Introduction Retroperitoneal lymph node dissection (RPLND) is an integral part of the multidisciplinary treatment of Testis cancer (TC). Up to now, only few studies compared traditional open RPLND (O-RPLND) with minimally invasive approach. We investigated surgical outcomes and complication rates of patient with TC treated with O-RPLND or robot assisted (RA-RPLND). Materials and methods We performed a retrospective analysis of all consecutive patients who underwent RPLND for TC, between 2001 and 2023. We recorded Patient demographics, perioperative and post-operative data. Descriptive statistics depicted differences between O-RPLND and RA-RPLND. Multivariable Poisson regression models (MPRMs) tested for predictors of surgical drain permanence, NSAIDs use (days), LOS, EBL and OT. Multivariable logistic regression models (MLRM) tested for of post operative complications. Results Of 144 patients who underwent RPLND, 53 (36.4 %) were treated with RA-RPLND and 91 (63.6 %) with O-RPLND. RA-RPLND group had significantly lower median EBL (50 ml vs 150 ml in O- RPLND; p < 0.01), median LOS (4 days vs 5.5 days in O-RPLND; p < 0.01), median drain indwelling days (4 vs 5 in O-RPLND; p = 0.03), Hb drop (1.5 g/dl vs 1.9 g/dl; p = 0.02) and median NSAIDs use (1 day vs 3 days in O-RPLND; p < 0.01). No difference in intra- and postoperative complication rates was recorded. In MPRM, RA-RPLND was associated with shorter LOS (RR:0.28; p < 0.01), drain permanence time (RR: 0.83; p = 0.01), NSAIDs use (RR:0.63; p < 0.01), and OT (RR 0.85; p < 0.01). Conclusion RA-RPLND appears to lead to shorter LOS and permanence of surgical drain, lower need for painkillers, lower blood loss and lower OT to O-RPLND, but does not seem associated with lower complication rates compared to O-RPLND. Our findings require prospective validation in future randomized trials.

ObjectivesTo test the performance of ex vivo fluorescence confocal microscopy (FCM; Vivascope 2500M‐G4), as compared to intra‐operative frozen section (IFS) analysis, to evaluate surgical margins during robot‐assisted radical prostatectomy (RARP), with final pathology as the reference standard.MethodsOverall, 54 margins in 45 patients treated with RARP were analysed with: (1) ex vivo FCM; (2) IFS analysis; and (3) final pathology. FCM margins were evaluated by two different pathologists (experienced [M.I.: 10 years] vs highly experienced [G.R.: >30 years]) as strongly negative, probably negative, doubtful, probably positive, or strongly positive. First, inter‐observer agreement (Cohen's κ) between pathologists was tested. Second, we reported the sensitivity, specificity, positive predictive (PPV) and negative predictive value (NPV) of ex vivo FCM. Finally, agreement between ex vivo FCM and IFS analysis (Cohen's κ) was reported. For all analyses, four combinations of FCM results were evaluated.ResultsAt ex vivo FCM, the inter‐observer agreement between pathologists ranged from moderate (κ = 0.74) to almost perfect (κ = 0.90), according to the four categories of results. Indeed, at ex vivo FCM, the highly experienced pathologist reached the best balance between sensitivity (70.5%) specificity (91.8%), PPV (80.0%) and NPV (87.1%). Conversely, on IFS analysis, the sensitivity, specificity, PPV and NPV were, respectively, 88.2% vs 100% vs 100% vs 94.8%. The agreement between the ex vivo FCM and IFS analyses ranged from moderate (κ = 0.62) to strong (κ = 0.86), according to the four categories of results.ConclusionEvaluation of prostate margins at ex vivo FCM appears to be feasible and reliable. The agreement between readers encourages its widespread use in daily practice. Nevertheless, as of today, the performance of FCM seems to be sub‐par when compared to the established standard of care (IFS analysis).

We designed a phase 3, prospective, randomized trial to evaluate the impact of augmented reality and augmented reality frozen section analysis in reducing the rates of positive surgical margins after robot-assisted radical prostatectomy.

