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Objectives To compare surgical and functional outcomes between off‐clamp robot‐assisted partial nephrectomy with indocyanine‐green tumour marking through preliminary superselective embolization and on‐clamp robot‐assisted partial nephrectomy with intraoperative ultrasound identification of the renal mass. Material and methods One hundred and forty patients with a single renal mass underwent indocyanine‐green fluorescence‐guided off‐clamp robot‐assisted partial nephrectomy with preoperative superselective embolization (Group A, 70 patients) versus intraoperative ultrasound‐guided on‐clamp robot‐assisted partial nephrectomy without embolization (Group B, 70 patients). We assessed operative time, intraoperative blood loss, complications, length of stay, renal function, need for ancillary procedures and blood transfusions. Results Mean tumour size was 24 versus 25 mm in Group A versus Group B (p = 0.19). Mean operative time was 86.5 versus 121.8 min (p = 0.02), mean blood loss was 72.8 versus 214.2 mL (p = 0.02), and mean haemoglobin drop on postoperative day 1 was 1.1 versus 2.6 g/dL (p = 0.04) in Group A versus Group B. One‐month creatinine, hospital stay and enucleated tumour volume were comparable. Ten postoperative complications occurred in Group A (13.3%) and 11 in Group B (15.3%). Following superselective embolization, no patients required blood transfusions versus two patients in Group B. Postoperative selective renal embolization was needed in one case per group. Conclusions Preoperative superselective embolization of a renal mass with indocyanine‐green before off‐clamp robot‐assisted partial nephrectomy significantly reduces operative time and intraoperative blood loss compared to on‐clamp intraoperative ultrasound‐guided robot‐assisted partial nephrectomy. A longer follow‐up is needed to establish the effect on renal function.

Purpose A novel Ho: YAG laser generator incorporating Magneto pulse modulation technology has been developed to enhance lithotripsy performance. This study evaluates the safety and effectiveness of the Holmium: YAG Cyber Ho generator with Magneto technology (Quanta System ® ) for the endoscopic treatment of renal and ureteral stones. Materials and methods An observational multicentric study was conducted on 55 prospectively enrolled patients with ureteral and renal stones who underwent endoscopic lithotripsy using the new Ho: YAG laser with Magneto pulse modulation technology. Recorded parameters included stone volume, density, laser-on time (LOT), and laser settings optimized for Magneto use. Outcome metrics included ablation speed (mm³/s) and energy consumption (J/mm³), while the stone-free rate (SFR) and complication rate were also assessed. The perceived effectiveness of lithotripsy and retropulsion were evaluated using a 5-point Likert scale. Results Included patients had a median age of 57 years (IQR 48–65). The median stone volume was 948 mm³ (IQR 107–3091), and the median stone density was 900 HU (IQR 750–1105). Stones were located in the ureter in 21 cases (38%), in the lower calyx in 13 cases (24%), and in the upper/mid calyx in 21 cases (38%). The median laser-on time was 16 min (IQR 5–17). Laser settings showed consistent performance, with a median energy of 0.8 J (IQR 0.8–0.8), a frequency of 10 Hz (IQR 10–10), and an average power of 8 W (IQR 8–10). Lithotripsy performance was reflected by a median energy consumption of 14.8 J/mm³ (IQR 11.9–24.3) and an ablation speed of 0.6 mm³/s (IQR 0.4–0.7). The stone-free rate (SFR) was 94.5%. 3.6% of patients experienced Clavien-Dindo grade 1–2 complications, and no severe complications (grade 3–4) were reported. Subjective efficacy was rated as “outstanding” and “very good” in 58.2% and 36.4% of cases, respectively, while retropulsion was subjectively evaluated as “absent” and “very low” in 91.0% and 9.0% of cases, respectively. Conclusions Endoscopic treatment of renal and ureteral stones using the Cyber Ho generator with the new Magneto pulse modulation technology is safe and effective in this preliminary report. High ablation efficiency and a satisfying anti-retropulsion effect have been reported, potentially leading to faster treatment, higher stone-free rates (SFR), and a lower need for second-stage procedures. Further studies are required to fully evaluate this technology.

