Publications by authors named "Franco Gaboardi"

59 Publications

Prostate cancer testicular metastasis: Are they underestimated? Case report and analysis of the literature.

Urologia 2021 Apr 8:3915603211009118. Epub 2021 Apr 8.

Department of Urology, San Raffaele Turro Hospital, San Raffaele University, Milan, Italy.

Introduction: We aim to present a rare case of a patient who developed a late testicular metastasis of PCa after radical prostatectomy.

Case Description: A 78 years old man presenting for left testicular swelling slowly increasing of size over the last 2 months. He underwent a retropubic radical prostatectomy and extended bilateral lymphadenectomy in 2007 for prostatic adenocarcinoma. At the time of the presentation the last PSA was 0.91 ng/mL. The patient underwent a standard left orchifunicolectomy in April 2019 without intra- or perioperative complications. The pathological analysis showed a testicular metastasis of acinar adenocarcinoma.

Conclusions: In conclusion, testicular metastasis from PCa are uncommon conditions. PSA evaluation and physical examination of all sites of metastasis and accurate evaluation of all signs/symptoms during the clinical visit remains crucial to the diagnosis of recurrence.
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http://dx.doi.org/10.1177/03915603211009118DOI Listing
April 2021

Endourologic Treatment of Late Migration of Embolization Causing Nephrolithiasis in Two Patients.

J Endourol Case Rep 2020 29;6(4):278-282. Epub 2020 Dec 29.

Ville Turro Division, Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy.

Selective renal artery angioembolization is the first treatment option in case of significant bleeding after percutaneous nephrolithotomy. Migration of embolization material into the collecting system is extremely rare. The treatment of this condition is not standardized, but manual extraction, ultrasound fragmentation, and holmium laser lithotripsy have been described. We report the laser extraction of these coils in two patients at our center with two different approaches: retrograde intrarenal surgery (RIRS) and endoscopic combined intrarenal surgery (ECIRS). They were young male patients aged 25 and 29 years at the time of surgery, and they were 2-5 years postembolization when they presented to our center for symptoms such as hematuria and passage of small stone fragments. The first patient was managed solely with RIRS, whereas the second patient required ECIRS because of significant bleeding after coil removal, which necessitated hemostasis using a resectoscope. For patients who present with recurrent stones or other symptoms such as pain, hematuria, or flank pain, the diagnosis of migrated embolization coils should be considered. Management can be via the retrograde or percutaneous approach, but in the setting of significant amount of migrated coils or significant bleeding after their removal, percutaneous access may allow more definitive hemostasis.
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http://dx.doi.org/10.1089/cren.2020.0028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797275PMC
December 2020

Protocol of the Italian Radical Cystectomy Registry (RIC): a non-randomized, 24-month, multicenter study comparing robotic-assisted, laparoscopic, and open surgery for radical cystectomy in bladder cancer.

BMC Cancer 2021 Jan 11;21(1):51. Epub 2021 Jan 11.

Department of Urology, Policlinico Abano Terme, Abano Terme, PD, Italy.

Background: Bladder cancer is the ninth most common type of cancer worldwide. In the past, radical cystectomy via open surgery has been considered the gold-standard treatment for muscle invasive bladder cancer. However, in recent years there has been a progressive increase in the use of robot-assisted laparoscopic radical cystectomy. The aim of the current project is to investigate the surgical, oncological, and functional outcomes of patients with bladder cancer who undergo radical cystectomy comparing three different surgical techniques (robotic-assisted, laparoscopic, and open surgery). Pre-, peri- and post-operative factors will be examined, and participants will be followed for a period of up to 24 months to identify risks of mortality, oncological outcomes, hospital readmission, sexual performance, and continence.

Methods: We describe a protocol for an observational, prospective, multicenter, cohort study to assess patients affected by bladder neoplasms undergoing radical cystectomy and urinary diversion. The Italian Radical Cystectomy Registry is an electronic registry to prospectively collect the data of patients undergoing radical cystectomy conducted with any technique (open, laparoscopic, robotic-assisted). Twenty-eight urology departments across Italy will provide data for the study, with the recruitment phase between 1st January 2017-31st October 2020. Information is collected from the patients at the moment of surgical intervention and during follow-up (3, 6, 12, and 24 months after radical cystectomy). Peri-operative variables include surgery time, type of urinary diversion, conversion to open surgery, bleeding, nerve sparing and lymphadenectomy. Follow-up data collection includes histological information (e.g., post-op staging, grading, and tumor histology), short- and long-term outcomes (e.g., mortality, post-op complications, hospital readmission, sexual potency, continence etc).

Discussion: The current protocol aims to contribute additional data to the field concerning the short- and long-term outcomes of three different radical cystectomy surgical techniques for patients with bladder cancer, including open, laparoscopic, and robot-assisted. This is a comparative-effectiveness trial that takes into account a complex range of factors and decision making by both physicians and patients that affect their choice of surgical technique.

Trial Registration: ClinicalTrials.gov , NCT04228198 . Registered 14th January 2020- Retrospectively registered.
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http://dx.doi.org/10.1186/s12885-020-07748-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802145PMC
January 2021

Decision making and treatment options in endourology post-coronavirus disease 2019 - adapting to the future.

Curr Opin Urol 2021 03;31(2):109-114

Department of Urology, European Training Center of Endourology, IRCCS San Raffaele Hospital, Milan.

Purpose Of Review: To describe and critically discuss the most recent evidence regarding stone management during the coronavirus disease 2019 (COVID-19) and post-COVID-19 era.

Recent Findings: There is a need to plan for resuming the normal elective stone surgery in the post-COVID era, keeping a clear record of all surgeries that are being deferred and identifying subgroups of surgical priorities, for the de-escalation phase. Telehealth is very useful because it contributes to reduce virus dissemination guaranteeing at the same time an adequate response to patients' care needs. Once the pandemic is over, teleurology will continue to be utilized to offer cost-effective care to urological patients and it will be totally integrated in our clinical practice.

