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ABSTRACT Background Several studies have explored the impact of BMI on size and composition of urinary stones. Because there were controversies, a meta-analysis was necessary to be carried out to provide some evidence of the relationship of BMI and urolithiasis. Materials and Methods PubMed, Medline, Embase, Web of Science databases, and the Cochrane Library were searched up to August 12th 2022 for eligible studies. The urolithiasis patients were summarized into two groups: BMI < 25 and ≥ 25 kg/m2. Summary weighted mean difference (WMD), relative risk (RR) and 95% confidence intervals (CI) were calculated through random effects models in RevMan 5.4 software. Results A total of fifteen studies involving 13,233 patients were enrolled in this meta-analysis. There was no significant correlation of BMI and size of urinary stone (WMD -0.13mm, 95% CI [-0.98, 0.73], p = 0.77). Overweight and obesity increased the risk of uric acid stones in both genders and in different regions (RR=0.87, [95% CI] = 0.83, 0.91, p<0.00001). There was a higher risk of calcium oxalate stones formation in overweight and obesity group in total patients (RR=0.95, [95% CI] = 0.91, 0.98, p = 0.006). The relationship of BMI and calcium phosphate was not observed in this meta-analysis (RR=1.12, [95% CI] = 0.98, 1.26, p = 0.09). Sensitivity analysis was performed and indicated similar results. Conclusions The current evidence suggests a positive association between BMI and uric acid and calcium oxalate stones. It would be of great guiding significance to consider losing weight when treating and preventing urinary stones.

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ABSTRACT Objective The objective of the present study is to evaluate the anatomy of the inferior hypogastric plexus, correlating it with urological pathologies, imaging exams and surgeries of the female pelvis, especially for treatment of endometriosis. Material and Methods We carried out a review about the anatomy of the inferior hypogastric plexus in the female pelvis. We analyzed papers published in the past 20 years in the databases of Pubmed, Embase and Scielo, and we included only papers in English and excluded case reports, editorials, and opinions of specialists. We also studied two human fixed female corpses and microsurgical dissection material with a stereoscopic magnifying glass with 2.5x magnification. Results Classical anatomical studies provide few details of the morphology of the inferior hypogastric plexus (IHP) or the location and nature of the associated nerves. The fusion of pelvic splanchnic nerves, sacral splanchnic nerves, and superior hypogastric plexus together with visceral afferent fibers form the IHP. The surgeon’s precise knowledge of the anatomical relationship between the hypogastric nerve and the uterosacral ligament is essential to reduce the risk of complications and postoperative morbidity of patients surgically treated for deep infiltrative endometriosis involving the uterosacral ligament. Conclusion Accurate knowledge of the innervation of the female pelvis is of fundamental importance for prevention of possible injuries and voiding dysfunctions as well as the evacuation mechanism in the postoperative period. Imaging exams such as nuclear magnetic resonance are interesting tools for more accurate visualization of the distribution of the hypogastric plexus in the female pelvis.

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ABSTRACT Pheochromocytomas/paragangliomas (PPGL) are rare, metastatic, and potentially fatal neuroendocrine tumors, often neglected because they present symptoms similar to other prevailing clinical conditions such panic syndrome, thyrotoxicosis, anxiety, hypoglycemia, etc., delaying diagnosis and treatment. The rate of diagnosis of PPGL has been increasing with the improvement in the measurement of catecholamine metabolites and the expanding availability of imaging procedures. Its essential genetic nature has been extensively investigated, comprising more than 20 genes currently related to PPGL and more new genes will probably be revealed. This overview will shed some light on the clinical, laboratory, topographical, genetic diagnosis, and management of PPGL.

