Publications by authors named "Nicola Pavan"

56 Publications

Physical, Mental and Sexual Health Among Transgender Women. A comparative Study Among Operated Transgender and Cisgender Women in a National Tertiary Referral Network.

J Sex Med 2021 Mar 23. Epub 2021 Mar 23.

Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy.

Background: Few studies have investigated how physical, mental and sexual function are associated with each other in operated transgender women (oTW).

Aim: To provide information on the physical, mental and sexual health of oTW in comparison with a group of cisgender women (cisW).

Methods: An age-matched control study was carried out, recruiting 125 oTW in 7 national referral centers and 80 volunteer women. Beck Depression Inventory Primary Care (BDI-PC), General Health Survey (SF-36), Female Sexual Function Index (FSFI) and operated Male to Female Sexual Function Index (oMtFSI) questionnaires were web-based administered. Data included: age, area of origin, educational level, sexual orientation, years since surgery and hormone therapy.

Outcomes: T-test was applied to inspect mean score differences between oTW and cisW, in mental, sexual and physical health; simple correlations and multiple regression analysis revealed how mental, sexual and physical health were concurrently associated in the two groups RESULTS: Response rate 60% (52% oTW, 71% cisW). oTW mean age 38.5 years (SD = 9.3), cisW 37.7 years (SD = 11.5). Both cisW and oTW reported average values in the range of mental, physical and sexual health. Statistical comparisons revealed no significant group differences in mental and physical health. oTW who referred a worse sexual function also reported worse overall mental well-being and higher levels of depressive symptoms. FSFI scores were negatively associated with years since surgery, but not with age. Multiple regression analysis showed that FSFI Pain accounted for a significant unique variance proportion of risk of depression in oTW. FSFI Sexual Pain was the strongest estimator of inter-individual differences in BDI-PC among oTW (P < .01).

Clinical Implications: No significant differences in the levels of depressive symptoms, physical and mental well- being were found in oTW and cis-W. The relation between depressive symptoms and sexual function in oTW is stronger than in cisW, and sexual pain substantially predicts risk of depression in oTW.

Strengths & Limitations: The evaluation of outcomes using validated questionnaires and the relatively large sample size. The convenience control group reported mental, physical and sexual health levels within the range of Italian normative data. Since this is a cross-sectional study, we must be careful in drawing conclusions from our results.

Conclusions: Sexual pain and lubrication difficulties are the main causes of worse sexual function in oTW, highlighting the importance of perioperative counseling to make surgical expectations realistic and to educate to a proper neovagina management. Vedovo F, Di Blas L, Aretusi F, et al. Physical, Mental and Sexual Health Among Transgender Women. A comparative Study Among Operated Transgender and Cisgender Women in a National Tertiary Referral Network. J Sex Med Rev 2021;xx:xxx-xxx.
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http://dx.doi.org/10.1016/j.jsxm.2021.02.006DOI Listing
March 2021

Introducing Trifecta for percutaneous nephrolithotomies: a proposal for standard reporting outcomes after treatment for renal stones.

Minerva Urol Nephrol 2021 Mar 26. Epub 2021 Mar 26.

Department of Urology, San Bassiano Hospital, Bassano del Grappa, Vicenza, Italy.

Background: In literature, the reports of outcomes after percutaneous nephrolithotomies are rather heterogeneous. This may influence studies comparison, it may also render difficult to evaluate surgical adequacy, peri-operative morbidity and patient's quality of life between studies. For this reason, we propose to introduce PNL-Trifecta as composite measure to standardize data reporting outcomes after percutaneous nephrolithotomies.

Methods: We performed a prospective multicentric study on consecutive patients undergone PNL to treat renal stones between 2018 and 2020. Successful PNL-trifecta was considered achieved when procedures obtained the three following results: no residual fragments > 2mm at unenhanced CT scan at 3 months post-op, no complications (defined as Clavien-Dindo Score 0) and operation carried out without placing a nephrostomy tube (tubeless or totally tubeless). We compared results of standard versus mini-PNL and between stones of different complexity (evaluated with Guy's Stone Score and S.T.O.N.E. nephrolithometry Score). Univariate analysis was utilized to identify other factors influencing achievement of PNL-Trifecta.

Results: 245 patients fulfilled inclusion/exclusion criteria and have been enrolled in the study (median age: 56, IQR 48-57). The overall PNL-Trifecta achievement rate was 22.85% (28.66% in the mini-PNL group and 13.68% in the standard-PNL group, p=0.010). The stone free rate, CD 0 rate and tubeless/totally tubeless rate in the mini-PNL group were 60.66%, 89.33% and 51.33% respectively. In the standard-PNL group they were 44.21%, 40.00% and 15.78% respectively. At the univariate analysis, differences between Guy's Stone Score groups in achieving PNL-Trifecta were significant (p=0.001). Also, the level of upper puncture (p=0.010) and utilization of device with active suction (p=0.002) showed statistically significant differences. Furthermore, the length of stay in the patient's group achieving Trifecta was 2.28 versus a mean length of stay of 4.64 days in the group of patients not achieving Trifecta (p=0.046).

Conclusions: We present Trifecta for PNLs as a potential tool to evaluate quality of percutaneous nephrolithotomies and to provide an instrument for an adequate standard data reporting. It can represent a valid way to assess and monitor surgeon's learning curves. It will require further external validation and studies to evaluate its correlation with mid- and long-term results and patient's health related quality of life outcomes.
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http://dx.doi.org/10.23736/S2724-6051.21.04046-7DOI Listing
March 2021

Percutaneous cryoablation for high-complexity renal masses: complications, functional and oncological outcomes.

Minerva Urol Nephrol 2021 Mar 26. Epub 2021 Mar 26.

Department of Urology, Surgery and Health Science, University of Trieste, Trieste, Italy.

