morbidity and good preservation of renal function. However, these results are counterbalanced by a recurrence rate that appears to be higher than those reported on surgically treated patients.

Background: The aim of this study was to analyze the incidence, preoperative findings, pathological features and prognosis in patients with incidental prostate cancer (iPCa) detected at radical cystectomy (RC) for bladder cancer (BCa)., Methods: We retrospectively reviewed data of patients who underwent RC for BCa at our Institution between January 2005 and March 2018. Data regarding patient's history, preoperative digital rectal examination (DRE), total serum PSA level were collected from the chart review. Univariable and multivariable Cox regression models addressed the association of iPCa with recurrence-free survival (RFS) and overall survival (OS)., Results: We obtained a final study cohort of 177 patients. Median age was 69 years (IQR 42-89) and 80(45.2%) patients had iPCa. Patients with iPCa had higher age, preoperative PSA levels and a significant rate of suspicious DRE (all P<0.05). Four patients had BCR during a median follow-up of 28 months (IQR 6-159) and none died for prostate cancer. In multivariable analyses adjusted for age, bladder cancer BCa pT and pN stage and LVI the ten-years RFS and OS rates were not impacted by iPCa regardless of whether it is a clinically significant cancer or not (HR=1.25, 95% CI: 0.65-2.38, P=0.51 vs. HR=1.37, 95% CI: 0.71-2.64, P=0.35) (HR=1.04, 95% CI: 0.53-1.86, P=0.89 vs. HR=1.20, 95% CI: 0.22-6.72, P=0.83)., Conclusions: iPCa is quite common in our study group and most of cases are organ-confined and well differentiated. Regardless of clinical relevance, iPCa does not have an impact on survival outcomes as BCa is driving the prognosis of these patients.

Background: Abdominopelvic computed tomography (CT) is widely used in the follow-up of seminoma patients after radical orchidectomy. The aim of this study was to evaluate the clinical utility of abdominopelvic computed tomography in the follow-up of patients with Stage I seminoma., Methods: The pathological reports of all patients that have undergone radical orchidectomy in our tertiary referral center between January 2002 and January 2018 have been retrospectively reviewed. All patients with Stage I seminoma and negative serum tumor markers after radical orchidectomy were included. Patients with follow-up shorter than 12 months were excluded. Surveillance records of every patient were reviewed with regard to abdominopelvic imaging., Results: Of the 133 patients who have undergone radical orchidectomy in our center, 55 had Stage I pure seminoma with normal levels of serum tumor markers after surgery. Two patients were excluded as the follow-up was inadequate. Mean follow-up was 63.2 months (IQR: 30-73). The results of 211 abdominopelvic CTs performed as part of the follow-up were reviewed. Two (3,7%) patients developed recurrence; one consisted of a scrotal lump and was diagnosed with ultrasonography (US) while the second appeared as paraaortic nodal metastasis and was diagnosed with abdominopelvic CT. The recurrence was successfully treated in both patients. A single abdominopelvic CT was useful for the detection of recurrent disease in our entire study population. No cancer specific death has been reported in the study population., Conclusions: Follow-up schedules for Stage I seminoma expose patients to potential risks of radiation-induced tumors, emotional distress and represent a significant burden for the healthcare system. The current series suggests that a better risk adapted patient-tailored follow-up program is needed in order to avoid unnecessary investigations.

The public health emergency caused by the Coronavirus Disease 2019 (COVID-19) pandemic has resulted in a significant reallocation of health resources with a consequent reorganization of the clinical activities also in several urological centers. A panel of Italian urologists has agreed on a set of recommendations on pathways of pre-, intra- and post-operative care for urological patients undergoing urgent procedures or non-deferrable oncological interventions during the COVID-19 pandemic. Simplification of the diagnostic and staging pathway has to be prioritized in order to reduce hospital visits and consequently the risk of contagion. In absence of strict uniform regulations that impose the implementation of nasopharyngeal swabs, we recommend that an accurate triage for COVID-19 symptoms be performed both by telephone at home before hospitalization and at the time of hospitalization. We recommend that during hospital stay patients should be provided with as many instructions as possible to facilitate their return to, and stay at, home. Patients should be discharged under stable good conditions in order to minimize the risk of readmission. It is advisable to reduce or reschedule post-discharge controls and implement an adequate system of communication for telemonitoring discharged patients.

The severe acute respiratory syndrome coronavirus 2 and the disease it causes, coronavirus disease 2019 (COVID-19) is generating a rapid and tragic health emergency in Italy due to the need to provide assistance to an overwhelming number of infected patients and, at the same time, treat all the non-deferrable oncological and benign conditions. A panel of Italian urologists has agreed on possible strategies for the reorganization of urological routine practice and on a set of recommendations that should facilitate the process of rescheduling both surgical and outpatient activities during the COVID-19 pandemic and in the subsequent phases. This document could be a valid tool to be used in routine clinical practice and, possibly, a cornerstone for further discussion on the topic also considering the further evolution of the COVID-19 pandemic. It also may provide useful recommendations for national and international urological societies in a condition of emergency.