OBJECTIVE:To report oncological outcomes after thulium-yttrium-aluminum-garnet (Tm:YAG) laser ablation for penile cancer patients. MATERIALS AND METHODS:We retrospectively analyzed 71 patients with ≤cT1 penile cancer (2013-2022). All patients underwent Tm:YAG ablation with a RevoLix 200W continuous-wave laser. First, Kaplan-Meier plots and multivariable Cox regression models tested local tumor recurrence rates. Second, Kaplan-Meier plots tested progression-free survival (≥T3 and/or N1-3 and/or M1). RESULTS:Median (interquartile range) follow-up time was 38 (22-58) months. Overall, 33 (50.5%) patients experienced local tumor recurrence. Specifically, 19 (29%) vs 9 (14%) vs 5 (7.5%) patients had 1 vs 2 vs 3 recurrences over time. In multivariable Cox regression models, a trend for higher recurrence rates was observed for G3 tumors (hazard ratio:6.1; P = .05), relative to G1. During follow-up, 12 (18.5%) vs 4 (6.0%) vs 2 (3.0%) men were retreated with 1 vs 2 vs 3 Tm:YAG laser ablations. Moreover, 11 (17.0%) and 3 (4.5%) patients underwent glansectomy and partial/total penile amputation. Last, 5 (7.5%) patients experienced disease progression. Specifically, TNM stage at the time of disease progression was: (1) pT3N0; (2) pT2N2; (3) pTxN3; (4) pT1N1 and (5) pT3N3, respectively. CONCLUSION:Tm:YAG laser ablation provides similar oncological results as those observed by other penile-sparing surgery procedures. In consequence, Tm:YAG laser ablation should be considered a valid alternative for treating selected penile cancer patients.

Sexual disorders following retroperitoneal pelvic lymph node dissection (RPLND) for testis tumor can affect the quality of life of patients. The aim of the current study was to investigate several different andrological outcomes, which may be influenced by robot-assisted (RA) RPLND. From January 2012 to March 2020, 32 patients underwent RA-RPLND for stage I nonseminomatous testis cancer or postchemotherapy (PC) residual mass. Modified unilateral RPLND nerve-sparing template was always used. Major variables of interest were erectile dysfunction (ED), premature ejaculation (PE), dry ejaculation (DE), or orgasm alteration. Finally, fertility as well as the fecundation process (sexual intercourse or medically assisted procreation [MAP]) was investigated. Ten patients (31.3%) presented an andrological disorder of any type after RA-RPLND. Hypospermia was present in 4 (12.5%) patients, DE (International Index of Erectile Function-5 [IIEF-5] <25) in 3 (9.4%) patients, and ED in 3 (9.4%) patients. No PE or orgasmic alterations were described. Similar median age at surgery, body mass index (BMI), number of nodes removed, scholar status, and preoperative risk factor rates were identified between groups. Of all these 10 patients, 6 (60.0%) were treated at the beginning of our robotic experience (2012–2016). Of all 32 patients, 5 (15.6%) attempted to have a child after RA-RPLND. All of these 5 patients have successfully fathered children, but 2 (40.0%) required a MAP. In conclusion, a nonnegligible number of andrological complications occurred after RA-RPLND, mainly represented by ejaculation disorders, but ED occurrence and overall sexual satisfaction deficit should be definitely considered. No negative impact on fertility was described after RA-RPLND.

Introduction: To compare surgical, oncologic, functional outcomes and complication rate between intracorporeal neobladder (ICNB) and extracorporeal neobladder (ECNB) orthotopic ileal neobladder of robot-assisted radical cystectomy (RARC) in patients with nonmetastatic bladder carcinoma (BC). Materials and Methods: From 2014 to 2019, we prospectively collected and retrospectively analyzed 101 patients with nonmetastatic BC treated with RARC and ortothopic neobladder. Chi-squared test estimated differences in proportions of functional and oncologic outcomes. Multivariable logistic regression models (MLRMs) focused on overall, early (<30 days from discharge), and late complication rate (>30 days from discharge) in ICNB vs ECNB. Results: Of all patients, 57 (56.4%) ICNB and 44 (43.6%) ECNB patients were identified. At least one complication occurred in 75.4% vs 72.7% in ICNB vs ECNB, respectively (p = 0.9). In MLRMs, focusing on complication rate, there was no statistically significant difference between ICNB vs ECNB for overall (p = 0.8), early (p = 0.6), and late complications (p = 0.8). No statistically significant differences were recorded for tumor relapse rate, cancer-specific and other cause mortality. No positive surgical margins were recorded in both groups. Daytime and nighttime continence recovery were 89.4% vs 87.1% (p = 1.0) and 63.8% vs 51.6% (p = 1.0) for ICNB vs ECNB. Potency recovery was 59.1% vs 54.3% (p = 0.5) for ICNB vs ECNB. Conclusions: No statistically significant differences in complication rate (overall, early, or late) were identified, when ICNB and ECNB were compared. Similarly, no statistically significant difference was found in oncologic and functional outcomes.