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ABSTRACT Purpose To evaluate the penile morphology after the isolated and combined administration of dutasteride and tamsulosin in a rodent model. Materials and Methods Forty male rats were assigned into the following groups: Control group (C, receiving distilled water, n=10); Dutasteride group (D, receiving 0.5 mg/Kg/day of dutasteride, n=10); Tamsulosin group (T, receiving 0.4 mg/Kg/day of tamsulosin, n=10); and Dutasteride associated with Tamsulosin group (DT, receiving both drugs n = 10). All drugs were administered via oral gavage. After 40 days, the animals were submitted to euthanasia and their penises were collected for histomorphometric analyses. Data were compared using one-way ANOVA followed by Bonferroni’s post-test, considering p<0.05 as significant. Results The sinusoidal space and smooth muscle fiber surface densities (Sv), and the cross-sectional penile areas of rats in groups D, T and DT were reduced in comparison to controls with the most notable reductions in the combined therapy group. The connective tissue and elastic system fibers Sv were augmented in groups D, T and DT in comparison with the control group, again with the most pronounced changes observed in animals receiving the combined therapy. Conclusion Both treatments with dutasteride or tamsulosin promoted penile morphometric modifications in a rodent model. The combination therapy resulted in more notable modifications. The results of this study may help to explain the erectile dysfunction observed in some men using these drugs.

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ABSTRACT Purpose To analyze the learning curve regarding complication rates of transrectal prostate biopsy (TRPB) versus transperineal prostate biopsy (TPPB), using real time software-based magnetic resonance imaging ultrasound (MRI-US) fusion techniques, along with first year experience of transperineal approach. Materials and Methods retrospective unicentric cohort study at a quaternary care hospital. Medical records of all consecutive patients that underwent TPPB between March 2021 and February 2022, after the introduction of MRI-US fusion device, and those who underwent TRPB throughout the entire years of 2019 and 2020 were analyzed. All complications that occurred as consequences of the procedure were considered. Descriptive statistics, Chi-squared and Fisher tests were used to describe complications and compare the two groups. Results A total of 283 patients were included in the transperineal group and 513 in the transrectal group. The analysis of a learning curve for the transperineal method showed lower complications rates comparing the first six months of TPPB procedures (group 1); The complication rate for TPPB was lower than that of TRPB (55.1% versus 81.9%, respectively; p<0.01). TPPB showed specifically lower rates of hematuria (48.8% versus 66.3%;p<0.001) and rectal bleeding(3.5% versus 18.1%; p<0.001). There were no cases of prostatitis after transperineal biopsies and three cases (0.6%) after transrectal procedures. Conclusions We evidenced the learning curve for performing the transperineal biopsy, with a lower rate of complications for the experienced team, after 142 cases after 6 months of practice. The lower complication rate of TPPB and the absence of infectious prostatitis imply a safer procedure when compared to TRPB.

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ABSTRACT Introduction We assessed the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) in patients with high comorbidity burden. Materials and methods Data from patients treated with HoLEP at our academic referral center from March 2017 to January 2021 were prospectively collected. Patients were divided according to their CCI (Charlson Comorbidity Index). Perioperative surgical data and 3-month functional outcomes were collected. Results Out of 305 patients included, 107 (35.1%) and 198 (64.9%) were classified as CCI ≥ 3 and < 3, respectively. The groups were comparable in terms of baseline prostate size, symptoms severity, post-void residue and Qmax. The amount of energy delivered during HoLEP (141.3 vs. 118.0 KJ, p=0.01) and lasing time (38 vs 31 minutes, p=0.01) were significantly higher in patients with CCI ≥ 3. However, median enucleation, morcellation and overall surgical time were comparable between the two groups (all p>0.05). Intraoperative complications rate (9.3% vs. 9.5%, p=0.77), median time to catheter removal and hospital stay were comparable between the two cohorts. Similarly, early (30 days) and delayed (>30 days) surgical complications rates were not significantly different between the two groups. At 3-month follow up, functional outcomes using validated questionnaires did not differ between the two groups (all p>0.05). Conclusions HoLEP represents a safe and effective treatment option for BPH also in patients with high comorbidity burden.