Background: During the past two decades cryoablation (CA) has become a therapeutic option for the management of localized cT1 renal masses in comorbid patients. We analyzed the midterm functional and oncological outcomes of CA in the treatment of cT1 renal masses which were classified as high-complexity masses according to the PADUA system.

Methods: A total of 299 patients underwent percutaneous CA between November 2007 and December 2018 in 4 institutions for cT1N0M0 renal masses. All patients with highcomplexity (PADUA ≥ 10) renal tumors were included. Technical failure of CA was considered an exclusion criterion.

Results: Inclusion criteria were met by 45 patients. Median Charlson Comorbidity Index (CCI) was 6.0 (IQR: 5.0-7.0), median age was 74 years (IQR: 64.5-79.5). Seven Clavien 1 and 1 Clavien 2 procedure-related complications were reported. Median eGFR at baseline was 64.3ml/min (IQR: 52.0 - 82.3) while at the 1-year follow-up was 61.4 ml/min (IQR: 44.0-74.5). The median follow-up was 32 months (IQR: 13.25-47.5). Local recurrences were detected in 6 patients; 3 of them underwent re-cryoablation while the others started active surveillance. Median time to recurrence was 17.5 months (IQR: 7.8-27.3). Cancer-Specific Survival and Metastasis-Free Survival were 100%. Overall survival was 86.7%.

Conclusions: CA proved to be a valuable therapeutic option for the management of patients with cT1 high-complexity PADUA ≥ 10 renal tumors as it provides a low rate of procedural morbidity and good preservation of renal function. However, these results are counterbalanced by a recurrence rate that appears to be higher than those reported on surgically treated patients.
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http://dx.doi.org/10.23736/S2724-6051.21.04015-5DOI Listing
March 2021

Available active surveillance follow-up protocols for small renal mass: a systematic review.

World J Urol 2021 Jan 16. Epub 2021 Jan 16.

Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain.

Purpose: To evaluate follow-up strategies for active surveillance of renal masses and to assess contemporary data.

Methods: We performed a comprehensive search of electronic databases (Embase, Medline, and Cochrane). A systematic review of the follow-up protocols was carried out. A total of 20 studies were included.

Result: Our analysis highlights that most of the series used different protocols of follow-up without consistent differences in the outcomes. Most common protocol consisted in imaging and clinical evaluation at 3, 6, and 12 months and yearly thereafter. Median length of follow-up was 42 months (range 1-137). Mean age was 74 years (range 67-83). Of 2243 patients 223 (10%) died during the follow-up and 19 patients died of kidney cancer (0.8%). The growth rate was the most used parameter to evaluate disease progression eventually triggering delayed intervention. Maximal axial diameter was the most common method to evaluate growth rate. CT scan is the most used, probably because it is usually more precise than kidney ultrasound and more accessible than MRI. Performing chest X-ray at every check does not seem to alter the clinical outcome during AS.

Conclusion: The minimal cancer-specific mortality does not seem to correlate with the follow-up scheme. Outside of growth rate and initial size, imaging features to predict outcome of RCC during AS are limited. Active surveillance of SRM is a well-established treatment option. However, standardized follow-up protocols are lacking. Prospective, randomized, trials to evaluate the best follow-up strategies are pending.
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http://dx.doi.org/10.1007/s00345-020-03581-6DOI Listing
January 2021

Development of a Novel Risk Score to Select the Optimal Candidate for Cytoreductive Nephrectomy Among Patients with Metastatic Renal Cell Carcinoma. Results from a Multi-institutional Registry (REMARCC).

Eur Urol Oncol 2020 Dec 29. Epub 2020 Dec 29.

Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain. Electronic address:

Background: Selection of patients for upfront cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) has to be improved.

Objective: To evaluate a new scoring system for the prediction of overall mortality (OM) in mRCC patients undergoing CN.

Design, Setting, And Participants: We identified a total of 519 patients with synchronous mRCC undergoing CN between 2005 and 2019 from a multi-institutional registry (Registry for Metastatic RCC [REMARCC]).

Outcome Measurements And Statistical Analysis: Cox proportional hazard regression was used to test the main predictors of OM. Restricted mean survival time was estimated as a measure of the average overall survival time up to 36 mo of follow-up. The concordance index (C-index) was used to determine the model's discrimination. Decision curve analyses were used to compare the net benefit from the REMARCC model with International mRCC Database Consortium (IMDC) or Memorial Sloan Kettering Cancer Center (MSKCC) risk scores.

Results And Limitations: The median follow-up period was 18 mo (interquartile range: 5.9-39.7). Our models showed lower mortality rates in obese patients (p = 0.007). Higher OM rates were recorded in those with bone (p = 0.010), liver (p = 0.002), and lung metastases (p < 0.001). Those with poor performance status (<80%) and those with more than three metastases had also higher OM rates (p = 0.026 and 0.040, respectively). The C-index of the REMARCC model was higher than that of the MSKCC and IMDC models (66.4% vs 60.4% vs 60.3%). After stratification, 113 (22.0%) patients were classified to have a favorable (no risk factors), 202 (39.5%) an intermediate (one or two risk factors), and 197 (38.5%) a poor (more than two risk factors) prognosis. Moreover, 72 (17.2%) and 51 (13.9%) patients classified as having an intermediate and a poor prognosis according to MSKCC and IMDC categories, respectively, would be reclassified as having a good prognosis according to the REMARCC score.

Conclusions: Our findings confirm the relevance of tumor and patient features for the risk stratification of mRCC patients and clinical decision-making regarding CN. Further prospective external validations are required for the scoring system proposed herein.

Patient Summary: Current stratification systems for selecting patients for kidney removal when metastatic disease is shown are controversial. We suggest a system that includes tumor and patient features besides the systems already in use, which are based on blood tests.
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http://dx.doi.org/10.1016/j.euo.2020.12.010DOI Listing
December 2020

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

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

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

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

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

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

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

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

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

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

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

Surgical Management and Outcomes of Renal Tumors Arising from Horseshoe Kidneys: Results from an International Multicenter Collaboration.

