Publications by authors named "Giovannalberto Pini"

47 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

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

Intensive simulation training on urological mini-invasive procedures using Thiel-embalmed cadavers: The IAMSurgery experience.

Arch Ital Urol Androl 2020 Jun 23;92(2). Epub 2020 Jun 23.

IAMSurgery, International Accademy of Miniinvasive Surgery; Department of Urology, Policlinico San Martino Hospital, University of Genova.

Introduction: The objective of the study was to evaluate the benefits perceived by the use of cadaver models by IAMSurgery attendees and to define indications to standardize future similar training camps.

Materials And Methods: A 25-item survey was distributed via e-mail to all the participants of previous training courses named as "Urological Advanced Course on Laparoscopic Cadaver Lab" held at the anatomy department of the University of Malta, for anonymous reply. Participants were asked to rate the training course, the Thiel's cadaveric model, and make comparison with other previously experienced simulation tools.

Results: The survey link was sent to 84 attendees, with a response rate of 47.6% (40 replies). There was improvement in the median self-rating of the laparoscopic skills before and after the training camp with a mean difference of 0.55/5 points in the post-training skills compared to the basal (p < 0.0001). The 72.2% of the urologists interviewed considered Thiel's HCM better than other training methods previously tried, while five urologists (27.8%) considered it equal (p = 0.00077). Globally, 77.5% (31) of attendees found the training course useful, and 82.5% (33) would advise it to colleagues.

Conclusions: Thiel's fixed human cadaveric models seem to be ideal for training purposes, and their use within properly structured training camps could significantly improve the surgical skills of the trainees. An important future step could be standardization of the training courses using cadavers, and their introduction into the standardized European curriculum.
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http://dx.doi.org/10.4081/aiua.2020.2.93DOI Listing
June 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

A comparison among PCNL, Miniperc and Ultraminiperc for lower calyceal stones between 1 and 2 cm: a prospective, comparative, multicenter and randomised study.

BMC Urol 2020 Jun 10;20(1):67. Epub 2020 Jun 10.

Department of Urology, ASST Valle Olona Busto Arsizio, Varese, Italy.

Background: Conventional Percutaneous Lithotripsy (PCNL) has been an effective, successful and easy approach for especially > 1 cm sized calyceal stones however risks of complications and nephron loss are inevitable. Our aim is to compare the efficacy and safety of PCNL, MiniPerc (MP) and UltraMiniPerc (UMP) for lower calyceal stones between 1 and 2 cm with a multicenter prospective randomized study.

Methods: Between January 2015 and June 2018, 132 consecutive patients with single lower calyceal stone were enrolled. Patients were randomized in three groups; A: PCNL; B: MP; C: UMP. 44 patients for the Group A, 47 for Group B and 41 for Group C. Exclusion criterias were the presence of coagulation impairments, age of < 18 or > 75, presence of infection or serious comorbidities. Patients were controlled with computerized tomography scan after 3 months. A negative CT or an asymptomatic patient with stone fragments < 3 mm size were the criteria to assess the stone-free status. Patient characteristics, stone free rates (SFR) s, complications and re-treatment rates were analyzed.

Results: The mean stone size were 16.38, 16.82 and 15.23 mm respectively in Group A, B and C(p = 0.34). The overall SFR was significantly higher in Group A (86.3%) and B (82.9%) as compared to Group C (78%)(p < 0.05). The re-treatment rate was significantly higher in Group C (12.1%) and complication rates was higher in Group A (13.6%) as compared to others(p < 0.05). The hospitalization was significantly shorter in Group C compared to Group A (p = 0.04).

Conclusions: PCNL and MP showed higher efficacy than UMP to obtain a better SFR. Auxiliary and re-treatment rates were higher in UMP. On the other hand for such this kind of stones PCNL had more complications. Overall evaluation favors MP as a better indication in stones 1-2 cm size.
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http://dx.doi.org/10.1186/s12894-020-00636-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288549PMC
June 2020

Urology in the Time of Coronavirus: Reduced Access to Urgent and Emergent Urological Care during the Coronavirus Disease 2019 Outbreak in Italy.

Urol Int 2020 20;104(7-8):631-636. Epub 2020 May 20.

Department of Urology, University of Florence, Florence, Italy.

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has put a substantial burden on the Italian healthcare system, resulting in the restructuring of hospitals to care for COVID-19 patients. However, this has likely impacted access to care for patients experiencing other conditions. We aimed to quantify the impact of COVID-19 on access to care for patients with urgent/emergent urological conditions throughout Italy.

Materials And Methods: A questionnaire was sent to 33 urological units in the AGILE consortium, asking clinicians to report on the number of urgent/emergent urological patients seen and/or undergoing surgery over a 3-week period during the peak of the COVID-19 outbreak and a reference week prior to the outbreak. ANOVA and linear regression models were used to quantify these changes.

