The significance of stone culture in the incidence of sepsis. Results from a prospective, multicenter study on Infections post Flexible UreteroreNescopy (I-FUN) and laser lithotripsy for renal stones.

Objective Sepsis is the most serious complication of flexible ureteroscopy (F-URS) and laser lithotripsy. We assessed the influence of positive stone culture (SC) on major infectious complications (sepsis, septic shock). Methods This prospective study enrolled adult patients deemed suitable for F-URS and laser lithotripsy from 9 centers (January 2022-August 2023). Inclusion criteria: kidney stone(s); preoperative mid-stream urine culture (MSU); stone(s) assessed at CT scan; SC. Exclusion criteria: bilateral procedures; ureteral stones; children. Group 1: patients with sterile SC. Group 2: patients with positive SC. Data are presented as median (interquartile range). A multivariable logistic regression analysis was performed to evaluate factors associated with having a positive SC. Results 293 were included. Median age was 51.0 (24) years. There were 167 (57.0%) males. Group 2 included 32 (2.5%) patients. Group 2 patients were significantly older [75.0 (14) vs 51.0 (23) years, p=0.02]. Stone features were similar. Major infectious complications were higher in Group 2 (15.6% vs 0.4%). One patient died due to sepsis in Group 2. 2/6 (33.3%) of patients with major infectious complications had the same pathogen in MSUC and SC. At multivariable regression analysis, diabetes (OR 3.23), symptomatic urinary infections within 3 months before surgery (OR 4.82), and preoperative stent/nephrostomy (OR 2.92) were factors significantly associated with higher odds of positive SC. Conclusions Patients with positive SC have a higher incidence of major infectious complications following F-URS lithotripsy. SC should be performed whenever feasible being a poor pathogen correlation between MSUC and SC.

Application of AI in urolithiasis risk of infection: a scoping review.

INTRODUCTION: Artificial intelligence and machine learning are the new frontier in urology; they can assist the diagnostic work-up and in prognostication bring superior to the existing nomograms. Infectious events and in particular the septic risk, are one of the most common and in some cases life threatening complication in patients with urolithiasis. We performed a scoping review to provide an overview of the current application of AI in prediction the infectious complications in patients affected by urolithiasis. EVIDENCE ACQUISITION: A systematic scoping review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Scoping Reviews (PRISMA-ScR) guidelines by screening Medline, PubMed, and Embase to detect pertinent studies. EVIDENCE SYNTHESIS: A total of 467 articles were found, of which nine met the inclusion criteria and were considered. All studies are retrospective and published between 2021 and 2023. Only two studies performed an external validation of the described models. The main event considered is urosepsis in four articles, urinary tract infection in two articles and diagnosis of infection stones in three articles. Different AI models were trained, each of which exploited several types and numbers of variables. All studies reveal good performance. Random forest and artificial neural networks seem to have higher AUC, specificity and sensibility and perform better than the traditional statistical analysis. CONCLUSIONS: Further prospective and multi-institutional studies with external validation are needed to better clarify which variables and AI models should be integrated in our clinical practice to predict infectious events.

External validation of a nomogram for outcome prediction in management of medium-sized (1-2 cm) kidney stones.

BACKGROUND: Stone nomogram by Micali et al., able topredict treatment failure of shock-wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PNL) in the management of single 1-2 cm renal stones, was developed on 2605 patients and showed a high predictive accuracy, with an area under ROC curve of 0.793 at internal validation. The aim of the present study is to externally validate the model to assess whether it displayed a satisfactory predictive performance if applied to different populations. METHODS: External validation was retrospectively performed on 3025 patients who underwent an active stone treatment from December 2010 to June 2021 in 26 centers from four countries (Italy, USA, Spain, Argentina). Collected variables included: age, gender, previous renal surgery, preoperative urine culture, hydronephrosis, stone side, site, density, skin-to-stone distance. Treatment failure was the defined outcome (residual fragments >4 mm at three months CT-scan). RESULTS: Model discrimination in external validation datasets showed an area under ROC curve of 0.66 (95% 0.59-0.68) with adequate calibration. The retrospective fashion of the study and the lack of generalizability of the tool towards populations from Asia, Africa or Oceania represent limitations of the current analysis. CONCLUSIONS: According to the current findings, Micali's nomogram can be used for treatment prediction after SWL, RIRS and PNL; however, a lower discrimination performance than the one at internal validation should be acknowledged, reflecting geographical, temporal and domain limitation of external validation studies. Further prospective evaluation is required to refine and improve the nomogram findings and to validate its clinical value.

