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ABSTRACT Despite the neuroanatomy knowledge of the prostate described initially in the 1980's and the robotic surgery advantages in terms of operative view magnification, potency outcomes following robotic-assisted radical prostatectomy still challenge surgeons and patients due to its multifactorial etiology. Recent studies performed in our center have described that, in addition to the surgical technique, some important factors are associated with erectile dysfunction (ED) following robotic-assisted radical prostatectomy (RARP). These include preoperative Sexual Health Inventory for Men (SHIM) score, age, preoperative Gleason score, and Charlson Comorbidity Index (CCI). After performing 15,000 cases, in this article we described our current Robotic-assisted Radical Prostatectomy technique with details and considerations regarding the optimal approach to neurovascular bundle preservation.

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ABSTRACT Introduction: Bladder and urinary sphincter malfunctioning that results from some change in the central and/or peripheral nervous system is defined as neurogenic bladder. The urinary tract symptoms that can be related to its filling, emptying, or both have a significant impact on the quality of life of individuals. The present review was based on the document prepared for the public health system in Brazil as a treatment guidelines proposal. Material and Methods: Survey questions were structured as per PICO (Population, Intervention, Control, and Outcome). Search strategies were defined and performed in the MEDLINE/Pubmed, Embase, Epistemonikos and Google Scholar databases. The selection of articles followed the evidence hierarchy concept; evidence body was identified, and the quantitative study data were extracted. The quality of evidence and grade of recommendation were qualitatively assessed according to GRADE (Grading of Recommendations, Assessment, Development and Evaluations). Results: A total of 2.707 articles were identified, with 49 of them being selected to compose the basis for this review. Neurogenic bladder treatments were classified according to their focus on filling or emptying symptoms and sub- classified in pharmacological and surgical treatments. Conclusion: Treatment guidelines are important tools for the public health system to promote the best practice when treating neurogenic bladder patients.

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ABSTRACT Objective: This review aimed to analyze interventions raised within primary and tertiary prevention concerning the disease's incidence, progression, and recurrence of Prostate Cancer (PCa). Priority was given to the multidisciplinary approach of PCa patients with an emphasis on modifiable risk factors. Materials and Methods: We conducted a comprehensive literature review in the following databases: Embase, Central, and Medline. We included the most recent evidence assessing cohort studies, case-control studies, clinical trials, and systematic reviews published in the last five years. We only included studies in adults and in vitro or cell culture studies. The review was limited to English and Spanish articles. Results: Preventive interventions at all levels are the cornerstone of adherence to disease treatment and progression avoidance. The relationship in terms of healthy lifestyles is related to greater survival. The risk of developing cancer is associated to different eating habits, determined by geographic variations, possibly related to different genetic susceptibilities. Discussion: PCa is the second most common cancer in men, representing a leading cause of death among men in Latin America. Prevention strategies and healthy lifestyles are associated with higher survival rates in PCa patients. Also, screening for anxiety and the presence of symptoms related to mood disorders is essential in the patient's follow-up concerning their perception of the condition.

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ABSTRACT Purpose: Prostate cancer (PCa) is the second most common oncologic disease among men. Radical treatment with curative intent provides good oncological results for PCa survivors, although definitive therapy is associated with significant number of serious side-effects. In modern-era of medicine tissue-sparing techniques, such as focal HIFU, have been proposed for PCa patients in order to provide cancer control equivalent to the standard-of-care procedures while reducing morbidities and complications. The aim of this systematic review was to summarise the available evidence about focal HIFU therapy as a primary treatment for localized PCa. Material and methods: We conducted a comprehensive literature review of focal HIFU therapy in the MEDLINE database (PROSPERO: CRD42021235581). Articles published in the English language between 2010 and 2020 with more than 50 patients were included. Results: Clinically significant in-field recurrence and out-of-field progression were detected to 22% and 29% PCa patients, respectively. Higher ISUP grade group, more positive cores at biopsy and bilateral disease were identified as the main risk factors for disease recurrence. The most common strategy for recurrence management was definitive therapy. Six months after focal HIFU therapy 98% of patients were totally continent and 80% of patients retained sufficient erections for sexual intercourse. The majority of complications presented in the early postoperative period and were classified as low-grade. Conclusions: This review highlights that focal HIFU therapy appears to be a safe procedure, while short-term cancer control rate is encouraging. Though, second-line treatment or active surveillance seems to be necessary in a significant number of patients.

