Publications by authors named "Estevão Lima"

94 Publications

Urethra-sparing minimally invasive simple prostatectomy: an old technique revisited.

Curr Opin Urol 2021 Jan;31(1):18-23

CUF Urology, Lisbon.

Purpose Of Review: The aim of this study was to review recent development in urethra and ejaculation preserving laparoscopic and robotic simple prostatectomy.

Recent Findings: Since Madigan prostatectomy original description in 1990, to recent reports of robotic-assisted surgery using this urethra-sparing technique, many studies have suggested the advantages of the preservation of urethra, bladder neck and ejaculatory ducts, when removing adenomatous tissue in benign prostatic obstruction (BPO) surgery. Allying anatomical preservation of this structure with the well known benefits of minimally invasive procedures seems to reduce postoperative haematuria, obviating the need for bladder irrigation, with shorter catheterization and hospitalization times, less risk of urethral stricture and, of utmost importance, reducing rates of retrograde ejaculation.

Summary: Urethra and bladder neck sparing techniques, especially in minimally invasive simple prostatectomy procedures, seem to provide real benefits, not only in the maintenance of preoperative potency and antegrade ejaculation but also accomplishing better perioperative outcomes, with faster patient recovery, and less complications. These techniques might well be the future standard techniques for sexually active men with large benign prostatic hyperplasia (BPH) requiring surgery.
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http://dx.doi.org/10.1097/MOU.0000000000000836DOI Listing
January 2021

Kidney Segmentation in Three-Dimensional Ultrasound Images using a Fast Phase-based Approach.

IEEE Trans Ultrason Ferroelectr Freq Control 2020 Nov 19;PP. Epub 2020 Nov 19.

Renal ultrasound imaging is the primary imaging modality for the assessment of the kidney's condition and is essential for diagnosis, treatment and surgical intervention planning, and follow-up. In this regard, kidney delineation in three-dimensional ultrasound images represents a relevant and challenging task in clinical practice. In this paper, a novel framework is proposed to accurately segment the kidney in 3D ultrasound images. The proposed framework can be divided into two stages: 1) initialization of the segmentation method; and 2) kidney segmentation. Within the initialization stage, a phase-based feature detection method is used to detect edge points at kidney boundaries, from which the segmentation is automatically initialized. In the segmentation stage, the B-Spline Explicit Active Surface framework is adapted to obtain the final kidney contour. Here, a novel hybrid energy functional that combines localized region-based and edge-based terms is used during segmentation. For the edge term, a fast signed phase-based detection approach is applied. The proposed framework was validated in two distinct datasets: (1) 15 3D challenging poor-quality ultrasound images used for experimental development, parameters assessment, and evaluation; and (2) 42 3D ultrasound images (both healthy and pathologic kidneys) used to unbiasedly assess its accuracy. Overall, the proposed method achieved a Dice overlap around 81% and an average point-to-surface error of ~2.8 mm. These results demonstrate the potential of the proposed method for clinical usage.
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http://dx.doi.org/10.1109/TUFFC.2020.3039334DOI Listing
November 2020

Outcomes of minimally invasive partial nephrectomy among very elderly patients: report from the RESURGE collaborative international database.

Cent European J Urol 2020 8;73(3):273-279. Epub 2020 Sep 8.

Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Milan, Italy.

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass. The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used. Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m. PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01). In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available.
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http://dx.doi.org/10.5173/ceju.2020.0179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587491PMC
September 2020

Active surveillance for small renal masses in elderly patients does not increase overall mortality rates compared to primary intervention: a propensity score weighted analysis.

Minerva Urol Nefrol 2020 Sep 29. Epub 2020 Sep 29.

Department of Urology, Instituto Valenciano de Oncología (IVO), Valencia, Spain -

Background: To test the effect of active surveillance (AS) versus primary intervention (PI) on overall mortality (OM) in elderly patients diagnosed with SRM.

Methods: Elderly patients (75 years or older) diagnosed with SRMs (< 4cm) and treated with either PI [i.e. partial nephrectomy or kidney ablation] or AS between 2009 and 2018 were abstracted from the REnal SURGery in the Elderly (RESURGE) and Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) datasets, respectively. OM rates were estimated among groups with Kaplan Meier method and Cox proportional hazards regression models after applying inverse probability of treatment weighting (IPTW). Multivariable logistic regression model was used to estimate IPTW. Covariates of interest were those unbalanced and/or significantly correlated with the treatment choice or with OM.

Results: A total of 483 patients were included; 121 (25.1%) underwent AS. 60 patients (12.4%) died. Overall, 6.7% of all deaths were related to cancer. IPTW-Kaplan Meier curves showed a 5-year overall survival rates of 70.0 ± 3.5% and 73.2 ± 4.8% in AS and PI groups, respectively (IPTW-Log-rank p-value=0.308). IPTW-Cox regression model did not show meaningfully increased OM rates in AS group (HR=1.31, 95% CI: 0.69-2.49).

Conclusions: AS represents an appealing treatment option for very elderly patients presenting with SRM, as it avoids the risks of a PI while not compromising the survival outcomes of these patients.
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http://dx.doi.org/10.23736/S0393-2249.20.03785-6DOI Listing
September 2020

Effects of testosterone replacement on serotonin levels in the prostate and plasma in a murine model of hypogonadism.

Sci Rep 2020 09 7;10(1):14688. Epub 2020 Sep 7.

School of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, 4710-057, Braga, Portugal.

Benign prostate hyperplasia is a dysfunctional disease with an elevated prevalence. Despite the accepted impact of aging and testosterone (TES) in its pathophysiology, its aetiology remains unknown. Recent studies described that serotonin (5-HT) inhibits benign prostate growth through the modulation of the androgen receptor, in the presence of TES. Accordingly, this work aimed to determine the impact of castration and TES replacement in plasmatic and prostatic 5-HT regulation. C57BL/6 mice were submitted to surgical castration and divided into three groups, continually exposed to either vehicle or different TES doses for 14 days. Plasmatic 5-HT concentration was measured before and after castration, and after TES reintroduction. Finally, total prostatic weight and intra-prostatic 5-HT were determined in the different groups. Our results demonstrate that mice prostate exhibits high 5-HT tissue levels and that intra-prostatic total 5-HT was independent of castration or TES reintroduction, in all studied groups. Also, 5-HT plasmatic concentration significantly increased after castration and then normalized after TES administration. Our findings revealed that mice prostate has a high 5-HT content and that total prostatic 5-HT levels do not depend on androgens' action. On the other hand, castration induced a significant increase in plasmatic 5-HT concentration, raising the hypothesis that androgens might be regulating the production of extra-prostatic 5-HT.
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http://dx.doi.org/10.1038/s41598-020-71718-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7477238PMC
September 2020

The performance improvement-score algorithm applied to endoscopic stone. Treatment step 1 protocol.