Stone centers: a national survey on surgical techniques performed in Italy.

BACKGROUND: Recurrent and complex stone disease may be considered a challenging disease. In 2018, the Calculus group of the SIU (Italian Society of Urology) set itself the goal of establishing the minimum requirements for a center that could continuously manage urolithiasis pathology, named a Stone Center. In this study we present the results of a pilot survey carried out in 2019 with the aim of drawing a map of the situation of Italian urological centers dealing with urinary stones. METHODS: A total of 260 national urology departments dealing with urolithiasis surgery were contacted for this study. A survey was issued to each of the centers to determine the number of patients treated for urinary stones and the amount of procedures performed per year: 1) extracorporeal shock wave lithotripsy ESWL; 2) ureterorenoscopy URS; 3) retrograde intrarenal surgery RIRS; 4) percutaneous nephrolithotomy PCNL. RESULTS: Out of 260 centers contacted, 188 fulfilled the survey. Outcomes were quite variable, with approximately 37% of the centers lacking a lithotripter, and 46% of those that did have it performing fewer than 100 treatments per year. In terms of endoscopic procedures, more than 80% of the centers contacted performed URS or RIRS; however, when it came to percutaneous lithotripsy, these numbers dropped significantly; 33% of the centers contacted did not perform PCNL, and of those who did, 18% had less than 5 years of experience as a center. CONCLUSIONS: Our survey shows a very heterogeneous national picture about urolithiasis treatments. Our goal is to create national paradigms to be able to define stone centers where the patient suffering from complex urinary stones can find a network of professionals with an adequate armamentarium suitable for the management of their pathology.

Current applications of ex-vivo fluorescent confocal microscope in urological practice: a systematic review of literature.

BACKGROUND: Histopathological examination, a cornerstone in diagnosing cancer, faces challenges due to its time-consuming nature. This review explores the potential of ex-vivo fluorescent confocal microscopy (FCM) in urology, addressing the need for real-time pathological assessment, particularly in prostate cancer. This systematic review aims to assess the applications of FCM in urology, including its role in prostate cancer diagnosis, surgical margin assessment, and other urological fields. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search of PubMed and SCOPUS was conducted, focusing on English written original articles published after January 1, 2018, discussing the use of FCM in urological practice. The search included keywords related to FCM and urological terms. The risk of bias assessment was performed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. RESULTS: A total of 17 relevant studies were included in the review that focuses on three main urological issues: prostate cancer (15 articles), bladder cancer (1 article), and renal biopsy (1 article). FCM exhibited significant promise in diagnosing prostate cancer. These studies reported an accuracy range of 85.33% to 95.1% in distinguishing between cancerous and non-cancerous prostate tissues. Moreover, FCM proved valuable for assessing surgical margins in real-time during radical prostatectomy, reducing the need for frozen section analysis. In some investigations, researchers explored the integration of artificial intelligence (AI) with FCM to automate diagnostic processes. Concerning bladder cancer, FCM played a beneficial role in evaluating urethral and ureteral margins during radical cystectomy. Notably, it showed substantial agreement with conventional histopathology and frozen section examination. In the context of renal biopsy, FCM demonstrated the potential to differentiate normal renal parenchyma from cancerous tissue, although the available evidence is limited in this area. The main limitation of the current study is the scarcity of data regarding the topic of interest. CONCLUSIONS: Ex-vivo FCM holds promise in urology, particularly in prostate cancer diagnosis and surgical margin assessment. Its real-time capabilities may reduce diagnostic delays and patient stress. However, most studies remain experimental, requiring further research to validate clinical utility.

Predictive Value of the Mayo Adhesive Probability (MAP) Score in Laparoscopic Partial Nephrectomies: A Systematic Review from the EAU Section of Uro-Technology (ESUT).