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ABSTRACT Purpose To evaluate the perioperative mortality and contributing variables among patients who underwent radical cystectomy (RC) for bladder cancer in recent decades, with comparison between modern (after 2010) and premodern (before 2010) eras. Materials and Methods Using our institutional review board-approved database, we reviewed the records of patients who underwent RC for primary urothelial bladder carcinoma with curative intent from January 2003 to December 2019. The primary and secondary outcomes were 90- and 30-day mortality. Univariate and multivariable logistic regression models were applied to assess the impact of perioperative variables on 90-day mortality. Results A total of 2047 patients with a mean±SD age of 69.6±10.6 years were included. The 30- and 90-day mortality rates were 1.3% and 4.9%, respectively, and consistent during the past two decades. Among 100 deaths within 90 days, 18 occurred during index hospitalization. Infectious, pulmonary, and cardiac complications were the leading mortality causes. Multivariable analysis showed that age (Odds Ratio: OR 1.05), Charlson comorbidity index ≥ 2 (OR 1.82), blood transfusion (OR 1.95), and pathological node disease (OR 2.85) were independently associated with 90-day mortality. Nevertheless, the surgical approach and enhanced recovery protocols had no significant effect on 90-day mortality. Conclusion The 90-day mortality for RC is approaching five percent, with infectious, pulmonary, and cardiac complications as the leading mortality causes. Older age, higher comorbidity, blood transfusion, and pathological lymph node involvement are independently associated with 90-day mortality.

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ABSTRACT Purpose Targeted biopsy (TB) combined with systematic biopsy (SB) is an optimized mode of prostate biopsy but can often lead to oversampling and overdiagnosis accompanied by potential biopsy-related complications and patient discomfort. Here, we attempted to reasonably stratify the patient population based on multi-parameter indicators with the aim of avoiding unnecessary SB. Methods In total, 340 biopsy-naïve men with suspected lesions, prostate-specific antigen (PSA) < 20 ng/mL and prostate imaging-reporting and data system (PI-RADS) ≥ 3 enrolled for study underwent both TB and SB. The primary outcome was to determine independent predictors for a valid diagnosis, assuming that only TB was performed and SB omitted (defined as mono-TB), taking TB + SB as the reference standard. The secondary outcomes were exploration of the predictive factors of mono-TB and TB + SB in detection of prostate cancer (PCa) and clinically significant PCa (csPCa). Results The mean PSA density (PSAD) of patient group was 0.27 ng/mL/mL. Multiparametric MRI PI-RADS scores were 3-5 in 146 (42.94%), 105 (30.88%), and 89 (26.18%) cases, respectively. PCa and csPCa were detected in 178/340 (52.35%) and 162/340 (47.65%) patients, respectively. Overall, 116/178 (65.17%) patients diagnosed with PCa displayed pathological consistencies between mono-TB and TB + SB modes. PSAD and PI-RADS were independent predictors of valid diagnosis using mono-TB. Conclusions PSAD combined with PI-RADS showed utility in guiding optimization of the prostate biopsy mode. Higher PSAD and PI-RADS values were associated with greater confidence in implementing mono-TB and safely omitting SB, thus effectively balancing the benefits and risks.