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ABSTRACT Objectives: The purpose of our study was to assess the association between the winter season and desmopressin treatment failure in South Chinese children with monosymptomatic nocturnal enuresis (MNE). Materials and Methods: A retrospective study was conducted to analyze the clinical data of children with monosymptomatic nocturnal enuresis who have visited our urology clinic from January to December 2019. All patients received desmopressin treatment. Final treatment outcomes were categorized as successful (complete response) or failed (absent and partial response). The relationship between winter season and treatment response to desmopressin was evaluated. Additionally, associated risk factors were investigated with both univariate and multivariate regression analysis. Results: In total, 393 patients diagnosed with MNE were included in the present study. There were no statistically significant differences in pretreatment variables at first visit between patients who visited the clinic in winter and those who did so in other seasons. However, the treatment failure rate of MNE in the winter season was higher than that of other seasons (77.50% vs. 52.74%). Multivariate logistic regression analysis demonstrated that the severity of symptoms and an initial clinic visit in the winter season were significantly related to desmopressin treatment failure in MNE patients. Conclusion: Winter season and severity of symptoms are two risk factors associated with desmopressin treatment failure in MNE patients.

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ABSTRACT A major challenge in the management of ureteropelvic junction obstruction (UPJO) is the selection of patients who would benefit from surgical treatment. Tissue inhibitor metalloproteinase-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) indicate renal cell stress and are associated with cell cycle arrest. The [TIMP-2] [IGFBP7] ratio (Nephrocheck®) has been recently applied in patients in intensive care units patients to predict the development of acute kidney injury. In this study, we evaluated the performance of these biomarkers performance to distinguishing obstructive hydronephrosis (HN) from non-obstructive HN. Materials and Methods: Consecutive patients with UPJO were enrolled in this study. Urinary [TIMP-2] [IGFBP7] and clinical characteristics (hydronephrosis grade, differential renal function, and drainage half-time) were measured in the following groups: 26 children with obstructive HN at initial diagnosis (group 1A) and after six months of dismembered pyeloplasty (group 1B); 22 children with non-obstructive HN (group 2), and 26 children without any urinary tract condition, as the control group (group 3). Results: Comparing the initial samples, [TIMP-2] [IGFBP7] had higher levels in the HN groups and lower levels in the control group; however, no difference was observed between the HN groups (obstructive vs. non-obstructive). After six months of follow-up, patients who underwent dismembered pyeloplasty showed stability in the urinary concentration of [TIMP-2] [IGFBP7]. All patients with [TIMP-2] [IGFBP7] higher than 1.0 (ng/mL)2/1000 had diffuse cortical atrophy on ultrasonography. Conclusions: We showed that urinary levels of urinary [TIMP-2] [IGFBP7] are higher in children with HN than controls. Nephrocheck® is not reliable in predicting the need for surgical intervention for pediatric patients with UPJO.