The Mayo Adhesive Probability (MAP) score is a radiographic scoring system that predicts the presence of adherent perinephric fat (APF) during partial nephrectomies (PNs). The purpose of this systematic review is to summarize the current literature on the application of the MAP score for predicting intraoperative difficulties related to APF and complications in laparoscopic PNs. Three databases, PubMed, Scopus and Cochrane, were screened, from inception to 29 October 2023, taking into consideration the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. All the inclusion criteria were met by eight studies. The total operative time was around two hours in most studies, while the warm ischemia time was <30 min in all studies and <20 min in four studies. Positive surgical margins, conversion and transfusion rates ranged from 0% to 6.3%, from 0% to 5.0% and from 0.7% to 7.5%, respectively. Finally, the majority of the complications were classified as Grade I-II, according to the Clavien-Dindo Classification System. The MAP score is a useful tool for predicting not only the presence of APF during laparoscopic PNs but also various intraoperative and postoperative characteristics. It was found to be significantly associated with an increased operative time, estimated blood loss and intraoperative and postoperative complication rates.

Applicability and feasibility of robot-assisted cystectomy and intracorporeal urinary diversion in a patient with right renal pelvic ectopia

ABSTRACT Background: The ectopic pelvic kidney, a common renal anomaly, is often smaller and malformed, with a shorter and sometimes tortuous ureter (1). Muscle-invasive bladder cancer (MIBC), constituting 15-25% of bladder cancer cases (2), mandates radical cystectomy with a 50% 5-year survival rate (2). Despite the growing use of robot-assisted radical cystectomy (RARC) (3, 4), there is limited data on its application in ectopic kidneys. Only one RARC case has been reported (5), in contrast to numerous open radical cystectomies (1, 6) involving an ectopic kidney. Patient and methods: After being diagnosed with T2 high-grade urothelial carcinoma, the 66-year-old patient, previously treated with multiple transurethral resections and adjuvant BCG therapy, received neoadjuvant chemotherapy. Preoperative staging CT revealed a 2.6 x 2.2 cm bladder neoformation and an ectopic right pelvic kidney. Results: Using the da Vinci Surgical System, radical cystectomy with ileal conduit (sec Wallace II) and lymphadenectomy were performed. During the demolition phase, the shorter right ureter was dissected with care to avoid damage to the renal pedicle. The reconstructive phase included intracorporeal urinary diversion (ICUD) and uretero-ileal anastomosis, facilitated by the favorable position of the kidney. The 8-hour console surgery resulted in minimal blood loss. Discharged on day 16 due to COVID-19, the patient exhibited positive outcomes. A 2-month CT follow-up revealed no cancer recurrence, metastasis, hydronephrosis, and complete regression of the lymphocele. Imaging follow-up continues without postoperative adjuvant chemotherapy. Conclusion: Robotic surgery with intracorporeal urinary diversion holds potential for right-sided pelvic kidney cases, but additional studies are necessary for validation.

Iatrogenic or recurrent bladder neck contracture treated by the Palminteri-Ferrari technique: a new way to approach a frustrating condition.

PURPOSE: Bladder neck stricture (BNS) is a bothersome disease which may affect patients after trauma or prostatic surgery. It is frustrating due to the low durable success rate of currently available surgical techniques. The aim of the study is to explore the efficacy of a novel technique. MATERIALS & METHODS: The surgical protocol was developed by two high case-volume surgeons. The technique consists of Holmium laser incisions at 3-6-9-12 o'clock. Subsequently, triamcinolone acetonide 40 mg is injected. Two months later, the BNS is endoscopically checked in operatory room and re-procedure take place, if necessary (max 3 times). Failure was defined as the need of definitive urinary diversion. Subjective satisfaction was measured through PGI-I Questionnaire. RESULTS: A total of 45 patients were enrolled. Median age was 63 (IQR 59-69) years and BNS developed by different causes. Naïve BNS procedure patients were 12 (26.7%), others 33 (73.3%) underwent median 2 (IQR 1-4) previous urethrotomies, including 16 other surgeries. Suprapubic bladder catheter was present in 34 patients (75.6%). No complications were registered. Re-procedure at control was necessary in 24 patients (53.3%) for a median of 1 (IQR 1-3) procedures. At median follow-up of 18 months, failures were 4 (8.9%) and urinary incontinence was reported in 2 patients (4.5%) who required incontinence surgery. Median PGI-I was 2. CONCLUSIONS: Our technique of BNS treatment allows good outcomes and high rate of subjective improvement amongst patients. Moreover, naïve patients seem to have better results. However, longer follow-up and higher sample size are mandatory to further assess these data.

Applicability and feasibility of robot-assisted cystectomy and intracorporeal urinary diversion in a patient with right renal pelvic ectopia.