Results: Data from 27 urological centres in Italy showed a decrease from 956 patients/week seen just prior to the outbreak to 291 patients/week seen by the end of the study period. There was a difference in the number of patients with urgent/emergent urological disease seen within/during the different weeks (all p values < 0.05). A significant decrease in the number of patients presenting with haematuria, urinary retention, urinary tract infection, scrotal pain, renal colic, or trauma and urgent/emergent cases that required surgery was reported (all p values < 0.05).

Conclusion: In Italy, during the COVID-19 outbreak there has been a decrease in patients seeking help for urgent/emergent urological conditions. Restructuring of hospitals and clinics is mandatory to cope with the COVID-19 pandemic; however, the healthcare system should continue to provide adequate levels of care also to patients with other conditions.
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http://dx.doi.org/10.1159/000508512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360500PMC
August 2020

European Association of Urology Guidelines Office Rapid Reaction Group: An Organisation-wide Collaborative Effort to Adapt the European Association of Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era.

Eur Urol 2020 Jul 27;78(1):21-28. Epub 2020 Apr 27.

Academic Urology Unit, University of Aberdeen, Aberdeen, UK.

The coronavirus disease 2019 (COVID-19) pandemic is unlike anything seen before by modern science-based medicine. Health systems across the world are struggling to manage it. Added to this struggle are the effects of social confinement and isolation. This brings into question whether the latest guidelines are relevant in this crisis. We aim to support urologists in this difficult situation by providing tools that can facilitate decision making, and to minimise the impact and risks for both patients and health professionals delivering urological care, whenever possible. We hope that the revised recommendations will assist urologist surgeons across the globe to guide the management of urological conditions during the current COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.eururo.2020.04.056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183974PMC
July 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

External validation of Cormio nomogram for predicting all prostate cancers and clinically significant prostate cancers.

World J Urol 2020 Oct 6;38(10):2555-2561. Epub 2020 Jan 6.

Department of Urology, Ospedale Sant'Andrea-Universitá di Roma "Sapienza", Rome, Italy.

Purpose: Recently, the Cormio et al. nomogram has been developed to predict prostate cancer (PCa) and clinically significant PCa using benign prostatic obstruction parameters. The aim of the present study was to externally validate the nomogram in a multicentric cohort.

Methods: Between 2013 and 2019, patients scheduled for ultrasound-guided prostate biopsy were prospectively enrolled at 11 Italian institutions. Demographic, clinical and histological data were collected and analysed. Discrimination and calibration of Cormio nomogram were assessed with the receiver operator characteristics (ROC) curve and calibration plots. The clinical net benefit of the nomogram was assessed with decision curve analysis. Clinically significant PCa was defined as ISUP grade group > 1.

Results: After accounting for inclusion criteria, 1377 patients were analysed. 816/1377 (59%) had cancer at final pathology (574/816, 70%, clinically significant PCa). Multivariable analysis showed age, prostate volume, DRE and post-voided residual volume as independent predictors of any PCa. Discrimination of the nomogram for cancer was 0.70 on ROC analysis. Calibration of the nomogram was excellent (p = 0.94) and the nomogram presented a net benefit in the 40-80% range of probabilities. Multivariable analysis for predictors of clinically significant PCa found age, PSA, prostate volume and DRE as independent variables. Discrimination of the nomogram was 0.73. Calibration was poor (p = 0.001) and the nomogram presented a net benefit in the 25-75% range of probabilities.

Conclusion: We confirmed that the Cormio nomogram can be used to predict the risk of PCa in patients at increased risk. Implementation of the nomogram in clinical practice will better define its role in the patient's counselling before prostate biopsy.
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http://dx.doi.org/10.1007/s00345-019-03058-1DOI Listing
October 2020

Role of androgen receptor expression in non-muscle-invasive bladder cancer: a systematic review and meta-analysis.

Histol Histopathol 2020 May 5;35(5):423-432. Epub 2019 Dec 5.

AGILE Group (Italian Group for Advanced Laparoscopic and Robotic Urologic Surgery), Italy.

In order to evaluate the potential prognostic/predictive role of androgen receptor (AR) expression in non-muscle-invasive bladder cancer (NMIBC), and whether it may represent a therapeutic target, we conducted a systematic search of the literature using 'androgen receptor or AR', 'testosterone', 'bladder cancer' and 'non-muscle invasive bladder cancer or NMIBC' as keywords. Eleven studies met the inclusion/exclusion criteria. No significant association was found between AR status and patients' gender (p=0.232), tumor size (p=0.975), tumor stage (p=0.237), tumor grade (p=0.444), tumor multicentricity (p=0.397), concomitant CIS (p=0.316) and progression of disease (p=0.397). On the other hand, relative lack of AR expression was significantly correlated to recurrent disease (p=0.001). Evidence for a direct correlation between AR expression and recurrence-free survival of patients with NMIBC indicate ARs as potential markers of BC behavior; moreover, the finding of a role of androgen blockade therapy in improving survival highlights the potential clinical application of this pathway, which deserves to be further explored.
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http://dx.doi.org/10.14670/HH-18-189DOI Listing
May 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

Current role of robotic bladder cancer surgery.