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ABSTRACT Objective: To compare enhancement patterns of typical adrenal adenomas, lipid-poor adenomas, and non-adenomas on magnetic resonance imaging (MRI). Materials and Methods: Evaluation of adrenal nodules larger than 1.0 cm, with at least 2-year follow-up, evaluated on MRI in January 2007 and December 2016. Two different protocols were included - upper abdomen MRI (delayed phase after 3 minutes) and abdomen and pelvis MRI (delayed phase after 7 minutes) – and nodules were divided in typical adenomas (characterized on out-of-phase MRI sequence), lipid-poor adenomas (based on follow-up imaging stability) and non-adenomas (based on pathological finding or follow-up imaging). T2-weighted and enhancement features were analyzed (absolute and relative washout and enhancement curve pattern), similarly to classic computed tomography equations. Results: Final cohort was composed of 123 nodules in 116 patients (mean diameter of 1.8 cm and mean follow up time of 4 years and 3 months). Of them, 98 (79%) nodules had features of typical adenomas by quantitative chemical shift imaging, and demonstrated type 3 curve pattern in 77%, mean absolute and relative washout of 29% and 16%, respectively. Size, oncologic history and T2-weighted features showed statistically significant differences among groups. Also, a threshold greater than 11.75% for absolute washout on MRI achieved sensitivity of 71.4% and specificity of 70.0%, in differentiating typical adenomas from non-adenomas. Conclusion: Calculating absolute washout of adrenal nodules on MRI may help identifying proportion of non-adenomas.

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ABSTRACT Purpose: To determine independent predictors of inguinal lymph node (ILN) metastasis in patients with penile cancer. Patients and methods: We retrospectively analyzed all patients with penile cancer who underwent surgery at our medical center in the last ten years (n=157). Using univariate and multivariate logistic-regression models, we assessed associations with age, medical-history, phimosis, onset-time, number and maximum diameter of involved ILNs measured by imaging, pathological T stage, degree of tumor differentiation and/or cornification, lymphatic vascular infiltration (LVI), nerve infiltration, and ILN metastases. Interaction and stratified analyses were used to assess age, phimosis, onset time, number of ILNs, cornification, and nerve infiltration. Results: A total of 110 patients were included in the study. Multiple logistic regression analysis showed that the following factors were significantly correlated with ILN metastasis: maximum diameter of enlarged ILNs, T stage, pathological differentiation, and LVI. Among patients with a maximum ILN diameter ≥1.5cm, 50% had lymph node metastasis whereas 30.6% patients with a maximum ILN diameter <1.5cm showed LNM. Among 44 patients with stage Ta/T1, 10 showed ILN metastases, while 47.0% patients with stage T2 showed ILN metastases. Among 40 patients with highly differentiated penile-cancer, eight showed ILN metastasis, while 47.1% patients with low-to-middle differentiation showed ILN metastases. The rate of LNM was 33.3% in the LVI-free group and 64.3% in the LVI group. Conclusion: Our single-center results suggested that maximum ILN diameter, pathological T stage, pathological differentiation, and LVI were independent risk factors for ILN metastases.

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ABSTRACT Purpose: Overactive bladder (OAB) is a common syndrome associated with lower urinary tract symptoms (LUTS), especially urinary incontinence in children, which may affect the patient's quality of life (QoL). Vitamin D deficiency has been shown to be associated with OAB syndrome. This study evaluated the relationship between vitamin D status and OAB-related symptoms and QoL in children. Materials and Methods: The study included 52 pediatric patients with OAB-related urinary incontinence and 41 healthy children. LUTS were assessed using the Dysfunctional Voiding and Incontinence Symptoms Score (DVISS) questionnaire, and QoL was assessed using the Pediatric Incontinence Questionnaire (PINQ). Oral vitamin D supplementation was given to patients with OAB with vitamin D deficiency. Urinary symptoms and QoL were evaluated before and after vitamin D supplementation. Results: Vitamin D deficiency was more common in the OAB group (75%) than in the control group (36.6%). Logistic regression analysis revealed that vitamin D status (<20ng/mL) was a significant predictor of OAB. Both pre-treatment and post-treatment DVISS and PINQ scores showed a positive correlation. After vitamin D supplementation, 8 (23.5%) patients had a complete response and 19 (55.9%) patients had a partial response. Significant improvement in QoL was also achieved. Conclusions: Vitamin D deficiency is more common in children with urinary incontinence and OAB than in healthy children. Although vitamin D deficiency is not routinely evaluated for every patient, it should be evaluated in treatment-resistant OAB cases. Vitamin D supplementation may improve urinary symptoms and QoL in patients with OAB.