Summary: This COVID-19 pandemic represents a real challenge for all national health providers: on the one hand, every effort should be made to assist COVID patients, while on the other hand we must remember that all other diseases have not disappeared in the meanwhile and they will urgently need to be treated as soon as the pandemic is more under control. A correct prioritization of cases when surgical activity will progressively return back to normality is of paramount importance.
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http://dx.doi.org/10.1097/MOU.0000000000000857DOI Listing
March 2021

Holmium laser for RIRS. Watts are we doing?

Arch Esp Urol 2020 Oct;73(8):735-744

European Training Center in Endourology at Department of Urology. IRCCS San Raffaele Hospital. Ville Turro Division. Milan. Italy.

Objective: To review recent and relevant information regarding the use of high-power (HPL) and low-power (LPL) Holmium:YAG lasers (Ho:YAG) in retrograde intrarenal surgery (RIRS) for lithotripsy. METHODS: A PubMed/Embase search was conducted and recent and relevant papers on Ho:YAG for RIRS were reviewed.

Results: Settings for Ho:YAG are pulse energy (PE), pulse frequency (PF), and pulse width. Currently, the majority of LPL can also adjust pulse-width but cannot reach PF as high as HPL, however, the higher energy outputs reached by HPL are rarely useful in lithotripsy. Higher PE might enhance ablation but generates larger fragments and higher retropulsion. Pulse width does not affect energy output but delivers energy for a longer time-length. Dusting and basketing are complementary techniques. Dusting seeks to pulverize stones into particles ≤250 μm avoiding the use of instruments for stone retrieval, whereas in fragmenting, the stones are break into smaller pieces which are then retrieved. Dusting can prevent the use of supplies such as access sheaths and baskets and also prevent the complications related to their use. However, is not always feasible in clinical practice to fully ablate a stone into dust, then the use of this supplies and popcorn technique are helpful for rendering a patient stonefree. The energy gap between HPL and LPL is wide and leaves room for a mid-power laser classification, which can overcome the main drawback of LPL, the expenses of HPL, and still holding its versatility for other procedures beyond stones.

Conclusions: HPL and LPL have similar effectiveness, but long-term cost-effectiveness comparisons are underexplored. Newer HPL would need to be compared to emerging technologies as the thulium fiber, and prove superiority to mid-power laser to determine how powerful is enough for Ho:YAG in the years to come.
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October 2020

Thulium:YAG Holmium:YAG Laser Effect on Upper Urinary Tract Soft Tissue: Evidence from an Experimental Study.

J Endourol 2021 Apr 7;35(4):544-551. Epub 2020 Sep 7.

Ville Turro Division, Department of Urology, European Training Center of Endourology, IRCCS San Raffaele Hospital, Milan, Italy.

There are limited data regarding the effect of thulium laser (Tm:YAG) and holmium laser (Ho:YAG) on upper urinary tract. The aim of this study was to compare soft tissue effects of these two lasers at various settings, with a focus on incision depth (ID) and coagulation area (CA). An experimental study was performed in a porcine model. The kidneys were dissected to expose the upper urinary tract and the block samples containing urothelium and renal parenchyma were prepared. The laser fiber, fixed on a robotic arm, perpendicular to the target tissue was used with a 100 W Ho:YAG and a 200 W Tm:YAG. Incisions were made with the laser tip in contact with the urothelium and in continuous movement at a constant speed of 2 mm/s over a length of 1.5 cm. Total energy varied from 5 to 30 W. Incision shape was classified as follows: saccular, triangular, tubular, and irregular. ID, vaporization area (VA), CA, and total laser area (TLA = VA + CA) were evaluated. Statistical analysis was performed using the SPSS V23 package, -values <0.05 were considered statistically significant. A total of 216 experiments were performed. Incision shapes were saccular (46%), triangular (38%), and irregular (16%) with the Ho:YAG, while they were tubular (89%) and irregular (11%) with the Tm:YAG. ID was significantly deeper with the Ho:YAG ( = 0.024), while CA and TLA were larger with the Tm:YAG ( < 0.001 and  < 0.005). ID was deeper with Ho:YAG, whereas CA and TLA were larger with the Tm:YAG. Considering surgical principles for endoscopic ablation of upper tract urothelial carcinoma, these results suggest that Tm:YAG may have a lower risk profile (less depth of incision) while also being more efficient at tissue destruction. Future studies are necessary to corroborate these findings.
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http://dx.doi.org/10.1089/end.2020.0222DOI Listing
April 2021

Hospital care in Departments defined as COVID-free: A proposal for a safe hospitalization protecting healthcare professionals and patients not affected by COVID-19.

Arch Ital Urol Androl 2020 Apr 24;92(2). Epub 2020 Apr 24.

Musumeci GECAS Clinic, Gravina di Catania, Catania.

The COVID-19 pandemic influenced the normal course of clinical practice leading to significant delays in the delivery of healthcare services for patients non affected by COVID-19. In the near future, it will be crucial to identify facilities capable of providing health care in compliance with the safety of healthcare professionals, administrative staff and patients. All the staff involved in the project of a Covid-free hospital should be subjected to a diagnostic swab for COVID-19 before the beginning of healthcare activity and then periodically in order to avoid the risk of contamination of patients during the process of care. The modifications of various activities involved in the process of care are described: outpatient care, reception of inpatients, inpatient ward and operating room. For outpatient care, modality of appointment procedure, characteristics of waiting room and personal protective equipment (PPE) for healthcare professionals and administrative staff are presented. Reception of inpatients shall be conditional on a negative swab for COVID-19 obtained with a drive-in procedure. The management of the operating room represents the most crucial step of the patient's care process. The surgical team should be restricted and monitored with periodic swabs; surgical procedures should be performed by experienced surgeons according to standard procedures; surgical training experimental treatments and research protocols should be suspended. Adequate personal protective equipment and measures to reduce aerosolization in the operating room (closed circuits, continuous cycle insufflators, fume extraction) should be adopted. Prevention of possible transmission of the virus during procedures in open, laparoscopic and endoscopic surgery is to use a multi-tactic approach, which includes correct filtration and ventilation of the operating room, the use of appropriate PPE (FFP3 plus surgical mask and protective visor for all the staff working in the operating room) and smoke evacuation devices with a suction and filter system.   on behalf of the UrOP Executive Committee Giuseppe Ludovico, Angelo Cafarelli, Ottavio De Cobelli, Ferdinando De Marco, Giovanni Ferrari, Stefano Pecoraro, Angelo Porreca, Domenico Tuzzolo.
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http://dx.doi.org/10.4081/aiua.2020.2.67DOI Listing
April 2020

The dramatic COVID 19 outbreak in Italy is responsible of a huge drop of urological surgical activity: a multicenter observational study.