Minerva Urol Nefrol 2019 Aug 7;71(4):301-308. Epub 2019 May 7.

Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden.

Introduction: Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in urology, that is not devoid of postoperative complications. Minimally invasive surgery, and especially robot-assisted RC (RARC) has emerged as an alternative to open RC (ORC) in an attempt to minimize surgical morbidity and facilitate the surgical approach. The aim of this paper was to present the current knowledge on the oncological efficacy and complication outcomes of RARC.

Evidence Acquisition: A non-systematic review on all relevant studies with the keywords "Radical cystectomy," "Open," "Robot-assisted," "Complications," "Recurrence," "Survival," "Neobladder," "Potency," "Continence" and "Intracorporeal" was performed using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) Guidelines.

Evidence Synthesis: RARC shows similar lymph node yields and positive surgical margin rates as well as perioperative complication outcomes compared with ORC. RARC exhibits significantly less blood loss and less intra- and postoperative blood transfusion. Moreover, survival and recurrence rates are not related to the surgical approach. Finally, RARC seems to be more expensive and has a longer operating time compared to the open technique.

Conclusions: As current evidence shows, RARC seems as a technically feasible and safe procedure, providing equivalent perioperative and oncological results compared to ORC. More prospective, randomized-controlled trials are necessary to draw definitive conclusions on all comparative aspects.
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http://dx.doi.org/10.23736/S0393-2249.19.03435-0DOI Listing
August 2019

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

Outcomes of European Basic Laparoscopic Urological Skills (EBLUS) Examinations: Results from European School of Urology (ESU) and EAU Section of Uro-Technology (ESUT) over 6 Years (2013-2018).

Eur Urol Focus 2020 11 17;6(6):1190-1194. Epub 2019 Jan 17.

Department of Urology and Kidney Transplant, Grande Ospedale Metropolitano, Reggio Calabria, Italy.

Background: The European School of Urology (ESU) and EAU Section of Uro-Technology (ESUT) started hands-on-training (HOT) sessions in 2007 along with structured European Basic Laparoscopic Urological Skills (EBLUS) examinations in 2013. EBLUS includes an online theoretical course, HOT by expert tutors on a set of dry-lab exercises, and finally a standardised examination for skill assessment and certification.

Objective: To analyse the results and predictors of success from the EBLUS examinations that were conducted during the European Urology Residents Education Programme (EUREP) and other international and national dedicated ESU events.

Design, Setting, And Participants: ESU has been delivering EBLUS courses and examinations over the past 6 yr (2013-2018) in more than 40 countries worldwide. Trainees were asked about their laparoscopic background (procedures assisted/performed) and about the availability of HOT or simulator/box trainer in their facility. Apart from the online theoretical course, 4 HOT tasks [(1) peg transfer, (2) pattern cutting, (3) single knot tying, and (4) clip and cut] with its quality assessment of depth perception, bimanual dexterity, and efficiency were a part of the assessment and were considered critical to pass the EBLUS examination.

Results And Limitations: A total of 875 EBLUS examinations were delivered (EUREP, n=385; other ESU events, n=490), with complete data available for 533 (61%) participants among which 295 (55%) passed the examinations. Pass rate increased on a yearly basis from 35% to 70% (p<0.001) and was similar between EUREP (56%) and other ESU/ESUT events (55%). The significant predictors of success were passing tasks 1 [odds ratio (OR): 869.9, 95% confidence interval (CI): 89.6-8449.0, p<0.001] and 2 (OR: 3045.0, 95% CI: 99.2-93 516.2, p<0.001) of the examinations. A limitation of EBLUS was its inability to provide more advanced training such as wet-lab or cadaveric training.

Conclusions: Over the past few years more trainees have passed the European Basic Laparoscopic Urological Skills (EBLUS) examinations. Trainees who spend more time on laparoscopic procedures demonstrated a better performance and pass rate. We found almost no difference between the EBLUS results collected from EUREP and other ESU/ESUT events, which confirms the robustness of the training and examinations conducted worldwide.

