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To determine the predictors of short and long-term renal function impairment after partial nephrectomy. MATERIALS AND METHODS: The clinical data of 769 consecutive patients submitted to partial nephrectomy were prospectively recorded in 19 urological Italian centers from 2009 to 2012 (RECORd1 Project). Of these, the clinical data of 708 patients alive, free from disease recurrence, and with a minimum 2-year functional follow-up were extracted. RESULTS: Patients underwent open (47.3%), laparoscopic (36,6%) or robot-assisted (16.1%) partial nephrectomy. Median baseline eGFR was 84.5 (interquartile range [IQR]: 69.9-99.1) ml/min/1.73m2. Immediate (3rd postoperative day), early (1th month) and late (24th month) renal function impairment >25% from baseline was identified in 25.3%, 21.6% and 14.8% of cases, respectively. Female gender and baseline eGFR were independent predictors of immediate, early and late RF impairment; age at diagnosis of immediate and late impairment; uncontrolled diabetes only to late impairment. Open and laparoscopic approaches and pedicle clamping were independent predictors of immediate and early renal function impairment. Overall 58/529 (11%) patients experienced postoperative cardiovascular events. Body mass index and late renal function impairment were independent predictors of postoperative cardiovascular events. CONCLUSIONS: Surgical modifiable factors were significantly associated with a worse immediate and early functional outcome after partial nephrectomy, while the clinical unmodifiable factors affected the renal function during the entire follow-up. Late renal function impairment is an independent predictor of development of postoperative cardiovascular events.

To evaluate the impact of multiparametric magnetic resonance imaging (mpMRI) to guide the nerve sparing (NS) surgical plan in prostate cancer (PCa) patients referred to robot assisted radical prostatectomy (RARP) Methods: 137 consecutive PCa patients were submitted to RARP between September 2016 and February 2017 at two high-volume European centers. Before RARP, each patient was referred to 1.5-T or 3.0 T mpMRI. NS was recorded as Grade 1, Grade 2, Grade 3 and Grade 4 according to Tewari et al.11 classification. A preliminary surgical plan to determinate the extent of NS approach was recorded basing on clinical data. The final surgical plan was re-assessed after mp-MRI revision. The appropriateness of surgical plan change was considered basing on the presence of ECE or positive surgical margins (PSMs) at level of NVBs area at final pathology. Furthermore, we analyzed a control group during the same period of 166 PCa patients referred to RARP in both institutions without preoperative mpMRI to assess the impact of the use of mpMRI on the surgical margins.

Introduction: Persistent Mullerian duct syndrome is a rare disorder of male organ development characterized by internal male pseudohermaphroditism. Persistent Mullerian duct syndrome is usually an incidental finding in patients presenting cryptorchidism, inguinal hernia, or a previous story of undescended testes. Case description: We report on two cases of persistent Mullerian duct syndrome: an adult fertile male with uterus and ectopic prostate occurring as pelvic mass and a 75-year-old organ donor with uterus and two fallopian tubes, discovered in course of organ recruitment. We performed routine histological analysis and immunohistochemical profiling of the different tissue components. Examined tissues were all benign, and the living patient is well after surgery. Conclusion: In order to prevent further complications such as infertility and potential malignant change, surgeons and surgical pathologists must be aware of this condition and should consider excision of the Mullerian remnant where possible.

Background The National Research Council (CNR) prostate cancer monitoring project in Italy (Pros-IT CNR) is an observational, prospective, ongoing, multicentre study aiming to monitor a sample of Italian males diagnosed as new cases of prostate cancer. The present study aims to present data on the quality of life at time prostate cancer is diagnosed. Methods One thousand seven hundred five patients were enrolled. Quality of life is evaluated at the time cancer was diagnosed and at subsequent assessments via the Italian version of the University of California Los Angeles-Prostate Cancer Index (UCLA-PCI) and the Short Form Health Survey (SF-12). Results At diagnosis, lower scores on the physical component of the SF-12 were associated to older ages, obesity and the presence of 3+ moderate/severe comorbidities. Lower scores on the mental component were associated to younger ages, the presence of 3+ moderate/severe comorbidities and a T-score higher than one. Urinary and bowel functions according to UCLA-PCI were generally good. Almost 5% of the sample reported using at least one safety pad daily to control urinary loss; less than 3% reported moderate/severe problems attributable to bowel functions, and sexual function was a moderate/severe problem for 26.7%. Diabetes, 3+ moderate/severe comorbidities, T2 or T3-T4 categories and a Gleason score of eight or more were significantly associated with lower sexual function scores at diagnosis. Conclusions Data collected by the Pros-IT CNR study have clarified the baseline status of newly diagnosed prostate cancer patients. A comprehensive assessment of quality of life will allow to objectively evaluate outcomes of different profile of care.

