Publications by authors named "Daniele Amparore"

129 Publications

Finding novel prognostic factors in metastatic renal cell carcinoma: what does peripheral blood tell us?

Minerva Urol Nephrol 2022 Jun;74(3):372-375

Division of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy.

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http://dx.doi.org/10.23736/S2724-6051.22.04957-6DOI Listing
June 2022

Selecting the best candidates for non-surgical management of localized renal masses: the Occam's razor.

Minerva Urol Nephrol 2022 Jun;74(3):368-371

School of Medicine, Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy.

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http://dx.doi.org/10.23736/S2724-6051.22.04964-3DOI Listing
June 2022

Complementary roles of surgery and systemic treatment in clear cell renal cell carcinoma.

Nat Rev Urol 2022 May 11. Epub 2022 May 11.

Department of Urology, University Hospital Henri Mondor, APHP, UPEC, Créteil, France.

Standard-of-care management of renal cell carcinoma (RCC) indisputably relies on surgery for low-risk localized tumours and systemic treatment for poor-prognosis metastatic disease, but a grey area remains, encompassing high-risk localized tumours and patients with metastatic disease with a good-to-intermediate prognosis. Over the past few years, results of major practice-changing trials for the management of metastatic RCC have completely transformed the therapeutic options for this disease. Treatments targeting vascular endothelial growth factor (VEGF) have been the mainstay of therapy for metastatic RCC in the past decade, but the advent of immune checkpoint inhibitors has revolutionized the therapeutic landscape in the metastatic setting. Results from several pivotal trials have shown a substantial benefit from the combination of VEGF-directed therapy and immune checkpoint inhibition, raising new hopes for the treatment of high-risk localized RCC. The potential of these therapeutics to facilitate the surgical extirpation of the tumour in the neoadjuvant setting or to improve disease-free survival in the adjuvant setting has been investigated. The role of surgery for metastatic RCC has been redefined, with results of large trials bringing into question the paradigm of upfront cytoreductive nephrectomy, inherited from the era of cytokine therapy, when initial extirpation of the primary tumour did show clinical benefits. The potential benefits and risks of deferred surgery for residual primary tumours or metastases after partial response to checkpoint inhibitor treatment are also gaining interest, considering the long-lasting effects of these new drugs, which encourages the complete removal of residual masses.
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http://dx.doi.org/10.1038/s41585-022-00592-3DOI Listing
May 2022

Retroperitoneal Robot-assisted Partial Nephrectomy: A Systematic Review and Pooled Analysis of Comparative Outcomes.

Eur Urol Open Sci 2022 Jun 26;40:27-37. Epub 2022 Apr 26.

Division of Urology, VCU Health, Richmond, VA, USA.

Context: Robot-assisted partial nephrectomy (RAPN) has gained increasing popularity as primary minimally invasive surgical treatment for localized renal tumors, and it has preferably been performed with a transperitoneal approach. However, the retroperitoneal approach represents an alternative approach given potential advantages.

Objective: To provide an updated analysis of the comparative outcomes of retroperitoneal RAPN (R-RAPN) versus transperitoneal RAPN (T-RAPN).

Evidence Acquisition: A systematic review of the literature was performed up to September 2021 using MEDLINE, EMBASE, and Web of Science databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. A sensitivity analysis was performed considering only matched-pair studies.

Evidence Synthesis: Seventeen studies, which were published between 2013 and 2021, were retrieved. None of them was a randomized clinical trial. Among the 6,266 patients included in the meta-analysis, 2261 (36.1%) and 4,005 (63.9%) underwent R-RAPN and T-RAPN, respectively. No significant difference was found in terms of baseline features. The T-RAPN group presented a higher rate of male patients (odds ratio [OR]: 0.86,  = 0.03) and larger tumor size (weighted mean difference [WMD]: 0.2 cm;  = 0.003). The R-RAPN group reported more frequent posterior renal masses (OR: 0.23;  < 0.0001). The retroperitoneal approach presented lower estimated blood loss (WMD: 30.41 ml;  = 0.001), shorter operative time (OT; WMD: 20.36 min;  = 0.0001), and shorter length of stay (LOS; WMD: 0.35 d;  = 0.002). Overall complication rates were 13.7% and 16.05% in the R-RAPN and T-RAPN groups, respectively (OR: 1.32;  = 0.008). There were no statistically significant differences between the two groups regarding major (Clavien-Dindo classification ≥3 grade) complication rate, "pentafecta" achievement, as well as positive margin rates. When considering only matched-pair studies, no difference between groups was found in terms of baseline characteristics. Posterior renal masses were more frequent in the R-RAPN group (OR: 0.6;  = 0.03). Similar to the analysis of the entire cohort, R-RAPN reported lower EBL (WMD: 35.56 ml;  < 0.0001) and a shorter OT (WMD: 18.31 min;  = 0.03). Overall and major complication rates were similar between the two groups. The LOS was significantly lower for R-RAPN (WMD: 0.46 d;  = 0.02). No statistically significant difference was found between groups in terms of overall PSM rates.

Conclusions: R-RAPN offers similar surgical outcomes to T-RAPN, and it carries potential advantages in terms of shorter OT and LOS. Available evidence remains limited by the lack of randomized clinical trials.

Patient Summary: In this review of the literature, we looked at comparative outcomes of two surgical approaches to robot-assisted partial nephrectomy. We found that the retroperitoneal technique offers similar surgical outcomes to the transperitoneal one, with potential advantages in terms of shorter operative time and length of hospital stay.
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http://dx.doi.org/10.1016/j.euros.2022.03.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9062267PMC
June 2022

Patients' perceptions of quality of care delivery by urology residents: A nationwide study.