Minerva Urol Nefrol 2020 Aug 4. Epub 2020 Aug 4.

Department of Urology, University of Southampton, Southampton, UK.

Background: Pi-score (Performance Improvement score) has been proven to be reliable to measure performance improvement during E-BLUS hands-on training sessions. Our study is aimed to adapt and test the score to EST s1 (Endoscopic Stone Treatment step 1) protocol, in consideration of its worldwide adoption for practical training.

Methods: The Pi-score algorithm considers time measurement and number of errors from two different repetitions (first and fifth) of the same training task and compares them to the relative task goals, to produce an objective score. Data were obtained from the first edition of 'ART in Flexible Course', during 4 courses in Barcelona and Milan. Collected data were independently analysed by the experts for Pi assessment. Their scores were compared for inter-rater reliability. The average scores from all tutors were then compared to the PI-score provided by our algorithm for each participant, in order to verify their statistical correlation. Kappa Statistics was used for comparison analysis.

Results: 16 Hands-on Training expert tutors and 47 3rd year residents in Urology were involved. Concordance found between the 16 proctors' scores was the following: Task1=0.30 ("fair"); Task2=0.18 ("slight"); Task3=0.10 ("slight"); Task4=0.20, ("slight"). Concordance between Pi-score results and proctor average scores per-participant was the following: Task1=0.74 ("substantial"); Task2=0.71 ("substantial"); Task3=0.46 ("moderate"); Task4=0.49 ("moderate").

Conclusions: Our exploratory study demonstrates that Pi-score can be effectively adapted to EST s1. Our algorithm successfully provided an objective score that equals the average performance improvement scores assigned by of a cohort of experts, in relation to a small amount of training attempts.
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http://dx.doi.org/10.23736/S0393-2249.20.03747-9DOI Listing
August 2020

Complications and quality of life of ileal conduit, orthotopic neobladder and ureterocutaneostomy: systematic review of reports using the Clavien-Dindo Classification.

Minerva Urol Nefrol 2020 Aug;72(4):408-419

Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy.

Introduction: Radical cystectomy (RC) and urinary diversion (UD) are two steps of the same surgical procedure involving likely complications and important impact on quality of life (QoL). The literature was reviewed to identify recent studies reporting UDs complications occurred 90 days after surgery and graded by Clavien-Dindo Classification System (CCS).

Evidence Acquisition: A comprehensive systematic Medline search was performed in PubMed/Medline, Embase and Scopus databases to identify reports published in English starting from 2013 using key words related to review outcome (i.e. neobladder, ileal conduct, ureterocutaneostomy, cystectomy, QoL). Complications were defined as minor or major whether the CCS grade was ≤2 or ≥3, respectively. Then, manuscripts references were screened to identify unfounded studies. Only studies using CCS to report surgical complications were considered.

Evidence Synthesis: Retrieved studies were reported according to two main items of complications and QoL. About UDs complications, fourteen studies were identified incorporating overall 4436 patients. Up to 50% of patients experienced at least one low-grade complications (CCS≤2) requiring pharmacological treatment to be healed. On the other hand, high-grade complications (CCS≥3) occurred in 0.7-42% of cases and required surgical interventions (CCS 3a and 3b) or life support (CCS=4). Finally, mortality (CCS=5) rated between 0.4-7%. Regarding QoL, six studies were analyzed with overall 445 patients. Most of them were retrospective and showed conflicting results whether the external UDs were better than neobladder in term of impact on QoL.

Conclusions: The use of a standardized system such as CCS improves analyses of literature. However, rigorous patient selection for UD type makes unable a randomized comparison between UDs in terms of complications and QoL impact.
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http://dx.doi.org/10.23736/S0393-2249.20.03641-3DOI Listing
August 2020

Use of hemostatic agents for surgical bleeding in laparoscopic partial nephrectomy: Biomaterials perspective.

J Biomed Mater Res B Appl Biomater 2020 11 26;108(8):3099-3123. Epub 2020 May 26.

3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.

In recent years, there was an abrupt increase in the incidence of renal tumors, which prompt up the appearance of cutting-edge technology, including minimally invasive and organ-preserving approaches, such as laparoscopic partial nephrectomy (LPN). LPN is an innovative technique used to treat small renal masses that have been gaining popularity in the last few decades due to its promissory results. However, the bleeding control remains the main challenge since the majority of currently available hemostatic agents (HAs) used in other surgical specialities are inefficient in LPN. This hurried the search for effective HAs adapted for LPN surgical peculiarities, which resulted on the emergence of different types of topical HAs. The most promising are the natural origin HAs because of their inherent biodegradability, biocompatibility, and lowest toxicity. These properties turn them top interests' candidates as HAs in LPN. In this review, we present a deep overview on the progress achieved in the design of HAs based on natural origin polymers, highlighting their distinguishable characteristics and providing a clear understanding of their hemostat's role in LPN. This way it may be possible to establish a structure-composition properties relation, so that novel HAs for LPN can be designed to explore current unmet medical needs.
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http://dx.doi.org/10.1002/jbm.b.34637DOI Listing
November 2020

Type 2 diabetes mellitus predicts worse outcomes in patients with high-grade T1 bladder cancer receiving bacillus Calmette-Guérin after transurethral resection of the bladder tumor.

Urol Oncol 2020 05 12;38(5):459-464. Epub 2020 Mar 12.

Department of Emergency and Organ Transplantation, Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy.

Objectives: The aim of this multicenter study was to investigate the prognostic role of type 2 diabetes mellitus (T2DM) comorbidity in a large multi-institutional cohort of patients with primary T1HG/G3 non-muscle-invasive bladder cancer (NMIBC) treated with transurethral resection of the bladder (TURB).

Materials And Methods: A total of 1,172 patients with primary T1 HG/G3 who had NMIBC on re-TURB and who received adjuvant intravesical bacillus Calmette-Guérin therapy with maintenance were included. Endpoints were recurrence-free survival and progression-free survival.

Results: A total of 231 (19.7%) of patients had T2DM prior to TURB. Five-year recurrence-free survival estimates were 12.5% in patients with T2DM compared to 36% in patients without T2DM, P < 0.0001. Five-year PFS estimates were 60.5% in patients with T2DM compared to 70.2% in patients without T2DM, P = 0.003. T2DM was independently associated with disease recurrence (hazard ratio = 1.41; 95% confidence interval = 1.20-1.66, P < 0.001) and progression (hazard ratio = 1.27; 95% confidence interval = 0.99-1.63, P < 0.001), after adjusting for other known predictive factors such as tumor size, multifocality, T1G3 on re-TURB, body mass index, lymphovascular invasion, and neutrophil-to-lymphocytes ratio.

Conclusions: Given the potential implications for management, prospective validation of this finding along with translational studies designed to investigate the underlying biology of such an association are warranted.
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http://dx.doi.org/10.1016/j.urolonc.2020.02.016DOI Listing
May 2020

Hyperbaric oxygen therapy reduces mortality in patients with Fournier's Gangrene. Results from a multi-institutional observational study.