Eur Urol 2021 Jan 16;79(1):133-140. Epub 2020 Sep 16.

Department of Urology, University Hospitals Leuven, Leuven, Belgium. Electronic address:

Background: Despite being the most frequent renal fusion anomaly, tumors arising from horseshoe kidneys (HSKs) are extremely rare and management guidance is lacking.

Objective: To evaluate the perioperative, oncological, and functional outcomes of surgically treated HSK tumors.

Design, Setting, And Participants: A retrospective, multicenter cohort study of 43 HSK tumors in 40 patients was conducted, and technical description of the surgical approach has been provided.

Surgical Procedure: Surgical resection of renal tumors arising from HSKs was performed either via open surgery or via minimally invasive surgery (MIS).

Measurements: We analyzed patient and tumor characteristics as well as surgical technique, and functional and oncological outcomes.

Results And Limitations: Eight patients were treated by MIS and 32 by open surgery. One patient (2.5%) experienced an intraoperative complication and 13 patients (32.5%) experienced postoperative complications, of which three (7.5%) were Clavien-Dindo ≥3 complications. Surgical margins were positive in two tumors (4.7%). The most frequent histology was clear-cell renal cell carcinoma (46.5%). The median follow-up was 51 (interquartile range [IQR] 17-73) mo. The 5-yr overall, cancer-specific, and recurrence-free survival rates were 81.2%, 86.8%, and 83.1%, respectively. The percent decreases in estimated glomerular filtration rate at discharge and the last follow-up were 15% (IQR 4-26%) and 17% (IQR 1-31%), respectively. Limitations include the cohort's retrospective nature, heterogeneity, and small sample size.

Conclusions: Surgical management of tumors in HSKs can be approached via both open surgery and MIS, with maximal preservation of functional renal parenchyma. In this cohort, rates of complications, positive surgical margins, and renal functional decrease were acceptable, considering the anatomical complexity of these kidneys and tumors. These tumors display great variation in histological subtypes. Meticulous presurgical planning, taking advantage of advanced imaging techniques, can aid in achieving good outcomes.

Patient Summary: We evaluated the surgical management of renal tumors in horseshoe kidneys, which are very rare. Although these procedures are highly complex, outcomes are acceptable. Modern imaging techniques are often required in presurgical planning.
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http://dx.doi.org/10.1016/j.eururo.2020.09.012DOI Listing
January 2021

Reconstruction of penile skin loss using a combined therapy of negative pressure wound therapy, dermal regeneration template, and split-thickness skin graft application.

Int J Impot Res 2020 Aug 16. Epub 2020 Aug 16.

Department of Plastic Surgery, University of Trieste, Trieste, Italy.

This study evaluates the use of acellular dermal matrix (ADM) in conjunction with negative pressure wound therapy (NPWT) and delayed split-thickness skin graft (STSG) application as an alternative to free tissue transfer for defect coverage of the penile shaft. Five patients with genital lymphedema and one with penile skin deficiency underwent penile shaft reconstruction with a two-stage surgical procedure. The first procedure aimed to the correction of skin defect and to neodermis regeneration through the use of an ADM (Integra®, Integra Lifesciences Corp., Plainsboro, NJ, USA) and NPWT. The second procedure 3 weeks later aimed to the covering of the skin defect with an unmeshed STSG. Both the Integra and skin graft showed completely taking at 7 days postop. No major complications occurred. At 6 months grafts gained sufficient elasticity to allow the sliding of the epidermis over the dermal layer, similarly the physiological penile shaft skin. Our results suggest that combined therapy might be an alternative to free tissue transfer for defect coverage of the penile shaft, leading to a good esthetic result, an optimal shaft coverage and providing adequate extensibility during erections. For best results we advise that in these cases urologists should collaborate with plastic surgeons.
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http://dx.doi.org/10.1038/s41443-020-00343-1DOI Listing
August 2020

Telehealth in Urology: A Systematic Review of the Literature. How Much Can Telemedicine Be Useful During and After the COVID-19 Pandemic?

Eur Urol 2020 12 18;78(6):786-811. Epub 2020 Jun 18.

Department of Human and Pediatric Pathology "Gaetano Barresi", Urologic Section, University of Messina, Italy.

Context: Coronavirus disease 2019 (COVID-19) pandemic has caused increased interest in the application of telehealth to provide care without exposing patients and physicians to the risk of contagion. The urological literature on the topic is sparse.

Objective: To perform a systematic review of the literature and evaluate all the available studies on urological applications of telehealth.

Evidence Acquisition: After registration on PROSPERO, we searched PubMed and Scopus databases to collect any kind of studies evaluating any telehealth interventions in any urological conditions. The National Toxicology Program/Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies was used to estimate the risk of bias. A narrative synthesis was performed.

Evidence Synthesis: We identified 45 studies (11 concerning prostate cancer [PCa], three hematuria management, six urinary stones, 14 urinary incontinence [UI], five urinary tract infections [UTIs], and six other conditions), including 12 randomized controlled trials. The available literature indicates that telemedicine has been implemented successfully in several common clinical scenarios, including the decision-making process following a diagnosis of nonmetastatic PCa, follow-up care of patients with localized PCa after curative treatments, initial diagnosis of hematuria, management diagnosis and follow-up care of uncomplicated urinary stones and uncomplicated UTIs, and initial evaluation, behavioral therapies, and pelvic floor muscle training in UI patients, as well as follow-up care after surgical treatments of stress urinary incontinence or pelvic organ prolapse. The methodological quality of most of the reports was good.