BJU Int 2022 May 2. Epub 2022 May 2.

Department of Surgery, Urology Section, University of Catania, Catania, Italy.

Objective: To present the results of a nationwide survey among urological patients to evaluate their perception of the quality of care provided by residents.

Methods: An anonymous survey was distributed to patients who were referred to 22 Italian academic institutions. The survey aimed to investigate the professional figure of the urology resident as perceived by the patient.

Results: A total of 2587 patients were enrolled in this study. In all, 51.6% of patients were able to correctly identify a urology resident; however, almost 40% of respondents discriminated residents from fully trained urologists based exclusively on their young age. Overall, 98.2% patients rated the service provided by the resident as at least sufficient. Urology trainees were considered by more than 50% of the patients interviewed to have good communication skills, expertise and willingness. Overall, patients showed an excellent willingness to be managed by urology residents. The percentage of patients not available for this purpose showed an increasing trend that directly correlated with the difficulty of the procedure. Approximately 5-10% of patients were not willing to be managed by residents for simple procedures such as clinical visits, cystoscopy or sonography, and up to a third of patients were not prepared to undergo any surgical procedure performed by residents during steps in major surgery, even if the residents were adequately tutored.

Conclusions: Our data showed that patients have a good willingness to be managed by residents during their training, especially for medium- to low-difficulty procedures. Furthermore, the majority of patients interviewed rated the residents' care delivery as sufficient. Urology trainees were considered to have good communication skills, expertise and willingness.
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http://dx.doi.org/10.1111/bju.15768DOI Listing
May 2022

PSMA PET/CT in Renal Cell Carcinoma: An Overview of Current Literature.

J Clin Med 2022 Mar 25;11(7). Epub 2022 Mar 25.

Unit of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, 50121 Florence, Italy.

Although the vast majority of prostate-specific membrane antigen (PSMA) positron emission tomography (PET) imaging occurs in the field of prostate cancer, PSMA is also highly expressed on the cell surface of the microvasculature of several other solid tumors, including renal cell carcinoma (RCC). This makes it a potentially interesting imaging target for the staging and monitoring of RCC. The objective of this review is to provide an overview of the current evidence regarding the use of PSMA PET/Computed Tomography in RCC patients.
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http://dx.doi.org/10.3390/jcm11071829DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8999609PMC
March 2022

Screening programs for renal cell carcinoma: a systematic review by the EAU young academic urologists renal cancer working group.

World J Urol 2022 Apr 1. Epub 2022 Apr 1.

European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group, Arnhem, The Netherlands.

Purpose: To systematically review studies focused on screening programs for renal cell carcinoma (RCC) and provide an exhaustive overview on their clinical impact, potential benefits, and harms.

Methods: A systematic review of the recent English-language literature was conducted according to the European Association of Urology guidelines and the PRISMA statement recommendations (PROSPERO ID: CRD42021283136) using the MEDLINE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases. Risk-of-bias assessment was performed according to the QUality In Prognosis Studies (QUIPS) tool.

Results: Overall, nine studies and one clinical trials were included. Eight studies reported results from RCC screening programs involving a total of 159 136 patients and four studies reported screening cost-analysis. The prevalence of RCC ranged between 0.02 and 0.22% and it was associated with the socio-demographic characteristics of the subjects; selection of the target population decreased, overall, the screening cost per diagnosis.

Conclusions: Despite an increasing interest in RCC screening programs from patients and clinicians there is a relative lack of studies reporting the efficacy, cost-effectiveness, and the optimal modality for RCC screening. Targeting high-risk individuals and/or combining detection of RCC with other health checks represent pragmatic options to improve the cost-effectiveness and reduce the potential harms of RCC screening.
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http://dx.doi.org/10.1007/s00345-022-03993-6DOI Listing
April 2022

Robot-assisted Simple Prostatectomy Is Better than Endoscopic Enucleation of the Prostate.

Eur Urol Focus 2022 Mar 25. Epub 2022 Mar 25.

Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy.

Robot-assisted simple prostatectomy represents a solid treatment option for benign prostatic obstruction in patients with large prostate glands. This procedure offers multiple attractive features that make it a strong competitor against endoscopic enucleation of the prostate.
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http://dx.doi.org/10.1016/j.euf.2022.03.014DOI Listing
March 2022

Identification of Recurrent Anatomical Clusters Using Three-dimensional Virtual Models for Complex Renal Tumors with an Imperative Indication for Nephron-sparing Surgery: New Technological Tools for Driving Decision-making.

Eur Urol Open Sci 2022 Apr 4;38:60-66. Epub 2022 Mar 4.

Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy.

Background: Some renal tumors have an imperative indication for nephron-sparing surgery (NSS), such as in cases of chronic kidney disease and bilateral complex tumors.

Objective: To demonstrate the degree to which three-dimensional virtual model (3DVM) assistance can be helpful in planning the surgical strategy for high-complexity renal masses with an imperative indication for NSS.

Design Setting And Participants: Three patients with high-complexity renal masses with unusual anatomy and an imperative indication for NSS were prospectively selected across 2020 and 2021 at our institution. All patients underwent contrast-enhanced computed tomography from which a 3DVM was obtained.

Surgical Procedure: Robot-assisted partial nephrectomy with 3DVM augmented reality guidance.

Measurements: Demographics and tumor-related features were recorded. Data for intraoperative, pathological, and functional assessments were collected for all three patients.