Minerva Urol Nefrol 2020 Apr 19;72(2):223-228. Epub 2020 Feb 19.

Department of Neurosciences, Sciences of Reproduction, and Odontostomatology, Federico II University, Naples, Italy -

Background: Evidence about the clinical benefits of Hyperbaric Oxygen Therapy (HBOT) in patients with Fournier's Gangrene (FG) is controversial and inconclusive. We aimed to compare the mortality related to FG between patients undergoing surgical debridement and/or standard antibiotic therapy alone or in combination with HBOT.

Methods: We performed a retrospective multi-institutional observational case-control study. All patients admitted with diagnosis of FG from June 2009 to June 2019 were included into the study. Patients received surgical debridement and/or standard antibiotic therapy alone or in combination with HBOT. Factors associated with FG related mortality were assessed with uni-and multivariate analyses. The main outcome measure was FG related mortality.

Results: A total of 161 patients with diagnosis of FG were identified. Mean FG Severity Index was 8.6±4.5. All patients had broad-spectrum parenteral antibiotic therapy. An aggressive debridement was performed in 139 (86.3%) patients. A total of 72 patients (44.7%) underwent HBOT. Mortality due to FG was observed in 32 (36.0%) of patients who do not underwent HBOT and in 14 (19.4%) of patients who underwent HBOT (P=0.01). At the multivariate analysis, surgical debridement and HBOT were independent predictors of lower mortality while higher FG Severity Index was independent predictor of higher mortality.

Conclusions: HBOT and surgical debridement are independent predictors of reduced FG related mortality.
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http://dx.doi.org/10.23736/S0393-2249.20.03696-6DOI Listing
April 2020

Impact of time to second transurethral resection on oncological outcomes of patients with high-grade T1 bladder cancer treated with intravesical Bacillus Calmette-Guerin.

World J Urol 2020 Dec 15;38(12):3161-3167. Epub 2020 Feb 15.

Department of Urology and Renal Transplantation, University of Foggia, Foggia, Italy.

Purpose: To determine the impact of time to restaging transurethral resection (Re-TUR) on recurrence-free survival (RFS), progression-free survival (PFS), and cancer specific survival (CSS) of patients with high-grade T1 bladder cancer (BC) treated with intravesical Bacillus Calmette-Guerin (BCG).

Materials And Patients: Our prospectively maintained NMIBC databases were queried to identify patients with high-grade T1 BC who underwent Re-TUR before receiving intravesical BCG treatment (induction + 1-year maintenance). Patients were divided into three groups based on time to Re-TUR (group A: ≤ 6 weeks; group B: > 6-12 weeks; group C: > 12-18 weeks). Kaplan-Meier plots were used to estimate differences in RFS, PFS, and CSS. Multivariate Cox regression analysis was used to assess the impact of time to Re-TUR on oncological outcomes.

Results: Overall, 269 high-grade T1 BC patients were eligible for the analysis. Nineteen (7.1%) had concomitant CIS. Median follow-up was 49.3 (IQR 25-65) months. Kaplan-Meier plots showed no differences in RFS, PFS, and CSS between the three groups. Multivariate Cox regression analysis showed that Group B had a slightly better RFS, while the other outcomes were not affected by time to Re-TUR.

Conclusions: This is the first study testing the role of time to Re-TUR in a homogeneous population of patients with high-grade T1 BC who received complete BCG treatment. The study challenged the concept the sooner the Re-TUR the better, since time to Re-TUR did not significantly affect oncological outcomes.
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http://dx.doi.org/10.1007/s00345-020-03108-zDOI Listing
December 2020

Efficacy and safety of renal drainage options for percutaneous nephrolithotomy.

Minerva Urol Nefrol 2020 Oct 7;72(5):629-636. Epub 2020 Jan 7.

Department of Urology, Hospital of Braga, Braga, Portugal.

Background: Percutaneous nephrolithotomy (PCNL) is the gold-standard for treatment of renal stones larger than 20 mm. Traditionally, a nephrostomy tube (NT) is placed, causing discomfort and prolonged hospitalization but some surgeons prefer the tubeless technique (TL). Simultaneously, the effectiveness of ureteral stents after PNCL is doubtful. We investigated the safety of the TL technique as well as that of the single loop (SL) over double loop (DL) stents.

Methods: Three hundred and twenty-one individuals submitted to PCNL in a single center were retrospectively reviewed. Statistical analysis was performed to compare procedures regarding safety and effectiveness (stone size, residual stones, operative time, peri- and post-operative complications, need for blood transfusion and length of hospital stay) between two groups regarding presence or absence of NT placement (NT [N.=198] vs. TL [N.=123]); and according to the type of stent used (SL [N.=74] vs. DL [N.=247]).

Results: NT was associated with a higher complications rate compared to the TL (30.3% and 13%, respectively; P=0.001) and longer hospitalization (4 vs. 2 days; P=0.001). Regarding ureteral stents, they cause similar morbidities (20.7% and 24.4%; P=0.881), and median length of stay (3 days; P=0.947). NT and DL were more frequent in patients with higher stone burden.

Conclusions: Tubeless PCNL encompasses lower morbidity and should be considered as an option for select patients, particularly with less stone burden and uncomplicated procedures. Regarding ureteral stents, SL is a safe option and does not require further procedures for removal.
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http://dx.doi.org/10.23736/S0393-2249.19.03643-9DOI Listing
October 2020

New endoscopic procedure for bladder wall closure: results from the porcine model.

Sci Rep 2019 12 10;9(1):18747. Epub 2019 Dec 10.

Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal.

Upper urinary tract urothelial carcinomas are usually managed by radical nephroureterectomy (RNU), often followed by intravesical chemotherapy to minimize recurrence. Open surgery is the gold standard procedure for RNU, but it associates with high morbidity, and it has been increasingly replaced by minimally invasive strategies, such as laparoscopy and endoscopy. Although effective, endoscopic ureteral excision leaves the bladder unsutured, increasing the risk of tumor spillage, and precluding the immediate administration of intravesical chemotherapy. Here we describe a new method to close the bladder wall after ureteral excision, using barbed sutures via the endoscopic access. Our results in 8 female pigs demonstrate that this method is effective to close the bladder wall. The procedure was completed in a median time of 24 min, and no adverse events were registered in the follow-up or at the three-week necropsy. This technique improves a previous approach described by our group because the device is more flexible and allows to tie the knots inside the bladder. Barbed sutures have been used in the clinical practice for other types of surgeries, and therefore this method can further be adapted to human patients with no safety concerns. Its use may allow to administer intravesical chemotherapy, which reduces tumor recurrence and improves patient outcomes.
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http://dx.doi.org/10.1038/s41598-019-54304-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6904675PMC
December 2019

Efficacy and safety of a combined anesthetic technique for transrectal prostate biopsy: a single center, prospective, randomized study.