Patient Summary: Training in laparoscopy helps trainees pass the European Basic Laparoscopic Urological Skills (EBLUS) examinations, reflected by an increase in the pass rate over the past 6 yr. Our results also confirm the robustness of EBLUS training and examinations worldwide.
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http://dx.doi.org/10.1016/j.euf.2019.01.007DOI Listing
November 2020

Developing a five-step training model for transperineal prostate biopsies in a naïve residents' group: a prospective observational randomised study of two different techniques.

World J Urol 2019 Sep 10;37(9):1845-1850. Epub 2018 Dec 10.

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

Purpose: To evaluate a five-step training model for transperineal prostate biopsies (TPPB) and the differences in terms of the detection rate (DR) and the ease of execution when using either the "fan technique" (FT) or the use of a Free Hand technique (FH).

Methods: A prospective observational randomised study was conducted from September 2015 to November 2017. Six naïve residents, who underwent the same five-steps training model, were randomly subdivided into two different groups of three residents based on the selected TPPB technique: A (FT) and B (FH). Patient characteristics (age, PSA, prostatic volume, DRE, MRI), intraoperative (operative time, number of samples) and postoperative parameters (histologic, pain) were evaluated in the 2 groups. The overall and stratified DR for PSA ranges and prostate volume (PV), operative time and complications were compared.

Results: The overall detection rate was very high in both groups (FT 58.2% vs FH 59.6%) and not statistically different between the two techniques. There were no differences in terms of complication rates and pain. The FH showed a better detection rate in prostates smaller than 40 cc (p = 0.023) and a faster operative time (p = 0.025) compared to FT.

Conclusions: Within the TPPB, FH is associated with a higher detection rate in patients with prostate < 40 cc compared to an FT when performed by inexperienced trainees. Standardised training organised in consecutive steps seems to contribute to the achievement of overall high detection rates with both methods.
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http://dx.doi.org/10.1007/s00345-018-2599-6DOI Listing
September 2019

Performance Improvement (Pi) score: an algorithm to score Pi objectively during E-BLUS hands-on training sessions. A European Association of Urology, Section of Uro-Technology (ESUT) project.

BJU Int 2019 04 28;123(4):726-732. Epub 2018 Dec 28.

ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal.

Objective: To evaluate the variability of subjective tutor performance improvement (Pi) assessment and to compare it with a novel measurement algorithm: the Pi score.

Materials And 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. We collected data during eight courses on the four European Association of Urology training in Basic Laparoscopic Urological Skills (E-BLUS) tasks. The same tutor instructed on all courses. Collected data were independently analysed by 14 hands-on training experts for Pi assessment. Their subjective Pi assessments were compared for inter-rater reliability. The average per-participant subjective scores from all 14 proctors were then compared with the objective Pi-score algorithm results. Cohen's κ statistic was used for comparison analysis.

Results: A total of 50 participants were enrolled. Concordance found between the 14 proctors' scores was the following: Task 1, κ = 0.42 (moderate); Task 2, κ = 0.27 (fair); Task 3, κ = 0.32 (fair); and Task 4, κ = 0.55 (moderate). Concordance between Pi-score results and proctor average scores per participant was the following: Task 1, κ = 0.85 (almost perfect); Task 2, κ = 0.46 (moderate); Task 3, κ = 0.92 (almost perfect); Task 4 = 0.65 (substantial).

Conclusion: The present study shows that evaluation of Pi is highly variable, even when formulated by a cohort of experts. Our algorithm successfully provided an objective score that was equal to the average Pi assessment of a cohort of experts, in relation to a small amount of training attempts.
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http://dx.doi.org/10.1111/bju.14621DOI Listing
April 2019

The Predictive Role of Biomarkers for the Detection of Acute Kidney Injury After Partial or Radical Nephrectomy: A Systematic Review of the Literature.

Eur Urol Focus 2020 03 9;6(2):344-353. Epub 2018 Oct 9.

Department of Urology, University of Florence, Careggi Hospital, Florence, Italy.

Context: Postoperative acute kidney injury (AKI) is a serious complication after kidney surgery, associated with prolonged hospital stay, high morbidity, and mortality. Biomarkers represent a tool of increasing importance to identify renal impairment after partial nephrectomy (PN) or radical nephrectomy (RN) in order to optimize and anticipate the diagnosis of AKI.

Objective: The goal of this systematic review is to investigate current insights on the role of biomarkers in predicting renal impairment in patients undergoing PN or RN.

Evidence Acquisition: A systematic review was conducted up to November 30, 2017 through PubMed, Scopus, and Embase databases, to identify eligible studies evaluating the role of biomarkers for the prediction of AKI after PN or RN. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria were applied to select articles.