Results And Limitations: Two of the three patients harbored bilateral renal tumors. The third patient presented with a renal mass in the left kidney and contralateral renal hypoplasia (right-split renal function of 25%). All of the patients demonstrated similar anatomical and tumor features on 3DVMs, with potentially independent vascularization and drainage for the lower pole. In one patient the upper pole of the kidney was spared, exiting in a functionally excluded hydrocalyx, while in the other two cases the upper pole was removed together with the lesion. The spared portion of the kidney retained vascularization, as demonstrated by intraoperative ultrasound and indocyanine green injection. The small sample size and short follow-up are the main limitations of the study.

Conclusions: 3DVMs, especially for complex renal masses with an imperative indication for NSS, allow planning of the surgical strategy on the basis of the anatomical characteristics of the organ in which the tumor is growing.

Patient Summary: Three-dimensional models help in defining the best surgical strategy for kidney tumors, especially for complex tumors that require surgery to spare as much of the kidney as possible.
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http://dx.doi.org/10.1016/j.euros.2022.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8898779PMC
April 2022

Expanding the Role of Ultrasound for the Characterization of Renal Masses.

J Clin Med 2022 Feb 19;11(4). Epub 2022 Feb 19.

Department of Urology, University Hospitals Leuven, 3000 Leuven, Belgium.

The incidental detection of renal masses has been steadily rising. As a significant proportion of renal masses that are surgically treated are benign or indolent in nature, there is a clear need for better presurgical characterization of renal masses to minimize unnecessary harm. Ultrasound is a widely available and relatively inexpensive real-time imaging technique, and novel ultrasound-based applications can potentially aid in the non-invasive characterization of renal masses. We performed a narrative review on novel ultrasound-based techniques that can aid in the non-invasive characterization of renal masses. Contrast-enhanced ultrasound (CEUS) adds significant diagnostic value, particularly for cystic renal masses, by improving the characterization of fine septations and small nodules, with a sensitivity and specificity comparable to magnetic resonance imaging (MRI). Additionally, the performance of CEUS for the classification of benign versus malignant renal masses is comparable to that of computed tomography (CT) and MRI, although the imaging features of different tumor subtypes overlap significantly. Ultrasound molecular imaging with targeted contrast agents is being investigated in preclinical research as an addition to CEUS. Elastography for the assessment of tissue stiffness and micro-Doppler imaging for the improved detection of intratumoral blood flow without the need for contrast are both being investigated for the characterization of renal masses, though few studies have been conducted and validation is lacking. Several novel ultrasound-based techniques have been investigated for the non-invasive characterization of renal masses. CEUS has several advantages over traditional grayscale ultrasound, including the improved characterization of cystic renal masses and the potential to differentiate benign from malignant renal masses to some extent. Ultrasound molecular imaging offers promise for serial disease monitoring and the longitudinal assessment of treatment response, though this remains in the preclinical stages of development. While elastography and emerging micro-Doppler techniques have shown some encouraging applications, they are currently not ready for widespread clinical use.
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http://dx.doi.org/10.3390/jcm11041112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8876198PMC
February 2022

Robotic partial nephrectomy in 3D virtual reconstructions era: is the paradigm changed?

World J Urol 2022 Mar 22;40(3):659-670. Epub 2022 Feb 22.

Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043, Orbassano (Turin), Italy.

Context: The development of a tailored, patient-specific medical and surgical approach is becoming object of intense research. In kidney oncologic surgery, where a clear understanding of case-specific surgical anatomy is considered a key point to optimize the perioperative outcomes, such philosophy gained increasing importance. Recently, important advances in 3D virtual modeling technologies have fueled the interest for their application in the field of robotic minimally invasive surgery for kidney tumors.

Objective: To provide a synthesis of current applications of 3D virtual models for robot-assisted partial nephrectomy.

Evidence Acquisition: Medline, PubMed, the Cochrane Database, and Embase were screened for Literature regarding the use of 3D virtual models for robot-assisted partial nephrectomy (RAPN).

Evidence Synthesis: The use of 3D virtual models for RAPN has been tested in different settings, including surgical indication and planning, intraoperative guidance, and training. Currently, several studies are available on the application of this technology for surgical planning, demonstrating impact on clinical outcomes such as renal function recovery, whilst experiences concerning their intraoperative application for navigation are still experimental. One of the latest innovations in this field is represented by the development of dedicated softwares able to automatically overlap the 3D virtual models to the real anatomy, to perform augmented reality procedures.

Conclusions: The available Literature suggests a potentially crucial role of 3D virtual reconstructions during RAPN. Encouraging results concerning surgical planning and indication, intraoperative navigation, and surgical training are available. In the future, artificial intelligence may represent the key to further improve the 3D virtual modeling technology during RAPN.
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http://dx.doi.org/10.1007/s00345-022-03964-xDOI Listing
March 2022

Partial vs. radical nephrectomy in non-metastatic pT3a kidney cancer patients: a population-based study.

Minerva Urol Nephrol 2022 Feb 11. Epub 2022 Feb 11.

Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy.

Background: To test for differences in cancer specific mortality (CSM) rates between radical nephrectomy (RN) and partial nephrectomy (PN) in pT3a nmRCC patients.

Methods: Within the Surveillance, Epidemiology, and End Results database (2005-2016), 13,177 pT3a patients treated with either PN or RN were identified. Before and after 1:2 ratio propensity score (PS)-match between PN and RN patients, cumulative incidence plot and competing risks regression (CRR) were used to test differences in CSM and other cause mortality (OCM) rates.