Cent European J Urol 2019 16;72(3):258-262. Epub 2019 Sep 16.

Department of Urology, Hospital de Braga, Portugal.

Introduction: A transrectal ultrasound-guided (TRUS) biopsy is the gold standard for diagnosis of prostatic neoplasia. This exam is associated with pain and discomfort, and numerous methods of analgesia during this procedure have been described. There is still no consensus among urologists about the pain control technique that should be performed, even though the periprostatic basal nerve block is the most studied technique. The main objective of this study is to evaluate the benefit of adding local periapical prostatic anesthesia to the traditional periprostatic basal nerve block during TRUS biopsy.

Material And Methods: A total of 70 patients with indication for TRUS biopsy were enrolled in this study. Patients were randomized into 2 groups. Group 1 received a periprostatic basal nerve block. Group 2 received both periapical prostatic and periprostatic basal nerve blocks . The pain experienced during different moments of the procedure (introduction of the probe, anesthesia administration, removal of cores and 30 minutes after biopsy) was assessed using visual analog scales of one to ten. The rate of complications at 30 days post-biopsy was also assessed.

Results: The difference in pain during the distinct moments of the TRUS biopsy was not significant between the two groups. There were no significant differences concerning age, level of total prostate-specific antigen (PSA) and prostate volume in both groups. There were also no statistically significant differences between the groups regarding the occurrence of complications and pathological findings.

Conclusions: The administration of concurent periprostatic basal and periapical nerve blocks has no significant benefits as compared to a periprostatic basal nerve block alone.
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http://dx.doi.org/10.5173/ceju.2019.1936DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830480PMC
September 2019

Technical Note: Assessment of electromagnetic tracking systems in a surgical environment using ultrasonography and ureteroscopy instruments for percutaneous renal access.

Med Phys 2020 Jan 22;47(1):19-26. Epub 2019 Nov 22.

Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.

Purpose: Electromagnetic tracking systems (EMTSs) have been proposed to assist the percutaneous renal access (PRA) during minimally invasive interventions to the renal system. However, the influence of other surgical instruments widely used during PRA (like ureteroscopy and ultrasound equipment) in the EMTS performance is not completely known. This work performs this assessment for two EMTSs [Aurora Planar Field Generator (PFG); Aurora Tabletop Field Generator (TTFG)].

Methods: An assessment platform, composed by a scaffold with specific supports to attach the surgical instruments and a plate phantom with multiple levels to precisely translate or rotate the surgical instruments, was developed. The median accuracy and precision in terms of position and orientation were estimated for the PFG and TTFG in a surgical environment using this platform. Then, the influence of different surgical instruments (alone or together), namely analogic flexible ureterorenoscope (AUR), digital flexible ureterorenoscope (DUR), two-dimensional (2D) ultrasound (US) probe, and four-dimensional (4D) mechanical US probe, was assessed for both EMTSs by coupling the instruments to 5-DOF and 6-DOF sensors.

Results: Overall, the median positional and orientation accuracies in the surgical environment were 0.85 mm and 0.42° for PFG, and 0.72 mm and 0.39° for TTFG, while precisions were 0.10 mm and 0.03° for PFG, and 0.20 mm and 0.12° for TTFG, respectively. No significant differences were found for accuracy between EMTSs. However, PFG showed a tendency for higher precision than TTFG. AUR, DUR, and 2D US probe did not influence the accuracy and precision of both EMTSs. In opposition, the 4D probe distorted the signal near the attached sensor, making readings unreliable.

Conclusions: Ureteroscopy- and ultrasonography-assisted PRA based on EMTS guidance are feasible with the tested AUR or DUR together with the 2D probe. More studies must be performed to evaluate the probes and ureterorenoscopes' influence before their use in PRA based on EMTS guidance.
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http://dx.doi.org/10.1002/mp.13879DOI Listing
January 2020

Bipolar endoscopic enucleation versus bipolar transurethral resection of the prostate: an ESUT systematic review and cumulative analysis.

World J Urol 2020 May 25;38(5):1177-1186. Epub 2019 Jul 25.

Urology Unit, Luigi Vanvitelli University, Naples, Italy.

Purpose: To perform a cumulative analysis of the current evidence on the surgical and functional outcomes of bipolar endoscopic enucleation of the prostate (b-EEP) versus bipolar transurethral resection of the prostate (b-TURP).

Methods: A systematic review of the literature was performed on PubMed, Ovid, and Scopus according to Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA Statement). The meta-analysis was conducted using the Review Manager 5.3 software. Parameters of interest were surgical and functional outcomes. Weighted mean difference, and odds ratio with 95% confidence interval were calculated for continuous and binary variables, respectively. Pooled estimates were calculated using the random-effect model.

Results: Fourteen comparative studies were included. No statistically significant difference in terms of overall baseline characteristics was found. b-EEP had higher amount of resected tissue (p < 0.0001), shorter catheter time (p = 0.006), lower Hb drop (p = 0.03), and shorter length of stay (p < 0.0001). Equally, overall post-operative complications were lower (p = 0.01) as well as short (p = 0.04), and long-term complication rate (p = 0.04). There was higher re-intervention rate in the b-TURP group (p = 0.02) whereas b-EEP group had smaller residual prostate volume (p = 0.03), and lower post-operative PSA values (p < 0.00001). At long term, b-EEP presented lower IPSS (p = 0.04), higher Q (p = 0.002), and lower PVR (p < 0.00001).

Conclusions: b-EEP is an effective and safe surgical treatment for BPO. This procedure might offer several advantages over standard b-TURP, including the resection of a larger amount of tissue within the same operative time, shorter hospitalization, lower risk of complications, and lower re-intervention rate. This was submitted to PROSPERO registry: CRD42019126748.
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http://dx.doi.org/10.1007/s00345-019-02890-9DOI Listing
May 2020

Systemic Inflammatory Markers and Oncologic Outcomes in Patients with High-risk Non-muscle-invasive Urothelial Bladder Cancer.

Eur Urol Oncol 2018 10 13;1(5):403-410. Epub 2018 Jul 13.

Division of Urology, European Institute of Oncology, Milan, Italy.

Background: Serum levels of neutrophils, platelets, and lymphocytes have been recognized as factors related to poor prognosis for many solid tumors, including bladder cancer (BC).

Objective: To evaluate the prognostic role of the combination of the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte ratio (LMR) in patients with high-risk non-muscle-invasive urothelial BC (NIMBC).

Design, Setting, And Participants: A total of 1151 NMIBC patients who underwent first transurethral resection of the bladder tumor (TURBT) at 13 academic institutions between January 1, 2002 and December 31, 2012 were included in this analysis. The median follow-up was 48 mo.

Intervention: TURBT with intravesical chemotherapy or immunotherapy.

