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ABSTRACT Purpose: Medical expulsive therapy (MET) is recommended for distal ureteral stones from 5 to 10 mm. The best drug for MET is still uncertain. In this review, we aim to compare the effectiveness of tadalafil and tamsulosin for distal ureteral stones from 5 to 10 mm in terms of stone expulsion rate (SER), stone expulsion time (SET) and the side effect profile. Materials and methods: A comprehensive literature search was conducted on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus and Web of Science, from inception until April 2023. Only randomized controlled trials were included in the analysis. Results: Eleven publications with 1,330 patients were included. We observed that tadalafil has a higher SER (OR 0.55, CI 95% 0.38;0.80, p=0.02, I2=52%) and the same efficacy in SET (MD 1.07, CI 95% -0.25; 2.39, p=0.11, I2=84%). No differences were found when comparing side effects as headache, backache, dizziness, and orthostatic hypotension. Conclusion: Tadalafil has a higher stone expulsion rate than tamsulosin as a medical expulsive therapy for patients with distal stones from 5 to 10 mm without differences in side effects.

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ABSTRACT Purpose: Salvage robotic-assisted radical prostatectomy (S-RARP) has gained prominence in recent years for treating patients with cancer recurrence following non-surgical treatments of Prostate Cancer. We conducted a systematic literature review to evaluate the role and outcomes of S-RARP over the past decade. Materials and Methods: A systematic review was conducted, encompassing articles published between January 1st, 2013, and June 1st, 2023, on S-RARP outcomes. Articles were screened according to PRISMA guidelines, resulting in 33 selected studies. Data were extracted, including patient demographics, operative times, complications, functional outcomes, and oncological outcomes. Results: Among 1,630 patients from 33 studies, radiotherapy was the most common primary treatment (42%). Operative times ranged from 110 to 303 minutes, with estimated blood loss between 50 to 745 mL. Intraoperative complications occurred in 0 to 9% of cases, while postoperative complications ranged from 0 to 90% (Clavien 1-5). Continence rates varied (from 0 to 100%), and potency rates ranged from 0 to 66.7%. Positive surgical margins were reported up to 65.6%, and biochemical recurrence ranged from 0 to 57%. Conclusion: Salvage robotic-assisted radical prostatectomy in patients with cancer recurrence after previous prostate cancer treatment is safe and feasible. The literature is based on retrospective studies with inherent limitations describing low rates of intraoperative complications and small blood loss. However, potency and continence rates are largely reduced compared to the primary RARP series, despite the type of the primary treatment. Better-designed studies to assess the long-term outcomes and individually specify each primary therapy impact on the salvage treatment are still needed. Future articles should be more specific and provide more details regarding the previous therapies and S-RARP surgical techniques.

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ABSTRACT Purpose: Parasacral Transcutaneous Electrical Stimulation (TENS) is one of the treatments for children with Bladder and Bowel Dysfunction (BBD). Some studies showed that children with increased Rectal Diameter (RD) have more Functional Constipation (FC). However, RD prediction in maintenance of BBD after treatment was never evaluated. Our aim is to evaluate the association between RD and response to treatment in children and adolescents with BBD. Materials and Methods: This study evaluated patients from 5-17 years old with BBD. Dysfunctional Voiding Scoring System (DVSS), Rome IV criteria, and the Constipation Score were used. RD was measured using abdominal ultrasound before treatment according to the technique established by Klijn et al. and was considered enlarged when >3cm. No laxatives were used during treatment. Descriptive analysis and binary regression were performed and the area under the ROC curve was calculated. Results: Forty children were included (mean age 8.4±2.8 years, 52.5% male). Before treatment, RD was enlarged in 15 children (37.5%) (mean diameter 3.84±0.6cm), with FC persisting post-treatment in 11/15(73.3%). Those patients also required more laxatives following treatment and had more severe FC. Binary regression showed pretreatment RD to be an independent predictor of the persistence of FC post-treatment (OR=9.56; 95%CI:2.05-44.60). In ROC curve analysis, the sensitivity was 100% (95%CI: 0.49-1.0) and specificity 77.14% (95%CI:0.60-0.90) for rectal diameter >3 cm. The likelihood ratio was 4.38 (95%CI:2.40-8.0) for the persistence of BBD following treatment. Conclusion: RD appears to be relevant in the evaluation of children with BBD, not only as a diagnostic tool but also as a predictor of treatment outcome.