Evidence Synthesis: According to the study selection criteria, 10 publications were included with a total number of 728 patients. Incidence of AKI was 26.7% (range: 9-58%). Based on the evidence reviewed, serum cystatin C and urinary neutrophil gelatinase-associated lipocalin (NGAL) showed a significant correlation with serum creatinine rise postoperatively, emerging as potential noninvasive and early biomarkers of AKI in patients undergoing renal surgery. In this setting, serum cystatin C and urinary NGAL have preceded the rise in serum creatinine peak from 3 up to 24h, even in case of mild renal damage.

Conclusions: The literature underlines the potential usefulness of biomarkers such as cystatin C and NGAL as promising and early tools to predict AKI after PN or RN. However, no strong evidence in support of their use is available to date and further investigations are awaited.

Patient Summary: We looked at the role of biomarkers in predicting renal injury in patients undergoing partial or radical nephrectomy. Serum cystatin C and urinary neutrophil gelatinase-associated lipocalin have emerged as promising noninvasive, accurate, and early biomarkers.
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http://dx.doi.org/10.1016/j.euf.2018.09.020DOI Listing
March 2020

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

The European Urology Residents Education Programme Hands-on Training Format: 4 Years of Hands-on Training Improvements from the European School of Urology.

Eur Urol Focus 2019 11 14;5(6):1152-1156. Epub 2018 Mar 14.

Department of Urology and Kidney Transplant, Grande Ospedale Metropolitano, Reggio Calabria, Italy; School of Medicine, Hofstra University, New York, NY, USA; Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.

Background: The European School of Urology (ESU) started the European Urology Residents Education Programme (EUREP) in 2003 for final year urology residents, with hands-on training (HOT) added later in 2007.

Objective: To assess the geographical reach of EUREP, trainee demographics, and individual quality feedback in relation to annual methodology improvements in HOT.

Design, Setting, And Participants: From September 2014 to October 2017 (four EUREP courses) several new features have been applied to the HOT format of the EUREP course: 1:1 training sessions (2015), fixed 60-min time slots (2016), and standardised teaching methodology (2017). The resulting EUREP HOT format was verified by collecting and prospectively analysing the following data: total number of participants attending different HOT courses; participants' age; country of origin; and feedback obtained annually.

Results And Limitations: A total of 796 participants from 54 countries participated in 1450 HOT sessions over the last 4 yr. This included 294 (20%) ureteroscopy (URS) sessions, 237 (16.5%) transurethral resection (TUR) sessions, 840 (58%) basic laparoscopic sessions, and 79 (5.5%) intermediate laparoscopic sessions. While 712 residents (89%) were from Europe, 84 (11%) were from non-European nations. Of the European residents, most came from Italy (16%), Germany (15%), Spain (15%), and Romania (8%). Feedback for the basic laparoscopic session showed a constant improvement in scores over the last 4 yr, with the highest scores achieved last year. This included feedback on improvements in tutor rating (p=0.017), organisation (p<0.001), and personal experience with EUREP (p<0.001). Limitations lie in the difficulties associated with the use of an advanced training curriculum with wet laboratory or cadaveric courses in this format, although these could be performed in other training centres in conjunction with EUREP.

Conclusions: The EUREP trainee demographics show that the purpose of the course is being achieved, with excellent feedback reported. While European trainees dominate the demographics, participation from a number of non-European countries suggests continued ESU collaboration with other national societies and wider dissemination of simulation training worldwide.

Patient Summary: In this paper we look at methodological improvements and feedback for the European Urology Residents Education Programme hands-on-training over the last 4 yr.
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http://dx.doi.org/10.1016/j.euf.2018.03.002DOI Listing
November 2019

Erectile Function and Oncologic Outcomes Following Open Retropubic and Robot-assisted Radical Prostatectomy: Results from the LAParoscopic Prostatectomy Robot Open Trial.

Eur Urol 2018 04 4;73(4):618-627. Epub 2017 Sep 4.

Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.

Background: Whether surgeons perform better utilising a robot-assisted laparoscopic technique compared with an open approach during prostate cancer surgery is debatable.

Objective: To report erectile function and early oncologic outcomes for both surgical modalities, stratified by prostate cancer risk grouping.

Design, Setting, And Participants: In a prospective nonrandomised trial, we recruited 2545 men with prostate cancer from seven open (n=753) and seven robot-assisted (n=1792) Swedish centres (2008-2011).

Outcome Measurements And Statistical Analysis: Clinometrically-validated questionnaire-based patient-reported erectile function was collected before, 3 mo, 12 mo, and 24 mo after surgery. Surgeon-reported degree of neurovascular-bundle preservation, pathologist-reported positive surgical margin (PSM) rates, and 2-yr prostate-specific antigen-relapse rates were measured.