BJU Int 2021 01 19;127(1):56-63. Epub 2020 Oct 19.

Azienda Ospedaliero Universitaria Careggi, Firenze, Italy.

Objective: To describe the trend in surgical volume in urology in Italy during the coronavirus disease 2019 (COVID-19) outbreak, as a result of the abrupt reorganisation of the Italian national health system to augment care provision to symptomatic patients with COVID-19.

Methods: A total of 33 urological units with physicians affiliated to the AGILE consortium (Italian Group for Advanced Laparo-Endoscopic Surgery; www.agilegroup.it) were surveyed. Urologists were asked to report the amount of surgical elective procedures week-by-week, from the beginning of the emergency to the following month.

Results: The 33 hospitals involved in the study account overall for 22 945 beds and are distributed in 13/20 Italian regions. Before the outbreak, the involved urology units performed overall 1213 procedures/week, half of which were oncological. A month later, the number of surgeries had declined by 78%. Lombardy, the first region with positive COVID-19 cases, experienced a 94% reduction. The decrease in oncological and non-oncological surgical activity was 35.9% and 89%, respectively. The trend of the decline showed a delay of roughly 2 weeks for the other regions.

Conclusion: Italy, a country with a high fatality rate from COVID-19, experienced a sudden decline in surgical activity. This decline was inversely related to the increase in COVID-19 care, with potential harm particularly in the oncological field. The Italian experience may be helpful for future surgical pre-planning in other countries not so drastically affected by the disease to date.
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http://dx.doi.org/10.1111/bju.15149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322984PMC
January 2021

Semirigid Ureteroscopy: Step by Step.

J Endourol 2020 05;34(S1):S13-S16

Department of Urology, San Raffaele Hospital, Ville Turro Division, Milan, Italy.

This article aims to demonstrate a step-by-step technique of semirigid ureteroscopy (URS) for the treatment of ureteral stones, urothelial tumors, and ureteral stenosis. Operating room setup, camera settings, access to the bladder, and negotiation of the ureteral orifice, lasertripsy, basketing of the stone fragments, endoscopic treatment of ureteral tumors and ureteral stenosis, flexible URS at the end of semirigid URS, and Double-J stent placement are described step by step.
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http://dx.doi.org/10.1089/end.2018.0286DOI Listing
May 2020

A comparative propensity score-matched analysis of perioperative outcomes of intracorporeal vs extracorporeal urinary diversion after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

BJU Int 2020 08 16;126(2):265-272. Epub 2020 May 16.

Roswell Park Cancer Institute, Buffalo, NY, USA.

Objective: To compare the perioperative outcomes of intracorporeal (ICUD) vs extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy (RARC).

Patients And Methods: We retrospectively reviewed the prospectively maintained International Robotic Cystectomy Consortium (IRCC) database. A total of 972 patients from 28 institutions who underwent RARC were included. Propensity score matching was used to match patients based on age, gender, body mass index (BMI), American Society of Anesthesiologists Score (ASA) score, Charlson Comorbidity Index (CCI) score, prior radiation and abdominal surgery, receipt of neoadjuvant chemotherapy, and clinical staging. Matched cohorts were compared. Multivariate stepwise logistic and linear regression models were fit to evaluate variables associated with receiving ICUD, operating time, 90-day high-grade complications (Clavien-Dindo Classification Grade ≥III), and 90-day readmissions after RARC.

Results: Utilisation of ICUD increased from 0% in 2005 to 95% in 2018. The ICUD patients had more overall complications (66% vs 58%, P = 0.01) and readmissions (27% vs 17%, P = 0.01), but not high-grade complications (21% vs 24%, P = 0.22). A more recent RC era and ileal conduit diversion were associated with receiving an ICUD. Higher BMI, ASA score ≥3, and receiving a neobladder were associated with longer operating times. Shorter operating time was associated with male gender, older age, ICUD, and centres with a larger annual average RC volume. Longer intensive care unit stay was associated with 90-day high-grade complications. Higher CCI score, prior radiation therapy, neoadjuvant chemotherapy, and ICUD were associated with a higher risk of 90-day readmissions.

Conclusions: Utilisation of ICUD has increased over the past decade. ICUD was associated with more overall complications and readmissions compared to ECUD, but not high-grade complications.
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http://dx.doi.org/10.1111/bju.15083DOI Listing
August 2020

Endourological Stone Management in the Era of the COVID-19.

Eur Urol 2020 08 14;78(2):131-133. Epub 2020 Apr 14.

European Training Center for Endourology, Department of Urology, IRCCS San Raffaele Hospital, Ville Turro Division, Milan, Italy.

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http://dx.doi.org/10.1016/j.eururo.2020.03.042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195508PMC
August 2020

The Italian andrology patient is changing. Broader cultural knowledge is needed!

Int J Impot Res 2020 Apr 14. Epub 2020 Apr 14.

Department of Urology-Policlinico San Martino Hospital, University of Genova, Genova, Italy.

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http://dx.doi.org/10.1038/s41443-020-0280-2DOI Listing
April 2020

ABLATE: a score to predict complications and recurrence rate in percutaneous treatments of renal lesions.

Med Oncol 2020 Mar 12;37(4):26. Epub 2020 Mar 12.

Ospedale San Raffaele Sede di Ville Turro - UOC Radiology, Milan, Italy.