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ABSTRACT Purpose: This study aimed to analyze the diagnostic accuracy of dynamic and static ultrasound (DSUS) in detecting vesicoureteral reflux (VUR) and renal scarring in a cohort of children with neurogenic bladder (NB). Materials and Methods: A retrospective, longitudinal, observational study was conducted using the Reporting Diagnostic Accuracy Studies guideline. The DSUS (index test) data were compared with voiding cystourethrography (VCUG) and renal scintigraphy 99mTc-dimercaptosuccinic (reference tests). Overall performance for predicting VUR and renal scarring was assessed using renal pelvic diameter (RPD)/distal ureteral diameter and renal parenchymal thinning on DSUS, respectively. Results: A total of 107 patients (66 girls, median age 9.6 years) participated. Seventeen patients (15.9%) presented VUR, eight bilateral. For overall reflux grade, the AUC was 0.624 for RPD and 0.630 for distal ureteral diameter. The diagnostic performance for detecting high-grade VUR was slightly better for DSUS parameters. The AUC was 0.666 for RPD and 0.691 for distal ureteral diameter. The cut-offs of 5 mm for RPD and 6.5 mm for distal ureteral diameter presented the best diagnostic odds ratio (DOR) to identify high-grade VUR. The increase of RPD during detrusor contractions showed an accuracy of 89.2%. The thinness of renal parenchyma presented an accuracy of 88% for renal scarring. Conclusion: DSUS predicts VUR and renal scarring in children with NB with fair to good accuracy, and all measurements exhibited a high negative predictive value (NPV). The increase in RPD during voiding or detrusor contractions proved to be the most accurate parameter for indicating the presence of VUR in this study.

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ABSTRACT Objectives: Accurate preoperative prediction of adverse pathology is crucial for treatment planning of renal cell carcinoma (RCC). Previous studies have emphasized the potential of prostate-specific membrane antigen positron emission tomography / computed tomography (PSMA PET/CT) in differentiating between benign and malignant localized renal tumors. However, there is a scarcity of case reports elucidating the identification of aggressive pathological features using PET/CT. Our study was designed to prospectively compare the diagnostic value of enhanced CT, 68Ga-PSMA-11 and 18F-fluorodeoxyglucose (18F-FDG) PET/CT in clear-cell renal cell carcinoma (ccRCC) with necrosis or sarcomatoid or rhabdoid differentiation. Materials and Methods: A prospective case series of patients with a newly diagnosed renal mass who underwent enhanced CT, 68Ga-PSMA-11 and 18F-FDG PET/CT within 30 days prior to nephrectomy was included. Complete preoperative and postoperative clinicopathological data were recorded. Patients who received neoadjuvant targeted therapy, declined enhanced CT or PET/CT scanning, refused surgical treatment or had non-ccRCC pathological indications were excluded. Radiological parameters were compared within subgroups of pathological characteristics. Bonferroni corrections were used to adjust for multiple testing and statistical significance was set at a p-value less than 0.017. Results: Seventy-two patients were available for the final analysis. Enhanced CT demonstrated poor performance in identifying necrosis, sarcomatoid or rhabdoid differentiation and adverse pathology (all P > 0.05). The maximum standardized uptake value (SUVmax) of 68Ga-PSMA-11 PET/CT was more effective than 18F-FDG PET/CT in identifying tumor necrosis and adverse pathology, with an area under the curve (AUC) of 0.85 (cutoff value=25.26, p<0.001; Delong test z=2.709, p=0.007) for tumor necrosis and AUC of 0.90 (cutoff value=25.26, p<0.001; Delong test z=3.433, p<0.001) for adverse pathology. However, no significant statistical difference was found between 68Ga-PSMA-11 and 18F-FDG PET/CT in predicting sarcomatoid or rhabdoid feature (AUC of 0.91 vs.0.75, Delong test z=1.998, p=0.046). Subgroup analyses based on age, sex, tumor location, maximal diameter, stage and WHO/ISUP grade demonstrated that 68Ga-PSMA-11 PET/CT SUVmax had a significant predictive value for adverse pathology. Enhanced CT value and SUVmax demonstrated strong reliability [intraclass correlation coefficient (ICC) > 0.80], indicating a robust correlation. Conclusions: 68Ga-PSMA-11 PET/CT demonstrates distinct advantages in identifying aggressive pathological features of primary ccRCC when compared to enhanced CT and 18F-FDG PET/CT. Further research and assessment are warranted to fully establish the clinical utility of 68Ga-PSMA-11 PET/CT in ccRCC.

