Abstract in English:

ABSTRACT Purpose: Radical cystectomy (RC) is the standard of care for patients with bladder cancer, and pelvic lymph node dissection (PLND) is a pivotal step that can be carried out either before or after RC. Evidence on the optimal timing for PLND remains limited. Materials and Methods: We searched PubMed, Embase, Cochrane Central, Scopus and Google Scholar for studies comparing PLND before versus after RC. Outcomes assessed were total operative time, PLND time, RC time, number of lymph nodes (LN) dissected, and estimated blood loss. Mean differences (MDs) and 95% confidence intervals (CIs) were computed using a random-effects model. Subgroup analysis was conducted for robot-assisted RC (RARC). Results: A total of 801 patients from six studies were included, of whom 360 (44.94%) underwent PLND before RC. There were no significant differences in total operative time (MD −17.49; 95% CI −41.65,6.67; p = 0.16; I2 = 94%), PLND time (MD −14.91; 95% CI −44.91,15.09; p = 0.33; I2 = 96%), LN yielded (MD −1.13; 95% CI −4.81,2.55; p = 0.55; I2 = 83%), and estimated blood loss (MD 0.17; 95% CI −51.33,51.68; p = 0.99; I2 = 81%). However, RC time was significantly reduced (MD −28.89; 95% CI −42.84,-14.93; p < 0.0001; I2 = 75%) when PLND was performed prior to RC. In RARC studies, PLND before RC decreased total operative time, RC time, and estimated blood loss. Conclusions: The timing of lymphadenectomy was not associated with a significant reduction in total operative time, PLND time, LN yield, and estimated blood loss.

Abstract in English:

ABSTRACT Purpose: to review the more relevant aspects of urogenital tuberculosis (UGT) and make recommendations about the diagnosis and treatment. Materials and Methods: a literature review was conducted in the Pubmed, Embase and Scielo databases in search of studies on UGT in the past 60 years. A narrative review was performed concerning six topics of UGT diagnosis and treatment. Recommendations were made supported on degrees of evidence according to the modified GRADE system. Results: UGT suspicion occurs in persistent hematuria or pollakiuria with sterile pyuria; stenosis and/or thickening of the urinary tract; or chronic prostatitis or epididymitis. Urinary bacteriological tests have low sensitivity, and a negative test does not rule out UGT diagnosis. In ureteral stenosis, a double-J catheter or nephrostomy should be used early (up to 1 month) during pharmacological treatment and in single less than 2 cm stenosis endoscopic treatment may be attempted. Bladder augmentation with ileum, sigmoid or ileocecal segments should be performed when the contracted bladder capacity is less than 100 mL. Spontaneous voiding occurs in most patients after bladder augmentation. Conclusion: The diagnosis of UGT depends on a high degree of suspicion based on non-specific symptoms and radiological findings. Urinary bacteriological tests have low sensitivity, but even in the absence of diagnostic confirmation, treatment can be carried out through a combination of drugs for a period of six months. In the presence of ureteral stenosis or contracted bladder, complex but well stablished reconstruction procedures are necessary.

Abstract in English:

ABSTRACT Purpose: There is substantial literature demonstrating minimal to no increased risk of three-piece penile prosthesis (PP) complications for patients undergoing placement with concomitant reconstructive urologic procedures. However, there is a paucity of research investigating outcomes for patients suffering from erectile dysfunction (ED) who undergo concomitant non-reconstructive urologic procedures at the time of PP placement. Materials and Methods: We performed a retrospective review of patients undergoing PP placement and a second non-reconstructive urologic procedure performed concomitantly at our institution between January 2007 and July 2021. This was compared to a control cohort of 127 patients who underwent PP placement only. Outcomes of interest were complications and device infections. Comparative statistics were used to compare the two groups, and the Kaplan-Meier method was used to estimate the rate of complications and infections over time. Results: We identified 44 patients who underwent concomitant surgery and 127 patients who underwent single surgery only. The types of concomitant surgeries were as follows: 23 endoscopic (52.3%), 9 penile (20.5%), 10 scrotal (22.7%), 1 hardware placement (2.3%), and 1 oncologic (2.3%). Hypertension was the only comorbidity that was more prevalent in the concomitant group (65.9% vs. 43.8%, P<0.01). Patients undergoing concomitant surgery had similar complication (4.6% vs. 3.6%, P=0.79) and device infection (2.3% vs. 0.7%, P=0.43) rates as the single surgery group. Conclusions: In the largest study of its kind, we observed that patients undergoing concomitant non-reconstructive urologic procedures at the time of PP placement are not at an increased risk of adverse events.