Introduction: Stuttering priapism is a variation of ischemic priapism, generally transient and self-limiting, occurring during sleep and lasting less than 3-4 hours. It may progress to episodes of complete ischemic priapism in approximately one third of cases, necessitating emergent intervention., Evidence Acquisition: This review aims to provide an up-to-date picture of the pathophysiology and management of stuttering priapism. A search using Medline and EMBASE for relevant publications using the terms "priapism", "stuttering", "diagnosis", "treatment", "fibrosis", was performed., Evidence Synthesis: Stuttering priapism shares its etiologies with ischemic priapism and a large number of diseases or clinical situations have risk association for developing the disorder. The most common causes are sickle cell disease or other hematologic and coagulative dyscrasias especially in children. In the adult population, idiopathic priapism occurring without any discernible cause is considered to be the most common form in adults. The medical management of priapism represents a therapeutic challenge to urologists. Unfortunately, although numerous medical treatment options have been reported, the majority are through small trials or anecdotal reports. Understanding the underlying pathophysiology and understanding the current and emerging future agents and therapeutic options are mandatory in order to provide the best solution for each patient., Conclusions: The goal of management of priapism is to achieve detumescence of the persistent erection in order to preserve erectile function. To achieve successful management, urologists should address this emergency clinical condition. In the present article, we review the diagnosis and clinical management of the three types of priapism.

Background: The aims of this study are to evaluate the prognostic factors of extracorporeal shockwave lithotripsy in patients with ureteric stones, and to identify which patients might directly benefit of an endoscopic treatment., Methods: We performed a prospective study from January 2013 and July 2016 on patients with single ureteric stone and undergoing extracorporeal shockwave lithotripsy (SWL). We divided patients into two groups: first group (success group) included cases resolved with SWL only, and a second group (failure group) including patients with stone not resolved by SWL and requiring an endoscopic treatment. We evaluated age, weight, height, body mass index, stone size, hydronephrosis, laterality, location, days elapsed from onset of symptoms to SWL and stone density when computed tomography was performed. In case of stone fragments >4 mm, the procedure was repeated up to a maximum of three times. SWL was considered as failed if patients had a residual stone of any size after a follow-up of 3 months or if a complication occurred., Results: 274 patients completed follow-up and were enrolled in the study. Mean age was 53.22 years (standard deviation: 13.98). SWL overall success rate was 84.3% (231 patients successfully treated with shockwaves) and failure rate was 15.7% (43 patients underwent auxiliary endoscopic procedure). At the univariate analysis, we observed a statistically significant difference for hydronephrosis (P=0.006), time elapsed from symptoms onset (P=0.013), patients' age (P=0.06) and mean stone density (0.023). In the multivariate logistic regression, patients' age (OR: 1.517), and time elapsed from obstruction to SWL (OR: 3.005) were independent predictive factors for SWL failure. Furthermore, moderate and severe hydronephrosis seemed to be independent predictive factors for SWL failure, presenting an OR of 2.451 and 4.207 respectively. High stone density resulted to be a predictive factor for SWL failure (OR: 2.293 if density was higher than 1100 Hounsfield Units)., Conclusions: We report a large series of patients undergone primary SWL for ureteric stones. Our data demonstrated the role of hydronephrosis, time elapsed from obstruction onset to treatment and stone density as independent predictive factors of SWL failure.

Background: The aim of this study was to assess the efficacy of emergency extracorporeal shockwave lithotripsy (eSWL) as first-line treatment in patients with acute colic due to obstructive ureteral stone., Methods: Seventy-four patients were randomized to emergency SWL within 12 hours (eSWL group) and deferred SWL later than 3 days (dSWL group). Follow-up included ultrasound, KUB (kidney-ureter-bladder) radiography and CT (computed tomography) scan at 24 hours, 7 days, 1 and 3 months from the treatment. When necessary, repeated SWL (re-SWL) or ureteroscopy (auxiliary-URS) was performed. Preoperative and postoperative data were compared and stone free rates (SFR) and efficiency quotients (EQ) were evaluated. Analyses were performed using SAS software., Results: Complete data of 70 patients were collected. 36 underwent eSWL and 34 dSWL. The mean patient age was 48.7. Mean stone size was 9.8 mm (CI 95%: 8.9-10.8). 25 (35.7%) were proximal and 45 (64.3%) distal. Mean SWL energy was 19.2 kV (CI 95%: 18.5-19.9) and mean number of shocks was 2657 (CI 95%: 2513-2802). eSWL patients needs less auxiliary-URS than dSWL patients (13.9% vs. 44.1%, P=0.039) and less re-SWL sessions (8.3% vs. 32.4%, P=0.093). SFR at 24 hours was 52.8% and 11.8% (P<0.001) and the EQ at 3 months was 79.1% and 57.5% in the eSWL and dSWL group respectively. Patients from the dSWL group spent more time in the hospital (2.21 vs. 1.36 days, P=0.046) and complication rates between the two groups were similar., Conclusions: eSWL is a safe procedure and delivers high SFR even within 24 hours especially for <10 mm stones. It is able to reduce the number of auxiliary procedures and hospitalization.