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ABSTRACT Purpose: To compare the perioperative outcomes of robot-assisted radical prostatectomy (RARP) with pelvic lymph-nodes dissection (PLND) when the same surgeon performs RARP and PLND versus one surgeon performs RARP and another surgeon performs PLND. Materials and Methods: From January 2022 to March 2023, data of consecutive patients who underwent RARP with PLND were prospectively collected. The surgeries were performed by two "young" surgeons with detailed profile. Specifically for the study purpose, one surgeon performed RARP, and the other surgeon performed PLND. A set of surgeries performed according to the standard setup (i.e., the same surgeon performing both RARP and PLND) was retrieved from the institutional database and used as comparator arm. To test the study hypothesis, patients were divided into two groups: "dual-surgeon" versus "single-surgeon". Results: Fifty patients underwent RARP and PLND performed according to dual-surgeon setup and were compared to the last 50 procedures performed according to the standard single-surgeon setup. Patients in the groups had comparable baseline characteristics. Dual-surgeon interventions had significantly shorter median total operative (194 [IQR 178–215] versus 174 [IQR 146–195] minutes, p<0.001) and console time (173 [IQR 158–194] versus 154 [IQR 129–170] minutes, p<0.001). No significant differences were found in terms of blood loss, intraoperative complications, postoperative outcomes, and final pathology results. Conclusions: The present analysis found that when RARP and PLND are split onto two surgeons, the operative time is shorter by 20 minutes compared to when a single surgeon performs RARP and PLND. This is an interesting finding that could sponsor further studies.

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ABSTRACT Purpose: Considerable controversy exists regarding the surgery for concealed penis. We describe a new technique for repairing concealed penis by symmetrical pterygoid flap surgery. Methods: From January 2016 to July 2022, we evaluated 181 cases of concealed penis that were surgically treated using the symmetrical pterygoid flap surgery. We measured the penile size preoperative and 2, 4, 12 weeks, and 1 year postoperative to confirm the improvement. A questionnaire was administered to the patients and parents to assess satisfaction regarding penile size, morphology, and hygiene. Result: The perpendicular penile length was1.59±0.32cm preoperative and 3.82±1.02 cm after the procedure (p < 0.05), and 4.21±1.91cm after one year of postoperative (p < 0.05). The overall satisfaction of patients was 97.89%, while the overall satisfaction of older children patients (age>7) was 75.24%. Parents focus more on the penile exposure size, while patients focus more on the penile morphology. Almost every patient had postoperative penile foreskin edema. However, this symptom had spontaneously resolved by 4-6 weeks. The complications such as skin necrosis, tissue contracture, or wound infection were 4.42%. Conclusion: The symmetrical pterygoid flap surgery is an effective surgical technique for the management of concealed penis in children producing predictable results and excellent satisfaction of the parents and patients.