Abstract in English:

ABSTRACT Purpose: Non-neurogenic overactive bladder (OAB) is a common problem in children. Antimuscarinics have been widely used as first-line medical treatment. However, their frequent side effects necessitate searching for therapeutic alternatives. We aimed to assess the efficacy and safety of the beta 3 agonist, mirabegron. Materials and Methods: A randomized controlled trial enrolled child with non-neurogenic OAB refractory to behavioral urotherapy. Patients were randomized to receive either Mirabegron 25/50 mg based on a 40-kg body weight cutoff or solifenacin 5 mg for 12 weeks. Patients were assessed using Dysfunctional Voiding Scoring System questionnaire (DVSS), 3-day voiding diary and uroflowmetry. Vital signs and adverse effects were recorded at baseline and follow-up. The study primary endpoint was ≥50% reduction of the baseline DVSS. Results: Among 128 patients screened, 72 patients (36 in each group) completed the study with a mean age of 9.2±2.3 years. Both groups had significant improvement of DVSS and voiding diary (p<0.001) at 12 weeks. In mirabegron group, 94.4% (34/36) had greater than 50% improvement of DVSS compared to 75% (27/36) of solifenacin group (P=0.02). Complete symptom resolution was observed in 22.2% (8/36) patients on mirabegron versus 8.3% (3/36) on solifenacin (P=0.1). Patients on mirabegron had less adverse effects (19.4% vs 47.2%; p=0.01). Conclusion: Mirabegron is more effective with fewer adverse effects than solifenacin for treatment of children with OAB. Mirabegron treatment improves daytime symptoms and nocturnal enuresis with less risk of constipation. It may be considered as first-line pharmacotherapy in this patient population.

Abstract in English:

ABSTRACT Purpose: Complications from testicular implantation in transgender men can cause significant distress, repeat visits to the emergency department, and require reoperation for explantation. Outcomes for these implants have not been well described in the literature. This study compares patient and surgery specific factors with complications from testicular implants in transgender men. Materials and Methods: We performed a retrospective review of patients who underwent testicular implantation. Surgery was standardized across patients with placement through incisions at the top of the labia majora or medially during metoidioplasty. Complication rates, including infection, erosion, migration, and pain requiring removal was compared with patient factors, including body mass index (BMI), smoking status, and implant size. Results: Of the 116 testicular implants, 12% had a complication requiring removal. The most common reason for removal was erosion of the prosthesis, which occurred in 6 instances. Migration was a relatively frequent complaint, with 10% of patients noting relocation of an implant. However, only 4 implants ultimately underwent reoperation for migration. Four implants caused enough pain to require reoperation. On logistic regression of BMI, age, smoking status, and immunocompromised state on removal of prosthesis, no factor was found to be a significant predictor of removal. Increasing implant size was not associated with an increased likelihood of removal. Conclusions: Complications after testicular implants in transgender men are not uncommon events. Although there appears to be a growing trend toward smaller prostheses in the literature, our data suggest that implant size is not a significant predictor of complications requiring prosthetic removal.

Abstract in English:

ABSTRACT Purpose: To evaluate the effect of real-time self-visualisation (SV) of the procedure during flexible cystoscopy (FC) on pain and anxiety in male and female patients with no prior cystoscopy history. Patients and Methods: Between Dec 2022-May 2024, 400 patients who underwent office-based FC were enrolled into prospective randomized study in accordance with CONSORT. Patients were randomised into two groups (SV and no-SV) using sequential (1:1 ratio) randomisation. To ensure equal numbers of male and female patients in each group, one consecutive male patient was assigned to the SV group, while the next male patient was assigned to the non-SV group; the same randomization was done for females. The primary endpoint was to evaluate the pain during FC (during urethral insertion of the cystoscope and bladder examination stages) of both groups. The secondary endpoint was to evaluate anxiety, patient satisfaction, and willingness to undergo the procedure of both groups. Results: In males, significant lower pain scores were detected in SV group during urethral insertion of the cystoscope (1.4 vs. 4.8, p<0.001) and during bladder examination (0.9 vs. 3.1, p<0.001). However, pain scores during urethral insertion of the cystoscope (1.9 vs. 2, p=0.38) and during bladder examination (1.2 vs. 1.3, p=0.63) were statistically similar between two groups in female patients. In both genders, significant lower anxiety levels, higher patient satisfaction and higher willingness to undergo repeat cystoscopy were detected in SV group. Conclusion: SV during FC may be beneficial in reducing pain in male patients but not in female patients. SV during FC has a positive effect on anxiety, patients’ satisfaction, and willingness to undergo repeat procedures, regardless of gender.