Conclusions: Telehealth has been implemented successfully in selected patients with PCa, UI, pelvic organ prolapse, uncomplicated urinary stones, and UTIs. Many urological conditions are suitable for telehealth, but more studies are needed on other highly prevalent urological malignant and benign conditions. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine. More robust data on long-term efficacy, safety, and health economics are necessary.

Patient Summary: The diffusion of coronavirus disease 2019 (COVID-19) infections has recently increased the interest in telehealth, which is the adoption of telecommunication to deliver any health care activity. The available literature indicates that telemedicine has been adopted successfully in selected patients with several common clinical urological conditions, including prostate cancer, uncomplicated urinary stones, uncomplicated urinary infections, urinary incontinence, or pelvic organ prolapse. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine, but more robust data on long-term efficacy, safety, and costs are necessary.
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http://dx.doi.org/10.1016/j.eururo.2020.06.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301090PMC
December 2020

Risk of Virus Contamination Through Surgical Smoke During Minimally Invasive Surgery: A Systematic Review of the Literature on a Neglected Issue Revived in the COVID-19 Pandemic Era.

Eur Urol Focus 2020 09 5;6(5):1058-1069. Epub 2020 Jun 5.

Department Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padova, Padova, Italy. Electronic address:

Context: The coronavirus disease 2019 (COVID-19) pandemic raised concerns about the safety of laparoscopy due to the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diffusion in surgical smoke. Although no case of SARS-CoV-2 contagion related to surgical smoke has been reported, several international surgical societies recommended caution or even discouraged the use of a laparoscopic approach.

Objective: To evaluate the risk of virus spread due to surgical smoke during surgical procedures.

Evidence Acquisition: We searched PubMed and Scopus for eligible studies, including clinical and preclinical studies assessing the presence of any virus in the surgical smoke from any surgical procedure or experimental model.

Evidence Synthesis: We identified 24 studies. No study was found investigating SARS-CoV-2 or any other coronavirus. About other viruses, hepatitis B virus was identified in the surgical smoke collected during different laparoscopic surgeries (colorectal resections, gastrectomies, and hepatic wedge resections). Other clinical studies suggested a consistent risk of transmission for human papillomavirus (HPV) in the surgical treatments of HPV-related disease (mainly genital warts, laryngeal papillomas, or cutaneous lesions). Preclinical studies showed conflicting results, but HPV was shown to have a high risk of transmission.

Conclusions: Although all the available data come from different viruses, considering that the SARS-CoV-2 virus has been shown in blood and stools, the theoretical risk of virus diffusion through surgical smoke cannot be excluded. Specific clinical studies are needed to understand the effective presence of the virus in the surgical smoke of different surgical procedures and its concentration. Meanwhile, adoption of all the required protective strategies, including preoperative patient nasopharyngeal swab for COVID-19, seems mandatory.

Patient Summary: In this systematic review, we looked at the risk of virus spread from surgical smoke exposure during surgery. Although no study was found investigating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or any other coronavirus, we found that the theoretical risk of virus diffusion through surgical smoke cannot be excluded.
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http://dx.doi.org/10.1016/j.euf.2020.05.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274598PMC
September 2020

Rates and Predictors of Perioperative Complications in Cytoreductive Nephrectomy: Analysis of the Registry for Metastatic Renal Cell Carcinoma.

Eur Urol Oncol 2020 08 12;3(4):523-529. Epub 2020 May 12.

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

Background: Cytoreductive nephrectomy (CN) plays an important role in the treatment of a subgroup of metastatic renal cell carcinoma (mRCC) patients.

Objective: We aimed to evaluate morbidity associated with this procedure and identify potential predictors thereof to aid patient selection for this procedure and potentially improve patient outcomes.

Design, Setting, And Participants: Data from 736 mRCC patients undergoing CN at 14 institutions were retrospectively recorded in the Registry for Metastatic RCC (REMARCC).

Outcome Measurements And Statistical Analysis: Logistic regression analysis was used to identify predictors for intraoperative, any-grade (AGCs), low-grade, and high-grade (HGCs) postoperative complications (according to the Clavien-Dindo classification) as well as 30-d readmission rates.

Results And Limitations: Intraoperative complications were observed in 69 patients (10.9%). Thrombectomy (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.08-1.75, p = 0.009) and adjacent organ removal (OR 2.7, 95% CI 1.38-5.30) were significant predictors of intraoperative complications at multivariable analysis. Two hundred seventeen patients (29.5%) encountered AGCs, while 45 (6.1%) encountered an HGC, of whom 10 (1.4%) died. Twenty-four (3.3%) patients had multiple postoperative complications. Estimated blood loss (EBL; OR 1.49, 95% CI 1.08-2.05, p = 0.01) was a significant predictor of AGCs at multivariable analysis. CN case load (OR 0.13, 95% CI 0.03-0.59, p = 0.009) and EBL (OR 2.93, 95% CI 1.20-7.15, p = 0.02) were significant predictors solely for HGCs at multivariable analysis. Forty-one patients (11.5%) were readmitted within 30 d of surgery. No significant predictors were identified. Results were confirmed in a subanalysis focusing solely on patients treated in the contemporary targeted therapy era.

Conclusions: Morbidity associated with CN is not negligible. Predictors of high-grade postoperative morbidity are predominantly indicators of complex surgery. EBL is a strong predictor of postoperative complications. CN case load correlates with lower high-grade morbidity and highlights the benefit of centralization of complex surgery. However, risks and benefits should be balanced when considering CN in mRCC patients.

Patient Summary: We studied patients with metastatic renal cancer to evaluate the outcomes associated with the surgical removal of the primary kidney tumor. We found that this procedure is often complex and adverse events are not uncommon. High intraoperative blood loss and a small number of cases performed at the treating center are associated with a higher rate of postoperative complications.
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http://dx.doi.org/10.1016/j.euo.2020.04.006DOI Listing
August 2020

Clinical pathways for urology patients during the COVID-19 pandemic.