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ABSTRACT Objectives To evaluate the role of three-dimensional (3D) reconstruction in preoperative planning for complex renal tumors. Materials and Methods A well-planned questionnaire was distributed among the attending urologists at an international meeting. The questionnaire inquired about demographic data, surgical experience, partial nephrectomy (PN) versus radical nephrectomy (RN), surgical approach, time of ischemia, probability of postoperative urine leakage and positive surgical margins after viewing computed tomography (CT) scans and their respective 3D models of six complex renal tumors. Following the CT scans, attendees were asked to view randomly selected reconstructions of the cases. Results One hundred expert urologists participated in the study; 61% were aged between 40 and 60 years. Most of them (74%) were consultants. The overall likelihood of PN after viewing the 3D reconstructions significantly increased (7.1±2.7 vs. 8.0±2.2, p<0.001), the probability of conversion to RN significantly decreased (4.3±2.8 vs. 3.2±2.5, p<0.001), and the likelihood of urine leakage and positive surgical margins significantly decreased (p<0.001). Preference for the open approach significantly decreased (21.2% vs. 12.1%, p<0.001), while selective clamping techniques significantly increased (p<0.001). After viewing the 3D models, low expected warm ischemia time and estimated blood loss were significantly preferred by the respondents (p<0.001). Surgical decision change was significantly associated with performance or participation in more than 20 PNs or RNs annually [3.25 (1.98-5.22) and 2.87 (1.43-3.87), respectively]. Conclusions 3D reconstruction models play a significant role in modifying surgeons’ strategy and surgical planning for patients with renal tumors, especially for patients with stronger indications for a minimally invasive and/or nephron-sparing approach.

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ABSTRACT Purpose Horseshoe kidney (HSK) is the most common renal fusion anomaly, occurring in 0.25% of the population (1). It presents technical obstacles to pyeloplasty for ureteropelvic junction obstruction (UPJO) despite robotic assistance (2, 3). KangDuo-Surgical-Robot-01 (KD-SR-01), an emerging robotic platform in China, has yielded satisfactory outcomes in pyeloplasty (4, 5). We first describe our modified technique of robotic bilateral pyeloplasty for UPJO in HSK using KD-SR-01 system in the Lithotomy Trendelenburg position. Materials and Methods A 36-year-old man with HSK and bilateral UPJO suffered right flank pain due to renal calculi (Figure-1). Repeated double-J stent insertion and ureteroscopy lithotripsy did not relieve his symptoms. A robot-assisted modified bilateral dismembered V-shaped flap pyeloplasty was performed using KD-SR-01 system in the Lithotomy Trendelenburg position. Results Total operative time was 298 minutes with 50 ml estimated blood loss. There was no conversion to laparoscopic or open surgery. A follow-up of 14 months showed relieving symptoms and stable renal function. Cine magnetic resonance urography and computed tomography urography revealed improved hydronephrosis and good drainage. No intraoperative or postoperative complications occurred. Conclusions It is technically feasible to perform a KD-SR-01-assisted modified bilateral dismembered V-shaped flap pyeloplasty in the Lithotomy Trendelenburg position for HSK. This procedure achieves managing UPJO on both sides without redocking the system and provides a wider operative field. In addition, it may be associated with better ergonomics, better cosmetic outcomes, and less possibility of postoperative bowel adhesion. However, further investigation is still warranted to confirm its safety, efficacy, and advantages over traditional procedures.

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ABSTRACT Introduction Urolift® is a surgical modality to treat lower urinary tract symptoms (LUTS) in patients with enlarged prostates (1). However, the inflammatory process caused by the device usually displaces the prostate’s anatomical landmarks and challenges surgeons performing robotic-assisted radical prostatectomy (RARP). In this video, we will illustrate several technical challenges in patients with Urolift ® who underwent RARP. Material and Methods We performed a video compilation with several surgical steps illustrating key aspects and critical details of the anterior bladder neck access, lateral bladder dissection from the prostate, and posterior prostate dissection to avoid ureteral and neural bundles injuries. Results We perform our RARP technique with our standard approach in all patients (2 -6). The beginning of the case is performed like every patient with an enlarged prostate. We first identify the anterior bladder neck and then complete its dissection with Maryland and Scissors. However, extra care must be taken in the anterior and posterior bladder neck approach due to the clips found during the dissection. The challenge starts when opening the lateral sides of the bladder until the base of the prostate. It is crucial to perform the bladder neck dissection beginning at the internal plane of the bladder wall. Such dissection is the easiest way to recognize the anatomical landmarks and potential foreign materials, such as clips, placed during previous surgeries. We cautiously work around the clip to avoid using cautery on the top of the metal clips because energy is transmitted from one edge to the other of the Urolift ®. This can be dangerous if the edge of the clip is close to the ureteral orifices. The clips are usually removed to minimize cautery conduction energy. Finally, after isolating and removing the clips, the prostate dissection and subsequent surgical steps are continued with our conventional technique. Before proceeding, we ensure that all clips are removed from the bladder neck to avoid complications during the anastomosis. Conclusions Robotic-assisted radical prostatectomy in patients with Urolift ® is challenging due to modified anatomical landmarks and intense inflammatory processes in the posterior bladder neck. When dissecting the clips placed next to the base of the prostate, it is crucial to avoid cautery because energy conduction to the other edge of the Urolift ® can cause thermal damage to the ureters and neural bundles.