Abstract in English:

ABSTRACT Background: Different modalities of percutaneous thermal ablation (PTA) have been used as possible minimally invasive nephron-sparing treatments for small renal masses (SRMs). The present study aimed to compare long-term outcomes of two guidelines-recommended ablative techniques, cryotherapy (CRYO) and radiofrequency ablation (RFA). Materials and Methods: Data of patients with single cT1 solid renal mass undergoing CRYO or RFA between 2004 and 2020 were retrospectively retrieved from a multi-institutional international database. Oncologic outcomes included "technical success", local recurrence-free survival (RFS), distant metastasis-free survival (MFS), and overall survival (OS). Intraoperative and postoperative complications, length of stay (LOS), and re-admission rate within 30 days were registered. Major complications were defined as CD grade ≥III. Baseline features and treatment outcomes were analyzed using descriptive statistics. RFS, MFS, and OS were estimated using the Kaplan-Meier method. Results: Overall, 643 patients were included, of which 492 (71.2%) underwent CRYO, and 151 (21.8%) RFA, with a median follow-up of 43 and 37 months, respectively (p=0.07). Technical success was achieved in 96.5% of CRYO vs 93.4% of RFA (p=0.09). No difference in terms of overall (CRYO: 10.4% vs RFA: 6%; p=0.1) and "major" (CRYO: 0.8% vs RFA: 1.3; p=0.06) post-operative complications were observed. RFS (CRYO:85.7%; RFA:84.9%, p=0.2), MFS (CRYO: 96.9%; RFA: 95.8%, p=0.4) and OS (CRYO: 89%; RFA: 87.4%; p=0.8) were comparable. Conclusions: CRYO and RFA are both valid minimally invasive options for the treatment of small renal tumors. They are particularly suitable for patients who are not good surgical candidates as they offer very low risk of major procedure-related complications. For the right indication, they both offer favorable mid to long term oncologic outcomes.

Abstract in English:

ABSTRACT Purpose: The accurate diagnosis of prostate cancer (PCa) remains challenging, particularly because standard biopsy techniques do not routinely include anterior zone, leading to potential missed diagnoses in this region. This study evaluates the accuracy and safety of biplanar stereotactic biopsy for diagnosing anterior clinically significant PCa (csPCa). Materials and Methods: After propensity score matching analysis, data from 256 patients were retrospectively analyzed, including 128 in the biplanar group (transrectal targeted biopsy with transperineal systematic biopsy) and 128 in the monoplanar group (transperineal targeted biopsy with transperineal systematic biopsy). PCa detection rates, lesion locations, csPCa, clinically insignificant PCa (ciPCa), and complication incidences were compared. Univariable and multivariable logistic regression models evaluated factors influencing biopsy outcomes. Results: No significant differences were observed in overall PCa detection, ciPCa, posterior lesions, or postoperative complications between biplanar and monoplanar groups. The biplanar group demonstrated a higher detection rate for anterior csPCa (P=0.025). The overall International Society of Urological Pathology grade group (ISUP GG) distributions for Prostate Imaging Reporting and Data System (PI-RADS) scores 3 to 5 were not significantly different. Logistic regression identified age and PSA levels as independent predictors of higher detection rates, while univariable analysis showed that prostate volume had a significantly smaller effect on PCa detection rates in the biplanar group compared to the monoplanar group. Postoperative complications showed no statistically significant differences. Conclusions: In conclusion, biplanar stereotactic biopsy was superior to monoplanar biopsy in detecting anterior csPCa. Both methods demonstrated no significant differences in overall PCa detection rates and safety.