Minerva Urol Nefrol 2020 Jun 30;72(3):376-383. Epub 2020 Mar 30.

Section of Urology, Gaetano Barresi Department of Human and Pediatric Pathology, University of Messina, Messina, Italy -

The public health emergency caused by the Coronavirus Disease 2019 (COVID-19) pandemic has resulted in a significant reallocation of health resources with a consequent reorganization of the clinical activities also in several urological centers. A panel of Italian urologists has agreed on a set of recommendations on pathways of pre-, intra- and post-operative care for urological patients undergoing urgent procedures or non-deferrable oncological interventions during the COVID-19 pandemic. Simplification of the diagnostic and staging pathway has to be prioritized in order to reduce hospital visits and consequently the risk of contagion. In absence of strict uniform regulations that impose the implementation of nasopharyngeal swabs, we recommend that an accurate triage for COVID-19 symptoms be performed both by telephone at home before hospitalization and at the time of hospitalization. We recommend that during hospital stay patients should be provided with as many instructions as possible to facilitate their return to, and stay at, home. Patients should be discharged under stable good conditions in order to minimize the risk of readmission. It is advisable to reduce or reschedule post-discharge controls and implement an adequate system of communication for telemonitoring discharged patients.
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http://dx.doi.org/10.23736/S0393-2249.20.03861-8DOI Listing
June 2020

Urology practice during the COVID-19 pandemic.

Minerva Urol Nefrol 2020 Jun 23;72(3):369-375. Epub 2020 Mar 23.

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

The severe acute respiratory syndrome coronavirus 2 and the disease it causes, coronavirus disease 2019 (COVID-19) is generating a rapid and tragic health emergency in Italy due to the need to provide assistance to an overwhelming number of infected patients and, at the same time, treat all the non-deferrable oncological and benign conditions. A panel of Italian urologists has agreed on possible strategies for the reorganization of urological routine practice and on a set of recommendations that should facilitate the process of rescheduling both surgical and outpatient activities during the COVID-19 pandemic and in the subsequent phases. This document could be a valid tool to be used in routine clinical practice and, possibly, a cornerstone for further discussion on the topic also considering the further evolution of the COVID-19 pandemic. It also may provide useful recommendations for national and international urological societies in a condition of emergency.
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http://dx.doi.org/10.23736/S0393-2249.20.03846-1DOI Listing
June 2020

Needle tract seeding after percutaneous cryoablation of small renal masses; a case series and literature review.

Scand J Urol 2020 Apr 10;54(2):122-127. Epub 2020 Mar 10.

Department of Urology, University of Trieste, Cattinara Hospital, Trieste, Italy.

Neoplastic cell seeding due to needle tumor manipulation during renal mass biopsy (RMB) or thermal ablative treatment is a rare but potentially serious event that can turn an organ-confined and curable tumor in a nonorgan-confined and non-curable disease. Despite the widespread use of percutaneous thermal ablative treatment for small renal masses (SRMs), this complication has been described in few case reports and small case series and has never been reported after ablative treatment alone. We report a series of two patients that underwent cryoablation for SRMs and developed recurrence along the needle tract. Available knowledge on the controversial topic of tumor seeding following needle manipulation are poor. So far, reporting cases of tumor cell seeding due to needle manipulation is useful to permit a better understanding of this complication.
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http://dx.doi.org/10.1080/21681805.2020.1736149DOI Listing
April 2020

Incidence, predictive factors and survival outcomes of incidental prostate cancer in patients who underwent radical cystectomy for bladder cancer.

Minerva Urol Nefrol 2020 Jan 30. Epub 2020 Jan 30.

Department of Medicine, Surgery and Health Sciences, Urological Clinic, University of Trieste, Trieste, Italy.

Background: To analyze the incidence, preoperative findings, pathological features and prognosis in patients with incidental prostate cancer (iPCa) detected at radical cystectomy (RC) for bladder cancer (BCa).

Methods: We retrospectively reviewed data of patients who underwent RC for BCa at our Institution between January 2005 and March 2018. Data regarding patient's history, preoperative digital rectal examination (DRE), total serum PSA level were collected from the chart review. Univariable and multivariable Cox regression models addressed the association of iPCa with Recurrence-free Survival (RFS) and Overall Survival (OS).

Results: We obtained a final study cohort of 177 patients. Median age was 69 years (IQR 42-89) and 80(45.2%) patients had iPCa. Patients with iPCa had higher age, preoperative PSA levels and a significant rate of suspicious DRE (all p<0.05). Four patients had BCR during a median follow-up of 28 months (IQR 6-159) and none died for prostate cancer. In multivariable analyses adjusted for age, bladder cancer BCa pT and pN stage and LVI the ten-years RFS and OS rates were not impacted by iPCa regardless of whether it is a clinically significant cancer or not (HR:1.25, 95% CI: 0.65 - 2.38, p=0.51 vs HR:1.37, 95% CI: 0.71 - 2.64, p=0.35) (HR:1.04, 95% CI: 0.53 - 1.86, p=0.89 vs HR:1.20, 95% CI: 0.22 - 6.72, p=0.83).

Conclusions: iPCa is quite common in our study group and most of cases are organ-confined and well differentiated. Regardless of clinical relevance, iPCa doesn't impact survival outcomes as BCa is driving the prognosis of these patients.
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http://dx.doi.org/10.23736/S0393-2249.20.03646-2DOI Listing
January 2020

Operated Male-to-Female Sexual Function Index: Validity of the First Questionnaire Developed to Assess Sexual Function after Male-to-Female Gender Affirming Surgery.

J Urol 2020 07 31;204(1):115-120. Epub 2020 Jan 31.

Department of Urology, ASUITS, Trieste, Italy.