Aims: The objective of the study was to analyze short-term outcomes and safety profile of the newly designed artificial urinary sphincters (AUSs) VICTO® and VICTOplus®. Methods: Data from the implant of VICTO® or VICTOplus® AUSs on a series of consecutive male patients with stress urinary incontinence (SUI) following radical prostatectomy (RP) were retrospectively collected in 3 tertiary referral centers between May 2017 and December 2019. Patients were affected by moderate-severe genuine SUI (200–400 or >400 g urine leakage in 24-h pad test) refractory to conservative treatment. Outcomes were evaluated through the 24-h pad test and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF). Follow-up was scheduled after 3, 6, and 12 months and then when clinically needed. Nonparametric tests were applied in subgroup analyses. Results: Seventeen patients were enrolled: 8 were implanted with the VICTO® device and 9 with VICTOplus®. The median age at surgery was 69 (interquartile range (IQR) 60–75) years. The median follow-up was 15 (IQR 12–18) months. At 12 months, the dry rate was 76.4% and the social continence rate was 94%. The postoperative complication rate was 17.6%. All complications were classified as Clavien-Dindo I. No difference in terms of outcomes was observed between the VICTO® and the VICTOplus® subgroups. Conclusions: Preliminary outcomes of the VICTO® and VICTOplus® implantation are satisfactory. These devices may represent a safe and realistic solution for patients with moderate-severe SUI following RP.

Aim: To investigate the prognostic role of neutrophil percentage-to-albumin ratio (NPAR) in muscle-invasive bladder cancer (MIBC) patients treated with neoadjuvant chemotherapy (NAC) and radical cystectomy (RC). Patients & methods: 213 patients were included. Inclusion criteria: Nonmetastatic, MIBC (cT2-T4aN0M0), at least three cycles of NAC, undergone RC and with blood count within 30 days before NAC. Results: Five-years overall survival (OS) with NPAR >18 was 34.06% (95% CI: 18.3–50.5) and 65.37% (95% CI: 52.4–75.6) with NPAR <18. Five years cancer-specific survival (CSS) with NPAR >18 was 42.9% (95% CI: 23.9–60.7) and 74.5% (95% CI: 62.6–83.1) with NPAR <18 (p < 0.001). In multivariable analysis, NPAR increased OS of 1.3 points and CSS of 4.37 points. Conclusion: High NPAR prior to NAC seems to be a strong predictor of OS and CSS in MIBC patients treated with NAC and RC.

Background: circulating levels of lymphocytes, platelets and neutrophils have been identified as factors related to unfavorable clinical outcome for many solid tumors. The aim of this cohort study is to evaluate and validate the use of the Prostatic Systemic Inflammatory Markers (PSIM) score in predicting and improving the detection of clinically significant prostate cancer (csPCa) in men undergoing robotic radical prostatectomy for low-risk prostate cancer who met the inclusion criteria for active surveillance. Methods: we reviewed the medical records of 260 patients who fulfilled the inclusion criteria for active surveillance. We performed a head-to-head comparison between the histological findings of specimens after radical prostatectomy (RP) and prostate biopsies. The PSIM score was calculated on the basis of positivity according to cutoffs (neutrophil-to-lymphocyte ratio (NLR) 2.0, platelets-to-lymphocyte ratio (PLR) 118 and monocyte-to-lymphocyte-ratio (MLR) 5.0), with 1 point assigned for each value exceeding the specified threshold and then summed, yielding a final score ranging from 0 to 3. Results: median NLR was 2.07, median PLR was 114.83, median MLR was 3.69. Conclusion: we found a significantly increase in the rate of pathological International Society of Urological Pathology (ISUP) ≥ 2 with the increase of PSIM. At the multivariate logistic regression analysis adjusted for age, prostate specific antigen (PSA), PSA density, prostate volume and PSIM, the latter was found the sole independent prognostic variable influencing probability of adverse pathology.