RENAL score has been validated on predicting adverse events and relapses in percutaneous treatments of renal lesions. To better fit interventional issues a modified score (mRENAL) has been introduced, but the only difference from the RENAL score is on the dimensional parameter. However, it remains of surgical derivation while a specific interventional score is missing. This study aims to obtain a specific score (ABLATE) to better quantify the risk of complications and relapses in percutaneous kidney ablation procedures compared to the existing surgical scores. Taking inspiration from previous papers, a score was built to quantify the real difficulties faced in percutaneous treatment of renal lesions. The ABLATE score was used on 71 cryoablations to evaluate its predictivity of complications and relapses. Logistic regression was used to predict complication incidence; Cox-regression was used for relapses; ROC analysis was used to evaluate the accuracy of the different scores. Between January 2014 and November 2019, 71 lesions in 68 patients were treated. Overall, malignant histology was found in 62 lesions (87.3%). Mean and median RENAL, mRENAL, and ABLATE scores were 7.04 and 7, 7.19 and 7, and 5.11 and 4, respectively. Out of 71 treatments, we experienced 3 bleeding with anemia (4.2%), only 2 of which needed further treatment (2.82%). The mean and median RENAL, mRENAL, and ABLATE scores in those with complications were 7.66 and 7.01 (p = 0.69), 8.0 and 7.1 (p = 0.54), and 6.6 and 5.0 (p = 0.38), respectively. Out of 62 malignant lesions, we experienced 2 persistent and 6 recurrent lesions (3.2% and 8.4%, respectively). At Cox-regression analyses, mABLATE score outperformed both RENAL and mRENAL scores in predicting recurrences (HR 1.48; p < 0.001 vs. 1.41; p = 0.1 vs. 1.38: p = 0.07, respectively). The ABLATE score showed to be a better predictor of relapses than RENAL and mRENAL. The small number of complications conditioned a lack of statistic power on complications for all the scores. At the moment to quantify the risks in percutaneous kidney ablation procedures, surgical scores are used. A specific score better performs this task.
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http://dx.doi.org/10.1007/s12032-020-01351-3DOI Listing
March 2020

Port-site metastasis and atypical recurrences after robotic-assisted radical cystectomy (RARC): an updated comprehensive and systematic review of current evidences.

J Robot Surg 2020 Dec 9;14(6):805-812. Epub 2020 Mar 9.

Department of Urology, Policlinico San Martino Hospital, University of Genoa, Largo Rosanna Benzi 10, 16130, Genoa, Italy.

The objective of this systematic review is to evaluate the current evidence regarding atypical metastases in patients undergoing robotic-assisted radical cystectomy (RARC). A review of the current literature was conducted through the Medline and NCBI PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases in October 2019. From the literature search using the cited keys and after a careful evaluation of the full texts, we included 31 articles in the study. Fourteen studies (45.2%) reported at least an atypical recurrence during the follow-up period with a rate between 4 and 40% of all the recurrences. Overall, 105 (1.63%) of the 6720 patients who have been evaluated in the included studies developed an atypical recurrence. Sixty-three (60%) of these atypical metastases were peritoneal carcinomatosis, 16 (15.2%) extrapelvic lymph nodes metastases, 11 (10.5%) port-site metastases, 10 (9.5%) retroperitoneal nodal metastases, while 5 (3.8%) patients developed more than one type of atypical recurrence. In literature, there is a low but not negligible incidence of atypical recurrences after RARC. However, publication bias and retrospective design of most studies could influence the evidences. Further prospective randomized studies are needed to clarify the real risk of patients undergoing RARC to develop atypical metastases.
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http://dx.doi.org/10.1007/s11701-020-01062-xDOI Listing
December 2020

Conservative treatment of upper urinary tract carcinoma in patients with imperative indications.

Minerva Urol Nefrol 2020 Feb 19. Epub 2020 Feb 19.

Department of Urology, IRCCS San Raffaele Hospital, Ville Turro, Milan, Italy.

Background: To report our experience for endoscopic treatment of upper urinary tract carcinoma (UTUC) in patients with imperative indications for management.

Methods: Retrospective data were collected for all patients who underwent endoscopic management of UTUC for imperative situations, from September 2013 to January 2019. Comorbidity was determined by using the age-adjusted Charlson comorbidity index (CCI). The primary endpoint of the study was overall survival (OS). Secondary outcomes were recurrence- free survival (RFS) rates, complication rates and global renal function.

Results: A total of 29 patients were enrolled in the study. The median age was 69.0 (IQR 63.0- 79.0) years and the median CCI was 6 (IQR 4-8). Overall, 137 endoscopic procedures were performed; 117 (85.4%) had no complication. Clavien-Dindo grade III and IV complications were 3 (2.2%) and 1 (0.7%) respectively. The median follow-up of 23 months (IQR 14-35). During the follow-up, 2 (6.9%) patients died for cause not related to cancer. Recurrence of UTUC occurred in 18 patients (61.1%). The 24-month OS was 96.4 ± 3.5% and the 24-month RFS was 31.7 ± 9.4%. Lower RFS rates were found in high grade tumor patients (22.2 ± 13.9%) compared to low grade tumor patients (35.6 ± 12.3%) (p=0.237). There was statistical difference in creatinine and eGFR values when comparing baseline to last follow-up (p=0.018 and p=0.005, respectively).

Conclusions: Endoscopic management of UTUC in patients with imperative indications appears to be a reasonable alternative to nephroureterectomy. However, stringent endoscopic follow- up is necessary due to the high risk of disease recurrence.
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http://dx.doi.org/10.23736/S0393-2249.20.03710-8DOI Listing
February 2020

The current use of human cadaveric models in urology: a systematic review.

Minerva Urol Nefrol 2020 Jun 11;72(3):313-320. Epub 2019 Nov 11.

Department of Urology, San Martino Hospital Polyclinic, University of Genoa, Genoa, Italy.

Introduction: We aim to perform a systematic review of the current use of cadaveric models in urology and analyze their role within urological training and the experimentation of novel surgical techniques.

Evidence Acquisition: A systematic review of the current literature was conducted through the Medline and NCBI PubMed, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL) databases in September 2019. All papers published after 2000, concerning studies conducted on human cadaveric models for training in urological surgical procedures, developing of new techniques and technologies were considered for the review.