Results: Relative to PN (n=1,615, 22.5%), RN patients harbored higher tumor size (72 vs. 38 mm; >70 mm 51 vs.10%), of more aggressive histology, collecting duct (0.4 vs. 0.2%) and sarcomatoid (2.3 vs.0.8%), of higher grade (51.0 vs. 37.5%). After PS-matching and OCM adjustment, 5-year CSM was 3-fold higher after RN than PN (p<0.01). Similarly, after PS matching and CSM adjustment, also 5-year OCM rates were higher after RN (HR: 1.59, p=0.0003).

Conclusions: PN does not appear to compromise the oncological outcomes in patients with pT3a or high-grade renal masses when compared with RN. Therefore, these concerns should not deter a surgeon from attempting PN when otherwise technically feasible.
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http://dx.doi.org/10.23736/S2724-6051.22.04680-8DOI Listing
February 2022

Inferior vena cava involvement in renal cell carcinoma: if you fail to plan, you're planning to fail.

Minerva Urol Nephrol 2021 Dec;73(6):854-857

European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group, Arnhem, the Netherlands.

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http://dx.doi.org/10.23736/S2724-6051.21.04811-4DOI Listing
December 2021

The impact of ischemic injury in patients with solitary kidneys: new cornerstones for contemporary "precision" robot-assisted partial nephrectomy.

Minerva Urol Nephrol 2021 Dec;73(6):851-853

Department of Urology, Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy.

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http://dx.doi.org/10.23736/S2724-6051.21.04810-2DOI Listing
December 2021

iTIND for BPH: Technique and procedural outcomes: A narrative review of current literature.

Turk J Urol 2021 11;47(6):470-481

Division of Urology, Department of Oncology, University of Turin School of Medicine, San Luigi Hospital, Orbassano, Italy.

In the last few years, new technologies have been developed to treat benign prostatic hyperplasia (BPH) in order to offer valid surgical alternatives to transurethral resection of the prostate with lower complications and hospitalization while maintaining satisfactory functional results. Among these new approaches, transurethral implantation of first- and second-generation temporary implantable nitinol device (TIND and iTIND, respectively) (Medi-TateVR ; Medi-Tate Ltd., Or Akiva, Israel) has been proposed. The aim of this work is to describe the surgical technique and to perform a systematic review of the available literature on follow-up of functional outcomes. A systematic research of the available literature on this topic was performed via Medline, Embase, and Cochrane databases in April 2021. Current evidence regarding the implantation of iTIND to treat BPH-related lower urinary tract symptoms (LUTSs) is still limited. Seven studies have been found. Only one randomized controlled trial has been published reporting short-term follow-up of implantation of iTIND versus sham procedure. All the studies reported that both procedures are safe, effective, and well-tolerated. Moreover, such treatment seems to not affect patient's sexual and ejaculatory functions. In conclusions, current clinical evidence suggests that temporary implantation of iTIND is a valid option for the minimally invasive surgical treatment of BPH-related LUTS. Further studies are required in order to confirm the functional results, especially over a long-term follow-up.
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http://dx.doi.org/10.5152/tud.2021.21145DOI Listing
November 2021

Indocyanine Green Drives Computer Vision Based 3D Augmented Reality Robot Assisted Partial Nephrectomy: The Beginning of "Automatic" Overlapping Era.

Urology 2022 Jan 19. Epub 2022 Jan 19.

Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy; EAU Section of Uro-Technology (ESUT).

Augmented reality robot-assisted partial nephrectomy (AR-RAPN) is limited by the need of a constant manual overlapping of the hyper-accuracy 3D (HA3D) virtual models to the real anatomy. To present our preliminary experience with automatic 3D virtual model overlapping during AR-RAPN. To reach a fully automated HA3D model overlapping, we pursued computer vision strategies, based on the identification of landmarks to link the virtual model. Due to the limited field of view of RAPN, we used the whole kidney as a marker. Moreover, to overcome the limit of similarity of colors between the kidney and its neighboring structures, we super-enhanced the organ, using the NIRF Firefly fluorescence imaging technology. A specifically developed software named "IGNITE" (Indocyanine GreeN automatIc augmenTed rEality) allowed the automatic anchorage of the HA3D model to the real organ, leveraging the enhanced view offered by NIRF technology. Ten automatic AR-RAPN were performed. For all the patients a HA3D model was produced and visualized as AR image inside the robotic console. During all the surgical procedures, the automatic ICG-guided AR technology successfully anchored the virtual model to the real organ without hand-assistance (mean anchorage time: 7 seconds), even when moving the camera throughout the operative field, while zooming and translating the organ. In 7 patients with totally endophytic or posterior lesions, the renal masses were correctly identified with automatic AR technology, performing a successful enucleoresection. No intraoperative or postoperative Clavien >2 complications or positive surgical margins were recorded. Our pilot study provides the first demonstration of the application of computer vision technology for AR procedures, with a software automatically performing a visual concordance during the overlap of 3D models and in vivo anatomy. Its actual limitations, related to the kidney deformations during surgery altering the automatic anchorage, will be overcome implementing the organ recognition with deep learning algorithms.
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http://dx.doi.org/10.1016/j.urology.2021.10.053DOI Listing
January 2022

Contemporary Trends of Systemic Neoadjuvant and Adjuvant Intravesical Chemotherapy in Patients With Upper Tract Urothelial Carcinomas Undergoing Minimally Invasive or Open Radical Nephroureterectomy: Analysis of US Claims on Perioperative Outcomes and Health Care Costs.

Clin Genitourin Cancer 2022 Apr 24;20(2):198.e1-198.e9. Epub 2021 Dec 24.

Department of Urology, Stanford Medical Center, Stanford, CA.