Results And Limitations: Among 1702 preoperatively potent men, we found enhanced erectile function recovery for low/intermediate-risk patients in the robot-assisted group at 3 mo. For patients with high-risk tumours, point estimates for erectile function recovery at 24 mo favoured the open surgery group. The degree of neurovascular bundle preservation and erectile function recovery were greater correlated for robot-assisted surgery. In pT2 tumours, 10% versus 17% PSM rates were observed for open and robot-assisted surgery, respectively; corresponding rates for pT3 tumours were 48% and 33%. These differences were associated with biochemical recurrence in pT3 but not pT2 disease. The study is limited by its nonrandomised design and relatively short follow-up.

Conclusions: Earlier recovery of erectile function in the robot-assisted surgery group in lower-risk patients is counterbalanced by lower PSM rates for open surgeons in organ-confined disease; thus, both open and robotic surgeons need to consider this trade-off when determining the plane of surgical dissection. Robot-assisted surgery also facilitates easier identification of nerve preservation planes during radical prostatectomy as well as wider dissection for pT3 cases.

Patient Summary: For prostate cancer surgery, an open operation reduces erection problems in high-risk cancers but has higher relapse rates than robotic surgery. Relapse rates appear similar in low/intermediate-risk cancers and the robot appears better at preserving erections in these cases.
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http://dx.doi.org/10.1016/j.eururo.2017.08.015DOI Listing
April 2018

Minilaparoendoscopic Single-site Pyeloplasty: The Best Compromise Between Surgeon's Ergonomy and Patient's Cosmesis (IDEAL Phase 2a).

Eur Urol Focus 2016 Aug 3;2(3):319-326. Epub 2015 Oct 3.

Department of Urology, Federico II University, Naples, Italy.

Background: Laparoendoscopic single-site (LESS) surgery and minilaparoscopy (ML) represent the evolution of laparoscopy for the treatment of urologic diseases.

Objective: To describe the technique and report the surgical outcomes of minilaparoendoscopic single-site dismembered pyeloplasty (MILESS-DP), a new technique overcoming the technical limitations of LESS and ML, and equally combining the advantages of both these surgical procedures.

Design, Setting, And Participants: Twenty consecutive patients underwent MILESS-DP for ureteropelvic junction obstruction.

Surgical Procedure: The SILS port was inserted through a transumbilical incision and two 3-mm trocars were inserted in the ipsilateral midclavicular line. The sequence of steps of MILESS-DP is comparable to standard laparoscopic dismembered pyeloplasty.

Measurements: The end points of this study were: (1) feasibility; (2) safety; (3) efficacy; and (4) cosmesis, evaluated using a body image questionnaire.

Results And Limitations: All patients were symptomatic (100%) and three (15%) had concomitant kidney stones. (1) Feasibility: a conversion to either standard laparoscopic technique or open technique did not occur in any case. Median operative time was 147.3min (interquartile range [IQR]: 110-195min); (2) safety: no intraoperative complications were reported. Only in two patients (10%), a urinoma was postoperatively identified and conservatively treated with an ureteral stent. The median difference in post- and preoperative creatinine and haemoglobin was +0.55mg/dl and -0.76mg/dl (IQR: -0.20/-1.20mg/dl); (3) efficacy: the median postoperative hospital stay was 4.4 d (IQR: 4-9 d). The overall success rate was 95% at the follow-up; (4) cosmesis: all patients were enthusiastic with the appearance of the scars; the median body image score and the median cosmesis score were 19.95 (IQR 19-20) and 23.95 (IQR 23-24), respectively. The limitations of this study are the limited series and short follow-up.

Conclusions: Our phase 2a studies demonstrate that MILESS-DP is a safe and reproducible procedure with excellent cosmetic outcomes and short-term clinical outcomes in the hands of a surgical team with experience in laparoscopy.

Patient Summary: Minilaparoscopy using 3-mm instruments and laparoendoscopic single-site using a single abdominal incision, still present several technical drawbacks which limit their reproducibility in urology. In order to overcome these technical limitations and equally combining the advantages of both these surgical procedures, we ideated a hybrid technique which we defined minilaparoendoscopic single-site. This study aims to demonstrate that minilaparoendoscopic single-site pyeloplasty is a safe and reproducible procedure with excellent cosmetic outcomes and short-term clinical outcomes in the hands of a surgical team with experience in mini-invasive surgery.
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http://dx.doi.org/10.1016/j.euf.2015.09.001DOI Listing
August 2016

Development of a patient and institutional-based model for estimation of operative times for robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

BJU Int 2017 11 16;120(5):695-701. Epub 2017 Jul 16.

Roswell Park Cancer Institute, Buffalo, NY, USA.

Objectives: To design a methodology to predict operative times for robot-assisted radical cystectomy (RARC) based on variation in institutional, patient, and disease characteristics to help in operating room scheduling and quality control.