Evidence Synthesis: From the literature search we found a total of 3769 different articles of those only 58 articles were included in the study. Eleven studies (19%) were published between 2000 and 2009, and the trend increased almost fourfold in the following period (2010-2019) with 47 studies (81%) being published. Surprisingly, a clear statement on the approval of the use of cadavers was written in less than 50% of the studies. About the 48% of the studies were aimed to experiment a novel surgical technique while in the 31% of studies the cadavers were used for surgical training. More than half of the studies evaluated did not provide any information about the type and method of preparation of cadaveric models while specific outcomes in terms of satisfaction with the use of cadaver models were reported clearly only in less than a third of them.

Conclusions: The quality of the materials and methods described in most studies is often characterized by poor detail with regards to the preservation and preparation of the bodies and the satisfaction of use, which might affect training and testing.
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http://dx.doi.org/10.23736/S0393-2249.19.03558-6DOI Listing
June 2020

Supine percutaneous nephrolithotomy: tips and tricks.

Transl Androl Urol 2019 Sep;8(Suppl 4):S381-S388

Department of Urology, IRCCS San Raffaele Hospital, Ville Turro Division, Milan, Italy.

This paper aims to give an exhaustive overview of supine percutaneous nephrolithotomy (PCNL) illustrating some tips and tricks in order to optimize its execution in full safety. Critical review of Pros and cons of supine PCNL is accomplished to allow the urologist to experience the beauty of this position while being ready to overcome its minimal shortcomings.
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http://dx.doi.org/10.21037/tau.2019.07.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6790418PMC
September 2019

Neoadjuvant Chemotherapy is Not Associated with Adverse Perioperative Outcomes after Robot-Assisted Radical Cystectomy: A Case for Increased Use from the IRCC.

J Urol 2020 01 17;203(1):57-61. Epub 2019 Jul 17.

Roswell Park Comprehensive Cancer Center, Buffalo, New York.

Purpose: We sought to determine the trend of neoadjuvant chemotherapy use for nonmetastatic muscle invasive urothelial bladder cancer and whether it is associated with adverse perioperative morbidity after robot-assisted radical cystectomy.

Materials And Methods: We retrospectively reviewed the IRCC (International Robotic Cystectomy Consortium) database between 2006 and 2017. After excluding patients with nonmuscle invasive bladder cancer the patients were divided into 2 groups, including those who did vs did not receive neoadjuvant chemotherapy. Data were reviewed for demographics, preoperative, operative and 90-day perioperative outcomes. We used the Cochran-Armitage trend test to assess trends of neoadjuvant chemotherapy associations with high grade and overall complications with time. Multivariate stepwise regression analyses were done to determine whether neoadjuvant chemotherapy was associated with prolonged operative time, 90-day postoperative complications, readmissions, reoperations and mortality after robot-assisted radical cystectomy.

Results: A total of 298 patients (26%) received neoadjuvant chemotherapy. These patients were younger (age 67 vs 69 years, p=0.01) and more frequently had an ASA™ (American Society of Anesthesiologists™) score of 3 or greater (62% vs 55%, p=0.02) and pathological T3 stage or greater disease (28% vs 22%, p=0.04). The use of neoadjuvant chemotherapy increased significantly from 10% in 2006 to 2007 to 42% in 2016 to 2017 (p <0.01). On multivariate analysis neoadjuvant chemotherapy was not significantly associated with prolonged operative time, hospital stay, 90-day postoperative complications, reoperation or mortality. Neoadjuvant chemotherapy was associated with 90-day readmissions after robot-assisted radical cystectomy (OR 5.90, 95% CI 3.30-10.90, p <0.01).

Conclusions: Neoadjuvant chemotherapy utilization has significantly increased in the last decade. It was not associated with perioperative surgical morbidity after robot-assisted radical cystectomy.
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http://dx.doi.org/10.1097/JU.0000000000000445DOI Listing
January 2020

Percutaneous Microwave Ablation Versus Cryoablation in the Treatment of T1a Renal Tumors.

Cardiovasc Intervent Radiol 2020 Jan 26;43(1):76-83. Epub 2019 Aug 26.

Department of Radiology, IRCCS Ospedale San Raffaele Turro, Via Stamina d'Ancona 32, 20154, Milan, Italy.

Purpose: Radiofrequency and cryoablation (Cryo) are the most widely used techniques for the treatment of T1a renal tumors in non-surgical candidates, yet microwave ablation (MWA) has been gaining popularity. In this study, we tested the hypothesis that MWA has comparable safety and efficacy to Cryo in the treatment of selected T1a renal masses.

Materials And Methods: A retrospective comparative analysis of two patient cohorts was carried out on 83 nodules in 72 consecutive patients treated using image-guided percutaneous ablation with either Cryo or MWA. Patient demographics, tumor histology and characteristics, technical success, procedure time, adverse events and complications, nephrometry score (mRENAL) and renal function were evaluated. Local recurrence was evaluated at 1, 6, 12 and 18-24 months.

Results: Fifty-one nodules were treated with Cryo and 32 with MWA (44 and 28 patients, respectively). No statistical differences were observed following Cryo or MWA in median tumor size (p = 0.6), mRENAL (p = 0.1) or technical success (p = 0.8). Median procedure time was significantly lower using microwave ablation (p = 0.003). Median follow-up time was similar in the two groups (22 and 20 months, respectively). Occurrence of complications did not differ (Cryo 5/51, MWA 2/32; p = 0.57), and probability of complications or technical success adjusted for mRENAL did not reach statistical significance (p = 0.6). Renal function was preserved in all patients regardless of techniques. Disease recurrence was observed in 3/47 and in 1/30 treated nodules in the Cryo and MWA groups, respectively, without reaching statistical significance (p = 0.06).

Conclusion: In the patient population studied, MWA showed comparable safety and efficacy relative to Cryo.

Level Of Evidence: Level 3, Non-randomized cohort study.
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http://dx.doi.org/10.1007/s00270-019-02313-7DOI Listing
January 2020

Not All Multiparametric Magnetic Resonance Imaging-targeted Biopsies Are Equal: The Impact of the Type of Approach and Operator Expertise on the Detection of Clinically Significant Prostate Cancer.