Outcome Measurements And Statistical Analysis: Multivariable Cox regression analysis was performed to identify factors predictive of recurrence, progression, cancer-specific mortality, and overall mortality. A systemic inflammatory marker (SIM) score was calculated based on cutoffs for NLR, PLR, and LMR.

Results And Limitations: The 48-mo recurrence-free survival was 80.8%, 47.35%, 20.67%, and 17.06% for patients with an SIM score of 0, 1, 2, and 3, respectively (p<0.01, log-rank test) while the corresponding 48-mo progression free-survival was 92.0%, 75.67%, 72.85%, and 63.1% (p<0.01, log-rank test). SIM scores of 1, 2, and 3 were associated with recurrence (hazard ratio [HR] 3.73, 7.06, and 7.88) and progression (HR 3.15, 4.41, and 5.83). Limitations include the lack of external validation and comparison to other clinical risk models.

Conclusions: Patients with high-grade T1 stage NMIBC with high SIM scores have worse oncologic outcomes in terms of recurrence and progression. Further studies should be conducted to stratify patients according to SIM scores to identify individuals who might benefit from early cystectomy.

Patient Summary: In this study, we defined a risk score (the SIM score) based on the measurement of routine systemic inflammatory markers. This score can identify patients with high-grade bladder cancer not invading the muscular layer who are more likely to suffer from tumor recurrence and progression. Therefore, the score could be used to select patients who might benefit from early bladder removal.
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http://dx.doi.org/10.1016/j.euo.2018.06.006DOI Listing
October 2018

Major Acute Cardiovascular Events After Transurethral Prostate Surgery: A Population-based Analysis.

Urology 2019 Sep 28;131:196-203. Epub 2019 May 28.

Department of Surgery, Division of Urology, VCU Health, Richmond, VA.

Objective: To test the prevalence and predictors of major acute cardiovascular events (MACE) after transurethral prostate surgery (TPS).

Material And Methods: The American College of Surgeons National Surgical Quality Improvement Program database (2011-2016) was queried for patients who underwent transurethral resection of the prostate, photoselective vaporization, or laser enucleation. MACE included: cerebrovascular events, cardiac arrest, myocardial infarction, deep venous thrombosis requiring therapy, and pulmonary embolism episodes occurred up to 30 days after discharge. Univariable and multivariable logistic regression models tested MACE predictors and effect of MACE on perioperative mortality. Within covariates significant at univariable analyses a stepwise selection, based on Akaike Information Criterion values, was performed to fit the most appropriate multivariable model.

Results: Overall 44,939 patients were included in our analyses. Of these 365 (0.8%) had MACE within 30 days after surgery. The strongest MACE predictors were recent congestive heart failure (odds ratio [OR]: 2.1, 95% confidence interval [CI]: 1.2-3.7, P = .007), transfusions (OR: 2.5, 95% CI: 1.5-4.1, P <.001) and preoperative Systemic Inflammatory Response Syndrome or sepsis (OR: 2.6, 95% CI: 1.6-4.2, P <.001). Similarly, inpatient (OR: 2.0, 95% CI: 1.6-2.5, P <.001) and nonelective (OR: 1.5, 95% CI: 1.1-2.1, P = .012) patients experienced higher MACE rates. Perioperative mortality rates were statistical significantly higher in MACE patients (OR: 13.1, 95% CI: 8.2-21.0, P <.001).

Conclusion: Up to 1% of patients undergoing transurethral prostate surgery experience MACE. MACE are burdened by high mortality rates (up to 14% in MACE patients). Proper patient selection and postoperative monitoring are necessary to reduce MACE incidence and mortality rates.
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http://dx.doi.org/10.1016/j.urology.2019.05.014DOI Listing
September 2019

Minimally Invasive Radical Prostatectomy after Previous Bladder Outlet Surgery: A Systematic Review and Pooled Analysis of Comparative Studies.

J Urol 2019 09 8;202(3):511-517. Epub 2019 Aug 8.

Division of Urology, Department of Surgery, VCU Health, Richmond, Virginia.

Purpose: Prostate cancer surgery after previous bladder outlet surgery of benign prostatic hyperplasia is an uncommon yet challenging scenario. We performed a systematic review and pooled analysis of comparative studies on laparoscopic and robotic minimally invasive radical prostatectomy after bladder outlet surgery.

Materials And Methods: We searched the literature on PubMed®, Embase® and Web of Science™ up to February 2019 according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to identify eligible studies. Surgical, oncologic and functional outcomes in patients who underwent minimally invasive radical prostatectomy after bladder outlet surgery were compared to those without a history of bladder outlet surgery. Sensitivity analysis was done according to surgical technique (laparoscopic or robotic). RevMan 5.3 was used for statistical analysis.

Results: A total of 12 comparative studies were included in analysis. Patients who underwent minimally invasive radical prostatectomy after bladder outlet surgery were older (p ≤0.00001) and had a smaller prostate (p = 0.04) and lower prostate specific antigen (p = 0.003). The previous bladder outlet surgery group had lower odds of nerve sparing procedures, longer operative time, a higher rate of bladder neck reconstruction (each p <0.0001) and longer catheter time (p = 0.03). They were at higher risk for intraoperative (p = 0.001), overall (p <0.00001) and major complications (p = 0.0008), a higher positive surgical margin rate (p = 0.0005) and biochemical recurrence (p = 0.05). Moreover, potency (p = 0.03) and continence recovery (p = 0.007) at 12 months were lower in men with previous bladder outlet surgery. Robotic surgery seemed to offer better outcomes than laparoscopy.

Conclusions: Minimally invasive radical prostatectomy after previous bladder outlet surgery represents a challenging surgical task with a higher risk of complications, and higher odds of worse functional and oncologic outcomes. Patients should be aware of these drawbacks and these factors should be considered during patient counseling. When surgery is pursued, robot-assisted radical prostatectomy should be preferred over laparoscopic radical prostatectomy since it can offer superior outcomes. The overall literature on this topic is of low quality and further efforts should be made to obtain higher levels of evidence.
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http://dx.doi.org/10.1097/JU.0000000000000312DOI Listing
September 2019

Partial versus radical nephrectomy in very elderly patients: a propensity score analysis of surgical, functional and oncologic outcomes (RESURGE project).

World J Urol 2020 Jan 1;38(1):151-158. Epub 2019 Apr 1.

Division of Urology, VCU Health, 1200 East Broad st, Richmond, VA, 23298, USA.

Purpose: To compare the outcomes of PN to those of RN in very elderly patients treated for clinically localized renal tumor.

Patients And Methods: A purpose-built multi-institutional international database (RESURGE project) was used for this retrospective analysis. Patients over 75 years old and surgically treated for a suspicious of localized renal with either PN or RN were included in this database. Surgical, renal function and oncological outcomes were analyzed. Propensity scores for the predicted probability to receive PN in each patient were estimated by logistic regression models. Cox proportional hazard models were estimated to determine the relative change in hazard associated with PN vs RN on overall mortality (OM), cancer-specific mortality (CSM) and other-cause mortality (OCM).