Purpose: No questionnaire is currently available to evaluate sexual function after male-to-female gender affirming surgery. Such a limit leads to a suboptimal evaluation in postoperative sexual function in these patients. We developed and validated a new questionnaire, the oMtFSFI (operated Male-to-Female Sexual Function Index), for assessing sexual function in male-to-female patients after surgery.

Materials And Methods: A panel of experts in gender dysphoria defined the main content areas to be assessed, including genital self-image, desire, arousal, lubrication, orgasm, satisfaction and sexual pain. After a pretest on 10 patients the oMtFSFI was applied in the main study to 65 operated male-to-female patients, recruited at 7 Italian centers, and 57 women. The participants provided self-ratings on online oMtFSFI, Female Sexual Function Index, Beck Depression Inventory for Primary Care and Short Form Health Survey questionnaires. Operated male-to-female patients completed the oMtFSFI twice, 4 weeks apart.

Results: Principal component analysis performed on self-ratings provided by operated male-to-female patients on oMtFSFI items yielded a 3-domain structure of sexual dissatisfaction, sexual pain and genital self-image. The 3 domains were internally consistent and test-retest reliable. Convergent associations with Female Sexual Function Index scales emerged for sexual dissatisfaction and sexual pain but not for genital self-image. Male-to-female patients reported lower sexual function levels than cisgender women.

Conclusions: The present preliminary results support reliability and psychometric validity of the oMtFSFI in the assessment of key sexual function domains in transgender women, further revealing that genital self-image represents an assessment area to be considered in male-to-female patients, in addition to domains that are salient for cis women as well.
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http://dx.doi.org/10.1097/JU.0000000000000791DOI Listing
July 2020

Analysis of clinical utility of abdominopelvic computed tomography in the follow-up of Stage I seminoma: a single center evaluation.

Minerva Urol Nephrol 2021 Feb 11;73(1):84-89. Epub 2019 Dec 11.

Department of Medicine, Surgery and Health Sciences, Clinic of Urology, University of Trieste, Trieste, Italy.

Background: Abdominopelvic computed tomography (CT) is widely used in the follow-up of seminoma patients after radical orchidectomy. The aim of this study was to evaluate the clinical utility of abdominopelvic computed tomography in the follow-up of patients with Stage I seminoma.

Methods: The pathological reports of all patients that have undergone radical orchidectomy in our tertiary referral center between January 2002 and January 2018 have been retrospectively reviewed. All patients with Stage I seminoma and negative serum tumor markers after radical orchidectomy were included. Patients with follow-up shorter than 12 months were excluded. Surveillance records of every patient were reviewed with regard to abdominopelvic imaging.

Results: Of the 133 patients who have undergone radical orchidectomy in our center, 55 had Stage I pure seminoma with normal levels of serum tumor markers after surgery. Two patients were excluded as the follow-up was inadequate. Mean follow-up was 63.2 months (IQR: 30-73). The results of 211 abdominopelvic CTs performed as part of the follow-up were reviewed. Two (3,7%) patients developed recurrence; one consisted of a scrotal lump and was diagnosed with ultrasonography (US) while the second appeared as paraaortic nodal metastasis and was diagnosed with abdominopelvic CT. The recurrence was successfully treated in both patients. A single abdominopelvic CT was useful for the detection of recurrent disease in our entire study population. No cancer specific death has been reported in the study population.

Conclusions: Follow-up schedules for Stage I seminoma expose patients to potential risks of radiation-induced tumors, emotional distress and represent a significant burden for the healthcare system. The current series suggests that a better risk adapted patient-tailored follow-up program is needed in order to avoid unnecessary investigations.
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http://dx.doi.org/10.23736/S0393-2249.19.03562-8DOI Listing
February 2021

Perioperative Antimicrobial Prophylaxis for Preventing Infectious Complications After Transurethral Resection of the Bladder: To Use or Not to Use?

J Endourol 2020 02;34(2):198-202

Department of Urology, Cattinara Hospital, University of Trieste, Trieste, Italy.

Transurethral resection of the bladder (TURB) is a common endoscopic procedure. Perioperative antimicrobial prophylaxis (AMP) is used to reduce the risk of infectious complications. However, there is an absence of knowledge about both incidence of infectious complications after TURB and advantage of AMP in general. The objective of this study is to determinate the prevalence of postoperative infectious complications after routine TURB without AMP. We retrospectively reviewed clinical data of all patients who underwent TURB in the same Academic Urologic Department between January 2011 and December 2013. We consider as relevant for analysis, patients that underwent TURB without receiving any AMP. Infection was defined as a body temperature >37.5°C sustained for at least 24 hours. Sepsis was defined according to the third international consensus definition for sepsis and septic shock. In the period of the study, 223 TURBs were performed without use of AMP. Mean age was 70.3 years (standard deviation [SD] 11.3). Mean operative time was 25.14 minutes (SD 16). Median length of hospital stay was 3 days (interquartile range [IQR]: 2-4). Six (2.7%) patients developed postoperative infective complications. No case of sepsis was reported. Two (0.9%) patients received an antimicrobial therapy with fluoroquinolones despite absence of any signs of infection. Two hundred fifteen (96.4%) patients of TURBs did not receive any antimicrobial drugs and did not develop any infectious complications. In our series, infectious complications after TURB occurred in <3% of cases. In conclusion AMP should not be routinely used prior TURB.
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http://dx.doi.org/10.1089/end.2019.0523DOI Listing
February 2020

Factors predictive of shockwave lithotripsy failure for ureteral stones: why we need to hurry.

Minerva Urol Nefrol 2019 Dec 4;71(6):644-650. Epub 2019 Jun 4.

Department of Urology, Cattinara Hospital, University of Trieste, Trieste, Italy.

Background: The aims of this study are to evaluate the prognostic factors of extracorporeal shockwave lithotripsy in patients with ureteric stones, and to identify which patients might directly benefit of an endoscopic treatment.