BACKGROUND: The ectopic pelvic kidney, a common renal anomaly, is often smaller and malformed, with a shorter and sometimes tortuous ureter (1). Muscle-invasive bladder cancer (MIBC), constituting 15-25% of bladder cancer cases (2), mandates radical cystectomy with a 50% 5-year survival rate (2). Despite the growing use of robot-assisted radical cystectomy (RARC) (3, 4), there is limited data on its application in ectopic kidneys. Only one RARC case has been reported (5), in contrast to numerous open radical cystectomies (1, 6) involving an ectopic kidney. PATIENT AND METHODS: After being diagnosed with T2 high-grade urothelial carcinoma, the 66-year-old patient, previously treated with multiple transurethral resections and adjuvant BCG therapy, received neoadjuvant chemotherapy. Preoperative staging CT revealed a 2.6 x 2.2 cm bladder neoformation and an ectopic right pelvic kidney. RESULTS: Using the da Vinci Surgical System, radical cystectomy with ileal conduit (sec Wallace II) and lymphadenectomy were performed. During the demolition phase, the shorter right ureter was dissected with care to avoid damage to the renal pedicle. The reconstructive phase included intracorporeal urinary diversion (ICUD) and uretero-ileal anastomosis, facilitated by the favorable position of the kidney. The 8-hour console surgery resulted in minimal blood loss. Discharged on day 16 due to COVID-19, the patient exhibited positive outcomes. A 2-month CT follow-up revealed no cancer recurrence, metastasis, hydronephrosis, and complete regression of the lymphocele. Imaging follow-up continues without postoperative adjuvant chemotherapy. CONCLUSION: Robotic surgery with intracorporeal urinary diversion holds potential for right-sided pelvic kidney cases, but additional studies are necessary for validation.

The use of Versius CMR for pelvic surgery: a multicentric analysis of surgical setup and early outcomes.

INTRODUCTION: Versius CMR is a novel robotic system characterized by an open surgical console and independent bedside units. The system has potentials of flexibility and versatility, and has been used in urological, gynecological, and general surgical procedure. The aim is to depict a comprehensive analysis of the Versius system for pelvic surgery. METHODS: This is a study involving two Institutions, ASST Santi Paolo and Carlo, Milan, and Apuane Hospital, Massa, Italy. All interventions performed in the pelvic area with the Versius were included. Data about indications, intra-, and post-operative course were prospectively collected and analyzed. RESULTS: A total of 171 interventions were performed with the Versius. Forty-two of them involved pelvic procedures. Twenty-two had an oncological indication (localized prostate cancer), the remaining had a non-oncological or functional purpose. The mostly performed pelvic procedure was radical prostatectomy (22) followed by annexectomy (9). No intra-operative complication nor conversion to other approaches occurred. A Clavien II complication and one Clavien IIIb were reported. Malfunctioning/alarms requiring a power cycle of the system occurred in 2 different cases. An adjustment in trocar placement according to patients' height was required in 2 patients undergoing prostatectomy, in which the trocar was moved caudally. In two cases, a pelvic prolapse was repaired concomitant with other gynecological procedures. CONCLUSIONS: Pelvic surgery with the Versius is feasible without major complications; either dissection and reconstructive steps could be accomplished, provided a proper OR setup and trocar placement are pursued. Versius can be easily adopted by surgeons of different disciplines and backgrounds; a further multi-specialty implementation is presumed and long-term oncological and functional outcomes are awaited.

Three-Dimensional Customized Imaging Reconstruction for Urological Surgery: Diffusion and Role in Real-Life Practice from an International Survey.

Despite the arising interest in three-dimensional (3D) reconstruction models from 2D imaging, their diffusion and perception among urologists have been scarcely explored. The aim of the study is to report the results of an international survey investigating the use of such tools among urologists of different backgrounds and origins. Beyond demographics, the survey explored the degree to which 3D models are perceived to improve surgical outcomes, the procedures mostly making use of them, the settings in which those tools are mostly applied, the surgical steps benefiting from 3D reconstructions and future perspectives of improvement. One hundred responders fully completed the survey. All levels of expertise were allowed; more than half (53%) were first surgeons, and 59% had already completed their training. Their main application was partial nephrectomy (85%), followed by radical nephrectomy and radical prostatectomy. Three-dimensional models are mostly used for preoperative planning (75%), intraoperative consultation and tailoring. More than half recognized that 3D models may highly improve surgical outcomes. Despite their recognized usefulness, 77% of responders use 3D models in less than 25% of their major operations due to costs or the extra time taken to perform the reconstruction. Technical improvements and a higher availability of the 3D models will further increase their role in surgical and clinical daily practice.

