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Background Well-defined clinical predictors of sepsis after upper tract drainage for obstructive uropathy are lacking. The study aim is to develop a data driven score to predict risk of sepsis after decompression of the upper urinary tract. Materials and methods Complete clinical and radiological data from 271 patients entering the emergency department for obstructive uropathy and submitted to stent/nephrostomy tube decompression were evaluated. The Charlson Comorbidity Index (CCI) was used to score comorbidities. The definition of sepsis was an increase in ≥2 SOFA points (or postoperative persistently elevated score +1 additional increase) and documented blood or urine cultures. Descriptive statistics and stepwise multivariable logistic regression modelling with ROC analysis were performed in order to obtain a composite risk score to predict the risk of sepsis after surgery. Results Fifty-five (20.3%) patients developed sepsis. At multivariable analysis, CCI ≥2 (OR 3.10; 95%CI 1.36-7.04), max body temperature ≥38°C (OR 4.35; 95%CI 1.89-9.44), grade III-IV hydronephrosis (OR 2.37; 95%CI 1.10-4.98), Hounsfield units of the dilated collecting system ≥7.0 (OR 4.47; 95%CI 2.03-9.81), WBC ≥15x103/mmc (OR 2.77; 95%CI 1.24-6.19) and C-reactive protein ≥10 (OR 3.27; 95%CI 1.41-7.56) were independently associated with sepsis. The PPV of a true sepsis increased incrementally as a function of number of positive variables, ranging from 1.6% to 100.0% among patients with 1 and 6 positive variables, respectively. Conclusion Our risk score identifies accurately patients with an increased risk of sepsis after urinary decompression for obstructive uropathy, hence improving clinical management.

Purpose To perform a cost analysis between vacuum-assisted percutaneous nephrolithotomy (vmPCNL) and minimally invasive PCNL (MIP) and explore potential predictors of costs associated with the procedures. Methods We analyzed data from 225 patients who underwent vmPCNL or MIP at a single tertiary referral academic center between January 2016 and December 2020. We collected patients’ demographics, peri-and postoperative data and detailed expense records. After propensity score matching, 108 (66.7%) vmPCNL and 54 (33.3%) MIP procedures were analyzed. Descriptive statistics assessed differences in clinical and operative parameters. Univariable and multivariable linear regression models tested the association between clinical variables and costs. Results Operative time (OT) was shorter for vmPCNL, and the use of additional instruments to complete litholapaxy was more frequent in MIP (all p ≤ 0.01). Length of stay (LOS) was longer for MIP patients (p = 0.03) and the stone-free (SF) rate was higher after vmPCNL (p = 0.04). The overall instrumentation cost was higher for vmPCNL (p p = 0.9). However, the overall cost for the hospitalization was higher for MIP than vmPCNL (p = 0.01). Univariable linear regression revealed that patient’s comorbidities, OT, any postoperative complication and LOS were associated with hospitalization costs (all p p Conclusion vmPCNL may represent a valid option due to clinical and economic benefits. Shorter OT, the lower need for disposable equipment and the lower complication rate reduced procedural and hospitalization costs.

Angiomyolipoma (AML) is a benign renal mesenchymal tumor. Active surveillance is considered the most appropriate option for most AMLs. The major complication of AML is its spontaneous bleeding in the retroperitoneum that could be life-threatening for the patient. In this case, acute bleeding from a sporadic AML was reported immediately after the induction of a 12 mmHg pneumoperitoneum during a planned laparoscopic resection of the rectum for oncological reasons. After immediate stabilization the patient underwent angiography of the renal artery and super-selective vascular embolization. Although rare, spontaneous rupture of asymptomatic AML should always be considered, especially in intraoperative setting.

Currently available surgical treatments for Lower Urinary Tract Symptoms (LUTS) due to Benign Prostatic Obstruction (BPO) are associated with an increased risk of sexual dysfunction. The aim of our study is to compare sexual and ejaculatory function after Holmium Laser Enucleation of the Prostate (HoLEP) and Bipolar Transurethral Enucleation of the Prostate (B-TUEP). We performed a retrospective analysis of data prospectively collected from 62 (44.9%) and 76 (55.1%) patients who underwent HoLEP and B-TUEP, respectively. Erectile function and ejaculation characteristics were assessed with the International Index of Erectile Function-Erectile Function (IIEF-EF) domain and the Male Sexual Health Questionnaire-Ejaculatory function (MSHQ-EJ) questionnaires. Our study recorded no change in erectile function and no significant difference in rates of preserved antegrade ejaculation after both surgeries. One month after surgery, rates of physical pain/discomfort and perceived decreased physical pleasure during ejaculation were higher in HoLEP than B-TUEP patients (all p < 0.03). Moreover, HoLEP patients were more bothered by their ejaculatory difficulties than B-TUEP men (p = 0.03). At 3- and 12-months follow-up, all ejaculation-related differences disappeared. In conclusion, both procedures are valid alternatives for BPO treatment as they offer comparable urinary and sexual outcomes in the long term. However, in the first month after surgery, HoLEP patients present with more ejaculatory difficulties.