Purpose To assess differences in efficacy and safety between Thulium:YAG laser enucleation of the prostate (ThuLEP) and enucleation performed with the Holmium:YAG Cyber Ho laser generator (HoLEP) with Magneto technology (Quanta System ® ). Methods Patients with surgical indication for benign prostatic hyperplasia underwent ThuLEP using Cyber TM generator (Group A) versus HoLEP using Cyber Ho generator with Magneto technology (Group B). In Group A settings were 100W for enucleation and 35W for coagulation. In Group B early apical detachment and coagulation were performed with energy 1 J and frequency 30 Hz by applying Magneto technology. Enucleation was performed with energy 2 J and frequency 40 Hz by applying Virtual Basket pulse modulation. Results 200 patients were enrolled (100 patients per group). Preoperative features were comparable. Mean prostate size was 78.9 vs. 80.5 ml in Group A vs. B (p = 0.09). Mean operative time was 70.6 vs. 64.3 min (p = 0.13) with mean enucleation time 48.8 vs. 43.7 min (p = 0.21) and morcellation time 21.2 vs. 14.6 min (p = 0.03) in ThuLEP vs. HoLEP group. Micturition improvements were comparable. Postoperative gross haematuria was significantly more frequent after ThuLEP and clots-induced urinary retention occurred in 5.0% of cases, compared to no cases after HoLEP (p = 0.02). Conclusions HoLEP using the Cyber Ho generator with the application of Magneto technology for coagulation seems to provide an haemostatic advantage compared to ThuLEP, suggested by the significantly shorter morcellation time, higher morcellation efficiency and lower rate of postoperative gross haematuria and clots-induced urinary retention. Functional outcomes are comparable.

PurposeTo compare endoscopic enucleation of the prostate using a thulium: yttrium–aluminum–garnet (Tm:YAG) laser and a super-pulsed thulium fiber laser set in continuous-wave (CW) mode, and to evaluate whether theoretical advantages of thulium fiber lasers, related to their shorter wavelength, translate into relevant clinical differences.MethodsIn total, 110 patients suffering from lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia were randomized to undergo either thulium:YAG laser enucleation of the prostate (ThuLEP) or CW thulium fiber laser enucleation of the prostate (CW-ThuFLEP). Intraoperative and postoperative variables and complications were compared. Micturition improvement was assessed at 3-month follow-up using the International Prostate Symptom Score (IPSS), post-void residual urine (PVR) and maximum flow rate (Qmax). Erectile function was evaluated using the International Index of Erectile Function-5 (IIEF-5).ResultsNo significant differences between the ThuLEP and CW-ThuFLEP groups were found in terms of operative time (70.69 vs 72.41 min), enucleation time (50.23 vs 53.33 min), enucleated tissue weight (40.2 vs 41.9 g), enucleation efficiency (0.80 vs 0.79 g/min), catheterization time (2.45 vs 2.57 days), hospital stay (2.82 vs 2.95 days) and hemoglobin drop (1.05 vs 1.27 g/dl). At 3-month follow-up, no significant differences were found in IPSS (5.09 vs 5.81), Qmax (26.51 vs 27.13 ml/s), PVR (25.22 vs 23.81 ml) and IIEF-5 (14.01 vs 14.54).ConclusionThuLEP and CW-ThuFLEP were equivalent in relieving patients from LUTS and improving micturition. Theoretical advantages of the TFL, such as shallower penetration depth and improved vaporization capacity, did not translate into relevant perioperative outcomes or clinical differences.