In very few years, several treatments have significantly improved the prognosis of patients with metastatic renal cell carcinoma (RCC). Despite this, the clinical outcomes of specific subgroups of patients including those with central nervous metastases still remain poor. In this population, a very infrequent and poorly described site of metastases is the pituitary gland. Because of the important endocrinal function and the anatomic site of this specific organ, clinical management of this complication requires several additional precautions compared with other central nervous metastases. Here, we describe a case of a single pituitary metastasis from clear cell RCC in a patient who showed a surprising progression-free survival and overall survival to sunitinib first-line treatment. Because of the uncommon clinical course of the disease of our patient and the atypical site of metastases, we want also to underline the importance of further investigation of molecular pathways associated with a favorable prognosis in patients with metastatic clear cell RCC.

PURPOSE: To assess survival and competing causes of mortality in prostate cancer (PCa) patients referred to radical prostatectomy through a combination of unfavorable characteristics. PATIENTS AND METHODS: We evaluated 615 PCa patients referred to radical prostatectomy and pelvic lymph node dissection at single tertiary-care center with at least one adverse feature (AF): preoperative prostate-specific antigen ≥ 20 ng/mL, pathologic Gleason score 8 to 10, and no organ-confined disease at final pathology (seminal vesicle involvement, positive surgical margins, and/or lymph node invasion). Kaplan-Meier analyses were used to assess cancer-specific mortality (CSM)-free survival rates by stratifying patients into 3 risk categories according to the number of AFs (namely, 1, 2, and 3 AFs). Multivariable competing risk Cox regression analyses were used to assess CSM and other cause of mortality. RESULTS: Significant differences were found in terms of preoperative and pathologic tumor characteristics, adjuvant therapies, and biochemical recurrence (BCR). Men with 1 AF had higher CSM-free survival estimates compared to those with 2 and 3 AFs (92.8% vs. 84.2% vs. 27.7% at 10 years' follow-up, P < .001). Moreover, the presence of 3 AFs (hazard ratio [HR], 2.96), postoperative adjuvant treatment status (HR, 2.44), and time to BCR (HR, 0.96) were all independent predictors of CSM (P ≤ .04). Age at surgery and time to BCR were the only independent predictors of other causes of mortality (P ≤ .0009). CONCLUSION: The risk group stratification according to the number of AFs could help physicians to accurately predict oncologic outcomes and to select PCa patients for the most appropriate postoperative strategies.

Nivolumab is an effective and tolerable treatment for metastatic renal cell carcinoma, showing longer median overall survival than everolimus and achieving a good percentage of objective response, stable disease, and prolonged responses. However, very few cases have been reported in the literature of a complete response to nivolumab in the metastatic pretreated setting. Here, we report a case of complete response to nivolumab in II line following sunitinib in a metastatic clear cell renal cell carcinoma with favorable risk according to the IMDC criteria. This is also an interesting case on the use of immunotherapy following a long period of antiangiogenetic therapy, underlining the importance of the sequence of treatment to achieve the best possible outcome in terms of prolonged overall survival, progression-free survival, and objective response.

Introduction and Objectives: We aim to present the use of 3D digital and physical renal model (1–5) to guide the percutaneous access during percutaneous nephrolithotripsy (PNL). Materials and Methods: We present the clinical case of a 30 years old man with left renal stone (25x15 mm). A virtual 3D reconstruction of the anatomical model including the stone, the renal parenchyma, the urinary collecting system (UCS) and the skeletal landmarks (lumbar spine and ribs) was elaborated. Finally, a physical 3D model was created with a 3D printer including the renal parenchyma, UCS and the stone. The surgeon evaluated the 3D virtual reconstruction and manipulated the printed model before surgery to improve the anatomical knowledge and to facilitate the percutaneous access. In prone position, combining ultrasound and fluoroscopy implemented by the preoperative anatomical planning based on the 3D virtual and printed model, an easy and safe access of the inferior calyx was achieved. Then, the patient underwent PNL using a 30 Fr Amplatz sheet with semi-rigid nephroscope and ultrasound energy to achieve a complete lithotripsy of the pelvic stone. Results: The procedure was safely completed with 1 single percutaneous puncture (time of puncture 2 minutes). Overall surgical time was 90 min. No intra and postoperative complications were reported. The CT scan performed before discharge confirmed a complete stone free state. Conclusion: The 3D-guided approach to PNL facilitates the preoperative planning of the puncture with better knowledge of the renal anatomy and may be helpful to reduce operative time and improve the learning curve.