Introduction: New evidence indicates that minimally invasive surgery (MIS) (laparoscopic or robotic-assisted [LNU, RANU]) reaches oncologic equivalence compared with Open Radical Nephroureterectomy (ORNU) for high-risk upper-tract urothelial carcinoma (UTUC). Recently, European Association of Urology (EAU) Guidelines suggested implementing neoadjuvant chemotherapy (NAC) to standard treatment to improve oncologic outcomes of high-risk UTUC. We aimed (1) To explore contemporary trends of MIS for RNU in the United States and to compare perioperative outcomes and costs with that of ORNU. (2) To determine the trends of NAC and postoperative intravesical chemotherapy (PIC) administration for high-risk UTUC and to assess their contribution to perioperative outcomes and costs.

Patients And Methods: The Optum Clinformatics Data Mart de-identified database was queried from 2003 to 2018 to retrospectively examine patients who had undergone LNU/RANU or ORNU with or without NAC and PIC. We evaluated temporal adoption trends, complications, and health care cost analyses. We obtained descriptive statistics and utilized multivariable regression modeling to assess outcomes.

Results: A total of n = 492 ORNU and n = 1618 LNU/RANU procedures were reviewed. The MIS approach was associated with a statistically significant lower risk of intraoperative complications (adjusted Odds Ratio [aOR], 0.48, 95% CI:0.24-0.96), risk of hospitalization costs (aOR: 0.62, 95% CI:0.49-0.78), and shorter hospital stay (aOR: 0.20, 95% CI:0.15-0.26) when compared to ORNU. Overall, adoption of NAC and PIC accounted for only n = 81 and n < 37 cases respectively. The implementation of NAC and higher number of cycles were associated with an increased probability of any complication rate (aOR: 2.06, 95% CI:1.26-3.36) and hospital costs (aOR: 2.12, 95% CI:1.33-3.38).

Conclusion: MIS has become the approach of choice for RNU in the US. Although recommended by guidelines, neither NAC nor postoperative bladder instillation of chemotherapy has been routinely incorporated into the clinical practice of patients with UTUC.
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http://dx.doi.org/10.1016/j.clgc.2021.11.016DOI Listing
April 2022

Robot-assisted-radical-cystectomy with total intracorporeal Y neobladder: Analysis of postoperative complications and functional outcomes with urodynamics findings.

Eur J Surg Oncol 2022 Mar 16;48(3):694-702. Epub 2021 Dec 16.

Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy.

Objectives: To describe our robotic Y intracorporeal neobladder (ICNB) technique and to report its post-operative complications and urodynamics (UD) findings.

Subjects: and Methods: In this prospective study we enrolled patients affected by MIBC (T1-T4N0-N1M0) from 01/2017 to 06/2021 at our Centers. All the patients underwent robotic radical cystectomy (RARC) with Y-ICNB reconfiguration. Early and late complications were collected and classified according to Clavien-Dindo. Continence and potency at 1, 3, 6 and 12 months were evaluated. At the 3rd month of follow-up patients underwent UD. Finally, in a retrospective match paired analysis the functional outcomes of Y RARC patients were compared with a cohort of open Y radical cystectomy.

Results: 45 patients were enrolled. Overall 30-day complications were observed in 25 (55,5%) patients and 30 to 90-days complications in 4 (8,9%). 9 patients (20%) had Clavien ≥3 complications. UDs revealed median neobladder capacity of 268 cc, with a median compliance of 13 ml/cm H20; the voiding phase showed a voiding volume and a post void residual (PVR) of 154 cc and 105 cc respectively. At 12 months of follow-up 4.4%, 15.5% and 4.4% of the patients experienced urge, stress and mix urinary incontinence respectively. The comparison between Y RARC and Y open RC revealed a higher neobladder capacity with open approach (p = 0.049) with subsequent better findings during the voiding phase in terms of maximum flow (p = 0.002), voiding volume (p = 0.001) and PVR (p = 0.01). Focusing on continence recovery, a slight trend in favor of RARC was shown without reaching the statistical significance.

Conclusions: Robotic Y-ICNB is feasible and safe as shown by the low rate of postoperative complications. Satisfying UD functional outcomes are achievable, both during filling and voiding phase.
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http://dx.doi.org/10.1016/j.ejso.2021.12.014DOI Listing
March 2022

External validation of the Palacios' equation: a simple and accurate tool to estimate the new baseline renal function after renal cancer surgery.

World J Urol 2022 Feb 26;40(2):467-473. Epub 2021 Nov 26.

Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Piazzale Aristide Stefani 1, 37126, Verona, Italy.

Purpose: To externally validate the Palacios' equation estimating the new baseline glomerular filtration rate (NB-GFR) after partial or radical-nephrectomy (PN, RN) for Renal cancer carcinoma (RCC).

Materials And Methods: Our research group recently published two studies that investigated the association between renal function and cancer-specific survival in RCC. The first one included 3457 patients undergone RN or PN for a cT1-2 RCC coming from five high-volume centers; the second one considered 1767 patients undergone RN or PN for a cT1-4 RCC in a single high-volume center. From such datasets, available complete patients' data were used to calculate the predicted NB-GFR through the Palacios' equation: predicted NB-GFR = 35.03 + 0.65 ∙ preoperative GFR - 18.19 ∙ (if radical nephrectomy) - 0.25 ∙ age + 2.83 ∙ (if tumor size > 7 cm) - 2.09 ∙ (if diabetes). The observed NB-GFR was calculated by the CKD-EPI equation on serum creatinine at 3-12 months after surgery. Concordance between observed and predicted NB-GFR was evaluated by Lin's concordance correlation coefficient and Bland-Altman analysis.