Methods: We performed a prospective study from January 2013 and July 2016 on patients with single ureteric stone and undergoing extracorporeal shockwave lithotripsy (SWL). We divided patients into two groups: first group (success group) included cases resolved with SWL only, and a second group (failure group) including patients with stone not resolved by SWL and requiring an endoscopic treatment. We evaluated age, weight, height, body mass index, stone size, hydronephrosis, laterality, location, days elapsed from onset of symptoms to SWL and stone density when computed tomography was performed. In case of stone fragments >4 mm, the procedure was repeated up to a maximum of three times. SWL was considered as failed if patients had a residual stone of any size after a follow-up of 3 months or if a complication occurred.

Results: 274 patients completed follow-up and were enrolled in the study. Mean age was 53.22 years (standard deviation: 13.98). SWL overall success rate was 84.3% (231 patients successfully treated with shockwaves) and failure rate was 15.7% (43 patients underwent auxiliary endoscopic procedure). At the univariate analysis, we observed a statistically significant difference for hydronephrosis (P=0.006), time elapsed from symptoms onset (P=0.013), patients' age (P=0.06) and mean stone density (0.023). In the multivariate logistic regression, patients' age (OR: 1.517), and time elapsed from obstruction to SWL (OR: 3.005) were independent predictive factors for SWL failure. Furthermore, moderate and severe hydronephrosis seemed to be independent predictive factors for SWL failure, presenting an OR of 2.451 and 4.207 respectively. High stone density resulted to be a predictive factor for SWL failure (OR: 2.293 if density was higher than 1100 Hounsfield Units).

Conclusions: We report a large series of patients undergone primary SWL for ureteric stones. Our data demonstrated the role of hydronephrosis, time elapsed from obstruction onset to treatment and stone density as independent predictive factors of SWL failure.
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http://dx.doi.org/10.23736/S0393-2249.19.03346-0DOI Listing
December 2019

The management of stuttering priapism.

Minerva Urol Nefrol 2020 Apr 5;72(2):173-186. Epub 2019 Apr 5.

Department of Urology, University of Trieste, Trieste, Italy.

Introduction: Stuttering priapism is a variation of ischemic priapism, generally transient and self-limiting, occurring during sleep and lasting less than 3-4 hours. It may progress to episodes of complete ischemic priapism in approximately one third of cases, necessitating emergent intervention.

Evidence Acquisition: This review aims to provide an up-to-date picture of the pathophysiology and management of stuttering priapism. A search using Medline and EMBASE for relevant publications using the terms "priapism", "stuttering", "diagnosis", "treatment", "fibrosis", was performed.

Evidence Synthesis: Stuttering priapism shares its etiologies with ischemic priapism and a large number of diseases or clinical situations have risk association for developing the disorder. The most common causes are sickle cell disease or other hematologic and coagulative dyscrasias especially in children. In the adult population, idiopathic priapism occurring without any discernible cause is considered to be the most common form in adults. The medical management of priapism represents a therapeutic challenge to urologists. Unfortunately, although numerous medical treatment options have been reported, the majority are through small trials or anecdotal reports. Understanding the underlying pathophysiology and understanding the current and emerging future agents and therapeutic options are mandatory in order to provide the best solution for each patient.

Conclusions: The goal of management of priapism is to achieve detumescence of the persistent erection in order to preserve erectile function. To achieve successful management, urologists should address this emergency clinical condition. In the present article, we review the diagnosis and clinical management of the three types of priapism.
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http://dx.doi.org/10.23736/S0393-2249.19.03323-XDOI Listing
April 2020

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Intervention: PN.

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

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

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

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

Surgery Versus Radiation for High-risk Prostate Cancer: The Fight Continues. But Is It Time To Call a Draw and Reach Consensus?

Eur Urol 2019 04 11;75(4):556-557. Epub 2019 Jan 11.

Departments of Radiation Oncology & Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA.

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http://dx.doi.org/10.1016/j.eururo.2018.12.032DOI Listing
April 2019

Rete Testis Invasion Is Consistent With Pathologic Stage T1 in Germ Cell Tumors.

Am J Clin Pathol 2019 04;151(5):479-485

Medical College of Wisconsin, Milwaukee.

Objectives: Rete testis invasion by germ cell tumors is frequently concomitant with lymphovascular or spermatic cord invasion (LVI/SCI); independent implications for staging are uncertain.

Methods: In total, 171 seminomas and 178 nonseminomatous germ cell tumors (NSGCTs; 46 had 1%-60% seminoma component) came from five institutions. Metastatic status at presentation, as a proxy for severity, was available for all; relapse data were unavailable for 152. Rete direct invasion (ReteD) and rete pagetoid spread (ReteP) were assessed.

Results: ReteP and ReteD were more frequent in seminoma than NSGCT. In seminoma, tumor size bifurcated at 3 cm or more or less than 3 cm predicted metastatic status. Tumors with ReteP or ReteD did not differ in size from those without invasions but were less than with LVI/SCI; metastatic status or relapse did not show differences. In NSGCT, ReteP/ReteD did not correlate with size, metastatic status, or relapse.

Conclusions: Findings support retaining American Joint Committee for Cancer pathologic T1 stage designation for rete testis invasion and pT1a/pT1b substaging of seminoma.
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http://dx.doi.org/10.1093/ajcp/aqy168DOI Listing
April 2019

Intraoperative ultrasound in robot-assisted partial nephrectomy: State of the art.

Arch Ital Urol Androl 2018 Sep 30;90(3):195-198. Epub 2018 Sep 30.

Università degli Studi Trieste, Urology Department - Cattinara Hospital, Trieste.

Introduction: Nephron-sparing surgery (NSS) is of one of the most studied fields in urology due to the balancing between renal function preservation and oncological safety of the procedure. Aim of this short review is to report the state of the art of intra-operative ultrasound as an operative tool to improve localization of small renal masses partially or completely endophytic during robotassisted partial nephrectomy (RAPN).