Multiparametric magnetic resonance imaging (mpMRI)represents nowadays an essential tool to guide radicalprostatectomy (RP). Despite nerve sparing (NS) approachwas traditionally precluded in high risk prostate cancer(HRPC) patients, Kumar et al. [1] suggested that a selectiveNS could be feasible even in HRPC patients with acceptablepositive surgical margins (PSMs) rates. Of note, accuratepreoperative selection of ideal candidates to NS surgery,especially in HRPC [2], is key. For this reason, we readwith interest the article by Baack et al. [3], thought theinnovative way of retrospective survey, the authors eval-uated the impact of mpMRI on surgical plan in HRPC bothconsidering NS approach, pelvic lymph node dissection(PLND) template, bladder neck approach and surgicaltechnique. They found that all patients had at least onechange to their surgical plan by urologists. Interestingly,considering the NS technique, the authors found that NSapproach was changed in 58% of cases with overallappropriateness of 72%, which is consistent with our pre-vious data with overall change in roughly 50% of cases,resulting an overall appropriateness of 75% [4]. This paperconfirms the important role of mpMRI even in HRPC inwhich NS approach is usually not considered for higher riskof extracapsular extension, suggesting that in selective casesof HRPC an incremental NS approach could be oncologi-cally safe only with a preoperative mpMRI.However, one important limitation is the lack of com-parison between the intended approach from the survey andthe real surgical plan performed during surgery. As weknow, the preoperative intended surgical plan (even afterrevision of mpMRI) could go through some modifications during surgery. Moreover, the definition of appropriatenessof the surgical plan change (defined as presence of extra-prostatic extension at pathologic specimen) is not ideal,since it considers only thefirst surgical outcomes of roboticRP (moreover it does not consider the presence of PSMs)rather than a real oncologic outcome (i.e. biochemicalrecurrence) or the postoperative erectile function.One more important aspect the authors underline is thepotential role of mpMRI to impact the PNLD template,suggesting that the use of mpMRI can modify the surgicalextension of PLND. We believe that an accurate mpMRI isuseful to investigate both the local stage of PC and the nodaland skeletal status within the pelvis, which is the mostcommon andfirst site of dissemination. Moreover, the PCcharacteristics detected at mpMRI, combined with clinicaldata, have the potential to influence surgeon during PLND.In fact, Gandaglia et al. [5] found that the information frommpMRI (i.e clinical stage at mpMRI, grade group at MRI-targeted biopsy and maximum size of index lesion) canimprove the accuracy of Briganti’s nomogram to predict thepresence of nodal metastases in patients with PC detected atMRI-targeted biopsy. Of course, further studies are neededto evaluate the role of mpMRI for both preoperative plan-ning of NS approach and the decision when to perform orhow to modify the template of PLND.

To perform an external validation of a recently published nomogram aimed to predict positiveOverall, 413 PCa patients with BCR after RP (two consecutive PSA ≥ 0.2 ng/ml) and PSA value between 0.2 and 1 ng/ml were included. A multivariable logistic regression model was produced to assess the predictors of positiveIn the external cohort, the overall detection rate ofWe assessed similar suboptimal predictive accuracies in the external cohort compared to the original one. PSA and ongoing ADT were confirmed as positive predictors, and the most informative nomogram cut-off resulted 35%.

To compare segmental ureterectomy (SU) and radical nephroureterectomy (RNU) in terms of overall survival (OS) and impact on postoperative renal function in patients treated for upper tract urothelial carcinoma (UTUC) of the ureter with preoperatively reduced estimated glomerular filtration rate (eGFR).We retrospectively collected the data of consecutive patients treated for UTUC, in 6 Italian tertiary referral centers, from 2003 to 2013, and analyzed those treated with RNU or SU for ureteral cancer and with a preoperative eGFR90 ml/min/1.73mOut of 521 patients with UTUC, 228 patients had preoperative reduced eGFR. Out of these patients, 93 had ureteral cancer and were included in the primary analyses - 67 (72.0%) treated with RNU and 26 (28.0%) with SU. Preoperative characteristics were similar in the 2 groups. The overall median follow-up period was 26.5 months. A nonsignificant postoperative eGFR decrease of 3.0 ml/min/1.73mThe type of surgery (SU vs. RNU) has a low impact on postoperative renal function and OS in patients with ureteral cancer and preoperative eGFR90 ml/min/1.73m

Objective: To compare the retroperitoneal with the transperitoneal approach in a series of patients underwent to robotic-assisted pyelolithotomy (RP). Materials and methods: From January 2015 to December 2018 we evaluated 20 patients subjected to robotic pyelolithotomy; 11 patients were treated with retroperitoneal approach (RRP) and 9 with transperitoneal approach (TRP). For each patient intra and perioperative data were recorded: operative time (OT), blood loss (BL), length of hospital stay (LOS), stone clearance, post-operative complications and time to remove the drain. The presence of stone fragments < 4 mm was considered as stone free rate. Results: The principal stone burden was greater in the TRP group than in the RRP group (48 ± 10 mm vs 32 ± 14 mm, p = 0.12). Preoperative hydronephrosis was present in 7 (64%) patients in RRP group and a mild hydronephrosis in 3 of TRP group (p = 0.04). The average operative time was higher in the RRP group than in the TRP group (203 ± 45 min vs 137 ± 31 min, p = 0.002). The average blood loss was 305 ± 175 ml in the RRP group versus 94 ± 104 ml in the TRP group (p = 0.005). The stone free rate was similar between the two groups, 36% (4 patients) in the RRP group and 44% (4 patients) in the TRP (p = 0.966). Conclusions: RP appears to be a safe and effective minimally invasive treatment for some patients with renal staghorn calculi or urinary tract malformations. The TRP may give lower operative time and better results in terms of blood loss and length of hospital stay.

BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) is a surgical technique that allows to safely and effectively treat bladder outlet obstruction due to benign prostate enlargement and retrieve an adequate surgical specimen. We investigated the role of multiparametric magnetic resonance imaging of the prostate (mpMRI) as a tool to exclude incidental prostate cancer (iPCa) and to compare mpMRI alone with a contextual transrectal ultrasound guided biopsy (TRUS-GB). METHODS: Retrospective multicentric evaluation of 244 patients underwent to HoLEP with a suspicion of prostate cancer (PCa) due to raised PSA and/or abnormal digital rectal examination (DRE) and a negative mpMRI (PI-RADS score < 3), was performed. Of these, 118 patients had only a negative mpMRI (MRI group) while 126 had a negative mpMRI and a contextual preoperative negative TRUS-GB (MRI + TRUS-GB group). Comparison between the two groups, univariate and multivariate analysis were conducted in order to identify any predictive factors of iPCa. RESULTS: Median age, PSA, prostate volume and PSA density were 64.0 years (IQR: 58.0 - 69.0), 6.10 ng/mL (IQR: 4.76 - 9.65), 86.0 cc (IQR: 65.0 - 115.0), 50.0 cc (IQR: 37.5 - 80.0) and 0.08 ng/mL/cc (IQR: 0.06 - 0.10), respectively. In surgical specimen, iPCa was detected in 21 cases (8.8%). No statistically differences between MRI and MRI + TRUS-GB group were found in terms of iPCa (7.6% and 8.5% respectively), pathological T stage and ISUP Grade Group. A contextual TRUS-GB added to mpMRI didn't correlate to iPCa either at uni- and multivariate analysis while a significant correlation of a PSA density > 0.15 ng/mL/cc was found only at univariate analysis. CONCLUSIONS: Including a mpMRI in clinical evaluation of patients eligible to HoLEP with a preoperative PCa suspicion leads to low the rates of iPCa and might avoid unnecessary TRUS-GB.

The objective of this study was to develop a clinical nomogram to predict gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography (Seven hundred three (n = 703) prostate cancer (PCa) patients with confirmed PSA failure after radical therapy were enrolled. Patients were stratified according to different clinical settings (first-time biochemical recurrence [BCR]: group 1; BCR after salvage therapy: group 2; biochemical persistence after radical prostatectomy [BCP]: group 3; advanced-stage PCa before second-line systemic therapies: group 4). First, we assessedThis novel nomogram proved its good accuracy in predicting a positive scan, with values ≥ 40% providing the most informative cutoff in counselling patients to

INTRODUCTION AND OBJECTIVES:The primary objective was the evaluation of Gallium 68(68Ga)-prostate-specific membrane antigen (PSMA)-11 positron emission tomography/computed tomography (PET/CT) detec...

INTRODUCTION AND OBJECTIVES:Localized low-risk prostate cancer (PCa) can have different biological behaviour and its treatment remains controversial. We investigated the incidence of unfavorable fe...

INTRODUCTION AND OBJECTIVES:Although multiparametric MRI (mpMRI) is the most accurate tool in the detection of clinically significant Prostate Cancer (CsPCa), some limitations have reduced its use ...

INTRODUCTION AND OBJECTIVES:Partial nephrectomy (PN) is the standard treatment for localized renal tumors, although it can be challenging in case of anatomically complex renal masses.Aim of the pre...

The aim of the study is to report surgical and early functional outcomes of first 100 patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD) in a single center. The main surgeon (A.P.) attended a modular training program at a referring center mentored by a worldwide-recognized robotic surgeon (P.W.). The program consisted of: (a) 10 h of theoretical lessons; (b) video session (c) step-by-step in vivo modular training. Each procedure was performed as taught, without any technique variation. Demographics, intra-operative data and post-operative complications, along with early functional outcomes, were recorded for each patient. We retrospectively evaluated the first consecutive 100 patients submitted to RARC with totally ICUD from July 2015 to December 2018. Median age at surgery was 69 years (IQR 60–74). 52 (52%), 32 (32%), and 17 (17%) patients received orthotopic neobladder, ileal conduit and uretero-cutaneostomy, respectively. Median operative time was 410 min. A median number of lymph nodes retrieved were 27 and median estimated blood loss was 240 mL with median hospitalization time of 7 days. All procedures were completed successfully without open conversion. A statistically significant improvement was found in the late (30–90 post-operative days) post-operative complications (p = 0.02) and operative time for urinary derivation. At multivariate logistic regression model ASA score ≥ 3 (OR = 4.2, p = 0.002) and number of lymph nodes retrieved (OR = 1.16, p = 0.02) were found to be predictors of 90-day complications. An adequate modular training is paramount to obtain successful results and reduce the learning curve of RARC, as demonstrated by our experience.