Results: A total of 613 patients who underwent RN were successfully matched with 613 controls who underwent PN. Higher overall complication rate was recorded in the PN group (33% vs 25%; p = 0.01). Median follow-up for the entire cohort was 35 months (interquartile range [IQR] 13-63 months). There was a significant difference between RN and PN in median decline of eGFR (39% vs 17%; p < 0.01). PN was not correlated with OM (HR = 0.71; p = 0.56), OCM (HR = 0.74; p = 0.5), and showed a protective trend for CSM (HR = 0.19; p = 0.05). PN was found to be a protective factor for surgical CKD (HR = 0.28; p < 0.01) and worsening of eGFR in patients with baseline CKD. Retrospective design represents a limitation of this analysis.

Conclusions: Adoption of PN in very elderly patients with localized renal tumor does not compromise oncological outcomes, and it allows better functional preservation at mid-term (3-year) follow-up, relative to RN. Whether this functional benefit translates into a survival benefit remains to be determined.
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http://dx.doi.org/10.1007/s00345-019-02665-2DOI Listing
January 2020

Outcomes of Partial and Radical Nephrectomy in Octogenarians - A Multicenter International Study (Resurge).

Urology 2019 Jul 23;129:139-145. Epub 2019 Mar 23.

Division of Urology, VCU Health, Richmond, VA. Electronic address:

Objective: To analyze the outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) in octogenarian patients.

Methods: The RESURGE (REnal SUrgery in the Eldely) multi-institutional database was queried to identify patients ≥80 years old who had undergone a PN or RN for a renal tumor. Multivariable binary logistic regression estimated the association between type of surgery and occurrence of complications. Multivariable Cox regression model assessed the association between type of surgery and All-Causes Mortality.

Results: The study analyzed 585 patients (median age 83 years, IQR 81-84), 364 of whom (62.2%) underwent RN and 221 (37.8%) PN. Patients undergoing RN were older (P = .0084), had larger tumor size (P < .0001) and higher clinical stage (P < .001). At multivariable analysis for complications, the only significant difference was found for lower risk of major postoperative complications for laparoscopic RN compared to open RN (OR: 0.42; P = .04). The rate of significant (>25%) decrease of eGFR in PN and RN was 18% versus 59% at 1 month, and 23% versus 65% at 6 months (P < .0001). After a median follow-up time of 39 months, 161 patients (31%) died, of whom 105 (20%) due to renal cancer.

Conclusion: In this patient population both RN and PN carry a non-negligible risk of complications. When surgical removal is indicated, PN should be preferred, whenever technically feasible, as it can offer better preservation of renal function, without increasing the risk of complications. Moreover, a minimally invasive approach should be pursued, as it can translate into lower surgical morbidity.
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http://dx.doi.org/10.1016/j.urology.2019.03.009DOI Listing
July 2019

Near-infrared Fluorescence Imaging with Indocyanine Green in Robot-assisted Partial Nephrectomy: Pooled Analysis of Comparative Studies.

Eur Urol Focus 2020 05 21;6(3):505-512. Epub 2019 Mar 21.

Division of Urology, VCU Health System, Richmond, VA, USA. Electronic address:

Context: The use of near-infrared fluorescence (NIRF) imaging was described to facilitate selective clamping during robot-assisted partial nephrectomy (RAPN).

Objective: To perform a systematic review and cumulative analysis of available studies comparing the outcomes of RAPN with or without use of this technology (NIRF).

Evidence Acquisition: A systematic review of the literature was performed to identify relevant studies up to December 2018 through PubMed and EMBASE databases. A meta-analysis was conducted with the RevMan 5.3 software.

Evidence Synthesis: Six comparative studies were identified. Overall, 369 cases were included for the analysis (171 NIRF-RAPN and 198 standard RAPN). No significant difference was identified between groups in baseline characteristics, operating time, and estimated blood loss; however, a shorter clamping time was recorded for the NIRF-RAPN group. Functional outcomes revealed higher overall estimated glomerular filtration rate (eGFR) values in the NIRF-RAPN group at short-term (1-3 mo) postoperative follow-up (weighted mean difference [WMD]: 9.26ml/min; 95% confidence interval [CI]: 6.46, 12.06; p<0.001). In two studies, a renal scan-based assessment of split eGFR was available, and pooled analysis revealed higher split eGFR for NIRF-RAPN (WMD: 7.91ml/min; 95% CI: 4.26, 11.56; p < 0.001), and lower Δ % between preoperative and 1-mo eGFR (WMD: -7.84%; 95% CI: -8.85, -6.83; p<0.00001).

Conclusions: Current evidence regarding the use of NIRF-guided selective clamping during RAPN is based on a limited number of studies from high-volume institutions. Notwithstanding these limitations, NIRF-RAPN can be safely performed, and it might offer better short-term renal functional outcomes. It remains to be determined whether this can ultimately translate into a clinical benefit for patients undergoing RAPN, especially in the long term.

Patient Summary: We assessed the outcomes of robot-assisted partial nephrectomy (RAPN) performed with or without the use of near-infrared fluorescence (NIRF) imaging. NIRF-RAPN appeared to be a safe procedure with potential better short-term functional outcomes.
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http://dx.doi.org/10.1016/j.euf.2019.03.005DOI Listing
May 2020

Trifecta Outcomes of Partial Nephrectomy in Patients Over 75 Years Old: Analysis of the REnal SURGery in Elderly (RESURGE) Group.

Eur Urol Focus 2020 09 22;6(5):982-990. Epub 2019 Feb 22.

Department ofUrology, University of California San Diego School of Medicine, La Jolla, CA, USA. Electronic address:

Background: Partial nephrectomy (PN) in elderly patients is underutilized with concerns regarding risk of complications and potential for poor outcomes.

Objective: To evaluate quality and functional outcomes of PN in patients >75 yr using trifecta as a composite outcome of surgical quality.

Design, Setting, And Participants: Multicenter retrospective analysis of 653 patients aged >75 yr who underwent PN (REnal SURGery in Elderly [RESURGE] Group).

Intervention: PN.

Outcome Measurements And Statistical Analysis: Primary outcome was achievement of trifecta (negative margin, no major [Clavien ≥3] urological complications, and ≥90% estimated glomerular filtration rate [eGFR] recovery). Secondary outcomes included chronic kidney disease (CKD) stage III and CKD upstaging. Multivariable analysis (MVA) was used to assess variables for achieving trifecta and functional outcomes. Kaplan-Meier survival analysis (KMA) was used to calculate renal functional outcomes.