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ABSTRACT Purpose: To analyze the histology and distribution of abdominal testicular vessels in human fetuses Patients and Methods: We studied 19 fetuses (34 testes) ranging in age from 12 to 19 weeks post-conception. The fetuses were evaluated regarding crown-rump length (CRL), total length (TL) and body weight immediately before dissection. Each testis was dissected and embedded in paraffin, from which 5 µm thick sections were obtained and stained with Masson's trichrome and Anti-CD31 antibody to quantify the vessels. The stereological analysis was carried out with the Image Pro and Image J programs, using a grid to determine volumetric densities (Vv). Means were statistically compared using the unpaired T-test (p<0.05). Results: The fetuses presented mean weight of 222.5g, mean CRL of 15.3 cm and mean TL of 23.2 cm. All testes were in the abdominal position. The mean percentage of vessels (Vv) in the upper portion of the testis was 7.6% (4.6 to 15%) and in the lower portion the mean was 5.11% (2.3 to 9.8%), with a significant difference (p=0.0001). In the analysis between the upper portion of the right and left testes (p=0.99) and in the analysis of the lower portion of the right and left testes (p=0.83), we did not observe significant differences. Conclusion: The upper portion of the abdominal testis in human fetuses had a higher concentration of vessels than the lower portion. These results suggest that manipulation of the lower end of the testis during Fowler-Stephens surgery should be avoided in order to preserve the collateral circulation.

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ABSTRACT Purpose: Ureteropelvic junction obstruction (UPJO) is a prevalent cause of hydronephrosis, especially in young patients. The treatment paradigm for this condition has shifted from open to minimally invasive pyeloplasty. In the present study we describe our initial single centre experience with single port (SP) robot-assisted pyeloplasty (RAP) via periumbilical incision. Material and methods: With the patient in a 60-degree left flank position, the SP system is docked with the Access port (Intuitive Surgical, Sunnyvale, CA, US) placed in a periumbilical 3 cm incision. Robotic instruments are deployed as follows: camera at 12 o'clock, bipolar grasper at 9 o'clock, scissors at 3 o'clock and Cadiere at 6 o'clock. After isolation and identification of the ureter and the ureteropelvic junction (UPJ), the ureter is transected at this level and then spatulated. Anastomosis is carried out by two hemicontinuous running sutures, over a JJ stent. Results: Between 2021 and 2023, a total of 8 SP RAP have been performed at our institution, with a median (interquartile range, IQR) of 23 years (20.5-36.5). Intraoperative outcomes showed a median (IQR) OT of 210.5 minutes (190-240.5) and a median (IQR) estimated blood loss (EBL) of 50 mL (22.5-50). No postoperative complications were encountered, with a median (IQR) length of stay (LOS) of 31 hours (28.5-34). Conclusion: In the present study we evaluated the feasibility and safety of SP RAP. The observed outcomes and potential benefits, combined with the adaptability of the SP platform, hold promising implications for the application of SP system in pyeloplasty treatment.

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ABSTRACT Introduction: The En-bloc Resection of Bladder Tumors (ERBT) is a method that offers more benefits compared to the traditional Transurethral Resection of Bladder Tumor (TURBT) (1, 2). Recent studies have shown that ERBT offers better pathological analysis and oncological outcomes (3-6). Thulium and holmium are the most frequently used lasers for this procedure, with the hybrid laser being a new addition that combines thulium and diode to improve hemostatic properties (5, 7-9). Objective: This report aims to discuss the use of two types of lasers, hybrid and holmium, for ERBT. Material and Methods: Two case studies were conducted. The first case featured a 68-year-old male with two tumors measuring 1.5cm and 2cm. The hybrid laser was used for the procedure. The second case involved a 70-year-old female with a 5cm tumor on the posterior bladder wall, and holmium laser was used with morcellation of the tumor. The quality of histopathological analysis was evaluated. The perioperative data and the entire procedure of the two cases were documented in a step-by-step video. Results: Both lasers demonstrated excellent results without technical difficulties. There was no bleeding, and both patients were discharged with one day of hospitalization. The detrusor muscle was present without artifacts, and the morcellation did not affect the analysis. The first case showed a pT1G3, and the second case showed a pT2 urothelial carcinoma. The hybrid laser exhibited superior hemostatic capacity compared to the holmium laser. Conclusion: ERBT can use hybrid or holmium lasers without affecting histopathological analysis, even with morcellation.