Pubic bone osteomyelitis is a rare infectious condition which is characterized by a complex diagnostic and therapeutic workup, due to its various clinical manifestations. Among the many causes of this condition, urinary fistula is the most common in case of previous urological procedures. In order to solve this complication, it is crucial to treat both the fistula and (moreover) the infectious locus arising from it, because treating the fistula alone does not provide any control on the infectious noxa. We present the first case of pubic bone osteomyelitis arising from a urinary fistula after a robotic radical cystectomy with intra corporeal continent neobladder, which has been successfully treated through a multidisciplinary approach.

To evaluate the clinical impact ofWe enrolled 276 prostate cancer patients referred toThe overall detection rate of

Background Robot-assisted radical prostatectomy (RARP) has gained increasing diffusion as standard of care in the surgical treatment of prostate cancer (PCa) patients, even in the absence of robust long-term oncologic comparative data. This article is a report of oncologic outcomes of RARP at more than 10 years follow-up. Methods We retrospectively evaluated 173 consecutive PCa patients underwent RARP between 2002 and 2005 at a single European center with complete clinic and pathologic data and potential follow-up of at least 10 years. Kaplan-Meier analyses assessed biochemical recurrence free survival (BCR-FS), clinical recurrence free survival (CR-FS), cancer specific mortality free survival (CSM-FS), other causes mortality free survival (OCM-FS) in the overall population and CR-FS after stratification according to pathologic stage and Gleason score. Multi-variable Cox regression analyses were performed to assess the predictors of BCR and CR. Results Median follow-up (Interquatile Range [IQR]) was 133 (123-145) months. The BCR-FS, CR-FS, CSM-FS and OCM-FS rates at median follow-up were 73.4%, 81.1%, 95.7%, and 68.6%, respectively. Patients staged as pT3b-T4 and men with Gleason score 8-10 experienced significantly lower CR-FS rates as compared to those with less aggressive pathologic features (all P≤0.001). At multivariable analysis, pathologic Gleason score 8-10 (Hazard Ratio [HR]: 2.85), pathologic stage pT3b-pT4 (HR: 2.76) and adjuvant therapy (HR: 2.09 for radiotherapy [RT] and HR: 13.66 for androgen deprivation therapy [ADT]) were independent predictors of BCR (all p≤0.02). While, pathologic Gleason score 8-10 (HR: 4.05) and pathologic stage pT3b-pT4 (HR: 6.78) were found to be independently related to higher risk of CR (all P≤0.03). Retrospective data and limited number of patients included could have affected our analyses. Conclusions In experienced centers, RARP allows optimal oncologic outcomes at long term follow-up. Adverse pathologic characteristics are independent predictors of BCR and CR.

Background: The treatment options for male lower urinary tract symptoms (LUTS) widely range from self-monitoring to oral medications to surgical procedures. As far as concerns surgical treatment of obstructive LUTS, transurethral incision of the prostate is considered as the gold standard in patients with mild benign prostatic enlargement. Objectives: The aim of our study is to describe this novel approach to perform ejaculation sparing Holmium laser bladder neck incision (ES-HoBNI), with particular regard to its effect on ejaculation and LUTS relief. Methods: We evaluated prospective clinical data from 143 consecutive patients who underwent ES-HoBNI at our institution from January 2012 to February 2018. Procedures were performed with a continuous flow 26 Ch resectoscope and a 550 µm holmium laser end-fire fiber. The stenotic bladder neck was deeply incised at 3 and 9’o clock down to the prostatic capsule in a retrograde direction to either side in front of the veromontanum. Results: Median Qmax, postvoid residual volume, International Prostate Symptom Score, and quality of life were 9 mL/s (7.4–10.2), 130 mL (100–190), 15 (13–19), and 3 (2–4), respectively. In total, 110 (76.9) reported regular anterograde ejaculation. Median operative time was 20 min (15–26). Median catheterization time and hospital stay were 3 days (3–4) and 22 h (20–24), respectively. Moreover, we have compared the frequency of anterograde ejaculation, which slightly increases after ES-HoBNI (77 vs. 81.2%) when compared to baseline data, despite not reaching statistical significancy. Conclusions: ES-HoBNI is a safe, reproducible technique to relieve obstructive LUTS in men with small prostates while preserving ejaculation in younger and sexually active individuals.

