Robot-Assisted, Laparoscopic, and Open Radical Cystectomy: Pre-Operative Data of 1400 Patients From The Italian Radical Cystectomy Registry.

Introduction: The Italian Radical Cystectomy Registry (RIC) is an observational prospective study aiming to understand clinical variables and patient characteristics associated with short- and long-term outcomes among bladder cancer (BC) patients undergoing radical cystectomy (RC). Moreover, it compares the effectiveness of three RC techniques - open, robotic, and laparoscopic. Methods: From 2017 to 2020, 1400 patients were enrolled at one of the 28 centers across Italy. Patient characteristics, as well as preoperative, postoperative, and follow-up (3, 6, 12, and 24 months) clinical variables and outcomes were collected. Results: Preoperatively, it was found that patients undergoing robotic procedures were younger (p<.001) and more likely to have undergone preoperative neoadjuvant chemotherapy (p<.001) and BCG instillation (p<.001). Hypertension was the most common comorbidity among all patients (55%), and overall, patients undergoing open and laparoscopic RC had a higher Charlson Comorbidities Index (CCI) compared to robotic RC (p<.001). Finally, laparoscopic patients had a lower G-stage classification (p=.003) and open patients had a higher ASA score (p<.001). Conclusion: The present study summarizes the characteristic of patients included in the RIC. Future results will provide invaluable information about outcomes among BC patients undergoing RC. This will inform physicians about the best techniques and course of care based on patient clinical factors and characteristics.

The new patterns of nephrolithiasis: What has been changing in the last millennium?

Nephrolithiasis has been increasing over the last millennium. Although early epidemiologic studies have shown that kidney stones were two to three times more frequent in males than in females, recent reports have suggested that this rate is decreasing. In parallel a dramatic increase of nephrolithiasis has also been observed among children and adolescents. Furthermore, epidemiologic studies have shown a strong association between metabolic syndrome (Mets) traits and kidney stone disease. Patients with hypertension have a higher risk of stone formation and stone formers are predisposed to develop hypertension compared to the general population. An incidence of nephrolithiasis greater than 75% has been shown in overweight and obese patients compared to those of normal weight. It has also been reported that a previous diagnosis of diabetes mellitus increases the risk of future nephrolithiasis. Additionally, an association between metabolic syndrome and uric acid stone formation has been clearly recognized. Furthermore, 24-h urinary metabolic abnormalities have been decreasing among patients with nephrolithiasis over the last decades. Finally, nephrolithiasis could cause chronic kidney disease (CKD) and end stage renal disease (ESRD), especially in women and overweight patients. According to these observations, a better understanding of these new features among stone former patients may be required. Hence, the recognition and the correction of metabolic disorders could help not only to reduce the primary disease, but also stone recurrence.

The role of bedside assistant during robot assisted radical prostatectomy: Is more experience better? Analysis on perioperative and clinical outcomes.

OBJECTIVES: To analyze the impact of the bedside assistant's experience during RARP. It is believed that the outcome of robotic surgery during Robot Assisted Radical Prostatectomy (RARP) for prostate cancer depends not only on the console surgeon's experience. MATERIALS AND METHODS: All consecutive RARPs from January 2017 to March 2018 were sourced from a prospectively maintained database. All cases were performed by the same surgeon. He was supported by three bedside assistants: one with bedside and console experience, one only with relevant bedside experience, one basically inexperienced. The patient's parameters analyzed: age, Body Mass Index (BMI), previous abdominal surgery, prostate volume (by TRUS), pre-operative PSA, bioptic grading. Surgical outcomes analyzed included skin-to-skin operative time and estimated blood loss; clinical outcomes included length of hospital stay and time to catheter removal; the oncological outcome was represented by positive surgical margin rate. RESULTS: A total of 116 RARPs were identified: 38 RARPs were performed with the console experienced bedside assistant, 38 with the experienced one, 40 with the novice one. The variables were similar between the three groups. As far as outcomes are concerned, there were no statistically significant differences between the three bedside assistants in terms of operative time, estimated blood loss, length of stay, days of catheterization, positive surgical margin rate.

"Endourological closure of a malformative vascular source of bleeding using the VortX 0.018" coil®".