Results: 2419 patients were included (1210, cohort #1; 1219, cohort #2). The median observed NB-GFR value in cohorts #1 and #2 was 73.0 ml/min/1.73 m (IQR 56.1-90.1) and 64.2 ml/min/1.73 m (IQR 49.6-83); the median predicted NB-GFR was 71.1 ml/min/1.73 m (IQR 58-81.5) and 62.6 ml/min/1.73m (IQR 47.9-75.9). The concordance line showed a slope of 0.80 and 0.86, and an intercept at 11.02 and 5.41 ml/min/1.73 m in the cohort#1 and #2, respectively. The Palacio's equation moderately over-estimated and under-estimated NB-GFR, for values below and above the cut-off of 50 ml/min/1.73 m and 35 ml/min/1.73m in cohort#1 and #2. The Lin's concordance correlation coefficient was 0.79 (95% CI 0.77-0.81) and 0.83 (95% CI 0.82-0.85).

Conclusions: We confirm the predictive performances of Palacios' equation, supporting its utilization in clinical practice.
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http://dx.doi.org/10.1007/s00345-021-03887-zDOI Listing
February 2022

Treatment of Ureteral Stent-Related Symptoms.

Urol Int 2021 Nov 2:1-16. Epub 2021 Nov 2.

Division of Urology, Department of Oncology, School of Medicine, San Luigi Hospital, University of Turin, Turin, Italy.

Background: The aim of the study was to assess the effectiveness of the main classes of drugs used at reducing morbidity related to ureteric stents.

Summary: After establishing a priori protocol, a systematic electronic literature search was conducted in July 2019. The randomized clinical trials (RCTs) selection proceeded in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and was registered (PROSPERO ID 178130). The risk of bias and the quality assessment of the included RCTs were performed. Ureteral Stent Symptom Questionnaire (USSQ), International Prostate Symptom Score (IPSS), and quality of life (QoL) were pooled for meta-analysis. Mean difference and risk difference were calculated as appropriate for each outcome to determine the cumulative effect size. Fourteen RCTs were included in the analysis accounting for 2,842 patients. Alpha antagonist, antimuscarinic, and phosphodiesterase (PDE) inhibitors significatively reduced all indexes of the USSQ, the IPSS and QoL scores relative to placebo. Conversely, combination therapy (alpha antagonist plus antimuscarinic) showed in all indexes of the USSQ, IPSS, and QoL over alpha antagonist or antimuscarinic alone. On comparison with alpha blockers, PDE inhibitors were found to be equally effective for urinary symptoms, general health, and body pain parameters, but sexual health parameters improved significantly with PDE inhibitors. Finally, antimuscarinic resulted in higher decrease in all indexes of the USSQ, the IPSS, and QoL relative to alpha antagonist. Key message: Relative to placebo, alpha antagonist alone, antimuscarinics alone, and PDE inhibitors alone have beneficial effect in reducing stent-related symptoms. Furthermore, there are significant advantages of combination therapy compared with monotherapy. Finally, PDE inhibitors are comparable to alpha antagonist, and antimuscarinic seems to be more effective than alpha antagonist alone.
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http://dx.doi.org/10.1159/000518387DOI Listing
November 2021

Percutaneous Kidney Puncture with Three-dimensional Mixed-reality Hologram Guidance: From Preoperative Planning to Intraoperative Navigation.

Eur Urol 2021 Nov 16. Epub 2021 Nov 16.

Division of Urology, Department Of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy.

Background: Despite technical and technological innovations, percutaneous puncture still represents the most challenging step when performing percutaneous nephrolithotomy. This maneuver is characterized by the steepest learning curve and a risk of injuring surrounding organs and kidney damage.

Objective: To evaluate the feasibility of three-dimensional mixed reality (3D MR) holograms in establishing the access point and guiding the needle during percutaneous kidney puncture.

Design, Setting, And Participants: This prospective study included ten patients who underwent 3D MR endoscopic combined intrarenal surgery (ECIRS) for kidney stones from July 2019 to January 2020. A retrospective series of patients who underwent a standard procedure were selected for matched pair analysis.

Surgical Procedure: For patients who underwent 3D MR ECIRS, holograms were overlapped on the real anatomy to guide the surgeon during percutaneous puncture. In the standard group, the procedures were only guided by ultrasound and fluoroscopy.

Measurements: Differences in preoperative and postoperative patient characteristics between the groups were tested using a χ test and a Kruskal-Wallis test for categorical and continuous variables, respectively. Results are reported as the median and interquartile range for continuous variables and as the frequency and percentage for categorical variables.

Results And Limitations: Ten patients underwent 3D MR ECIRS. In all cases, the inferior calyx was punctured correctly, as planned using the overlapping hologram. The median puncture and radiation exposure times were 27 min and 120 s, respectively. No intraoperative or major postoperative complications occurred. Matched pair analysis with the standard ECIRS group revealed a significantly shorter radiation exposure time for the 3D MR group (p < 0.001) even though the puncture time was longer in comparison to the standard group (p < 0.001). Finally, use of 3D MR led to a higher success rate for renal puncture at the first attempt (100% vs 50%; p = 0.032). The main limitations of the study are the small sample size and manual overlapping of the rigid hologram models.

Conclusions: Our experience demonstrates that 3D MR guidance for renal puncture is feasible and safe. The procedure proved to be effective, with the inferior calyx correctly punctured in all cases, and was associated with a low intraoperative radiation exposure time because of the MR guidance.

Patient Summary: Three-dimensional virtual models visualized as holograms and intraoperatively overlapped on the patient's real anatomy seem to be a valid new tool for guiding puncture of the kidney through the skin for minimally invasive treatment.
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http://dx.doi.org/10.1016/j.eururo.2021.10.023DOI Listing
November 2021

Editorial Comment to Randomized trials to determine the ideal management of the renal artery during partial nephrectomy: Life's under no obligation to give us what we expect.