Patients And Methods: The model included preoperative variables and therefore can be used for prediction of surgical times: institutional volume, age, gender, body mass index, American Society of Anesthesiologists score, history of prior surgery and radiation, clinical stage, neoadjuvant chemotherapy, type, technique of diversion, and the extent of lymph node dissection. A conditional inference tree method was used to fit a binary decision tree predicting operative time. Permutation tests were performed to determine the variables having the strongest association with surgical time. The data were split at the value of this variable resulting in the largest difference in means for the surgical time across the split. This process was repeated recursively on the resultant data sets until the permutation tests showed no significant association with operative time.

Results: In all, 2 134 procedures were included. The variable most strongly associated with surgical time was type of diversion, with ileal conduits being 70 min shorter (P < 0.001). Amongst patients who received neobladders, the type of lymph node dissection was also strongly associated with surgical time. Amongst ileal conduit patients, institutional surgeon volume (>66 RARCs) was important, with those with a higher volume being 55 min shorter (P < 0.001). The regression tree output was in the form of box plots that show the median and ranges of surgical times according to the patient, disease, and institutional characteristics.

Conclusion: We developed a method to estimate operative times for RARC based on patient, disease, and institutional metrics that can help operating room scheduling for RARC.
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http://dx.doi.org/10.1111/bju.13934DOI Listing
November 2017

Robot assisted lymphadenectomy in urology: pelvic, retroperitoneal and inguinal.

Minerva Urol Nefrol 2017 02 8;69(1):38-55. Epub 2016 Nov 8.

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

Lymph node dissection represents an essential surgical step in the treatment of the most commonly treated urological cancers. The introduction of robotic surgery has lead to the possibility of treating these diseases with a minimally invasive surgical approach, but the surgical principles of open surgery need to be carefully respected in order to achieve comparable oncological results. Therefore, the robotic approach to urological cancers must include a carefully performed lymph node dissection when indicated. In the current manuscript we reviewed the current indications and extensions of lymph node dissection in prostate, bladder, testicular, upper urinary tract, renal and penile cancers respectively, with a special focus on the state of the art surgical technique for each procedure.
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http://dx.doi.org/10.23736/S0393-2249.16.02823-XDOI Listing
February 2017

Introducing an enhanced recovery programme to an established totally intracorporeal robot-assisted radical cystectomy service.

Scand J Urol 2016 25;50(1):39-46. Epub 2015 Aug 25.

a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden.

Objective: The aim of this study was to assess the effect of introducing an enhanced recovery programme (ERP) to an established robot-assisted radical cystectomy (RARC) service.

Materials And Methods: Data were prospectively collected on 221 consecutive patients undergoing totally intracorporeal RARC between December 2003 and May 2014. The ERP was specifically designed to support an evolving RARC service, where increasing proportions of patients requiring radical cystectomy underwent RARC. Patient demographics and outcomes before and after implementation of the ERP were compared. The primary endpoint was length of stay (LOS). Secondary outcomes included age, American Society of Anesthesiologists (ASA) score, preoperative staging, operative time, complications and readmissions. Differences in outcomes between patients before and after implementation of ERP were tested with the Jonckheere-Terpstra trend test and quantile regression with backward selection.

Results: Following implementation of the ERP, the demographics of the patients (n = 135) changed, with median age increasing from 66 to 70 years (p < 0.01), higher ASA grade (p < 0.001), higher preoperative stage cancer (pT ≥ 2, p < 0.05) and increased likelihood of undergoing an ileal conduit diversion (p < 0.001). Median LOS before ERP was 9 days [interquartile range (IQR) 8-13 days] and after ERP was 8 days (IQR 6-10 days) (p < 0.001). ASA grade and neoadjuvant chemotherapy also affected LOS (p < 0.05 and p < 0.01, respectively). There was no significant difference in 30 day complication rates, readmission rates or 90 day mortality, with 59% experiencing complications before ERP implementation and 57% after implementation. The majority of complications were low grade.

Conclusions: Patient demographics changed as the RARC service evolved from selected patients to a general service. Despite worsening demographics, LOS decreased following ERP implementation. This evidence-based ERP safely standardized perioperative care, resulting in decreased LOS and decreased variability in LOS.
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http://dx.doi.org/10.3109/21681805.2015.1076514DOI Listing
December 2016

Guidance on patient consultation. Current evidence for prostate-specific antigen screening in healthy men and treatment options for men with proven localised prostate cancer.

Curr Urol Rep 2015 May;16(5):28

Karolinska Institute, Department of Molecular Medicine and Surgery, Section of Urology, Solna, Stockholm, Sweden,

The main objective of this review is to summarise, for primary and secondary care doctors, the management options and current supporting evidence for clinically localised prostate cancer. We review all aspects of management including current guidelines on early cancer detection and the importance of informed consent on PSA-based screening and assess the most common treatment options and the evidence for managing patients with low-, medium-, and high-risk disease.
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http://dx.doi.org/10.1007/s11934-015-0502-1DOI Listing
May 2015

Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European-American Multi-institutional Analysis.