AIMS: Renal vascular malformations, congenital or acquired, are sometimes challenging for urologists and interventional radiologists to resolve. Arterovenous fistulas and pseudoaneuryms are usually embolized by interventional radiologists, with a low rate of complications. We propose a new endourological/interventional radiology technique to treat a source of arterovenous bleeding coming from a renal calyx in a minimally invasive way. METHODS: A combined endourological and interventional radiology procedure is described, using a Flexible Fiberoptic Ureteroscopes to undertake a retrograde intrarenal surgery (RIRS) to identify the source of bleeding; subsequently the VortX Coil® is inserted through a microcatheter to stop the bleeding and the correct position of the VortX coil is evaluated. Furthermore, we made a literature research on Pubmed and Medline to look for similar procedures. RESULTS: In case of a renal bleeding that could not be treated by endovascular way, a combined urological and interventional radiology procedure can be undertaken. We did not find similar endourological and interventional radiology procedure on Pubmed and Medline, so this is the first tecnique of endourological closure of a bleeding point using a coil. CONCLUSION: From our experience this could be a mininvasive technique to solve renal bleedings coming from a calyx that are not found by endovascular approach. Indeed, in our knowledge, the technique here described is the first that provides the use of an endovascular coil by endourological way in renal vascular malformations.

Changing in gender prevalence of nephrolithiasis.

Although nephrolithiasis is a more common disease in men rather than women, several studies over the last decades show that the male to female ratio 3:1 is narrowing. These finding may be associated to modified risk factors for stone formation between females and males. Changes in lifestyle and increasing obesity in women may play a role in shifting of gender disparity. Furthermore, recent studies have demonstrated an increase of kidney stones in women which have necessitated emergency department visits (ED). Therefore, females show a greater percentage of mortality rate if compared to males, especially if stone disease is associated to urosepsis and requires the admission to the Intensive Care Unit (ICU). This article reviews recent insights into changing gender prevalence in urinary calculi and into identifying the relation between gender and risk factors for stone disease, that in case of severe urosepsis might also lead to mortality.

Urological emergency activities during COVID-19 pandemic: Our experience.

BACKGROUND: The Coronavirus Disease (COVID-19) is causing a significant health emergency which is overturning dramatically routine activities in hospitals. The outbreak is generating the need to provide assistance to infected patients and in parallel to treat all nondeferrable oncological and urgent benign diseases. A panel of Italian urologists agreed on possible strategies for the reorganization of urological routine practices and on a set of recommendations that should facilitate a further planning of both inpatient visits and surgical activities during the COVID- 19 pandemic. According to this only urgent benign and nondeferrable oncological activities have been kept. MATERIALS AND METHODS: We have considered urgent outpatient visits requested by Emergency Department (ED) or by General Practitioner (GP) and emergency surgical procedures performed in our Urology Unit from March 9th to April 14th 2020, during COVID-19 pandemic. These figures have been compared to those observed last year from March 9th to April 14th 2019. RESULTS: Our data show that urgent care visits decreased during COCID-19 pandemic (from 293 to 179). Urgent care visits of patients who accessed directly to the ED decreased (from 219 to 107) whereas the number of urgent care visits referred by GP remained unchanged (74 vs 72). Consequently, the rate of visits from ED decreased from 75% to 60% and the rate of visit requested by GP increased from 25% to 40% (p = 0.001). Particularly, the rate of visits for renal colic, LUTS and other not precisely defined disorders from ED decreased and the corresponding rates of visits of patients referred by GPs increased significantly (p = 0.0001, p = 0.0180 and p = 0.0185, respectively). The rate of visits for acute urinary retention, hematuria, sepsis, acute scrotum, cystitis, prostatitis and genito-urinary trauma from ED and GP remained unchanged. Finally, urgency endourology and surgical activities have been stable in relation to the same period last year. CONCLUSIONS: Urological emergency activities during COVID- 19 pandemic are more appropriate since urgent outpatients' visits required by ED are decreased and emergency surgical and endourological procedures are stable.

The impact of potassium citrate therapy in the natural course of Medullary Sponge Kidney with associated nephrolithiasis.