Material And Methods: We performed a literature review by electronic database on Pubmed about the use of intra-operative US in RAPN to evaluate the usefulness and the feasibility of this procedure.

Results: Several studies analyzed the use of different US probes during RAPN. Among them some focused on using contrastenhanced ultra sonography (CEUS) for improving the dynamic evaluation of microvascular structure allowing the reduction of ischemia time (IT). We reported that nowaday the use of intraoperative US during RAPN could be helpful to improve the preservation of renal tissue without compromising oncological safety. Moreover, during RAPN there is no need for assistant to hand the US probe increasing surgeon autonomy.

Conclusions: The use of a robotic ultrasound probe during partial nephrectomy allows the surgeon to optimize tumor identification with maximal autonomy, and to benefit from the precision and articulation of the robotic instrument during this key step of the partial nephrectomy procedure. Moreover US could be useful to reduce ischemia time (IT). The advantages of nephron-sparing surgery over radical nephrectomy is well established with a pool of data providing strong evidence of oncological and survival equivalency. With the progressive growth of robot-assisted partial nephrectomy (RAPN) techniques, the use of several tools has been progressively developed to help the surgeon in the identification of masses and its vascular net. In this short review we tried to analyze the current use of intra-operative ultrasound as an operative tool to improve localization of small renal masses partially or completely endophytic during RAPN.
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http://dx.doi.org/10.4081/aiua.2018.3.195DOI Listing
September 2018

Perioperative outcomes and complication predictors associated with open and minimally invasive nephroureterectomy.

Can J Urol 2018 08;25(4):9395-9400

Department of Urology, University of Miami Miller School of Medicine, Miami, Florida, USA.

Introduction: Minimally invasive nephroureterectomy (MINU) and open nephroureterectomy (ONU) have similar oncological outcomes for treatment of upper tract urothelial carcinoma (UTUC). We investigated perioperative outcomes and predictors of complications associated with MINU and ONU.

Material And Methods: Using the National Surgical Quality Improvement Program (NSQIP) database, 912 patients were identified that underwent radical nephroureterectomy for UTUC between 2005 and 2013. Logistic regression and contingency table methods used preoperative covariates to predict rates of major (Clavien-Dindo grade ≥ 3) and 16 common perioperative complications. Additional comparisons between treatment groups were performed using unpaired t-tests, Wilcoxon rank-sum tests, or Fisher's Exact tests. P values were adjusted to maintain an experiment-wise p < 0.05.

Results: A total of 625 (69%) and 287 (31%) patients underwent MINU and ONU, respectively. ONU was associated with a higher rate of major complications (OR: 2.5, CI: 1.2-5.1, p < 0.03). The incidence of pulmonary embolism (bias adjusted OR: 24, CI: 1.3-441, p < 0.003), postoperative pneumonia (OR: 4.9, CI: 1.7-16, p < 0.0016), and transfusion (OR: 2.7, CI: 1.8-4.0, p < 0.0001) was higher for ONU compared to MINU. There were no significant differences in the incidence of other complications. MINU took longer on average (median 223 versus 213 mins, p < 0.02). Time to discharge was longer for ONU (median 5 versus 4 days, p < 0.0001). No other covariates were independent predictors of major complications regardless of surgical approach.

Conclusions: Occurrence of major complications were higher for ONU compared to MINU. These data suggest that MINU is an acceptable surgical option with lower morbidity compared to ONU for the management of UTUC.
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August 2018

Emergency extracorporeal shockwave lithotripsy as opposed to delayed shockwave lithotripsy for the treatment of acute renal colic due to obstructive ureteral stone: a prospective randomized trial.

Minerva Urol Nefrol 2018 Oct 14;70(5):526-533. Epub 2018 May 14.

Department of Urology, Cattinara Hospital, University of Trieste, Trieste, Italy.

Background: The aim of this study was to assess the efficacy of emergency extracorporeal shockwave lithotripsy (eSWL) as first-line treatment in patients with acute colic due to obstructive ureteral stone.

Methods: Seventy-four patients were randomized to emergency SWL within 12 hours (eSWL group) and deferred SWL later than 3 days (dSWL group). Follow-up included ultrasound, KUB (kidney-ureter-bladder) radiography and CT (computed tomography) scan at 24 hours, 7 days, 1 and 3 months from the treatment. When necessary, repeated SWL (re-SWL) or ureteroscopy (auxiliary-URS) was performed. Preoperative and postoperative data were compared and stone free rates (SFR) and efficiency quotients (EQ) were evaluated. Analyses were performed using SAS software.

Results: Complete data of 70 patients were collected. 36 underwent eSWL and 34 dSWL. The mean patient age was 48.7. Mean stone size was 9.8 mm (CI 95%: 8.9-10.8). 25 (35.7%) were proximal and 45 (64.3%) distal. Mean SWL energy was 19.2 kV (CI 95%: 18.5-19.9) and mean number of shocks was 2657 (CI 95%: 2513-2802). eSWL patients needs less auxiliary-URS than dSWL patients (13.9% vs. 44.1%, P=0.039) and less re-SWL sessions (8.3% vs. 32.4%, P=0.093). SFR at 24 hours was 52.8% and 11.8% (P<0.001) and the EQ at 3 months was 79.1% and 57.5% in the eSWL and dSWL group respectively. Patients from the dSWL group spent more time in the hospital (2.21 vs. 1.36 days, P=0.046) and complication rates between the two groups were similar.

Conclusions: eSWL is a safe procedure and delivers high SFR even within 24 hours especially for <10 mm stones. It is able to reduce the number of auxiliary procedures and hospitalization.
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http://dx.doi.org/10.23736/S0393-2249.18.03084-9DOI Listing
October 2018