Eur Urol 2015 Jul 4;68(1):86-94. Epub 2014 Dec 4.

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

Background: Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique.

Objective: To report a large multi-institutional series of minimally invasive SP (MISP).

Design, Setting, And Participants: Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis.

Intervention: Laparoscopic or robotic SP.

Outcome Measurements And Statistical Analysis: Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score <8, maximum flow rate >15ml/s, and no perioperative complications.

Results And Limitations: Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100ml (range: 89-128). Median estimated blood loss was 200ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p=0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p=0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss (p=0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis.

Conclusions: This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications.

Patient Summary: Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.
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http://dx.doi.org/10.1016/j.eururo.2014.11.044DOI Listing
July 2015

Comparative study for evaluating the cosmetic outcome of small-incision access retroperitoneoscopic technique (SMART) with standard retroperitoneoscopy using the Observer Scar Assessment Scale: are small incisions a big deal?

J Endourol 2014 Dec;28(12):1409-13

Department of Urology, Klinikum Heilbronn , Heilbronn, Germany .

Aim: To compare the scars and cosmetic results of trocars of 3, 5, and 10 mm in cases by small-incision access retroperitoneoscopic technique pyeloplasty (SMARTp) and standard laparoscopy pyeloplasty (SLp).

Methods: Between January 2012 and October 2013, 20 pyeloplasties were performed: 12 with SMARTp and 8 with SLp techniques. A 5-mm homemade balloon trocar was used to create the retroperitoneal space. In SMARTp, 3- and 5-mm trocars were used and in SLp, 5- and 10-mm trocars were used. All patients underwent a ureteral (Double-J) stent placement preoperatively. The study included a total of 72 trocar-site scars: 3 mm (24 scars), 5 mm (24 scars), and 10 mm (24 scars). Cosmetic outcome was assessed at the 3rd, 12th, and 24th month of surgeries by the Observer Scar Assessment Scale (OSAS).

Results: Mean age was 34.7±10.5 (19-52) years, and mean follow up was 18.7±9.2 months. Fifteen patients (75%) underwent Y-V plasty, and 5 (25%) underwent Anderson-Hynes pyeloplasty. Mean operative time was 125.4±28.7 minutes. There was only minimal blood loss, no need for conversion to standard laparoscopic or open pyeloplasty, no intraoperative complications, and only two postoperative complications were recorded: retroperitoneal hemorrhage and wound infection and both were treated conservatively. There were significant differences between objective questions of "vascularization" in a 3-mm trocar and "thickness" in a 10-mm trocar. Twenty-four months after surgery, the cosmetic data assessed by OSAS showed statistically significant differenecs in favor of the 3-mm trocar sites versus the 10-mm trocar sites (OSAS: 13.8±3.9 vs 24.6±1.7; p=0.006) with no statistically significant difference between 3- and 5-mm port sites.

Conclusions: The SMARTp is proved to be an efficacious and tolerable procedure with better cosmetic results and can be used for the treatment of ureteropelvic junction obstruction (UPJO) in suitable patients. We believe that this technique is likely to become an established procedure.
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http://dx.doi.org/10.1089/end.2014.0142DOI Listing
December 2014

An objective comparison of novice trainees learning LESS versus traditional laparoscopy with the use of a pelvic trainer.

Urologia 2013 Sep-Dec;80(4):302-6. Epub 2013 Sep 5.

Urology Department, "Policlinico" Hospital of Modena, University of Modena and Reggio Emilia, Modena - Italy.

Objectives: To compare the differences between LESS and SL among a population of subjects inexperienced of both techniques.

Materials And Methods: Participants were randomly assigned to the LESS or SL arm of the course; between the population examined, none had previous laparoscopic experience. The trial consisted in performing three increasingly difficult exercises either with LESS or standard laparoscopy.

Results: Time of execution and Objective Structured Assessment of Technical Skills score (OSATS) were recorded. Statistical analysis failed to detect any significant difference between the two arms of the trial. A trend in favor of standard laparoscopy was observed anyway.

Discussion: Our study evaluates the technical performance on a surgical simulator in the laboratory setting, with the use of standardized tasks and validated metrics. We believe that a controlled and safe environment aids objective evaluation of LESS compared to SL. Literature on this particular topic is somehow conflicting and heterogeneous. Our trial demonstrated that novices performed LESS tasks without any additional difficulties compared to standard laparoscopy. The aim of such investigation is to support knowledge of this new technology in order to facilitate its use in selected patients and surgical procedures.
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http://dx.doi.org/10.5301/urologia.5000026DOI Listing
April 2015