Results And Limitations: We analyzed 653 patients (mean age 78.4 yr, median follow-up 33 mo; 382 open, 157 laparoscopic, and 114 robotic). Trifecta rate was 40.4% (n=264). Trifecta patients had less transfusion (p<0.001), lower intraoperative (5.3% vs 27%, p<0.001) and postoperative (25.4% vs 37.8%, p=0.001) complications, shorter hospital stay (p=0.045), and lower ΔeGFR (p <0.001). MVA for predictive factors for trifecta revealed decreasing RENAL nephrometry score (odds ratio [OR] 1.26, 95% confidence interval 1.07-1.51, p=0.007) as being associated with increased likelihood to achieve trifecta. Achievement of trifecta was associated with decreased risk of CKD upstaging (OR 0.47, 95% confidence interval 0.32-0.62, p<0.001). KMA showed that trifecta patients had improved 5-yr freedom from CKD stage 3 (93.5% vs 57.7%, p<0.001) and CKD upstaging (84.3% vs 8.2%, p<0.001). Limitations include retrospective design.

Conclusions: PN in elderly patients can be performed with acceptable quality outcomes. Trifecta was associated with decreased tumor complexity and improved functional preservation.

Patient Summary: We looked at quality outcomes after partial nephrectomy in elderly patients. Acceptable quality outcomes were achieved, measured by a composite outcome called trifecta, whose achievement was associated with improved kidney functional preservation.
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http://dx.doi.org/10.1016/j.euf.2019.02.010DOI Listing
September 2020

Surface-based registration between CT and US for image-guided percutaneous renal access - A feasibility study.

Med Phys 2019 Mar 22;46(3):1115-1126. Epub 2019 Jan 22.

Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.

Purpose: As a crucial step in accessing the kidney in several minimally invasive interventions, percutaneous renal access (PRA) practicality and safety may be improved through the fusion of computed tomography (CT) and ultrasound (US) data. This work aims to assess the potential of a surface-based registration technique and establish an optimal US acquisition protocol to fuse two-dimensional (2D) US and CT data for image-guided PRA.

Methods: Ten porcine kidney phantoms with fiducial markers were imaged using CT and three-dimensional (3D) US. Both images were manually segmented and aligned. In a virtual environment, 2D contours were extracted by slicing the 3D US kidney surfaces and using usual PRA US-guided views, while the 3D CT kidney surfaces were transformed to simulate positional variability. Surface-based registration was performed using two methods of the iterative closest point algorithm (point-to-point, ICP1; and point-to-plane, ICP2), while four acquisition variants were studied: (a) use of single-plane (transverse, SP ; or longitudinal, SP ) vs bi-plane views (BP); (b) use of different kidney's coverage ranges acquired by a probe's sweep; (c) influence of sweep movements; and (d) influence of the spacing between consecutive slices acquired for a specific coverage range.

Results: BP view showed the best performance (TRE = 2.26 mm) when ICP2 method, a wide kidney coverage range (20°, with slices spaced by 5°), and a large sweep along the central longitudinal view were used, showing a statistically similar performance (P = 0.097) to a full 3D US surface registration (TRE = 2.28 mm).

Conclusions: An optimal 2D US acquisition protocol was evaluated. Surface-based registration, using multiple slices and specific sweep movements and views, is here suggested as a valid strategy for intraoperative image fusion using CT and US data, having the potential to be applied to other image modalities and/or interventions.
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http://dx.doi.org/10.1002/mp.13369DOI Listing
March 2019

Predictors of Residual T1 High Grade on Re-Transurethral Resection in a Large Multi-Institutional Cohort of Patients with Primary T1 High-Grade/Grade 3 Bladder Cancer.

J Cancer 2018 20;9(22):4250-4254. Epub 2018 Oct 20.

Division of Urology, European Institute of Oncology, Milan, Italy.

The aim of this multi-institutional study was to identify predictors of residual high-grade (HG) disease at re-transurethral resection (reTUR) in a large cohort of primary T1 HG/Grade 3 (G3) bladder cancer patients. A total of 1155 patients with primary T1 HG/G3 bladder cancer from 13 academic institutions that underwent a reTUR within 6 weeks after first TUR were evaluated. Logistic regression analysis was performed to assess the association of predictive factors with residual HG at reTUR. Residual HG cancer was found in 288 (24.9%) of patients at reTUR. Patients presenting residual HG cancer were more likely to have carcinoma in situ (CIS) at first resection (p<0.001), multiple tumors (p=0.02), and tumor size larger than 3 cm (p=0.02). Residual HG disease at reTUR was associated with increased preoperative neutrophil-to-lymphocytes ratio (NLR) (p=0.006) and body mass index (BMI)>=25 kg/m. On multivariable analysis, independent predictors for HG residual disease at reTUR were tumor size >3cm (OR = 1.37; 95% CI: 1.02-1.84, p=0.03), concomitant CIS (OR 1.92; 95% CI: 1.32-2.78, p=0.001), being overweight (OR= 2.08; 95% CI: 1.44-3.01, p<0.001) and obesity (OR 2.48; 95% CI: 1.64-3.77, p<0.001). A reTUR in high grade T1 bladder cancer is mandatory as about 25% of patients, presents residual high grade disease. Independent predictors to identify patients at risk of residual high grade disease after a complete TUR include tumor size, presence of carcinoma in situ, and BMI >=25 kg/m.
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http://dx.doi.org/10.7150/jca.26129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277616PMC
October 2018

Late presentation of vesicoureteral reflux: An unusual cause of pyelonephritis in adults.

Int J Surg Case Rep 2018 29;53:238-241. Epub 2018 Oct 29.

Urology Department, Hospital de Braga, Braga, Portugal; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal. Electronic address:

Introduction: Vesicoureteral reflux (VUR) corresponds to the reflux of urine from the bladder into the upper urinary system. It can be a congenital or an acquired anomaly and although its incidence is high in children it is uncommon in the adult life. One of its presentations in the adult population is the presence of recurrent Pyelonephritis.

Case Presentation: Here we report a case of an adult patient with repetitive uncomplicated pyelonephritis caused by VUR. VUR was successfully managed endoscopically with subureteral injection of a bulking agent. A literature review of adult presenting VUR was performed.

Discussion: The first presentation of VUR in the adult life is rare. One of the most typical presentation is the presence of recurrent uncomplicated Pyelonephritis. Although no guidelines exists to study the presence of VUR in adult patients with Pyelonephritis, in the presence of several recurrent episodes of Pyelonephritis we should think in VUR as a possible cause. Even in adults, endoscopic management of VUR is an effective treatment with low morbidity.

Conclusion: VUR can first present in the adult life, with recurrent episodes of UTI. The diagnosis is a suspicious one and is confirmed by VUCG. VUR in adults can be effectively managed with endoscopic injection of bulking agents.
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http://dx.doi.org/10.1016/j.ijscr.2018.10.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232627PMC
October 2018

Percutaneous nephrostomy vs ureteral stent for hydronephrosis secondary to ureteric calculi: impact on spontaneous stone passage and health-related quality of life-a prospective study.