Objective: Overview of bladder cancer (BC) management in Italy during the first month of the COVID-19 pandemic (March 2020) with head to head comparison of the data from March 2019, considered “usual activity” period. The aim is to analyze performance of different Italian Centers in North, Center and South, with a special eye for Lombardy (the Italian epicenter). Patients and methods: During April 2020, a survey containing 14 multiple-choice questions focused on general staffing and surgical activity related to BC during the months of March 2019 and March 2020 was sent to 32 Italian Centers. Statistical analysis was performed using IBM SPSS Statistics (v26) software. A Medline search was performed, in order to attempt a comparative analysis with published papers. Results: 28 Centers answered, for a response rate of 87.5%. Most of the urology staff in the Lombardy region were employed in COVID wards (p = 0.003), with a statistically significant reduction in the number of radical cystectomies (RC) performed during that time (p = 0.036). The total amount of RC across Italy remained the same between 2019 and 2020, however there was an increase in the number of surgeries performed in the Southern region. This was most likely due to travel restrictions limiting travel the North. The number of Trans-Urethral Resection of Bladder Tumors (TURBT) (p = 0.046) was higher in Academic Centers (AC) in 2020 (p = 0.037).Conclusions: The data of our survey, although limited, represents a snap shot of the management of BC during the first month of the COVD-19 pandemic, which posed a major challenge for cancer centers seeking to provide care during an extremely dynamic clinical and political situation which requires maximum flexibility to be appropriately managed.

Objectives: Real-life overview of bladder cancer (BC) surgical management in Italy during the first month of COVID-19 pandemic (March 2020) with head to head comparison of the data from March 2019, considered “usual activity” period. The aim is to confront performance of Academic Centers (AC) vs Non Academic Centers (NAC) as well as non-COVID Centers (nCC) and COVID Centers (CC). Patients and methods: During April 2020, an e-mail survey was sent to 32 Sections of Urology across Italy. It contained 14 multiple-choice questions focused on activities during March 2019 and March 2020. Statistical analysis was performed using IBM SPSS Statistics (v26) software. Results28 centers answered to survey. AC and NAC showed statistically significant differences (chi-square test pConclusionThe COVID-19 pandemic represents an important challenge for cancer centers, in the context of an extremely dynamic clinical and political situation which requires maximum flexibility to be appropriately managed.

Objective To compare the clinical reliability of the 1973 and 2004 World Health Organisation (WHO) classification systems in pT1 bladder cancer. Patients and Methods We retrospectively evaluated 291 consecutive patients who had pT1 high grade bladder cancer between 2004 and 2011. All tumours were simultaneously evaluated by a single uro-pathologist as high grade and G2 or G3. All patients underwent a second transurethral resection (TUR) and those confirmed with non-muscle-invasive bladder cancer at second TUR received bacille Calmette-Guerin. Follow-up included urine cytology and cystoscopy 3 months after second TUR and then every 6 months for 5 years. Univariate and multivariate analysis to determine recurrence-free survival (RFS) and progression-free survival (PFS) rates were performed using the Kaplan–Meier method with the log-rank test. Results G2 tumours were found in 124 (46.6%) and G3 in 142 (53.4%) patients. The mean (median; range) follow-up period was 31.1 (19; 1–93) months. The 5-year RFS rate was 39.1% for the overall high grade population, and 49.1 and 31.8% for G2 and G3 subgroups, respectively. The 5-year PFS was 82% for the overall high grade population and 89 and 73% for G2 and G3 subgroups, respectively. RFS (P < 0.002) and PFS (P < 0.001) rates were significantly different between the G2 and G3 subgroups. In multivariate analysis, only the grade assessed according to the 1973 WHO significantly correlated with both RFS (P = 0.003) and PFS (P < 0.001). Conclusion The results suggest that the 1973 WHO classification system has higher prognostic reliability for patients with T1 disease. If confirmed, these findings should be carefully taken into account when making treatment decisions for patients with T1 bladder cancer.