OBJECTIVES: The present study was carried out to evaluate the effectiveness of medical therapy with potassium citrate in preventing calculosis complicating Medullary Sponge Kidney (MSK) without renal acidification defects. MATERIALS AND METHODS: In a open, uncontrolled, retrospective analysis, 49 MSK patients with nephrolithiasis without renal tubular acidosis, underwent a complete metabolic evaluation and received potassium citrate therapy 4-6 g/day. The course of stone disease before and after citrate therapy was determined in each patient from a combination of clinical history, past records, radiographs and kidney ultrasound. The rate of new stone formation/pt/yr, of endourological and extracorporeal procedures, of urinary tract infection (UTI) and number of hospitalization before and after medical treatment were calculated. RESULTS: Metabolic anomalies (hypercalciuria, hypocitraturia, hyperuricuria and hyperoxaluria) were present in 83% of the patients. Follow-up before and after alkali citrate therapy was comparable (4.7+/-1.4 and 4.9+/-1.7 years respectively). Medical treatment significantly reduced rates of stone formation from 2.0+/-1.0 to 0.2+/-0.5 pt/yr, ureteroscopy (URS) from 0.9+/0.8 to 0.4+/-0.5 pt/yr, extratracoporeal lithotripsy (ESWL) from 1.1+/-0.8 to 0.4+/-0.6 pt/yr, urinary tract infections (UTIs) from 0.8+/-1.2 to 0.3+/-0.5 pt/yr and hospitalization from 1.1+/-0.6 to 0.2+/-0.3 pt/yr, p < 0.001. This effect was observed also in MSK patients without metabolic anomalies. In 35 patients the asymptomatic disappearance of calcium stones was also observed. CONCLUSIONS: Our study documents the effectiveness of potassium citrate therapy in preventing neprolithiasis in MSK patients also in the absence of distal tubular acidosis. It suggests that in MSK patients alkali citrate may promote calcium stone dissolution by oral administration.

Testicular metastasis from renal cell carcinoma after nephrectomy and on tyrosine kinase inhibitors therapy: Case report and review.

Renal cell carcinoma has extremely heterogeneous presentation at the diagnosis: it may present as a confined organ disease, locally advanced, metastatic to locoregional lymph nodes or with single or multiple systemic metastases. Since chemotherapy and radiation therapy have not demonstrated efficacy either in primary therapy or in neo-adjuvant or adjuvant therapy for renal clear cell carcinoma, targeted agents like tirosine kinase inhibitors were developed and are largely used in locally advanced and metastatic renal cell carcinoma. Here, we present a rare case of ipsilateral renal cell carcinoma testicle metastasis, after radical nephrectomy and during tyrosine kinase inhibitors therapy. In addition, a retrospective search in PubMed, ScienceDirect, and Web of Science database on testicular metasteses from renal cell carcinoma under tyrosine kinase inhibitors therapy was performed.

Robot-assisted nerve-sparing radical prostatectomy using near-infrared fluorescence technology and indocyanine green: initial experience.

INTRODUCTION: Indocyanine green (ICG) is a fluorescent molecule that provokes detectable photon emission. The use of ICG with near-infrared (NIR) imaging system (Akorn, Lake Forest, IL) has been described during robotic partial nephrectomy (RAPN) as an adjunctive means of identifying renal artery and parenchymal perfusion. We propose the use of the ICG with NIR fluorescence during laparoscopic robot-assisted radical prostatectomy (RARP), to identify the benchmark artery improving the preservation of neurovascular bundle and to improve the visualization of the vascularization and then the hemostasis. METHODS: From April 2015 to February 2016, 62 patients underwent to RARP in our Urology Unit. In 26 consecutive patients, in the attempt to have a better visualization of neurovascular bundles, we used to inject ICG during the procedure. We evaluated the percentage of identification of neurovascular bundles using NIR fluorescence. Then, we evaluated complications related to injection of ICG and operative time differences between RARP with and without ICG injection performed by the same surgeons. RESULTS: We identified prostatic arteries and neurovascular bundles using NIR fluorescence technology in all patients (100%). There was not any increase in the operative time compared with RARP without ICG injection performed by the same surgeons. Complications related to injection of ICG did not occurred. CONCLUSIONS: In our experience, even if on a limited number of patients, the application of ICG with NIR fluorescence during RARP is helpful to identify the benchmark artery of neurovascular bundle.

Actinic cystitis: causes, treatment and experience of a single centre in the last five years.

INTRODUCTION: Actinic cystitis (AC) is the manifestation of symptoms and signs following pelvic radiotherapy. Pelvic radiotherapy produces both acute and chronic damage and such damage may have a devastating impact on the quality and on the amount of life of the patient. OBJECTIVES: To evaluate the number of radical cystectomies that have become necessary in the last five years in our department for AC after radiation treatment. MATERIALS AND METHODS: From February 2012 to February 2017, 11 patients underwent "open" cystectomy for AC. All patients were studied with radiographic examinations and endoscopy prior to surgery. We retrospectively evaluated the type of primitive cancer, the radiation dose administered, the time between radiation treatment and cystectomy. We also studied the related symptoms that required surgery. RESULTS: The mean age of patients at the time of cystectomy was 75 years. In six patients (54.4%) radiotherapy was performed for prostate cancer, for rectal cancer in two patients (18.1%), and for endometrial cancer in three patients (27.2%). Total radiant dose was different in different patients depending on the type and localization of cancer. The median time between radiotherapy and cystectomy was 111 months (24-256 months). All patients had symptoms before surgery. Seven patients (63.3%) with gross haematuria were treated with endoscopic clot evacuation and fulguration. DISCUSSION: The first approach to patients with AC is often supportive care. Surgery remains the most invasive treatment in the management of those patients who are not responsive to conservative treatments.

