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ABSTRACT Introduction: Urothelial carcinomas (UC) represent the sixth most common tumor by incidence, involving the lower or upper urinary tracts (UTUC) (1). High-risk patients should be treated by nephroureterectomy with complete bladder cuff excision (2), conservative approach is reserved for low-risk UTUCs and/or imperative cases (3). Materials and Methods: We present a 70-year-old male patient, smoker, with history of urothelial carcinoma. He underwent distal ureterectomy with ileal replacement in April 2019. Since then, he has developed several UTUC recurrences bilaterally and in the bladder, which have been treated conservatively. In August 2023, CT- scan showed multiple recurrences in the left kidney and ureter. Hence, on November 2023, we performed cystoscopy, monopolar resection of bladder tumor and bilateral flexible ureteroscopy (fURS) with pulsed thulium:YAG (p-Tm:YAG) ablation of the tumors. We performed a no-touch technique fURS with Video Uretero-Renoscope FLEX-XC1 by Storz. After this, we placed an ureteral access sheath and then a biopsy by using a tipless basket. The laser fiber used was 272 μm and the laser settings were 0.8 J – 10 Hz – Long pulse Ablation (10 W). Results: The pathological results showed UTUC bilaterally and high-grade UC in the bladder. Then, he underwent intravenous therapy with enfortumab - vedotin and the follow-ups, in February 2024 and June 2024, showed no evidence of recurrences at the multiple biopsies. Conclusion: The p-Tm:YAG laser can be considered a valid alternative option for the conservative treatment of UTUCs. With that said, stringent follow-up remains a mainstay in the conservative treatment of imperative cases of UTUC.

RENAL score has been validated on predicting adverse events and relapses in percutaneous treatments of renal lesions. To better fit interventional issues a modified score (mRENAL) has been introduced, but the only difference from the RENAL score is on the dimensional parameter. However, it remains of surgical derivation while a specific interventional score is missing. This study aims to obtain a specific score (ABLATE) to better quantify the risk of complications and relapses in percutaneous kidney ablation procedures compared to the existing surgical scores. Taking inspiration from previous papers, a score was built to quantify the real difficulties faced in percutaneous treatment of renal lesions. The ABLATE score was used on 71 cryoablations to evaluate its predictivity of complications and relapses. Logistic regression was used to predict complication incidence; Cox-regression was used for relapses; ROC analysis was used to evaluate the accuracy of the different scores. Between January 2014 and November 2019, 71 lesions in 68 patients were treated. Overall, malignant histology was found in 62 lesions (87.3%). Mean and median RENAL, mRENAL, and ABLATE scores were 7.04 and 7, 7.19 and 7, and 5.11 and 4, respectively. Out of 71 treatments, we experienced 3 bleeding with anemia (4.2%), only 2 of which needed further treatment (2.82%). The mean and median RENAL, mRENAL, and ABLATE scores in those with complications were 7.66 and 7.01 (p = 0.69), 8.0 and 7.1 (p = 0.54), and 6.6 and 5.0 (p = 0.38), respectively. Out of 62 malignant lesions, we experienced 2 persistent and 6 recurrent lesions (3.2% and 8.4%, respectively). At Cox-regression analyses, mABLATE score outperformed both RENAL and mRENAL scores in predicting recurrences (HR 1.48; p < 0.001 vs. 1.41; p = 0.1 vs. 1.38: p = 0.07, respectively). The ABLATE score showed to be a better predictor of relapses than RENAL and mRENAL. The small number of complications conditioned a lack of statistic power on complications for all the scores. At the moment to quantify the risks in percutaneous kidney ablation procedures, surgical scores are used. A specific score better performs this task.