Artificial Intelligence in Surgical Training for Kidney Cancer: A Systematic Review of the Literature.

The prevalence of renal cell carcinoma (RCC) is increasing due to advanced imaging techniques. Surgical resection is the standard treatment, involving complex radical and partial nephrectomy procedures that demand extensive training and planning. Furthermore, artificial intelligence (AI) can potentially aid the training process in the field of kidney cancer. This review explores how artificial intelligence (AI) can create a framework for kidney cancer surgery to address training difficulties. Following PRISMA 2020 criteria, an exhaustive search of PubMed and SCOPUS databases was conducted without any filters or restrictions. Inclusion criteria encompassed original English articles focusing on AI's role in kidney cancer surgical training. On the other hand, all non-original articles and articles published in any language other than English were excluded. Two independent reviewers assessed the articles, with a third party settling any disagreement. Study specifics, AI tools, methodologies, endpoints, and outcomes were extracted by the same authors. The Oxford Center for Evidence-Based Medicine's evidence levels were employed to assess the studies. Out of 468 identified records, 14 eligible studies were selected. Potential AI applications in kidney cancer surgical training include analyzing surgical workflow, annotating instruments, identifying tissues, and 3D reconstruction. AI is capable of appraising surgical skills, including the identification of procedural steps and instrument tracking. While AI and augmented reality (AR) enhance training, challenges persist in real-time tracking and registration. The utilization of AI-driven 3D reconstruction proves beneficial for intraoperative guidance and preoperative preparation. Artificial intelligence (AI) shows potential for advancing surgical training by providing unbiased evaluations, personalized feedback, and enhanced learning processes. Yet challenges such as consistent metric measurement, ethical concerns, and data privacy must be addressed. The integration of AI into kidney cancer surgical training offers solutions to training difficulties and a boost to surgical education. However, to fully harness its potential, additional studies are imperative.

Semen Analysis in "Urology-Naïve" Patients: A Chance of Uroandrological Screening in Young Males.

(1) Background: While females start their gynecological examinations during puberty, only few men decide to be visited by urologists in their youth. Given the participation in the EcoFoodFertility research project, our department had the opportunity to screen young males that were supposedly healthy. (2) Results: from January 2019 to July 2020, we evaluated 157 patients with sperm, blood analysis, and uroandrological examinations. The inclusion criteria were age 18-40 and absence of previous urological disease (urology-naïve). The primary endpoint of the study was to record uroandrological diseases that are occasionally discovered during examination in asymptomatic young men. The average age was 26.9 years (range 18-40); average testicular volume was 15.7 mL (range 12-22 mL); and 45.2% reported abnormal semen analysis: 62 cases of teratozoospermia, 27 asthenozoospermia, 18 oligozoospermia, and 2 azoospermia were discovered respectively; 4/157 patients were diagnosed with hypogonadism; 2 cases with suspicious testicular mass resulted in testicular cancer; and 31 suspected varicoceles and 8 patients with mild sexual dysfunctions were managed. (3) Conclusions: an uroandrological evaluation of young asymptomatic males allowed for the prompt diagnosis of different urological conditions, including cancerous ones, in our series. Despite being debatable, combining urological counselling with physical examination, semen analysis, and a laboratory profile could be useful and cost-effective in order to ameliorate male health.

Digital real-time microscopy of ex-vivo tissues: A novel strategy to control surgical accuracy.