Background: Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder (ICNB) remains a very complicated, technically demanding and time-consuming surgical procedure. In the current study we describe our robot-assisted intracorporeal “Shell” neobladder reconstruction. Methods: From January 2017 to December 2019, we performed 30 intracorporeal ileal neobladder “Shell” reconstructions. We prospectively collected demographics and clinical and pathological data and retrospectively analysed perioperative, functional and oncological outcomes. Results: No conversion to open surgery or intraoperative blood transfusion was necessary. The median whole operative time was 493 min (IQR 433–530 min), ranging from 514 min (IQR 502–554 min) recorded during the first ten procedures to 470 min (IQR 442–503 min) of the last ten. The median estimated blood loss was 400 mL (IQR 350–700 mL). The median length of stay was 11 days (IQR 10–17). Both early and late complication rates were 46.7%. The high-grade early complication rate accounted for 20%, while the high-grade late complication rate was 30%. The daytime continence rate registered was 73.3%, while night-time continence rate was 60%. Conclusions: Our results demonstrated “Shell” neobladder reconstruction as a technically feasible procedure, with good functional outcomes in tertiary referral centre. Longer follow-up and larger populations are needed to validate these preliminary results.

A 42-year-old male patient presented with dull aching pain on the left side of his abdomen and an abdominal contrast-enhanced CT revealing a left-sided renal mass of 45 mm in diameter and an analogous lesion of 20 mm at the apex of the right moiety of a horseshoe kidney (Figs. 1, 2A). The major lesion was in the left posterior mesorenal region and almost completely buried by normal renal parenchyma, in tight contact with the omolateral calyceal structures and with the iliopsoas muscle. Its R.E.N.A.L. Nephrometry score and Padua score were 10p and 12p, respectively. Preoperative fine needle biopsy was performed and the histopathological analysis demonstrated bilateral clear cell renal carcinoma. Three-dimensional (3D) CT revealed precise vascular information around the horseshoe kidney and the renal tumor (Fig. 2B), and we judged that 3 renal arteries were arising from the abdominal aorta. The left renal artery was seen arising at the L1 level at 3-o'clock position and was supplying the left renal moiety along with the mass lesion; in its distal tract, it released 4 terminal branches, 3 to the left hilum, and 1 to the perilesional parenchyma. The right renal artery originated at the L1 level at 9-o' clock position and was supplying the right moiety and the right lesser lesion. The mid renal artery was arising at the upper border of the L3 level at 12-o'clock position and released 2 terminal branches, 1 to the right and the other to the left moiety of the kidney. The whole horseshoe kidney was drained into the inferior vena cava. The left moiety of the kidney along with the mass lesion were drained into the inferior vena cava at the L1 level by 1 renal vein arising from the left hilum. The right moiety of the kidney was drained by 2 renal veins one arising from the hilum and the other from the inferior renal pole, both reaching the inferior vena cava at the L1-L2 level. There was a further small renal vein draining the isthmus into the inferior vena cava at the L2-L3 level. Both renal moieties showed normal contrast excretion into the omolateral vescicoureteric junction (Fig. 2C). The left ureter was seen coursing along the anteromedial margin of the mass lesion, which was in tight contact with omolateral calyceal structures. The right ureter was draining both the right moiety and the isthmus. No significant regional lymphadenopathy or distant metastasis were present and the patient was staged cT1bN0M0. Preoperative serum creatinine was 1.00 mg/dL and estimated glomerular filtration rate was 93 mL/min/1.73m2. We planned robot-assisted enucleation on the left-sided tumor (Fig. 3), while the right lesion would later undergo renal termoablation with percutaneous radiofrequency. We chose not to treat both renal tumors at the same surgical time because, doing so in an horseshoe kidney (HK) would imply a major risk of operative complications, such