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ABSTRACT Objectives: To compare thulium laser enucleation of prostate (ThuLEP) versus laparoscopic trans-vesical simple prostatectomy (LSP) in the treatment of benign prostatic hyperplasia (BPH). Materials and Methods: Data of patients who underwent surgery for “large” BPH (>80mL) at three Institutions were collected and analyzed. Two institutions performed ThuLEP only; the third institution performed LSP only. Preoperative (indwelling catheter status, prostate volume (PVol), hemoglobin (Hb), Qmax, post-voiding residual volume (PVR), IPSS, QoL, IIEF-5) and perioperative data (operative time, enucleated adenoma, catheterization time, length of stay, Hb-drop, complications) were compared. Functional (Qmax, PVR, %ΔQmax) and patient-reported outcomes (IPSS, QoL, IIEF-5, %ΔIPSS, %ΔQoL) were compared at last follow-up. Results: 80 and 115 patients underwent LSP and ThuLEP, respectively. At baseline, median PVol was 130 versus 120mL, p <0.001; Qmax 9.6 vs. 7.1mL/s, p=0.005; IPSS 21 versus 25, p <0.001. Groups were comparable in terms of intraoperative complications (1 during LSP vs. 3 during ThuLEP) and transfusions (1 per group). Differences in terms of operative time (156 vs. 92 minutes, p <0.001), Hb-drop (-2.5 vs. −0.9g/dL, p <0.001), catheterization time (5 vs. 2 days, p <0.001) and postoperative complications (13.8% vs. 0, p <0.001) favored ThuLEP. At median follow-up of 40 months after LSP versus 30 after ThuLEP (p <0.001), Qmax improved by 226% vs. 205% (p=0.5), IPSS decreased by 88% versus 85% (p=0.9), QoL decreased by 80% with IIEF-5 remaining almost unmodified for both the approaches. Conclusions: Our analysis showed that LSP and ThuLEP are comparable in relieving from BPO and improving the patient-reported outcomes. Invasiveness of LSP is more significant.

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ABSTRACT Background: To analyze the incidence of epididymal anomalies (EAs) associated to spermatic obstruction in patients with undescended testis (UT) according to testicular position and age. Materials and Methods: We studied 87 patients (110 testis) with cryptorchidism and analyzed the presence of EAs correlated with the testicular position, age and patency of the processus vaginalis (PV). To analyze the relations between the testis and epididymis we considered three situations: (a) Normal pattern: the epididymis was attached to the testis at the head and tail and epididymis totally attached to the testis; (b) EAs: when the epididymis was attached to the testis only at the head (Figure-1A) and (c) EAs associated to spermatic obstruction: epididymis was attached to the testis only at the tail (Figure-1B) and when there are no visible connection between testis and epididymis (Figure-1C). We used the Wilcoxon-Mann-Whitney test and the Chi-square test for contingency analysis (p <0.05). Results: The mean age of the patients was 5.18 years (SD=2.867). Of 110 testes analyzed, 14 were abdominal (12.72%); 83 inguinal (75.45%) and 13 suprascrotal (11.81%). Normal relationships between testis and epididymis were observed in 54 patients (62.1%) with no significant differences in relation to the patient's age (p=0.666). Epididymal tail disjunction was observed in 23 patients (26.44%), with no significant differences in relation to age (p=0.59). EAs associated to spermatic obstruction were observed in 16 patients (18.4%), also with no significant differences in relation to age (p=0.684). We did not observe significant correlation between the testis position and the incidence of EAs (p=0.119). We did not observe significant correlations between patency of the PV (64.7%) and incidence of EAs (p=0.742). Conclusions: Epididymal anomalies associated with spermatic obstruction are present in almost 20% of undescended testes, without significant correlation with age, testicular position and patency of the PV. This information needs to be correlated to the infertility risk of this congenital anomaly.