Background Radiotherapy (RT) is a standard curative treatment for prostate cancer (PCa) and there is growing evidence of the high efficacy of moderate and ultra-hypofractionated RT. Reducing treatment duration to one week or less is a major advance, but very few studies have explored single-fraction therapy. This study evaluates the feasibility, safety, and efficacy of single-fraction stereotactic body RT (SBRT) while delivering the entire procedure in one day, with a potentially high benefit in terms of patient comfort and therapy cost and logistics. Methods This prospective, non-randomized monocentric trial uses Robotic Radiosurgery (CyberKnife v.7 system) to deliver a single 24 Gy fraction to the prostate (± seminal vesicles) with a “urethral sparing HDR-like” technique, and target tracking. The first phase will enroll 13 PCa patients following Simon’s optimal design. Treatment is to be stopped if ≥ 2 patients develop ≥ G3 toxicity (CTCAE v5.0) within a month from RT end; otherwise, 52 more patients will be added, totaling 65. To account for minimal drop-out, 5 extra patients will be enrolled, reaching 70. All procedures are performed in a single day, including fiducial implantation, imaging acquisition, contouring, planning, dosimetry quality control, and treatment. Apart from treatment feasibility in terms of one-month acute toxicity, secondary endpoints include late toxicity, biochemical and clinical control. Discussion Few others have investigated the 24 Gy single-fraction schedule using different delivery modalities (not including tracking), which has proved to be non-inferior to 5 fraction SBRT. Our approach aims to maintain (and possibly improve) the previously reported acute, subacute and late toxicity as well as disease control, adding evidence in favor of single-fraction delivery. Another significant goal of the study is the demonstration that all the complex treatment procedures can be safely delivered in a single day. This would be especially appealing for patients far from radiotherapy centers and those with work commitments not allowing daily hospital visits. The study of response to RT can also provide useful information about PCa radiobiology. Planned additional analyses may help in better assessing the clinical value of PSMA PET/CT in the selection of high-risk patients with true limited disease, and in identifying radiomic features associated to outcome. Trial registration : The study was prospectively registered at clinicaltrials.gov (NCT 05936736).

PurposeThere is currently no consensus regarding the optimal treatment strategy for patients presenting with synchronous bilateral renal masses. The decision to perform bilateral procedures on the same intervention or in staged procedures is debated. The aim of this manuscript is to analyse the outcomes of simultaneous robot-assisted partial nephrectomy (RAPN) in a series of patients with bilateral renal masses treated at five Italian robotic institutions.MethodsData from a prospectively maintained multi-institutional database on patients subjected to simultaneous RAPN between November 2011 and July 2019 were reviewed. RAPNs were performed with da Vinci Si or Xi surgical system by expert robotic surgeons. Baseline demographics and clinical features, peri- and post-operative data were collected.ResultsOverall, 27 patients underwent simultaneous bilateral RAPN, and 54 RAPNs were performed without need of conversion; median operative time was 250 minutes, median estimated blood loss was 200 mL. Renal artery clamping was needed for 27 (50%) RAPNs with a median warm ischemia time of 15 minutes and no case of acute kidney injury. Complications were reported in 7 (25.9%) patients, mainly represented by Clavien 2 events (6 blood transfusions). Positive surgical margins were assessed in 2 (3.7%) of the renal cell carcinoma. At the median follow-up of 30 months, recurrence-free survival was 100%.ConclusionOur data showed that, in selected patients and expert hands, simultaneous bilateral RAPNs could be a safe and feasible procedure with promising results for the treatment of bilateral synchronous renal masses.

Background and Objectives: To evaluate the oncological impact of squamous cell carcinoma (SCC) variant in patients submitted to intravesical therapy for non-muscle-invasive bladder cancer (NMIBC). Materials and Methods: Between January 2015 and January 2020, patients with conventional urothelial NMIBC (TCC) or urothelial NMIBC with SCC variant (TCC + SCC) and submitted to adjuvant intravesical therapies were collected. Kaplan–Meier analyses targeted disease recurrence and progression. Uni- and multivariable Cox regression analyses were used to test the role of SCC on disease recurrence and/or progression. Results: A total of 32 patients out of 353 had SCC at diagnosis. Recurrence was observed in 42% of TCC and 44% of TCC + SCC patients (p = 0.88), while progression was observed in 12% of both TCC and TCC + SCC patients (p = 0.78). At multivariable Cox regression analyses, the presence of SCC variant was not associated with higher rates of neither recurrence (p = 0.663) nor progression (p = 0.582). Conclusions: We presented data from the largest series on patients with TCC and concomitant SCC histological variant managed with intravesical therapy (BCG or MMC). No significant differences were found in term of recurrence and progression between TCC and TCC + SCC. Despite the limited sample size, this study paves the way for a possible implementation of the use of intravesical BCG and MMC in NMIBC with histological variants.

Purpose To analyze postoperative complications after laparoscopic radical cystectomy (LRC) and evaluate its risk factors in a large prospective cohort built by the ESUT across European centers involved in minimally invasive urology in the last decade. Methods Patients were prospectively enrolled, and data were retrospectively analyzed. Only oncologic cases were included. There were no formal contraindications for LRC: Also patients with locally advanced tumors (pT4a), serious comorbidities, and previous major abdominal surgery were enrolled. All procedures were performed via a standard laparoscopic approach, with no robotic assistance. Early and late postoperative complications were graded according to the modified Clavien–Dindo classification. Multivariate logistic regression was performed to explore possible risk factors for developing complications. Results A total of 548 patients were available for final analysis, of which 258 (47 %) experienced early complications during the first 90 days after LRC. Infectious, gastrointestinal, and genitourinary were, respectively, the most frequent systems involved. Postoperative ileus occurred in 51/548 (9.3 %) patients. A total of 65/548 (12 %) patients underwent surgical re-operation, and 10/548 (2 %) patients died in the early postoperative period. Increased BMI ( p  = 0.024), blood loss ( p  = 0.021), and neoadjuvant treatment ( p  = 0.016) were significantly associated with a greater overall risk of experiencing complications on multivariate logistic regression. Long-term complications were documented in 64/548 (12 %), and involved mainly stenosis of the uretero-ileal anastomosis or incisional hernias. Conclusions In this multicenter, prospective, large database, LRC appears to be a safe but morbid procedure. Standardized complication reporting should be encouraged to evaluate objectively a surgical procedure and permit comparison across studies.