Metabolic evaluation in patients with infected nephrolithiasis: Is it necessary?

Fifty-four patients with infected renal lithiasis underwent complete metabolic evaluation searching for underlying factors contributing to stone formation including urine analysis and culture. Metabolic abnormalities were significantly more present in patients with mixed infected stones (struvite+/-apatite and calcium oxalate) than in patients with pure infected stones (struvite+/-carbonate apatite): hypercalciuria in 40%, hyperoxaluria in 34% and hyperuricosuria in 28% (p < 0.05). Urinary excretion of citrate was low in both groups without statistically significant difference (238+/-117 mg/24 h vs 214+/-104 mg/24/h, t = 0.72, p = 0.5). The few metabolic abnormalities present in patients with pure infected stones should suggest that urinary tract infection could change the urine chemistry in a lithogenic direction and be only cause of stone formation.

Urolithiasis in renal transplantation: diagnosis and management.

OBJECTIVES: To report our experience of diagnosis and multimodal management of urolithiasis in renal transplantation. PATIENTS AND METHODS: From January 1995 to December 2012, 953 patients underwent renal transplantation in the Kidney Transplant Unit of Treviso General Hospital. Ten (10%) of them developed urinary calculi and were referred at our institution. Their mode of presentation, investigation and treatment were recorded. RESULTS: Seven had renal and 3 ureteral calculi. Urolithiasis was incidentally discovered on routine ultrasound in 6 patients, 1 presented with oliguria, 1 with anuria and acute renal failure and in 2 urolithiasis was found at removal of the ureteral stent. Nephrostomy tube was placed in 5 patients. Hypercalcemia with hyperparathyroidism (HPT) was present in 5 patients and hyperuricemia in 3. Two patients were primary treated by shock wave lithotripsy (SWL) and one of them was stone-free after two sessions. Two patients, one with multiple pielocaliceal calculi and the other with staghorn calculus in the lower calyx, were treated with percutaneous nephrolitothotomy (PCNL). Three patients were treated by ureteroscopy (URS) and in one of them two treatments were carried out. One patient had calculus impacted in the uretero-vesical anastomosis and surgical ureterolithotomy with re-do ureterocystoneostomy was performed after failure of URS. Two patients with calculi discovered at removal of the ureteral stent were treated by URS. CONCLUSIONS: The incidence of urolithiasis in renal transplantation is uncommon. In the most of patients the condition occurs without pain. Metabolic anomalies and medical treatment after renal transplantation may cause stone formation. Advancements in endourology and interventional radiology have influenced the management of urolithiasis that can be actually treated with a minimal incidence of risk for the renal allograft.

Stenting after ureteroscopy for ureteral lithiasis: results of a retrospective study.

OBJECTIVES: Routine ureteral stenting after ureteroscopy for stone removal is common. However ureteral stent negatively impact quality of life and can cause significant morbidity. This study was carried out to report our experience. MATERIALS AND METHODS: A total of 529 patients underwent ureteroscopy for the treatment of ureteral stones. In 436 pts (82%) a stent was placed, in 281 double J (removed within 2-4 weeks) and in 155 mono J (removed within 24 h). Ninethy-three did not received stenting. At 24 hour the mesaured outcomes were post operative pain, fever and hematuria, at 4 weeks need for hospital care (readmission or visit in the clinic) for lower urinary tract symptoms (LUTS), hematuria, fever or pain. RESULTS: No significant difference was observed between two groups regarding the complications at 24 hour after the treatment ( pain p = 0.6, fever = 0.7, hematuria p = 0.8). At 4 weeks after the ureteroscopy the incidence of LUTS, hematuria, pain and fever requiring the need for hospital care (readmission or visit in the clinic) was higher in the group with double J stent respect to the group with mono J stent (p < 0.05). At 3 months follow-up no difference was oberved between the two groups regarding stone-free rate and incidence of ureteral stricture formation. CONCLUSIONS: Routine stenting is necessary after ureteroscopy for ureteral lithiasis to prevent pain and fever without difference in stone free rate and incidence of stricture formation rate between the two groups. LUTS, hematuria and/or pain needing for hospital care were more frequent in the group with double J stent in spite of high stone free rate and low incidence of stricture formation. Further prospective randomized studies are needed to assess the role of using "short" and "long-term" stenting after ureteroscopy lithotripsy, considering that the choice actually depends on the surgeon's intraoperative judgment.