Introduction: Purpose of the study was to investigate the correlation of a preoperative multiparametric magnetic resonance imaging of the prostate (mpMRI) in patients with a suspicion of prostate cancer and eligible for Holmium Laser Enucleation of the Prostate (HoLEP). Material and methods: Data of 228 patients who had undergone HoLEP was selected and retrospectively analyzed from a multicentric database. All patients presented with a raised serum PSA and/or an abnormal digital rectal examination (DRE). Prostate cancer (PCa) was excluded either with a negative mpMRI (group 'NEGATIVE MRI' n = 113) or a standard biopsy (group 'NO MRI' n = 115). Preoperative characteristic surgical and histological outcomes were confronted. A univariate and multivariate logistic regression model was performed to investigate independent predictors of incidental Prostate Cancer (iPCa). Results: Both groups presented with no statistical differences in preoperative characteristics besides previous acute urinary retention rates and post-voided residual volume, found to be higher (27.8% vs. 14.2% and median 120cc vs. 80cc) in NO MRI and NEGATIVE MRI respectively.No differences were registered in surgical time, removed tissue, catheterization time, hospital stay and complications rate.Statistically lower rate of iPCa (p = 0.03) was detected in the NEGATIVE MRI group (6.2%) in comparison with NO MRI group (14.8%). In multivariate logistic regression only presence of a preoperative negative mpMRI correlated (p = 0.04) as an independent predictive factor (OR 2.63; 95% CI: 1.02-6.75). Conclusions: A negative mpMRI might be a useful tool to be included in a novel preoperative assessment to patients eligible for HoLEP with a suspicion of PCa in order to avoid an incidental PCa.

To maximize the functional advantage of PN, different selective clamping approaches have been proposed.1 However, conventional 2-D cross-sectional images are suboptimal to identify the exact intrarenal vascular anatomy and to predict the real tumor blood supply from segmental branches. Digital 3-D models of renal masses with the complete anatomical reconstruction of the kidney can be elaborated from conventional 2-D preoperative imaging2 and can be used as an additional tool to improve the understanding of the size, location, depth of a renal mass and vascular anatomy before PN.3–6 We aim to report our preliminary experience with preoperative use of 3-D digital reconstruction of renal models to guide the surgical approach during RAPN. We prospectively enrolled 20 consecutive patients with clinical diagnoses of renal mass, submitted to RAPN at a single tertiary institution. Before surgery, all patients underwent chest and abdominal contrast-enhanced CT. Furthermore, 3-D virtual reconstruction of an anatomical model for supporting surgical planning including the lesion, the renal parenchyma, the urinary collecting system and vascular anatomy (including extra- and intra-renal arterial and venous branches) was created by the Laboratory of Bioengineering of the University of Bologna in Bologna, Italy. For the creation of 3-D anatomical renal models, preoperative high-quality contrast-enhanced CT images were collected (slice thickness: 1.25/2.5 mm, step interval: 0.8/2.0 mm). Multiple imaging series with different contrast levels were used for the selective identification of each anatomical structure of interest. Segmentation was achieved using D2 software (DICOM to PRINT; 3D Systems, Rock Hill, SC, USA), to convert DICOM medical images into 3-D digital models. The segmented anatomical structures were then combined into one file using alignment of common regions. The obtained 3-D virtual model is navigable; that is, the surgeon can interact with it changing the transparency of each structure in the 3-D rendering. The preoperative surgical plan to define the level of arterial clamping (namely, no clamping, main artery, selective or super-selective) was recorded by the surgeon based on conventional imaging blinded to the 3-D model. The surgical plan regarding the level of arterial clamping was re-assessed after revision of the 3-D model immediately before intervention. The intraoperative effective clamping technique after revision of the 3-D virtual model was compared with the preoperative plan based on conventional imaging using the v2 -test. All statistical tests were carried out using SPSS 22.0 (IBM, Armonk, NY, USA). RAPN was carried out using the DaVinci Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in a four-arm configuration with the integrated Firefly fluorescence-imaging mode, as previously described.7 One single experienced surgeon carried out all the RAPN cases. Overall, 16 (80%) and four (20%) of the tumors were clinical T1a and T1b stage, respectively. The median WIT was 10 min (IQR 7–12 min). No intraoperative and postoperative complications were observed. The median postoperative creatinine levels was 0.9 mg/dL (IQR 0.84–1.09 mg/dL) at 6 months’ follow up (Table 1). Based on conventional imaging, the preoperative plan of arterial clamping was: no clamping in four patients (20%), clamping of the main artery in 12 patients (60%) and selective clamping in four patients (20%). During surgery, the 3-D virtual model revision induced the surgeon to modify the clamping plan in eight patients (40%), towards a selective clamping approach, resulting in no cases of unclamped approach, clamping of the main artery in eight patients (40%) and selective clamping in 12 patients (60%; P = 0.01; Table 2). The preoperative plan based on 3-D reconstruction remained unchanged during surgery in 60% of patients, with intraoperative modification of the preoperative clamping plan in eight patients (40%) during RAPN (Video S1). Of note, due to better reconstruction of vascular anatomy, the use of the 3-D model influenced the surgeon to carry out selective clamping in most of the patients in our cohort. However, due to intraoperative findings of complex renal vasculature and adhesive fatty tissues in the hilum region, four patients planned for selective clamping were finally shifted to non-selective preoperative surgeon’s plan of arterial clamping in 40% ofpatients during RAPN toward a more selective clamping approach.