INTRODUCTION: Ex-vivo FCM is a novel digital optical technique that provides images of fresh tissues in a real-time fashion with magnification to subcellular details of a flattened unprocessed sample. Digital images are hematoxylin-eosin-like and can be shared and interpreted remotely. In urology, FCM has been successfully applied for prostate tissue interpretation, either during biopsy and radical prostatectomy. Possible applications of FCM may reflect those of frozen section analysis and can be extended to all fields in which the intra-operative microscopical control is advisable. MATERIALS AND METHODS: This is an investigative prospective case series that aims to explore FCM feasibility in novel surgical settings and provide a depiction of FCM digital images in those fields. The definite purpose is to check the accuracy of surgical specimen during the following interventions: (a) trans-urethral resection of bladder tumors, to confirm the presence of muscular layer; (b) biopsy of a retroperitoneal mass, to check for the location and quality of cores; (c) training in robotic radical prostatectomy, to control surgical margins after a nerve sparing performed by a trainee. To this aim, we collected FCM images during seven surgical procedures. FCM findings were compared to those from the final histopathological analysis and the agreement was assessed. RESULTS: In all cases, FCM digital images were obtained in the OR. FCM was able to confirm the presence of muscular layer in TURB specimen, the presence of lymphomatous tissue, surgical margins at prostate specimen. FCM intra-operative interpretation was consistent with final histopathology in all cases. CONCLUSIONS: Ex vivo FCM may represent a novel approach to control the quality of specimens, likely to tailor surgical strategy in a real-time fashion. Moreover, digitalization represents a step toward the implementation of telepathology in clinical practice.

Corrigendum to "Rectal Perforation During Pelvic Surgery" [Eur Urol Open Sci 44 (2022) 54-59].

[This corrects the article DOI: 10.1016/j.euros.2022.04.006.].

Efficacy and safety profile of GreenLight laser photoselective vaporization of the prostate in ≥ 75 years old patients: results from the Italian GreenLight Laser Study Group.

BACKGROUND: Benign Prostatic Obstruction (BPO) is the most common non-malignant urological condition among men and its incidence rise with age. Among prostate treatments, GreenLight laser seems to reduce bleeding and would be safer in the aging population. AIMS: We aimed to compare the functional outcomes and safety profile of < 75 years old (Group A) and ≥ 75 years old (Group B) patients. METHODS: In a multicenter setting, we retrospectively analyzed all the patients treated with GreenLight Laser vaporization of the prostate (PVP). RESULTS: 1077 patients were eligible for this study. 757 belonged to Group A (median age 66 years) and 320 to Group B (median age 78 years). No differences were present between the two groups in terms of prostate volume, operative time, hospital stay, PSA decrease over time after surgery, complications and re-intervention rate with a median follow-up period of 18 months (IQR 12-26). Nevertheless, focusing on complications, GreenLight laser PVP demonstrated an excellent safety profile in terms of hospital stay, re-intervention and complications, with an overall 29.6% complication rate in older patients and only two cases of Clavien III. Functional outcomes were similar at 12 month and became in favor of Group A over time. These data are satisfactory with a Qmax improvement of 111.7% and an IPSS reduction of 69.5% in older patients. DISCUSSION AND CONCLUSIONS: GreenLight laser photoselective vaporization of the prostate is a safe and efficient procedure for all patients, despite their age, with comparable outcomes and an equal safety profile.

Reproducibility of a modified posterior reconstruction during robotic intracorporeal neobladder reconfiguration

ABSTRACT Objective: Robotic intracorporeal neobladder reconstruction is a complex procedure in which the approximation of the reservoir to the urethral stump can be a demanding step. The aim of the study is to evaluate the reproducibility of a modified posterior reconstruction (PR) during the reconfiguration of intracorporeal neobladder after robot assisted radical cystectomy (RARC). Materials and Methods: From July 2021 to July 2022, 35 RARC were performed, and 17 patients underwent intracorporeal neobladder reconstruction. A PR was planned in males (14). Intra- and peri-operative data were collected. Surgical technique: RARC and node dissection are performed. Afterwards, 40-cm ileal segment is isolated; the portion with the more adequate mesenteric length is brought down to the pelvis. A modified PR is performed with a double-armed barbed suture: a first layer connects the Denonvillier's fascia to the rhabdosphincter in a running fashion; the second layer is created with the other arm and approximates the posterior side of the ileal segment towards the urethral stump. In the anterior caudal part of the ileum, a 1.5-cm incision is made to realize the neobladder neck; the neovesical-urethral anastomosis is performed with a second bidirectional suture. Results: Anastomotic and PR time were 14 (range 7-20) and 5 minutes (4-8), respectively. A single Clavien IIIa complication was recorded in a patient who underwent NAC and had a C. albicans superinfection in the post-operative course. All patients were discharged with complete or acceptable bladder voiding. Twelve patients with follow-up >90-days reported a satisfying daytime continence. Conclusions: PR represents a simple technical refinement that improves neobladder-urethral anastomosis by favoring ileal approximation to the urethral stump and decreasing anastomotic tension.