BACKGROUND: Bladder cancer accounts for 5-10% of all cancers in Europe and up to 85% patients presents a noninvasive tumor, whose treatment of choice is the transurethral bladder resection (TURB) paired with adjuvant intravesical chemotherapy or immunotherapy. Despite several clinical trials showed that this treatment is safe and decreases recurrences by 17% to 44% this practice is limited for many reasons. The study objective is to analyze the economical advantages of the single immediate post operative Mitomycin C instillation in Non Muscle-invasive Bladder Cancer (NMIBC) low-risk patients.METHODS: A cost-benefit analysis was performed evaluating the economical gain that would raised from a scenario with a single immediate post operative mitomycin C instillation in each low-risk NMIBC patient who underwent to TURB. Net present value and cost-benefit ratio were calculated and sensitivity analyses were performed. Base case analysis was performed considering tumor recurrence rate reduction of 11.7% and a TURB costs of 2,167.0 €, while sensitivity analyses were performed using a recurrence rate reduction of 19.2% and 15.0% and a TURB cost of 2,472.93 €. The discount rate was 2%.RESULTS: The single immediate post operative instillation of mitomycin C resulted to be cost-beneficial with a cost-benefit ratio that goes from 0.48 to 0.79 when compared to TURB alone raising a Net Present Value that goes from 660,284.39 € to 2,650,530.79 €.CONCLUSION: This study demonstrates that even assuming conservative parameters for recurrence rates reduction, a single immediate post operative mitomycin C instillation in low risk NMIBC patients would lower not only the recurrence rate but also the caring cost for bladder cancer.

Introduction Prostatic Specific Antigen (PSA), Bacillus Calmette-Guerin (BCG) increase after intravesical BCG has been reported. The need of prostate biopsy in these patients is object of debate. The aim of our study was to evaluate the effect of intravesical therapy on PSA after transurethral resection (TUR) of nonmuscle-invasive bladder cancer (NMIBC). Materials and methods Patients undergoing intravesical chemotherapy or immunotherapy for NMIBC were entered. PSA was measured before TUR, before the first and after the sixth instillation, 30 and 90 days after the last instillation. Patients with PSA ≥4 ng/ml or palpable prostate nodule were excluded. Results Out of 130 patients, 105 were evaluable. PSA increase (mean: 7.15 ng/ml) was detected after TUR and before intravesical therapy in 14 patients (13.3%). Of the remaining 91 patients, 65 (71.4%) received chemotherapy and 26 (28.6%) BCG. Median PSA before and during therapy was 1.80 and 1.97 ng/ml, with a 36% median increase in 66 patients (72.5%) (p = 0.13). No statistically significant difference emerged between chemotherapy and BCG (p = 0.22). PSA higher than 4 ng/ml was detected in six (6.3%) and two (2.1%) patients after chemotherapy and BCG, respectively, and was no more evident at 90 days. Discussion PSA increase due to intravesical therapy is rare and usually not clinically significant. PSA rising above 4 ng/ml during intravesical treatment was evident only in 8% of patients. PSA before TUR should be available and considered as the basal value. Elevated PSA detected during therapy should be monitored and biopsy proposed only if persisting more than 3 months after the end.

Background: The bladder is the most common affected site in urinary tract endometriosis, being diagnosed during gynecologic follow-up. The surgical urological treatment might lead to good results. Study Objective: To define the state of the art in the diagnosis and treatment of bladder endometriosis. Methods: We performed a literature review by searching the MEDLINE database for articles published between 1996 and 2011, limiting the searches to the words: urinary tract endometriosis, bladderendometriosis, symptoms, diagnosis and treatment.Results: Deep pelvic endometriosis usually involves the urinary system, with the bladder being affected in 85% of cases. The diagnosis has to be considered as a step-by-step procedure. Currently, the treatment is usually surgical, consisting of either transurethral resection or partial cystectomy, and eventually associated with hormonal therapy. The hormonal therapy alone counteracts only the stimulus of endometriotic tissue proliferation, with no effects on the scarring caused by this tissue. The overall recurrence rate is about 30% for combined therapies and about 35% for the hormonal treatment alone. Conclusions: The bladder is the most common affected site in urinary tract endometriosis. Most of the time, this condition is diagnosed because of the complaint of urinary symptoms during gynecologic follow-up procedures for a deep pelvic endometriosis: a close collaboration between the gynecologist and the urologist is advisable, especially in highly specialized centers. The surgical urological treatment might lead to good results in terms of patients’ compliance and prognosis.