Aim: To assess urologists’ proficiency in the interpretation of multiparametric magnetic resonance imaging (mpMRI). Materials and Methods: Twelve mpMRIs were shown to 73 urologists from seven Italian institutions. Responders were asked to identify the site of the suspicious nodule (SN) but not to assign a PIRADS score. We set an a priori cut-off of 75% correct identification of SN as a threshold for proficiency in mpMRI reading. Data were analyzed according to urologists’ hierarchy (UH; resident vs. consultant) and previous experience in fusion prostate biopsies (E-fPB, defined as <125 vs. ≥125). Additionally, we tested for differences between non-proficient vs. proficient mpMRI readers. Multivariable logistic regression analyses (MVLRA) tested potential predictors of proficiency in mpMRI reading. Results: The median (IQR) number of correct identifications was 8 (6–8). Anterior nodules (number 3, 4 and 6) represented the most likely prone to misinterpretation. Overall, 34 (47%) participants achieved the 75% cut-off. When comparing consultants vs. residents, we found no differences in terms of E-fPB (p = 0.9) or in correct identification rates (p = 0.6). We recorded higher identification rates in urologists with E-fBP vs. their no E-fBP counterparts (75% vs. 67%, p = 0.004). At MVLRA, only E- fPB reached the status of independent predictor of proficiency in mpMRI reading (OR: 3.4, 95% CI 1.2–9.9, p = 0.02) after adjusting for UH and type of institution. Conclusions: Despite urologists becoming more familiar with interpretation of mpMRI, their results are still far from proficient. E-fPB enhances the proficiency in mpMRI interpretation.

Prostate cancer (PCa) is a heterogeneous disease with a wide spectrum of aggressiveness. Evidence-based guidelines are invaluable but cannot be expected to be extensive enough to provide detailed guidance on the management of all patients. As such, the use of individualized, risk-adapted approaches to the management of PCa is indispensable. However, wide variation in treatment approaches observed for patients in practice suggests that there is an unmet need to improve the individualized approach towards patient care. A holistic approach that encompasses guidelines and evidence-based medicine could be used to guide individualized care for patients with PCa, from first contact through to final outcomes. As a result of an international expert meeting, this paper proposes this approach and highlights some of the factors that can be considered when aiming to identify patients’ profiles; individualize treatment; and improve communication between patients and the healthcare teams.

Introduction: Urothelial carcinomas (UC) represent the sixth most common tumor by incidence, involving the lower or upper urinary tracts (UTUC) (1). High-risk patients should be treated by nephroureterectomy with complete bladder cuff excision (2), conservative approach is reserved for low-risk UTUCs and/or imperative cases (3). Materials and Methods: We present a 70-year-old male patient, smoker, with history of urothelial carcinoma. He underwent distal ureterectomy with ileal replacement in April 2019. Since then, he has developed several UTUC recurrences bilaterally and in the bladder, which have been treated conservatively. In August 2023, CT- scan showed multiple recurrences in the left kidney and ureter. Hence, on November 2023, we performed cystoscopy, monopolar resection of bladder tumor and bilateral flexible ureteroscopy (fURS) with pulsed thulium:YAG (p-Tm:YAG) ablation of the tumors. We performed a no-touch technique fURS with Video Uretero-Renoscope FLEX-XC1 by Storz. After this, we placed an ureteral access sheath and then a biopsy by using a tipless basket. The laser fiber used was 272 pm and the laser settings were 0.8 J - 10 Hz - Long pulse Ablation (10 W). Results: The pathological results showed UTUC bilaterally and high-grade UC in the bladder. Then, he underwent intravenous therapy with enfortumab - vedotin and the follow-ups, in February 2024 and June 2024, showed no evidence of recurrences at the multiple biopsies. Conclusion: The p-Tm:YAG laser can be considered a valid alternative option for the conservative treatment of UTUCs. With that said, stringent follow-up remains a mainstay in the conservative treatment of imperative cases of UTUC.