as hemorrhage which would lead to the necessity to perform partial nephrectomy or even heminephrectomy. Moreover, percutaneous ablation techniques are technically suited and demonstrated to be able to radically ablate tumors not exceeding 4 cm staged as T1a, giving the main advantage over surgery of less invasiveness, lower complication rates and better patient tolerability 1 Filippiadis D. Mauri G. Marra P et al. Percutaneous ablation techniques for renal cell carcinoma: current status and future trends. Int J Hyperth Off J Eur Soc Hyperthermic Oncol North Am Hyperth Gr. 2019; 36: 21-30 Crossref PubMed Scopus (33) Google Scholar . Both cryoablation and percutaneous radiofrequency are promising therapies in patients with small renal masses (<4 cm). A review of clinical series with a proportional meta-analysis of renal tumor ablation was performed. Successfully treated tumor was defined as no growth or no evidence of recurrence on CT scan or MRI. This demonstrated that both cryoablation and radiofrequency ablation have similar efficacy and no significant differences in complication rates 2 El Dib R. Touma N.J. Kapoor A. Cryoablation vs radiofrequency ablation for the treatment of renal cell carcinoma: a meta-analysis of case series studies. BJU Int. 2012; 110: 510-516 Crossref PubMed Scopus (142) Google Scholar . Figure 2Three dimensional CT, arterial and venous vascularization and renal contrast excretion. (A) 3D CT image revealing the shape of horseshoe kidney and bilateral renal cell carcinoma (yellow-red). (B) 3D CT vascular image anterior view: the shape of horseshoe kidney, arterial and venous vessels. Only 1 artery is nourishing the left kidney and releases 4 terminal branches, 1 nourishing the left renal mass (arrow). (C) 3D CT revealing normal renal contrast excretion, the right ureter draining both the right moiety and the isthmus. (Color version available online.) View Large Image Figure Viewer Download Hi-res image Figure 3Robot-assisted enucleation of left renal mass. (A) Schematic of port site placement for enucleation of left renal carcinoma; (B) Dissection of the parietal peritoneum and medial mobilization of the bowel to expose the left kidney included in its adipose capsule; (C) Direct access to left renal hilum and isolation of left renal artery; (D) The anterior mobilization of the kidney to expose its posterior face; (E) Intraoperative ultrasound image of renal cell carcinoma (arrow); (F) Identification of tumor pseudocapsule; (G) Selective clamping of renal artery nourishing the tumor using Bulldog endoscopic forceps; (H) Enucleation of the tumor with SIB Margin Score of 0; (I) Renal medulla and renal cortex reconstruction; (J) Resected renal cell carcinoma: gross appearance of tumor specimen showing a parenchymal nodule of 4 × 3.7 × 3 cm almost entirely substituted by a yellow-red neoplasia, with negative surgical margins. SIB, surface-intermediate-base. (Color version available online.) 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BACKGROUND The aim of this study was to assess the long-term oncologic and functional outcomes in elderly patients having undergone robot-assisted partial nephrectomy (RAPN) for renal cancer (RC). METHODS Sixty-one patients out of 323 who underwent RAPN for localized RC between July 2009 and March 2016 in our high-volume robotic surgery center (>800 procedures/year), had 70 years or more. Inclusion criteria of the study were age ≥70 years; pathological confirmed RCC and ASA Score ≤3. All patients were stratified according to PADUA classification system in three groups: <7 points, 8-9 points, >10 points. Trifecta was defined as a warm ischemia time (WIT) less then 25 min, negative surgical margins and no perioperative complications. RESULTS A total of 52 patients were included; median follow-up was 47 months. Median age was 74 yrs. (IQR 72-76.5). Complication rate was 15.4%. Trifecta failure was associated to PADUA Score (P=0.02), and tumor diameter (P=0.04). Renal function was altered in 10 (19.2%) patients before surgery and at last follow-up in 11 (21.1%) patients (CKD stage>2) The DFS, OS and CSS were 89.33%, 90.06% and 94.4%, respectively. CONCLUSIONS In a high-volume center, robot-assisted approach is feasible and safe in surgical fit elderly patients with good long-term oncologic outcomes.