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ABSTRACT Introduction: We aim to publish our innovative modified biplanar 0-90 endoscopic guided puncture technique for percutaneous nephrolithotomy in supine recorded with a GoPro® camera for standardization of the technique. It solves drawbacks of the fluoroscopic technique, i.e., in kidneys with complex anatomy, it may be challenging to distinguish calyces as they are often superposed, and it does not allow for all benefits of a combined endoscopic approach (1, 2). Our technique shortens puncture and fluoroscopic time and is easy to teach and reproduce. Methods: A 77-year-old female patient had previous double J insertion due to an obstructing stone in the right distal ureter. She managed to pass the distal stone but remained with the double J and a 20mm stone (1300HU) in the right renal pelvis. The shared decision was for the actual standard of care (3, 4) endoscopic combined intrarenal surgery (ECIRS). The MiniECIRS started with flexible ureteroscopy and a posterior calix which gave direct access to the stone was chosen. The tip of the flexible scope was used to mark point A with the C-arm in the 0-degree position and line B in the 90-degree position. Puncture was fast and the MiniECIRS was uneventful with a single mid-pole access guided by the flexible scope. The surgeon had a Full-HD GoPro® camera mounted on his head, controlled by the surgical staff. All essential surgical steps were recorded. Results: The quality of the recorded movie was graded as excellent, and the camera did not cause any discomfort to the surgeon. Operative and X-Ray time were 120minutes and 2minutes (7.64mGy). Hemoglobin drop was 0.8g/dL. The post-operative day-1 computed tomography scan was stone-free. The patient was discharged 24h after surgery. Kidney stent was left with a string and removed after 5days. The patient remained asymptomatic and metabolic evaluation revealed a calcium oxalate stone, low urinary volume and hypocitraturia which were treated with potassium citrate and hydration. Conclusion: The Modified Biplanar (0-90 degree) Endoscopic-Guided Puncture Technique for Percutaneous Nephrolithotomy joins the reproducibility of the same technique under fluoroscopy with advantages regarding safety and efficiency of ECIRS.

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ABSTRACT Introduction: Robotic approach has shown its feasibility and safety with respect to open approach for radical cystectomy (1). The performances of Hugo™ RAS system (Medtronic, Minneapolis, USA) have been demonstrated in several clinical scenarios (2-5). We report the feasibility and surgical settings of the first series of robot-assisted radical cystectomy (RARC) with intracorporeal ileal-conduit performed with Hugo™ RAS system. Methods: Two patients were submitted to RARC with ileal conduit at our institution. The trocar placement scheme and the operating room setting with docking angles of the four arms were already described (6). A 12-mm and a 5-mm trocar for the assistant were placed. In both cases, an ileal-conduit with a Wallace type-1 uretero-enteric derivation was performed intra-corporeally. Results: The first patient was a 71-year-old male with a very-high risk non-muscle invasive bladder cancer(BC), and the second patient was a 64-year-old male with a diagnosis of T2 high-grade BC. Operative times were 360 and 420 minutes with a docking time of 12 and 9 minutes, respectively. No intraoperative complications occurred. The estimated blood loss was 200ml and 400ml, respectively. The second patient developed an ileus on postoperative day 4 (Clavien-Dindo grade 2). No positive surgical margins were recorded. No recurrence nor progression occurred during follow-up. Conclusion: RARC with intracorporeal ileal conduit urinary diversion is feasible with Hugo™ RAS system. We provided insight into the surgical setting using this novel robotic platform to help new adopters to face this challenging procedure. These findings may help a wider distribution of robotic programs for BC treatment.