Eur Urol Oncol 2018 06 15;1(2):120-128. Epub 2018 May 15.

Department of Urology and Division of Experimental Oncology, Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.

Background: The extensive use of multiparametric magnetic resonance imaging (mpMRI) has led to an even more widespread use of different targeted biopsy techniques and approaches. The best way of performing targeted biopsies and the effect of operator expertise have still to be defined.

Objective: To compare the rate of detection of clinically significant prostate cancer (csPCa) of different mpMRI targeted approaches and to assess the role of operator expertise in the detection of csPCa.

Design, Setting, And Participants: We included 244 consecutive patients who underwent both 12-core transrectal ultrasound (TRUS) biopsy and mpMRI targeted biopsy with either a cognitive biopsy (CB) or fusion biopsy (FB) approach during the same session between 2013 and 2016 at a single tertiary referral centre.

Intervention: All men underwent 1.5-T mpMRI with an endorectal coil. All biopsies were performed by three operators as their first cases of targeted biopsy. Lesions with a Prostate Imaging Recording and Data System (PI-RADS) v.2 score of ≥3 detected at mpMRI were targeted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: csPCa was defined as disease with a Gleason score at biopsy of ≥7. Operator expertise was coded as the progressive number of targeted biopsies performed by each physician. Multivariable logistic regression analyses (MVA) were used to assess the association between the targeted biopsy technique (FB vs CB) and operator expertise for detection of csPCa. Covariates consisted of prostate-specific antigen, prostate volume, PI-RADS v.2 (3 vs >3), number of targeted cores per MRI lesion, and digital rectal examination (negative vs positive). The same analyses were performed for patients undergoing FB only after accounting for the FB approach (transrectal vs transperineal). A lowess smoothing weighted function was used to graphically assess the effect of operator expertise on the probability of detecting csPCa, after accounting for all confounders.

Results And Limitations: Overall, 157 patients (64%) underwent FB and 87 (36%) underwent CB. The overall csPCa detection rate was 58% for FB and 45% for CB (p=0.07). A significantly higher rate of csPCa detection in targeted samples was observed for FB compared to CB (57% vs 36%; p=0.002). On MVA, FB and operator expertise were significantly associated with a higher probability of csPCa detection in targeted samples (odds ratio [OR] 2.4 and 1.7, respectively; both p≤0.03). When the same analyses were repeated for patients undergoing FB, operator expertise remained an independent predictor of csPCa detection (OR 1.9; p=0.004). An increase in the probability of detecting csPCa with the number of procedures performed was observed after accounting for all confounders.

Conclusions: We demonstrated that FB had higher detection rate than CB for csPCa. Moreover, operator expertise was significantly associated with higher detection rates for csPCa.

Patient Summary: When different targeted biopsy techniques were compared, fusion biopsy provided a higher detection rate compared to cognitive biopsy for clinically significant prostate cancer (csPCa). Moreover, we found that operator expertise was an important predictor of the detection of csPCa, regardless of the procedure used.
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http://dx.doi.org/10.1016/j.euo.2018.02.002DOI Listing
June 2018

Association Between Prostate Imaging Reporting and Data System (PI-RADS) Score for the Index Lesion and Multifocal, Clinically Significant Prostate Cancer.

Eur Urol Oncol 2018 05 15;1(1):29-36. Epub 2018 May 15.

Department of Urology and Division of Experimental Oncology, Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.

Background: The ability to identify clinically significant prostate cancer (csPCa) has dramatically improved with the introduction of multiparametric magnetic resonance imaging (mpMRI). Given the growing interest in targeted biopsy and focal therapy, improving our knowledge on the relationship between mpMRI parameters and the ability to predict csPCa multifocality is mandatory.

Objective: To assess whether the Prostate Imaging Reporting and Data System (PI-RADS) score for the index lesion (IL) may predict multifocal csPCa undetected by mpMRI.

Design, Setting, And Participants: The study included 343 patients who underwent mpMRI of the prostate with subsequent biopsy between 2014 and 2017 at a single tertiary care referral centre.

Intervention: Lesions with a PI-RADS v.2 score ≥2 detected at mpMRI (IL) were targeted with a fusion biopsy (Bx) approach (mpMRI-Bx). Moreover, each patient underwent a random extended transrectal ultrasound-guided biopsy (TRUS-Bx) during the same session. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: csPCa outside the IL was defined as disease detected at TRUS-Bx with a Gleason score (GS)≥3+4 and equal to or greater than the GS for the IL. The extent of csPCa detected in target and random cores was reported and stratified according to the GS and PI-RADS score for the IL. The probability of diagnosing csPCa outside the IL according to the PI-RADS score was also assessed in multivariable logistic regression analyses (MVA) after accounting for confounders.

Results And Limitations: The detection rate for csPCa outside the IL was 30%. The detection rate for csPCa at TRUS-Bx was 8% for PI-RADS 2, 15% for PI-RADS 3, 36% for PI-RADS 4, and 58% for PI-RADS 5 lesions (p=0.03). Overall, the median length of csPCa found at TRUS-Bx and thus missed at mpMRI was 2.6mm. However, the length significantly increased with PI-RADS score for the IL, and was 1.8, 2.3, 2.8, and 3.8mm for PI-RADS 2, 3, 4, and 5 lesions, respectively (p=0.03). On MVA, PI-RADS 4 (odds ratio [OR] 7.6; p=0.008) and PI-RADS 5 scores (OR 17.3; p<0.001) were independent predictors of the presence of csPCa outside the IL. The study is limited by its retrospective design.

Conclusions: Overall, the accuracy of mpMRI in identifying multifocal csPCa is poor, missing low-volume csPCa in approximately 30% of patients. Moreover, the rate and the extent of csPCa undetected by mpMRI significantly increased with the PI-RADS score for the IL, which can thus be considered a proxy for tumour multifocality.

Patient Summary: The accuracy of multiparametric magnetic resonance imaging in identifying prostate cancer multifocality is poor. False negative findings were highly related to the PI-RADS score of the index lesion. These findings raise concerns about the indication for targeting the index lesion only when considering prostate biopsy and focal approaches.
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http://dx.doi.org/10.1016/j.euo.2018.01.002DOI Listing
May 2018

Robotic-assisted laparoscopic pyeloplasty with the use of the Contour™ stent: description of the technique and analysis of outcomes after the first 30 cases.