Background The most common presenting symptom of bladder cancer (BCa) is hematuria. The present study was designed to define whether patients taking antiplatelet and/or anticoagulant drugs might experience hematuria at an earlier stage or grade of BCa. Patients and Methods The data from 1532 consecutive patients who presented to the emergency unit of our institute from 2004 to 2012 because of gross hematuria as a single symptom were evaluated. Patients (n = 227) with a further diagnosis of BCa were included in our study. For the purpose of the present study, patients were divided into 2 groups: patients receiving antiplatelet or anticoagulant therapy (AAT) (group 1) and patients not receiving AAT (group 2) at the moment of the macroscopic hematuria episode. The effect of AAT on the pathologic stage and grade of BCa was statistically assessed using univariate and multivariate logistic regression analysis. Results A total of 59 (26%) and 168 (74%) patients were included in groups 1 and 2, respectively. On multivariate logistic regression analysis, ATT conferred a protective effect against both pathologic stage ≥ T2 (odds ratio [OR], 0.37; 95% confidential interval [CI], 0.12-0.66; P = .01) and higher grade (OR, 0.56; 95% CI, 0.26-0.85; P = .02) at tumor presentation. Conclusion According to the results of the present retrospective investigation, patients who received AAT seem to experience gross hematuria significantly earlier than do untreated patients, resulting in the chance of an earlier diagnosis and treatment of bladder cancer.

Purpose: Despite the increasing number of studies confirming the importance of neoadjuvant chemotherapy (NC) in patients before radical cystectomy (RC) for bladder cancer (BCa), NC remains underused. The aim of our study was to develop a nomogram predicting the cancer-specific mortality (CSM) of patients who underwent RC for transitional BCa, evaluating the available clinical information and the NC. Materials and methods: We identified 423 patients who underwent RC and pelvic lymph node dissection, treated or not with NC, in two European high-volume centers between 2007 and 2013. Chi-square and Student’s t tests were used to evaluate differences between groups. Kaplan–Meier curves were used to assess time to cancer-specific (CSS) and overall survival (OS). Uni- (UVA) and multivariable (MVA) Cox regression analyses were developed to address predictors of CSS and OS. A nomogram based on the Cox regression coefficient was developed to show the impact of NC on CSM. Results: Mean follow-up was 20.3Âmonths. Our population had mainly pT2 disease (77.1Â%), and 19.4Â% had preoperative cisplatinum-based NC. NC showed better CSS at UVA (pÂ=Â0.014) and MVA (odds ratio: 0.44; pÂ=Â0.043). Overall, the 3-year OS and the CSS rate were 69.3 and 79Â%, respectively. The nomogram developed to predict the 36-month CSM showed predictive accuracy of 67Â%. Conclusions: We developed the first nomogram predicting the 36-month CSM rate in patients with high-risk BCa according to the clinical data. Moreover, we demonstrate that preoperative cisplatinum-based chemotherapy is associated with better CSS.

Despite the good quality of treatment expected with optimized transurethral resection (TUR) and adjuvant Bacillus Calmette-Guerin (BCG) regimen, many high-risk non-muscle invasive bladder cancer (NMIBC) patients recur and progress. According to the EORTC Tables of risk, cases with a score of 10-17 and those with a score of 7-23 should be considered as being at high risk of recurrence and progression, respectively. AUA and NCCN consider all T1 stage tumors, high grade Ta and CIS at high risk of recurrence and progression. Long-term follow-up shows that T1,G3 patients treated with BCG will suffer from up to 45% and 17% rate of recurrence and progression, respectively. Consequently, EAU, AUA and NCCN Guidelines for bladder cancer recommend radical cystectomy as a first treatment option for those patients who failed after two cycles of adjuvant BCG. However, to date, there is no definitive evidence that in this special subgroup of patients an early radical cystectomy is better than any additional salvage strategy, in terms of oncologic outcome. On the other hand, it is well accepted that radical cystectomy is burdened with consistent reduction of overall post-operative quality of life. The reluctance of patient to accept (and of surgeon to recommend) this major extirpative surgery may explain the reduced disease-free survival rate, well documented when radical cystectomy has been extremely delayed. Defining the criteria for the selection of BCG-failure patients for whom any conservative procedure should be definitively abandoned in favor of a timely radical cystectomy has become of critical importance. Recently, clinical, laboratory and pathologic acquisitions allowed the development of more accurate predictive factors for tumor progression in NMIBC. Among these factors, clinical type of BCG-failure, morphology and tumor growth patterns, pathologic sub-staging and immunohistochemistry will play a paramount role in decision-making with these patients in routine practice.