ABSTRACT Introduction: The aim of the study was to investigate clinical and surgical factors associated with early catheter replacement in patients treated with Holmium Laser Enucleation of the Prostate (HoLEP). Materials and Methods: Data of patients treated with HoLEP at our Institution by a single surgeon from March 2017 to January 2021 were collected. Preoperative variables, including non-invasive uroflowmetry and abdominal ultrasonography (US), were recorded. Bladder wall modifications (BWM) at preoperative US were defined as the presence of single or multiple bladder diverticula or bladder wall thickening ≥5 mm. Clinical symptoms were assessed using validated questionnaires. Only events occurred within the first week after catheter removal were considered. Results: Overall, 305 patients were included, of which 46 (15.1%) experienced early catheter replacement. Maintenance of anticoagulants/antiplatelets (AC/AP) therapy at surgery (p=0.001), indwelling urinary catheter (p=0.02) and the presence of BWM (p=0.001) were more frequently reported in patients needing postoperative re-catheterization. Intraoperative complications (p=0.02) and median lasing time (p=0.02) were significantly higher in this group. At univariate analysis, indwelling urinary catheter (p=0.02), BWM (p=0.01), ongoing AC/AP therapy (p=0.01) and intraoperative complications (p=0.01) were significantly associated with early catheter replacement. At multivariate analysis, indwelling urinary catheter (OR: 1.28; p=0.02), BWM (OR: 2.87; p=0.001), and AC/AP therapy (OR: 2.21; p=0.01) were confirmed as independent predictors of catheter replacement. Conclusions: In our experience the presence of indwelling urinary catheter before surgery, BWM and the maintenance of AC/AP therapy were shown to be independent predictors of early catheter replacement after HoLEP.

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.

ABSTRACT Purpose: Robot-assisted partial nephrectomy (RAPN) is rapidly increasing its role in the nephron-sparing surgery setting (1). The recent introduction of technological advancements is leading more experienced surgeons to approach complex renal mass with a conservative intent (2, 3). In particular, three-dimensional reconstruction and the use of intraoperative ultrasonography are gaining attention as crucial tools to safely and effectively approach complex cases (4, 5). We aimed to video-report the management of highly complex renal mass treated with RAPN, focusing on preoperative surgical planning and intraoperative technical nuances. Materials and methods: A 73-year-old male patient was referred to our institution for an incidental detection of a 70 mm diameter, completely endophytic, hilar renal mass (PADUA score 13, RENAL score 11a). Contrast-enhanced CT scan images were processed by M3DICS (Turin, Italy) and used to obtain a 3D virtual model. RAPN was performed by a highly experienced surgeon using Da Vinci Si robotic platform with a three-arm configuration. Results: The overall operative time was 114 min, with a warm ischemia time of 16 min. No intraoperative or postoperative complications were recorded. According to the SIB score, the pure enucleation excision strategy was performed. Histopathological analysis revealed a pT3a low-grade oncocytic kidney tumor with negative surgical margins. with negative surgical margins. At 24-months follow up, no local or systemic recurrence was detected. Conclusions: Conservative management of complex renal masses is challenging with a highly nuanced decision-making process. In this regard, preoperative 3D models and intraoperative ultrasound (US) guidance play a pivotal role to develop a tailored surgical strategy according to patient’ and tumor's characteristics.