Cent European J Urol 2019 4;72(1):51-53. Epub 2019 Jan 4.

Department of Urology, San Raffaele Turro Hospital, San Raffaele University, Milan, Italy.

Introduction: We present a technical variation of robot-assisted pyeloplasty (RAP) using the Contour™ stent that allows a minimal incision of the retroperitoneum.

Material And Methods: The main difference from the standard robot-assisted pyeloplasty (RAP) is the preventive retrograde insertion of a Contour™ stent, which is a single J stent subsequently easily convertible in a double J stent.

Results: The mean operative time was 141.2 minutes. Blood losses were negligible, median length of stay was 4 days.

Conclusions: The use of a Contour™ stent showed to be a safe and feasible technical variation while performing a RAP.
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http://dx.doi.org/10.5173/ceju.2018.1844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469006PMC
January 2019

Robotic surgery in patients with achondroplastic dwarfism: evaluation of risks and issues in an anatomical challenging bilateral partial nephrectomy.

J Robot Surg 2019 Dec 23;13(6):783-786. Epub 2019 Jan 23.

Department of Urology, San Raffaele Turro Hospital, San Raffaele University, Milan Via Stamira d'Ancona, 20, 20127, Milano, Italy.

The reports on the performance of robotic surgery in patients with dwarfism are anecdotal; anesthesiological issues and a challenging anatomy are the main factors that lead most of surgeons to prefer a more traditional approach. We present a case of bilateral robotic partial nephrectomy in a patient affected by achondroplastic dwarfism and aim to evaluate risks and issues in this type of surgery.
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http://dx.doi.org/10.1007/s11701-018-00904-zDOI Listing
December 2019

Italian endourological panorama: results from a national survey.

Cent European J Urol 2018 27;71(2):190-195. Epub 2018 Mar 27.

Urology Department, IRCCS San Raffaele Scientific Institute, Ville Turro Division, Milan, Italy.

Introduction: The purpose of this survey was to explore the dissemination of flexible ureteroscopy (fURS), shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) in the Italian urological community and to know the real availability of the complex endourological armamentarium all over the country.

Materials And Methods: An online questionnaire characterizing the case volume/year of upper urinary tract stone treatment and the availability of flexible ureteroscopes (FUs) armamentarium was sent to all urological Italian centers.

Results: The survey was sent to 294 urological centers and 146 responded (49.7%). The case volume/year of fURS was the following: <20 cases in 20 centers (13.7%); 20-50 cases in 40 centers (27.4%), >50- <100 cases in 55 centers (37.8%) and >100 cases in 28 centers (19.2%). The case volume/year of SWL was the following: <50 cases in 18 centers (12.3%); >50- <200 cases in 56 centers (36.4%) and >200 cases in 35 centers (24%). In 37 centers (25.3%) SWL was not utilized at all. The case volume/year of PCNL was the following: <10 cases in 20 centers (14%); >10 - <30 cases in 55 centers (30%), >30- < 50 cases in 33 centers(23%), >50- <100 cases in 13 centers (9%) and >100 procedures in 2 centers (1%). However, 24 centers (16%) did not perform any PCNL procedure.Four centers (3%) did not have any FU at the moment of the survey. The availability of FUs was as follows: 1 FU in 21 (14%) centers, 2 FUs in 61 (42%) centers, 3 FUs in 29 (20%) centers, 4 FUs in 13 (9%) centers and ≥5 FUs in 16 (9%) centers. Only 82 (56%) centers had all of their FUs in working condition.

Conclusions: This survey succeeded in providing a complete overview on the Italian endourological panorama.
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http://dx.doi.org/10.5173/ceju.2018.1623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051357PMC
March 2018

Laparoscopic Radical Prostatectomy in Patients with High-Risk Prostate Cancer: Feasibility and Safety. Results of a Multicentric Study.

J Endourol 2018 09 21;32(9):843-851. Epub 2018 Aug 21.

6 Division of Experimental Oncology, Department of Urology, Vita-Salute San Raffaele University of Milan , Milan, Italy .

Introduction: In Western countries about 25% of prostate cancer (PCa) are high-risk tumors at presentation and its treatment is still a matter of debate among urologists. When a surgical approach is preferred the use of a mininvasive tecnique is still difficult due to the lack of data supporting it in literature. The aim of this study is to evaluate feasibility and safety of laparoscopic radical prostatectomy (LRP) for high-risk PCa.

Materials And Methods: The study included 1114 patients with high-risk PCa submitted to LRP between 1998 and 2014. High-risk patients were defined according to D'Amico classification. We collected functional and oncological long-term outcomes and evaluated with univariate and multivariate analyses the role of predictive factors for survival and biochemical recurrence (BR).

Results: Mean age at treatment was 62 ± 8 years; mean follow-up was 74 ± 50 months. We obtained an overall survival (OS) of 96.6% at a mean follow-up of 74 months (1076 patients) and a disease-free survival of 66.2% (737 patients). Age (p = 0.0006), pT (p < 0.0001), pN (p = 0.0018), and surgical margins (p = 0.0076) resulted as independent predictors for BR in multivariate analysis. pN (p = 0.0025) and Gs (p = 0.0003) are independent predictors for OS and cancer-specific survival in a univariate analysis; just the Gs results significant in the multivariate model.

Conclusions: According to our encouraging data about oncological and functional outcomes we believe that radical prostatectomy represents an effective treatment for patients with high-risk PCa and that laparoscopy is a safe approach offering a mini-invasive alternative to open surgery.
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http://dx.doi.org/10.1089/end.2018.0086DOI Listing
September 2018

Robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) with daVinci Single-Site® platform. Concept and evolution of the technique following an IDEAL phase 1.

J Robot Surg 2019 Apr 17;13(2):215-226. Epub 2018 Jul 17.

Department of Urology, IRCCS San Raffaele Turro Hospital, Via Stamira d'Ancona 20, 20127, Milan, Italy.