Int J Urol 2022 01 5;29(1):93-94. Epub 2021 Nov 5.

European Association of Urology (EAU) Young Academic Urologists (YAU) Renal Cancer Working Group, Arnhem, The Netherlands.

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http://dx.doi.org/10.1111/iju.14739DOI Listing
January 2022

Impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for renal cancer: a systematic review.

Minerva Urol Nephrol 2022 Apr 29;74(2):146-160. Epub 2021 Oct 29.

Department of Urology, Campus Bio-Medico University, Rome, Italy.

Introduction: Frailty has been recognized as a major risk factor for adverse perioperative and oncological outcomes in patients with genitourinary malignancies. Yet, the evidence supporting such an association in patients with renal cell carcinoma (RCC) is still sparse. Herein we provide an updated comprehensive overview of the impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for RCC.

Evidence Acquisition: A systematic review of the English-language literature was conducted using the MEDLINE (via PubMed), Web of Science and the Cochrane Library databases according to the principles highlighted by the EAU Guidelines Office and the PRISMA statement recommendations. The review protocol was registered on PROSPERO (CRD42021242516). The overall quality of evidence was assessed according to GRADE recommendations.

Evidence Synthesis: Overall, 18 studies were included in the qualitative analysis. Most of these were retrospective single-center series including patients undergoing surgery for non-metastatic RCC. The overall quality of evidence was low. A variety of measures were used for frailty assessment, including the Canadian Study of Health and Aging Frailty Index, the five-item frailty index, the Modified Rockwood's Clinical Frailty Scale Score, the Hopkins Frailty score, the Groningen Frailty Index, and the Geriatric nutritional risk index. Sarcopenia was defined based on the Lumbar skeletal muscle mass at cross-sectional imaging, the skeletal muscle index, the total psoas area, or the Psoas Muscle Index. Overall, available studies point to frailty and sarcopenia as potential independent risk factors for worse perioperative and oncological outcomes after surgery or ablation for different RCC stages. Increased patient's frailty was indeed associated with higher risk of perioperative complications, healthcare resources utilization, readmission rates and longer hospitalization periods, as well as potentially lower cancer specific or overall survival.

Conclusions: Frailty has been consistently associated with worse outcomes after surgery for RCC, reinforcing the value of preoperative frailty assessment in carefully selected patients. Given the low quality of the available evidence (especially in the setting of tumor ablation), prospective studies are needed to standardize frailty assessments and to identify patients who are expected to benefit most from preoperative geriatric evaluation, aiming to optimize decision-making and postoperative outcomes in patients with RCC.
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http://dx.doi.org/10.23736/S2724-6051.21.04583-3DOI Listing
April 2022

New Ultra-minimally Invasive Surgical Treatment for Benign Prostatic Hyperplasia: A Systematic Review and Analysis of Comparative Outcomes.

Eur Urol Open Sci 2021 Nov 22;33:28-41. Epub 2021 Sep 22.

Department of Oncology, Division of Urology, University of Turin, Turin, Italy.

Context: Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr.

Objective: To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection.

Evidence Acquisition: A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses.

Evidence Synthesis: The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; -9.81 points, 95% confidence interval [CI] -11.37 to -8.25 at 1 mo; -13.13 points, 95% CI -14.98 to -11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8-4.5 to +4.14 ml/s, 95% CI 0.72-7.56 at 12 mo), and postvoid residual volume (-10.10 ml, 95% CI -27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34-2.42 at the start of follow-up; and 1.04, 95% CI 0.28-1.8 after 1 yr), or the IPSS-Quality of Life questionnaire.

Conclusions: Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients' sexual function with respect to baseline, especially regarding preservation of ejaculation.

Patient Summary: We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function.

Take Home Message: Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient's quality of life.
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http://dx.doi.org/10.1016/j.euros.2021.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8473553PMC
November 2021

A Nomogram for the Prediction of Intermediate Significant Renal Function Loss After Robot-assisted Partial Nephrectomy for Localized Renal Tumors: A Prospective Multicenter Observational Study (RECORd2 Project).

Eur Urol Focus 2021 Sep 21. Epub 2021 Sep 21.

Department of Urology, Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, University of Florence, Florence, Italy. Electronic address:

Background: Robot-assisted partial nephrectomy (RAPN) is increasingly adopted for the treatment of localized renal tumors; however, rates and predictors of significant renal function (RF) loss after RAPN are still poorly investigated, especially at a long-term evaluation.

Objective: To analyze the predictive factors and develop a clinical nomogram for predicting the likelihood of ultimate RF loss after RAPN.

Design, Setting, And Participants: We prospectively evaluated all patients treated with RAPN in a multicenter series (RECORd2 project).

Outcome Measurements And Statistical Analysis: Significant RF loss was defined as >25% reduction in estimated glomerular filtration rate (eGFR) from preoperative assessment at 48th month follow-up after surgery. Uni- and multivariable logistic regression analyses for RF loss were performed. The area under the receiving operator characteristic curve (AUC) was used to quantify predictive discrimination. A nomogram was created from the multivariable model.