Urolithiasis 2019 Dec 15;47(6):567-573. Epub 2018 Sep 15.

Urology Department, Hospital de Braga, Rua das Sete Fontes, São Victor, Braga, Portugal.

Ureteral calculi can be associated with urinary drainage blockage, requiring urinary diversion with percutaneous nephrostomy (PCN) or retrograde ureteral stent (RUS). Currently no evidence exists to support the superiority of one method over the other. This study proposes to compare both approaches regarding the probability of spontaneous stone passage (SSP) and its effect on patient's quality of life (QoL). A prospective trial was carried out from July to October of 2017. 50 patients were selected with hydronephrosis secondary to ureteral stones requiring urgent urinary diversion and divided into two groups according to diversion technique: percutaneous nephrostomy (PCN) or retrograde ureteral stent (RUS). The rate of SSP and QoL were evaluated. A PCN group (18 patients) and a RUS group (32 patients) were set. Stone size was higher in PCN (median 92 mm) than RUS (median 47 mm) (p = .012). The rate of SSP was 25% in RUS group and 38.9% in PCN. On the univariable analysis no statistical effect was found; however, when adjusted for stone size, location, previous ureteral manipulation and expulsive therapy, PCN showed a significant higher chance of SSP than RUS (OR = 6667). Besides, it was found that 30.2% (n = 13) of stones had an upward displacement associated with retrograde endoscopy. A significant decrease between pre- and post-intervention QoL was found with RUS (p < .001), but not found with PCN (p = .206). Patients in RUS group experienced more urinary symptoms, mostly haematuria (68.7% vs 16.7% in PCN group < .001) and dysuria (78.3% vs 16.7% in PCN group, p < .001). PCN was associated with a higher rate of spontaneous stone passage when adjusted for stone size and location. Moreover, PCN was better tolerated and associated with fewer urinary symptoms when compared with RUS.
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http://dx.doi.org/10.1007/s00240-018-1078-2DOI Listing
December 2019

Resistance of different guidewires to laser injury: an in-vitro experiment.

Minerva Urol Nefrol 2018 Dec 29;70(6):624-629. Epub 2018 Aug 29.

Department of Urology, Hospital of Braga, Braga, Portugal.

Background: In urology, lasers are used in a variety of endoscopic procedures such as ureteroscopy and retrograde renal surgery for stone fragmentation of urinary calculi and ablation of urothelial tumors. To perform these procedures, guidewires are used as a preliminary safe-mainstay for referencing the urinary tract. This study aims to determine the effect of two different lasers: holmium:YAG (Ho:YAG) and thulium:YAG (Tm:YAG) lasers on metal guidewires with PTFE coating (PTFE), nitinol guidewires with hydrophilic coating (Hydrophilic) and nitinol guidewires with hydrophilic listed coating (Zebra).

Methods: Different combinations of frequency (5, 10 and 12 Hz) and energy per pulse (0.5, 1.5, and 2.6 J) of Ho:YAG laser were applied on the three kinds of guidewires in two experiments (50 J vs. 100 J of total energy). For the Tm:YAG laser three power levels (5, 35, and 70 W) with a total energy of 100 J were applied to the guidewires. The degree of damage (0 to 5) of the guidewire was assessed after each laser application.

Results: A higher degree of injury of guidewires was related to higher values of total energy used for the Ho:YAG laser (P=0.036), and to higher values of power applied with the Tm:YAG (P=0.051). The most resistant guidewire to Ho:YAG laser energy was Zebra, followed by PTFE and Hydrophilic (P<0.001). With the Tm:YAG laser, PTFE guidewire appears to be the most resistant and the Hydrophilic the most fragile, although without reaching the statistical significance (P=0.223).

Conclusions: Both lasers revealed a harmful effect on the three tested guidewires. There was an association between the degree of injury and the amount of Ho:YAG laser energy and Tm:YAG laser power. The guidewire Zebra proved to be the safest when using Ho:YAG laser and the PTFE guidewire the most resistant to laser Tm:YAG. Further studies are necessary to confirm these results.
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http://dx.doi.org/10.23736/S0393-2249.18.03050-3DOI Listing
December 2018

Validation of Neutrophil-to-lymphocyte Ratio in a Multi-institutional Cohort of Patients With T1G3 Non-muscle-invasive Bladder Cancer.

Clin Genitourin Cancer 2018 12 6;16(6):445-452. Epub 2018 Jul 6.

Department of Urology, Medical University of Vienna, Vienna, Austria; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Urology, Weill Cornell Medical College, New York, NY.

Introduction: The aim of this multicenter study was to investigate the prognostic role of neutrophil-to-lymphocyte ratio (NLR) and to validate the NLR cutoff of 3 in a large multi-institutional cohort of patients with primary T1 HG/G3 non-muscle-invasive bladder cancer (NMIBC).

Patients And Methods: The study period was from January 2002 through December 2012. A total of 1046 patients with primary T1 HG/G3 who had NMIBC on re-transurethral bladder resection (TURB) who received adjuvant intravesical bacillus Calmette-Guérin therapy with maintenance from 13 academic institutions were included. Endpoints were time to disease, and recurrence-free (RFS), progression-free (PFS), overall (OS), and cancer-specific survival (CSS).

Results: A total of 512 (48.9%) of patients had NLR ≥ 3 prior to TURB. High pretreatment NLR was associated with female gender and residual T1HG/G3 on re-TURB. The 5-year RFS estimates were 9.4% (95% confidence interval [CI], 6.8%-12.4%) in patients with NLR ≥ 3 compared with 58.8% (95% CI, 54%-63.2%) in patients with NLR < 3; the 5-year PFS estimates were 57.1% (95% CI, 51.5%-62.2%) versus 79.2% (95% CI, 74.7%-83%; P < .0001); the 10-year OS estimates were 63.6% (95% CI, 55%-71%) versus 66.5% (95% CI, 56.8%-74.5%; P = .03); the 10-year CSS estimates were 77.4% (95% CI, 68.4%-84.2%) versus 84.3% (95% CI, 76.6%-89.7%; P = .004). NLR was independently associated with disease recurrence (hazard ratio [HR], 3.34; 95% CI, 2.82-3.95; P < .001), progression (HR, 2.18; 95% CI, 1.71-2.78; P < .001) and CSS (HR, 1.65; 95% CI, 1.02-2.66; P = .03). The addition of NLR to a multivariable model that included established features increased its discrimination for predicting of RFS (+6.9%), PFS (+1.8%), and CSS (+1.7%).

Conclusions: Pretreatment NLR ≥ 3 was a strong predictor for RFS, PFS, and CSS in patients with primary T1 HG/G3 NMIBC. It could help in the decision-making regarding intensity of therapy and follow-up.
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http://dx.doi.org/10.1016/j.clgc.2018.07.003DOI Listing
December 2018