Abstract in English:

ABSTRACT Objective: The aim of this study is to evaluate the integrity and the microstructural characteristics of the bladder mucosa graft harvested using a minimally invasive technique with the Holmium laser (Ho-YAG) for the treatment of urethral stricture. Materials and Methods: We studied patients with urethral strictures greater than 2 cm, with a urethroplasty indication. The patients were submitted to urethroplasty with the dorsal onlay reconstruction by a single surgeon. After the urethral dissection we use the Ho-YAG laser with a 550µg end fire laser fiber to obtain a fragment of bladder mucosa for the graft confection. A fragment of the bladder mucosa was fixed in a 10% buffered formalin to HE and Masson's trichrome analysis for the tissue integrity. Five sections were stained, and five fields of each section were selected. We used the Image J software, version 1.46r, loaded with its own plug-in to determine tissue integrity. Results: We studied 11 patients (Mean age= 47.64); 9 (81.8%) with bulbar stricture and 2 (18.2%) with penile stricture (mean size = 4.63mm). The mean of bladder graft size was 53.64mm and the meantime of harvesting was 47.63 minutes. The histological study of the bladder wall graft showed an organization in accordance with normal standards, with the presence of an intact urothelium in the bladder graft. The submucosal layer is preserved, joining the detrusor to the urothelium and the collagen and elastic fibers are well organized. Conclusion: The graft harvested from the bladder uroepithelium using Ho-YAG has its histological integrity preserved, which makes this technique a viable option for reconstructive surgery. However, more studies are needed to establish its long-term efficacy and safety of this new technique.

Abstract in English:

ABSTRACT Background: In the last decade, several studies have proven the effectiveness of low-intensity shock waves (LI-ESWT), but with several factors that make it difficult to carry out systematic reviews. Aim: To demonstrate the effectiveness of LI-ESWT and define the best tool for routine clinical assessment of erectile dysfunction. Materials and Methods: Twenty-one participants with purely vasculogenic erectile dysfunction were selected and randomized to LI-ESWT or placebo. All patients underwent evaluation with The International Index of Erectile Function (IIEF-5), V-EHS (new visual scale), and standardized penile doppler ultrasound before and after shock wave therapy. Outcomes: LI-ESWT has proven effective in the treatment of moderate erectile dysfunction, and the new V-EHS has demonstrated greater accuracy than Doppler in the diagnosis and follow-up of erectile dysfunction. Results: Using the IIEF-5 as a control tool, we observed a clinical response after 1 month, with a greater increase in the shock wave therapy arm of +3.21 points compared to + 0.57 in the sham group. At six months, the treated group showed a mean increase of 4.71 points compared to baseline (p = 0.006), while those who received sham therapy had a decrease (case = +4.71 points vs. sham control = −1.0, p = 0.006). Based on this observed difference, we performed a comparative analysis between the V-EHS and penile doppler ultrasound to observe whether the test results corroborated the IIEF-5 findings. The correlation between V-EHS and IIEF-5 in the therapy group in the pre-therapy period was strong (r = 0.816, p < 0.001), and at 6 months it increased to very strong (r = 0.928, p < 0.001). Penile Doppler ultrasound did not show the same correlation strength with IIEF-5, presenting a moderate correlation at 6 months (Pearson correlation score = 0.540), as also demonstrated in the ROC curve through the V-EHS AUC = 0.963 (p = 0.001) vs. Doppler AUC = 0.713 (p = 0,290). Strengths and Limitations: The main strengths of the present study are the blinded, randomized, placebo-controlled clinical trial and the comparison between penile Doppler and a new visual classification for erection hardness score. The limitations are the number of patients and the short follow-up. Conclusions: LI-ESWT has proven effective in the treatment of moderate vasculogenic erectile dysfunction, with optimal results at 6 months. The new V-EHS offers a simple, reliable and reproducible assessment of erectile function.

Abstract in English:

ABSTRACT Introduction: Some endourological surgeries require multiple screens to perform combined procedures, which can present ergonomic challenges (1, 2). Apple Vision Pro (AVP) is a spatial computing device developed by Apple that incorporates virtual reality (VR) for life-like simulations, realistic medical scenarios, interactive anatomical models, and augmented reality (AR) technologies (3). In health care, VR is used for pain management, physical therapy, psychological therapy, and surgical simulations, providing a controlled and safe environment for both patients and healthcare professionals (4). Objective: To demonstrate the step-by-step technique of the Mini-Endoscopic Combined Intra-Renal Surgery (Mini-ECIRS) procedure guided by ultrasound and using mixed reality technology with the Apple Vision Pro (multiscreen and 3D reconstruction). To the best of our knowledge, this is the first report of this procedure being performed with AVP assistance. Patient and Methods: We present the case of a 40-year-old female with a history of right lumbar pain for one year. A CT scan revealed a proximal ureteral stone (20mm) and a lower pole stone (14mm) on the right side, with a Guys's Score grade 2 4. In this case, we opted for Ultrasound-Guided Mini-ECIRS (5, 6). This choice allowed for precise puncture and dilation, ensuring effective treatment and minimal invasiveness, assisted by the Apple Vision Pro. This device is equipped with eight external cameras that capture the real world at a resolution of 4K, enhancing the surgeon's experience with unparalleled efficiency and ease of mixed reality. This advanced imaging allows for precise visualization and integration of digital elements into the physical environment, significantly improving the accuracy and effectiveness of surgical procedures. During this procedure, the multitude of equipment in the operating room often obstructs the view of the physical monitors, including ultrasound. However, this technology addresses these challenges by offering enhanced ergonomics, efficiency, and safety to the surgeon. By providing seamless integration of digital overlays and real-world visuals, it ensures that crucial information is always within the surgeon's line of sight, thereby improving operational precision and overall outcomes. The surgeon had no previous contact with the AVP and was assisted by an AVP expert urologist throughout the procedure. Results: The procedure was performed in the Barts flank-free position. Initially, ureterolithotomy was performed using holmium laser. After the dusting phase, an ultrasound-guided renal puncture was performed using a virtual screen, providing enhanced comfort and ergonomics for the surgeon. Throughout the procedure, the surgeon had simultaneous access to both screens (nephroscope and flexible ureteroscope), facilitating efficient location of any residual stones. The AVP functioned effectively, displaying multiple screens within its own interface, improving ergonomics during surgery and maintaining safety throughout the procedure. The surgery was performed uneventfully in 2 hours, and the patient was rendered stone-free on CT and was discharged on the first postoperative day. Conclusion: Apple Vision Pro provides multiscreen and 3D reconstruction capabilities, ensuring a comfortable, safe, and easily replicable procedure. Its advanced technology may be particularly beneficial for surgeries, such as Mini-ECIRS, which require simultaneous screens.

Abstract in English:

ABSTRACT Objective: The current management for complex urethral strictures commonly uses open reconstruction with buccal mucosa urethroplasty. However, there are multiple situations whereby buccal mucosa is inadequate (pan-urethral stricture or prior buccal harvest) or inappropriate for utilization (heavy tobacco use or oral radiation). Multiple options exist for use as alternatives or adjuncts to buccal mucosa in complex urethral strictures (injectable antifibrotic agents, augmentation urethroplasty with skin flaps, lingual mucosa, bladder mucosa, colonic mucosa, and new developments in tissue engineering for urethral graft material) (1, 2). In the present video, we present a case where we used a new option of graft to treat urethral strictures: the L-Hydro® tissue treatment technology 100% aldehyde free, VIVENDI graft. Materials and Methods: The present study was approved according to the ethical standards of the hospital's institutional committee on experimentation with human beings. A 57 year-old male patient developed a urethral stricture due to prolonged use of a urinary catheter during a previous hospitalization. A cystourethrogram was performed, which revealed a stenosis of the penile urethra measuring 2.5 cm in length. Urethroplasty was proposed for the surgical treatment in this case. We used a longitudinal penile incision with a ventral sagittal urethrotomy in the penile stricture. A free VIVENDI graft was placed into the longitudinal incision in the dorsal urethra and fixed with interrupted suture as dorsal inlay. The ventral urethrotomy was closed over a 16Fr Foley catheter and the skin incision was then closed in layers. The patient will receive post-operative follow-up for 3 months for clinical assessment through symptoms, uroflowmetry, urethroscopy and residual urine volume after urination. Results: No intraoperative or postoperative complications occurred. The patient could achieve satisfactory voiding and no complication was seen during the three-month follow-up. Four weeks after surgery, he underwent urethroscopy, which revealed a good appearance of the urethra, with no stenosis or signs of infection. Conclusion: In the present case the use of bovine pericardium graft for the treatment of penile urethral stricture had a good result and can be an option to repair complex urethral strictures. However, the results presented require a larger population group in addition to multicenter studies with longer follow-up time to ensure the findings obtained.