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ABSTRACT Background: Reports in the literature describe lymphocele formation in up to half of patients following pelvic lymph node dissection (PLND) (1) in robotic-assisted radical prostatectomy (RARP), with 1-2% requiring intervention (2). The advantage of surgical approach is permanent excision of the lymphocele capsule and fewer days with pelvic drains compared to percutaneous drainage. This study aims to describe the step-by-step surgical management of symptomatic lymphoceles using a less invasive robotic platform, the Da Vinci® Single Port (SP). Material and Methods: We describe the technique of lymphocelectomy and marsupialization with the Da Vinci® SP for symptomatic lymphocele. For this study, several treatment modalities for symptomatic lymphoceles were available, including percutaneous drainage, sclerosing agents, and surgical marsupialization. All the data for this study were obtained through the procedure via Da Vinci® SP. Results: Operative time for the case was 84 minutes. Blood loss was 25ml. No intra- or post- operative complications were reported. The patient had his drain removed in under 24 hours after surgery. The mean follow-up period was 7.7 months. There were no complications or lymphocele recurrence. Conclusion: Da Vinci® SP lymphocelectomy is safe and feasible with satisfactory outcomes. The SP enables definitive treatment of the lymphocele sac (3), reducing the number of days with abdominal drains and allows further decrease in surgical invasiveness with fewer incisions and better cosmesis.

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ABSTRACT Introduction: A challenging situation in proximal hypospadias is the presentation of patients with successful urethroplasty but with persistent or recurrent ventral curvature (VC) after multiple hypospadias repair. Materials and Methods: We present a 13 year-old boy with 7 previous surgeries (long TIP, Duplay, meatoplasty) to treat hypospadias presenting with 60 degrees of VC, in spite of a well-accepted coronally neomeatus. We degloved the penis and artificial erection clearly appointed corporal disproportion causing curvature. We disconnected urethra from corpora. After excision of remnant fibrotic tissue, there was a residual curvature so a lenghtening corporoplasty with dermal graft from groin was performed. We have adjusted the urethral meatus position into a proximal penile shaft. We used a buccal mucosa graft placed in an inverted U-shape position planning a second stage urethroplasty (1). An indwelling silicone Foley tube was left for one week. The patient was discharged the day after surgery. Results: The aspect after corporoplasty proved satisfactory curvature correction. Patient had an excellent outcome and is scheduled for a second-stage after 6 months. Discussion: Snodgrass and Bush (2) reported that on 73 patients with an average of 2.7 operations for proximal shaft to perineal hypospadias; of which, 83% had VC at re-operation averaging 50°. We do believe that some good results with minimal dorsal plicature may recur in adolescence and therefore when these procedures may be considered, they should be performed by classic Nesbit technique (3). Otherwise, the choice for primary ventral lengthening should be taken. Conclusion: Severe curvature associated with hypospadias should undergo a major procedure at early stage to avoid decompensation after dorsal plicature in adolescence. We had a very satisfactory result, the patient awaits the second stage procedure (Figure-1). Figure 1 End aspect after complete healing of buccal mucosa. Notice that penis is straight and second stage will be performed after 6 months of interval.

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ABSTRACT Introduction and Objective: Upper tract urothelial carcinoma (UTUC) represents 5% of all urothelial malignancies (1–3). Accurate pathologic diagnosis is key and may direct treatment decisions. Current ureteroscopic biopsy techniques include cold-cup, backloaded cold-cup and stone basket (4–6). The study objective was to compare a standard cold-cup biopsy technique to a novel cold-cup biopsy technique and evaluate histopathologic results. Materials and Methods: We developed a novel UTUC biopsy technique termed the “form tackle” biopsy. Ureteroscope is passed into ureter/renal collecting system. Cold-cup forceps are opened and pressed into the lesion base (to engage the urothelial wall/submucosal tissue) then closed. Ureteroscope/forceps are advanced forward 3-10mm and then extracted from the patient. We compared standard versus novel upper tract biopsy techniques in a series of patients with lesions ≥1cm. In each procedure, two standard and two novel biopsies were obtained from the same lesion. The primary study aim was diagnosis of malignancy. IRB approved: 21-006907. Results: Fourteen procedures performed on 12 patients between June 2020 and March 2021. Twenty-eight specimens sent (14 standard, 14 novel) (Two biopsies per specimen). Ten procedures with concordant pathology. In 4 procedures the novel biopsy technique resulted in a diagnosis of UTUC (2 high-grade, 2 low-grade) in the setting of a benign standard biopsy. Significant difference in pathologic diagnoses was detected between standard and novel upper tract biopsy techniques (p=0.008). Conclusions: The “form tackle” upper tract ureteroscopic biopsy technique provides higher tissue yield which may increase diagnostic accuracy. Further study on additional patients required. Early results are encouraging.