Results And Limitations: A total of 981 patients were included. The median age at surgery was 64.2 (interquartile range [IQR] 54.3-71.4) yr, and 62.4% of patients were male. The median Charlson Comorbidity Index (CCI) was 1 (IQR 0-2), 12.9% of patients suffered from diabetes mellitus, and 18.6% of patients showed peripheral vascular disease (PVD). The median Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 7 (IQR 7-9). Imperative indications to partial nephrectomy were present in 3.6% of patients. Significant RF loss at 48th month postoperative evaluation was registered in 108 (11%) patients. At multivariable analysis, age (p = 0.04), female gender (p < 0.0001), CCI (p < 0.0001), CCI (p < 0.0001), diabetes (p < 0.0001), PVD (p < 0.0001), eGFR (p = 0.02), imperative (p = 0.001) surgical indication, and PADUA score (p < 0.0001) were found to be predictors of RF loss. The developed nomogram including these variables showed an AUC of 0.816.

Conclusions: We developed a clinical nomogram for the prediction of late RF loss after RAPN using preoperative and surgical variables from a large multicenter dataset.

Patient Summary: We developed a nomogram that could represent a clinical tool for early detection of patients at the highest risk of significant renal function impairment after robotic conservative surgery for renal tumors.
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http://dx.doi.org/10.1016/j.euf.2021.09.012DOI Listing
September 2021

Functional and sexual outcomes recovery after simple prostatectomy: the past, the present, the future of the surgical technique.

Minerva Urol Nephrol 2021 Aug;73(4):554-556

School of Medicine, Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy.

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http://dx.doi.org/10.23736/S2724-6051.21.04633-4DOI Listing
August 2021

Renal tumors ablation.

Minerva Urol Nephrol 2021 Aug;73(4):549-551

Unit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy.

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http://dx.doi.org/10.23736/S2724-6051.21.04605-XDOI Listing
August 2021

Robotic surgery for renal cell carcinoma with inferior vena cava thrombosis: balancing feasibility and safety toward individualized decision-making.

Minerva Urol Nephrol 2021 Aug;73(4):544-548

School of Medicine, Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy -

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http://dx.doi.org/10.23736/S2724-6051.21.04606-1DOI Listing
August 2021

Artificial intelligence for target prostate biopsy outcomes prediction the potential application of fuzzy logic.

Prostate Cancer Prostatic Dis 2021 Sep 3. Epub 2021 Sep 3.

Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy.

Background: In current precision prostate cancer (PCa) surgery era the identification of the best patients candidate for prostate biopsy still remains an open issue. The aim of this study was to evaluate if the prostate target biopsy (TB) outcomes could be predicted by using artificial intelligence approach based on a set of clinical pre-biopsy.

Methods: Pre-biopsy characteristics in terms of PSA, PSA density, digital rectal examination (DRE), previous prostate biopsies, number of suspicious lesions at mp-MRI, lesion volume, lesion location, and Pi-Rads score were extracted from our prospectively maintained TB database from March 2014 to December 2019. Our approach is based on Fuzzy logic and associative rules mining, with the aim to predict TB outcomes.

Results: A total of 1448 patients were included. Using the Frequent-Pattern growth algorithm we extracted 875 rules and used to build the fuzzy classifier. 963 subjects were classified whereas for the remaining 484 subjects were not classified since no rules matched with their input variables. Analyzing the classified subjects we obtained a specificity of 59.2% and sensitivity of 90.8% with a negative and the positive predictive values of 81.3% and 76.6%, respectively. In particular, focusing on ISUP ≥ 3 PCa, our model is able to correctly predict the biopsy outcomes in 98.1% of the cases.

Conclusions: In this study we demonstrated that the possibility to look at several pre-biopsy variables simultaneously with artificial intelligence algorithms can improve the prediction of TB outcomes, outclassing the performance of PSA, its derivates and MRI alone.
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http://dx.doi.org/10.1038/s41391-021-00441-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8413110PMC
September 2021

Urology Residency Training at the Time of COVID-19 in Italy: 1 Year After the Beginning.

Eur Urol Open Sci 2021 Sep 17;31:37-40. Epub 2021 Jul 17.

European Society of Residents in Urology (ESRU), Arnhem, The Netherlands.

The coronavirus disease 2019 (COVID-19) pandemic has led to significant changes in urology practice and residency programs. One year ago, the first nationwide survey on this topic showed a dramatic impact of the acute phase of the pandemic on residents' training activities. Aiming to assess for the first time how the COVID-19 scenario reshaped the pattern of urology training over a whole pandemic year, a cross-sectional, 38-item, web-based survey was developed. Residents scored the percentage decrease of their involvement in various clinical and surgical activities during the period of March 2020-March 2021 (as compared with the pre-COVID period). Overall, 312/585 (53.3%) residents from 27 schools of urology were included. The proportions of those experiencing a significant decrease of training exposure were 13.6%, 28.8%, 26.7%, 46.9%, 37.6%, and 33.3% (as compared with 40.2%, 85.8%. 82.3%, 69.7%, 59.7%, and 50.2% in the previous survey) for on-call activities, outpatient visits, diagnostic procedures, endoscopic surgery, open surgery, and minimally invasive surgery, respectively. The most impactful reductions in training activities were reached by final-year residents. Our findings highlight that, even if less burdensome than expected, urology residency training (especially in endoscopic surgery) was highly affected throughout the whole past year. This critical gap of skills may jeopardize residents' training even beyond the COVID-19 pandemic.

Patient Summary: In this study, we assessed whether the training activities of Italian urology residents were impacted negatively by a whole year of COVID-19 pandemic (March 2020-March 2021). We also compared our results with those reported in a previous survey evaluating how the coronavirus disease 2019 (COVID-19) pandemic changed the training pattern of urology residents during the peak of the outbreak in March 2020. We found a critical decrease in residents' activities (especially for those in their final years of residency and for surgical procedures) that, even if lower than expected, might negatively impact their education and training in the future.
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http://dx.doi.org/10.1016/j.euros.2021.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8342892PMC
September 2021
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