To describe the evolution of robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) performed with the daVinci Single-Site Platform® and a home-made multiport aimed to overcome classical drawbacks of LESS, still present with this platform. Between 09/2015 and 06/2017 12 patients underwent R-LESS RP for clinical localized prostate cancer. Following a "phase 1 (development-stage)" innovation, development, exploration, assessment, long-term study (IDEAL) framework, different solutions were drawn to overcome drawbacks of daVinci Single-Site Platform®, included 3 (A, B, and C) multi-ports developed and evaluated in term of advantages/drawbacks concerning ergonomy. The end points of this study were: feasibility, safety, efficacy, by reporting rational description of multiports configuration, demographics, perioperative variables, functional and oncological results. Semi-flexible robotic 5-mm needle-holder instead of Maryland forceps, 30° lenses up and barbed-suture allowed overcoming limits of robotic-platform. Multiport-C (GelPOINT Advanced-Access® and an extra 8-mm robotic trocar outside the multiport) showed the best compromise to ensure both surgeon and bed-side assistant to reproduce a standard robotic procedure. No conversion to either standard robotic or open technique or intraoperative complications occur in any case. Two patients experienced "high-grade" Clavien-Dindo complications. After 12.4 months follow-up, all patients were continent without any sign of biochemical relapse and among 5 preoperative potent patients submitted to nerve-sparing dissection, 4 reported good erectile-function. R-LESS-RP is feasible and safe in the hands of experienced minimally-invasive surgeons. Do date, we recommend a hybrid solution with a home-made multiport and use of an additional standard robotic trocar which allows the use endowrist® technology instruments.
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http://dx.doi.org/10.1007/s11701-018-0839-9DOI Listing
April 2019

Simultaneous Bilateral Endoscopic Surgery (SBES) for Patients with Bilateral Upper Tract Urolithiasis: Technique and Outcomes.

Eur Urol 2018 12 14;74(6):810-815. Epub 2018 Jul 14.

Department of Urology, IRCCS San Raffaele Hospital, Ville Turro Division, Milan, Italy.

Background: The incidence of bilateral and multiple renal stones is not negligible. To date, some sparse data on simultaneous bilateral stone surgery are available in literature showing good outcomes in terms of both effectiveness and safety.

Objective: To describe our series of patients with bilateral renal stones who underwent simultaneous bilateral endoscopic surgery (SBES), reporting its effectiveness and safety.

Design, Setting, And Participants: A prospective analysis of 27 consecutive patients who underwent simultaneous flexible ureteroscopy (fURS) in one side and percutaneous nephrolithotomy (PCNL) in the other side for bilateral renal stones was performed.

Surgical Procedure: SBES, performing fURS in one side and PCNL in the other side contemporaneously.

Measurements: Clinical data were collected in a dedicated database. Intra- and postoperative outcomes were assessed. Comparisons among pre- and postoperative serum creatinine levels and estimated glomerular filtration rate values during the study period were performed using the Kruskal-Wallis test with the Dunn multiple comparison test.

Results And Limitations: All the procedures were carried out until the end in both sides without encountering any complications intraoperatively. The mean stone size was 27.1±8.1 and 11.1±3.6mm for the PCNL and fURS side respectively. The mean operative time was 79.4±25.2min. There were no differences in patients' creatinine and eGFR when comparing at baseline with 1-mo after SBES. No postoperative major complications were experienced (Clavien-Dindo grade I 3.7%; II 11.1%). Stone-free rate was 74% at 1-mo follow-up. The main limitation of the study is the small size of the group analyzed.

Conclusions: SBES is safe and effective, with minimal morbidity. SBES has the potential advantages of shorter operative time, reduced anesthesia, and reduced hospital time, which can benefit patients, surgeons, and health care systems.

Patient Summary: Simultaneous bilateral endoscopic surgery is an effective treatment with low complication rates for bilateral urolithiasis. This innovative and complicated procedure should be performed in high-volume centers by experienced surgeons.
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http://dx.doi.org/10.1016/j.eururo.2018.06.034DOI Listing
December 2018

The "Body Mass Index" of Flexible Ureteroscopes.

J Endourol 2017 10 28;31(10):1090-1095. Epub 2017 Sep 28.

1 Department of Urology, San Raffaele Hospital , Ville Turro Division, Milan, Italy .

Objective: To assess the "body mass index" (BMI) (weight and length) of 12 flexible ureteroscopes (digital and fiber optic) along with the light cables and camera heads, to make the best use of our instruments.

Materials And Methods: Twelve different brand-new flexible ureteroscopes from four different manufacturers, along with eight camera heads and three light cables were evaluated. Each ureteroscope, camera head, and light cable was weighted; the total length of each ureteroscope, shaft, handle, flexible end-tip, and cable were all measured.

Results: According to our measurements (in grams [g]), the lightest ureteroscope was the LithoVue (277.5 g), while the heaviest was the URF-V2 (942.5 g). The lightest fiber optic endoscope was the Viper (309 g), while the heaviest was the Cobra (351.5 g). Taking into account the entirety of the endoscopes, the lightest ureteroscope was the Lithovue and the heaviest was the Wolf Cobra with the Wolf camera "3 CHIP HD KAMERA KOPF ENDOCAM LOGIC HD" (1474 g). The longest ureteroscope was the URF-P6 (101.6 cm) and the shortest was the LithoVue (95.5 cm); whereas the Viper and Cobra had the longest shaft (69 cm) and URF-V had the shortest shaft (67.2 cm). The URF-V2 had the longest flexible end-tip (7.6 cm), while the LithoVue had the shortest end-tip (5.7 cm) in both directions (up/down), while the URF-V had the shortest upward deflection (3.7 cm).

Conclusions: Newer more versatile digital endoscopes were lighter than their traditional fiber optic counterparts in their entirety, with disposable endoscope having a clear advantage over other reusable ureteroscopes. Knowing the "BMI" of our flexible ureteroscopes is an important information that every endourologist should always take into consideration.
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http://dx.doi.org/10.1089/end.2017.0438DOI Listing
October 2017