ABSTRACT Purpose: The expansion of technology is leading to a paradigm shift in several urological fields (1, 2). In particular, the adoption of lasers within the surgical treatment of patients with benign prostatic hyperplasia (BPH) is considered one of the most relevant innovations (3-5). In this video, we aimed to report our experience with holmium laser for the ablation of the prostate (HoLAP) in patients with obstructive lower urinary tract symptoms (LUTS) due to BPH. Materials and Methods: From 2018 to 2020, 10 patients with obstructive LUTS secondary to BPH were treated at our Institution with HoLAP (120W Holmium laser Lumenis® with Moses® technology). Main inclusion criteria were: 1) International Prostate Symptom Score ≥12; 2) prostate volume ≤65mL, 3) maximal flow rate (Qmax) ≤15ml/s at preoperative non-invasive uroflowmetry. Results: Mean patient age was 65 (range: 59-72) years. Preoperative mean prostate volume was 50 (range: 35-65) mL. Mean operative time was 66 (range: 45-85) minutes with a mean laser time/operative time ratio of 0.51 (range: 0.44-0.60). Voiding symptoms, Qmax and post voiding residual were significantly improved after 3 and 12 months (all p <0.05). No postoperative urinary incontinence was detected. Conclusions: The present findings suggest that HoLAP is a slightly time-spending procedure, thus its use should be limited to prostate volume <70-80mL. However, no postoperative complications were recorded at all. This technique showed to be a safe option in patients with low-intermediate prostate volume, also in patients whose antiaggregant/anticoagulant therapy is maintained.

ABSTRACT Purpose: Three-dimensional (3D) virtual models have recently gained consideration in the partial nephrectomy (PN) field as useful tools since they may potentially improve preoperative surgical planning and thus contributing to maximizing postoperative outcomes (1-5). The aim of the present study was to describe our first experience with 3D virtual models as preoperative guidance for robot-assisted PN. Materials and methods: Data of patients with renal mass amenable to robotic PN were prospectively collected at our Institution from January to April 2020. Using a dedicated web-based platform, abdominal CT-scan images were processed by M3DICS (Turin, Italy) and used to obtain 3D virtual models. 2D CT images and 3D models were separately assessed by two different highly experienced urologists to assess the PADUA score and risk category and to forecast the surgical strategy of the single cases, accordingly. Results: Overall, 30 patients were included in the study. Median tumor size was 4.3cm (range 1.3-11). Interestingly, 8 (26.4%) cases had their PADUA score downgraded when switching from 2D CT-scan to 3D virtual model assessment and 4 (13.4%) cases had also lowered their PADUA risk category. Moreover, preoperative off-clamp, selective clamping strategy and enucleation resection strategy increased from CT-scan to 3D evaluation. Conclusion: 3D virtual models are promising tools as they showed to offer a reliable assessment of surgical planning. However, the advantages offered by the 3D reconstruction appeared to be more evident as the complexity of the mass raises. These tools may ultimately increase tumor's selection for PN, particularly in highly complex renal masses. Disclosure of potential conflicts of interest: The authors declare they do not have conflict of interests. Informed consent: Informed consent was obtained from all individual participants included in the study. All the procedures were in accordance with the ethical standards of the institutional and national research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

ABSTRACT Purpose: The conservative management of localized renal masses has been recently widened to cT2 tumors showing encouraging functional and oncological outcomes (1). This video aims to report the conservative management of a highly complex renal tumor treated with robotic pure enucleation in our center, specifically focusing on preoperative work-up, video-reported surgical steps and perioperative outcomes. Materials and Methods: A 63 year-old lady underwent CT scan revealing a single 75 x 68mm, mainly endophytic, right renal mass dislocating the vascular pedicle (cT3a). Two renal arteries and two veins were identified. PADUA, RENAL and simplified SPARE scores were 14a, 12a and 12 respectively. Since the contralateral kidney was hypotrophic, the indication for nephron-sparing approach was considered absolute. Preoperative surgical planning included the employment of 3D-virtual models (2). Results: Operative time was 150 minutes and warm ischemia time was 25 minutes. No major complication occurred. Histopathological analysis revealed a cromophobe renal cell carcinoma with extension to perirenal fat tissue (pT3a). Resection technique was classified as pure enucleation since Surface-Intermediate-Base (SIB) score was 0-0-0 (3, 4). At seven-months follow-up no signs of local or systemic recurrence were recorded. Postoperative CT-scan revealed optimal parenchymal volume preservation with last creatinine blood level of 1.16mg/dL. Conclusion: This video highlights how, in experienced hands, robotic partial nephrectomy represents a feasible, effective treatment option for surgical management of highly complex renal tumors. The employment of intraoperative ultrasonography and 3D-virtual models allowed to accurately tailor surgical approach, improving the perception of tumor anatomy and its vascularization and maximizing perioperative outcomes.