OBJECTIVES: To compare overall (OS), cancer-specific (CSS), recurrence free survival (RFS) and post-operative renal function among patients affected by upper tract urothelial carcinoma (UTUC) of the distal (lower lumbar and pelvic) ureter, electively treated with segmental resection and termino-terminal anastomosis (TT) vs bladder cuff removal and ureteral re-implantation (RR). PATIENTS AND METHODS: A multicentre retrospective study, including 84 patients diagnosed with UTUC of the distal ureter and treated with TT or RR, is presented. The primary endpoint was to compare TT and RR in terms of OS, CSS and RFS. As a secondary outcome we compared the post-operative creatinine values as an index of renal function in the two groups. RESULTS: Out of 521 patients with UTUC, 65 (77.4%) and 19 (22.6%) patients underwent RR and TT, respectively. Pre- and post-operative characteristics were not statistically different between the two groups. The median follow-up period was 22.7 months. Patients treated with TT and those treated with RR did not show significantly different 5yOS, 5yCSS and 5yRFS (73.7 vs 92.3%, p = 0.052, 94.7 vs 95.4%, p = 0.970, and 63.2 vs 53.9%, p = 0.489, respectively). No difference in post-operative creatinine variation emerged in association with the surgical technique (p = 0.411). CONCLUSION: Patients treated with TT or RR for UTUC showed comparable OS, CSS, RFS and post-operative renal function. Our data suggest that the bladder cuff removal is not imperative in the treatment of distal ureteral UTUC, and TT can be a safe solution in selected cases. This article is protected by copyright. All rights reserved.

We aimed to review the current state-of-the-art imaging methods used for primary and secondary staging of prostate cancer, mainly focusing on multiparametric magnetic resonance imaging and positron-emission tomography/computed tomography with new radiotracers. An expert panel of urologists, radiologists and nuclear medicine physicians with wide experience in prostate cancer led a PubMed/MEDLINE search for prospective, retrospective original research, systematic review, meta-analyses and clinical guidelines for local and systemic staging of the primary tumor and recurrence disease after treatment. Despite magnetic resonance imaging having low sensitivity for microscopic extracapsular extension, it is now a mainstay of prostate cancer diagnosis and local staging, and is becoming a crucial tool in treatment planning. Cross-sectional imaging for nodal staging, such as computed tomography and magnetic resonance imaging, is clinically useless even in high-risk patients, but is still suggested by current clinical guidelines. Positron-emission tomography/computed tomography with newer tracers has some advantage over conventional images, but is not cost-effective. Bone scan and computed tomography are often useless in early biochemical relapse, when salvage treatments are potentially curative. New imaging modalities, such as prostate-specific membrane antigen positron-emission tomography/computed tomography and whole-body magnetic resonance imaging, are showing promising results for early local and systemic detection. Newer imaging techniques, such as multiparametric magnetic resonance imaging, whole-body magnetic resonance imaging and positron-emission tomography/computed tomography with prostate-specific membrane antigen, have the potential to fill the historical limitations of conventional imaging methods in some clinical situations of primary and secondary staging of prostate cancer.

Objectives: To evaluate the detection rate of prostate cancer (PCa) in patients who underwent to “in bore” Magnetic Resonance Imaging -guided prostate (MRI-GB) biopsy compared to the standard transrectal ultrasound guided prostate biopsy (TRUS-GB). Materials and methods: Between January 2017 and March 2015 a cohort of 39 consecutive patients was prospectively enrolled. All the patients underwent an "in-bore" guided MRI prostatic biopsy and subsequently ultrasound-guided standard prostate biopsy. Results: Median age of patients was 65.5 years (SD ± 6.6), median total PSA serum level was 6.6 ng/ml (SD ± 4.1), median prostate total volume was 51.1 cc (SD ± 26.7). Thirty of 39 (76.9%) were biopsy-naïve patients while 7/39 (17.9%) had at least one previous negative random TRUS-GB; 2/39 (5.1%) patients were already diagnosed as PCa and were on active surveillance. In 18/39 (53.8%) men Pca was diagnosed; as regards the MRI-GB results related to the PI-RADS score, biopsies of PIRADS 3 lesions were positive in 5/18 cases (27.8%), while the number of positive cases of PI-RADS 4 and 5 lesions was 7/11 (63.6%) and 6/10 (60%)respectively. At the histological examination, 4/39 (10.3%) had a PCa ISUP grade group 1, 11/39 (28.2%) had a ISUP 2, 6/39(15.4%) had a ISUP grade group 3 and 2/39 (5.1%) had a ISUP 4-5. Conclusions: MRI-GB represents a promising technique that may offer some of advantages compared to standard systematic TRUSGB. Our preliminary experience in MRI-GB resulted safe and feasible and represents a viable procedure for the diagnosis and characterization of PCa.