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ABSTRACT Introduction Main renal artery clamping and selective arterial clamping are two conventional devascularization methods for robot-assisted partial nephrectomy (RAPN) (1, 2). Decreasing warm ischemic (WI) time (3, 4) and improving clear surgical visualization (5) are the main surgically modifiable factors for RAPN, especially in large complex renal cancer (6). In this study, we described our surgical technique, focusing on gradual segmental artery unclamping on patients with large renal tumors. Material and methods Two patients (R.E.N.A.L score 10 and 11) underwent RAPN with gradual segmental artery unclamping (Figures 1 and 2). The unclamping included five key steps. First, all renal segmental arteries were identified as tumor feeding vessel(s) and the vessels for normal kidney parenchyma under the guidance of CT angiography (CTA) 3-division (3D) reconstruction. Second, all segmental arteries were isolated, and the feeding one(s) should be blocked before other arteries were blocked. Third, the tumor was resected outside the pseudocapsule, and the deep resection bed was sutured for initial hemostasis. Fourth, the segmental arteries were reopened except for the tumor feeding one(s), and normal kidney parenchyma restored blood supply. And fifth, the resection bed was completely sutured, and the feeding vessel supplying the tumor was opened after the suture. Warm ischemia time (WIT) was defined as the time measured between clamping and unclamping of the renal artery. WIT1 was the time for normal kidney parenchyma and WIT2 was the time for resection area. Patient demographics, perioperative variables, and warm ischemic time were included in our study. And we presented the details of gradual segmental artery unclamping in the video. Results In both cases, the total operation times were 215 and 130 mins for patient 1 and patient 2, respectively. WIT1 and WIT2 for patient 1 were 15 min and 33 min., and WIT1 and WIT2 for patient 2 were 21 min and 32 min, respectivelly. The maximum diameters of the masses resected were 10.8 and 7.3 cm, and surgical margins were negative. No patient had complications after operation. Preoperative and postoperative eGFR did not change significantly. Pre- and postoperative eGFR were 111 and 108 mL/min for patient 1, 91 and 83 mL/min for patient 2, respectively. Key hints for outcomes optimization during RAPN on patients with large complex renal tumors: 1) Each segmental renal artery is precised clamped before we excise the tumor, and an excellent surgical vision is essential for precising excision and shortening clamping time, 2) Other segmental renal arteries are unclamped except tumor feeding branch after suturing deep layer of parenchyma, and most normal parenchyma restores blood supply, 3) Preoperative high-resolution computed tomography angiography (CTA) and 3D reconstructive renal structure serve as a guide to clear the approach to find the tumor and segmental arteries (7, 8). Conclusions Gradual segmental artery unclamping is feasible and efficient to excise large complex renal cancer. Compared with main renal artery clamping, it can shorten the warm ischemic time of normal parenchyma; On the other hand, compared with selective segmental arterial clamping, the technique can reduce bleeding from the deep resection bed, keep a clear surgical vision, and decrease the incidence of positive margin.