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ABSTRACT Introduction: Over the years, since Binder and Kramer described the first Robotic-assisted Radical Prostatectomy (RARP) in 2000, different Nerve-sparing (NS) techniques have been proposed by several authors (1). However, even with the robotic surgery advantages, functional outcomes following RARP, especially erection recovery, still challenge surgeons and patients (2, 3). In this scenario, we have described different ways and grades of neurovascular bundle preservation (NVB) using the prostatic artery as a landmark until our most recent technique with lateral prostatic fascia preservation and modified apical dissection (4-6). In this video compilation, we have illustrated the anatomical and technical details of different grades of NVB preservation. Surgical technique: After the anterior and posterior bladder neck dissection, we lift the prostate by the seminal vesicles to access the posterior aspect of the prostate. Then, we incise the Denonvilliers layers and work between an avascular plane to release the posterior NVB from 5 to 1 and 7 to 11 o'clock positions on the right and left sides, respectively6. In sequence, we access the prostate anteriorly by incising the endopelvic fascia bilaterally (close to the prostate) until communicating the anterior and posterior planes. Finally, we control the prostatic pedicles with Hem-o-lok clips and then proceed for the apical dissection preserving the maximum amount of urethra length and periurethral tissues. Considerations: Potency recovery following radical prostatectomy remains a challenge due to its multifactorial etiology. However, basic concepts for nerve-sparing are crucial to achieving optimal outcomes, such as minimizing the amount of traction used on dissection, avoiding excessive cautery, and neural preservation based on anatomical landmarks (arteries and planes of dissection).

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ABSTRACT Introduction: Tissue transfer has been used in urethral reconstruction for decades, and several grafts have been described (1, 2). The ideal graft would have optimal tissue characteristics and lead to minimal morbidity at the donor site. Urethroplasty using bladder mucosa was first described by Memmelaar in 1947 (3). The main limitation in using bladder mucosal grafts has been the invasiveness of open harvesting (4). We describe an endoscopic technique using Holmium: YAG laser to harvest bladder mucosal graft for substitution urethroplasty. Methodology: A 33-year-old male with no history of urethral instrumentation, trauma, or infection presented with obstructive lower urinary tract symptoms. On retrograde urethrogram a 6cm bulbar urethral stricture was identified. Several options were discussed, and the patient opted for a one-sided onlay dorsal urethroplasty (5) using a bladder mucosal graft. Equipment used to harvest the graft included an 18.5Fr continuous flow laser endoscope with a Kuntz working element (RZ) and a 60W Holmium Laser (Quanta) with 550μm laser fiber. The procedure was started by making a perineal incision, urethral mobilization and incision of the stricture segment. The laser endoscope was then introduced via the perineum. Settings of 0.5J, 30 Hz, and long pulse were used and a 7 x 2.5cm graft was harvested from the posterior bladder wall. Hemostasis of the harvest site was performed. The bladder mucosal graft was thinned in similar fashion to a buccal mucosal graft and sutured as per previously described techniques. Conclusion: Endoscopic Holmium Laser harvesting of bladder mucosal graft is feasible and may allow this graft to become an alternative to buccal mucosa. Further studies are required to define its role in urethral reconstruction.