BACKGROUND: The aim of this study was to analyze the predictive factors of intraoperative complications in patients submitted to PN and the impact of intraoperative complications on postoperative outcomes. METHODS: Data of 1055 patients who underwent PN for cortical renal masses were recorded from a multicenter prospective observational study (RECORd1 project). RESULTS: Overall, 48 (5%) patients experienced 49 intraoperative complications (four medical, 45 surgical). At multivariable analysis, age (OR=1.02, 95% CI: 1.00-1.08, P=0.03), imperative versus elective surgical indication (OR=2.55, 95% CI: 1.12-5.85, P=0.03), open (OR=5.76, 95% CI: 1.05-9.21, P=0.01) and laparoscopic (OR=2.35, 95% CI: 1.11-4.95, P=0.03) versus robotic approaches resulted independent predictive factors of intraoperative complications. Patients experiencing intraoperative complications had a significantly higher rate of overall postoperative complications (41.6% vs. 17.3%, P

Objective: The aim of our study is to describe the use of posterior muscle-fascial reconstruction during urethro-ileal anastomosis in bladder cancer (BC) patients submitted to robot-assisted radical cystectomy (RC) with orthotopic neobladder (ON) and its role in facilitating day- and night-time continence recovery during a 12-month follow up. Materials and methods: We prospectively collected data from 42 consecutive patients who underwent RARC with totally intracorporeal ON and extended pelvic lymph node dissection (PLND) at our Institution from June 2014 to October 2017. Prior to the urethro-neobladder anastomosis we reconstructed the Denonvilliers Fascia (DF) as previously described for radical prostatectomy using a bidirectional barbed suture. Day and night-time recovery rates were reported at 3, 6 and 12 months after surgery, with continent patients being those using either no urinary pads or 1 safety pads. Results: Median age at surgery was 63 yrs, 41 (97.6%) patients were male. 28 (66.7%) patients presented a clinical T2 disease. Median operative time and median ON reconstruction time were 450 minutes and 180 minutes respectively. 13 (31%) individuals had non-organ confined disease, with 11 (26.2%) patients with positive lymph nodes (median 3 positive lymph nodes) and 2 (4.8%) with non-urothelial cancer at final pathologic examination. Median hospital stay and median catheterization time were 7 (IQR 7-8) and 21 (IQR 19-22). During first 30 post-operative days we recorded 7 (16.7%) low-grade Clavien and 2 (4.8%) IIIa Clavien complications, whereas between 30 and 90 postoperative days we recorded 4 (9.5%) low-grade, 4 (9.5) IIIa and 1 (2.4%) IIIb complications. Day-time and night-time continence rates were 61.9% vs 52.4%, 73.8% vs 64.3% and 90.5% vs 73.8% at three, six and twelve months follow up. Day-time continence was significantly superior in the younger group (97% vs 57%, p 0.01); night-time continence rates were also superior among < 70 yrs patients, despite not reaching statistical significance (77% vs 57%, p 0.3). Conclusions: Posterior muscle-fascial reconstruction aids continence recovery in BC patients undergoing RARC with ON, with younger and fitter patients most benefitting from ON reconstruction.

OBJECTIVE: To report and compare the peri-operative outcomes of patients undergoing open (ORC) and robotic-assisted radical cystectomy (RARC) for bladder cancer performed with a radiofrequency seal and cut device (Caiman®). MATERIALS AND METHODS: Data of patients undergoing ORC or RARC between January 2015 and March 2016 at 6 Italian institutions were prospectively recorded and analyzed. Thirty-and 90-day complications were stratified according to the Martin's criteria and graded according to the Clavien-Dindo classification. Data on operative time, blood loss, transfusion rate, complications, and length of stay were evaluated and compared between the ORC and RARC groups. RESULTS: Thirty-three (66%) and 17 (34%) patients were treated with ORC and RARC, respectively. The median age was 72 (64-78) years. Overall operative time was longer in RARC compared to ORC (389 ± 80.1 vs. 242 ± 62.2 min, p < 0.001), while the estimated blood loss during cystectomy was higher after ORC (370 ± 126.8 vs. 243.3 ± 201.6 ml, p = 0.03). The transfusion rate was significantly higher in the ORC compared to RARC (24.2 vs. 5.9%, p = 0.04). Eight (19%) and 7 (16.7%) patients experienced 30- and 90-day post-operative complications, with no significant difference between ORC and RARC. Length of stay was significantly shorter in RARC group (median 7 vs. 14 days, p < 0.001). CONCLUSION: Open and robot-assisted procedures were safely performed by using a new advanced bipolar seal and cut technology (Caiman®). RARC demonstrated to be superior to ORC in terms of bleeding, transfusion rates and length of hospital stay, despite longer operative time.