PurposeThe purpose of the study was to assess the diagnostic accuracy of ADC ratio and to evaluate its efficacy in reducing the number of false positives in prostatic mpMRI.Materials and methodsAll patients who underwent an mpMRI and a targeted fusion biopsy in our institution from 2016 to 2021 were retrospectively selected. Two experienced readers (R1 and R2) independently evaluated the images, blindly to biopsy results. The radiologists assessed the ADC ratios by tracing a circular 10 mm2 ROI on the biopsied lesion and on the apparently benign contralateral parenchyma. Prostate cancers were divided into non-clinically significant (nsPC, Gleason score = 6) and clinically significant (sPC, Gleason score ≥ 7). ROC analyses were performed.Results167 patients and188 lesions were included. Concordance was 0.62 according to Cohen’s K. ADC ratio showed an AUC for PCAs of 0.78 in R1 and 0.8 in R2. The AUC for sPC was 0.85 in R1 and 0.84 in R2. The 100% sensitivity cut-off for sPCs was 0.65 (specificity 25.6%) in R1 and 0.66 (specificity 27.4%) in R2. Forty-three benign or not clinically significant lesions were above the 0.65 threshold in R1; 46 were above the 0.66 cut-off in R2. This would have allowed to avoid an equal number of unnecessary biopsies at the cost of 2 nsPCs in R1 and one nsPC in R2.ConclusionIn our sample, the ADC ratio was a useful and accurate tool that could potentially reduce the number of false positives in mpMRI.

PurposeWe performed a prospective randomized comparison among Retrograde IntraRenal Surgery (RIRS) and MiniPerc (MP) for stones between 10 and 20 mm to evaluate outcomes with the same laser device: Fiber Dust.MethodsPatients with a single renal stone between 10 and 20 mm were randomized to RIRS (Group A) versus MP (Group B). Exclusion criteria were age < 18 or > 75, presence of acute infection, coagulation impairments, cardiovascular or pulmonary comorbidities. In both groups, the Fiber Dust laser was used. A CT scan after 3 months was performed. A negative CT scan or asymptomatic patients with stone fragments < 3 mm and a negative urinary culture were the criteria to assess the stone-free status. A statistical analysis was carried out to assess success, complication and retreatment rates and need for auxiliary treatments.ResultsBetween January 2021 and January 2022, 186 patients were enrolled (90 in Group A and 96 in Group B). Mean stone size was 15.8 mm and 14.9 mm in Group A and B, respectively (p = 0.23). The overall stone-free rate (SFR) was 73.3% for Group A and 84.4% for Group B. A higher SFR was reached for upper calyceal stones in Group A (90.4%) lower calyceal stones in Group B (91.6%). Retreatment rate (p = 0.31) and auxiliary procedure rate (p = 0.18) were comparable. Complication rate was 5.5% and 5.2% for Groups A and B, respectively.ConclusionsRIRS and MP are both effective to obtain a postoperative SFR with Fiber Dust. According to the stone position one treatment is superior to the other one.

Purpose To assess differences in safety and efficacy between 24 and 18 Fr pneumatic balloon dilators for percutaneous nephrolithotripsy (PCNL) of renal stones between 10 and 20 mm. Methods Patients were randomized to dilatation with a 24 Fr (Group A) versus 18 Fr (Group B) Ultraxx pneumatic dilator (Cook Medical ® ). In all procedures percutaneous puncture was performed under ultrasound guidance. In both groups the Holmium: YAG Cyber Ho laser generator was used (Quanta System ® ). Stone-free rate (SFR) and postoperative complications were assessed. Results 42 and 44 patients were assigned to Groups A and B, respectively. Preoperative features were comparable. Mean stone size was 17.8 vs. 16.6 mm in Group A vs. B ( p  = 0.21). SFR was 95.2% in Group A and 95.4% in Group B ( p  = 0.19). Postoperative gross haematuria was observed in 5 vs. 2 cases in Group A vs. B ( p  = 0.04). Mean haemoglobin drop at first postoperative day (POD) was higher in Group A (2.4 vs. 1.1 mg/dl, p  = 0.04), while comparable at third POD. Blood transfusion was required in 2 cases in Group A and 1 case in Group B. No patients required embolization. No significant difference was observed in terms of postoperative pain and urinary infection. Conclusions 24 and 18 Fr pneumatic dilators are both effective to access renal cavity during PCNL for the treatment of renal stones between 10 and 20 mm. Gross haematuria rate and mean haemoglobin decrease at first POD were significantly higher with 24 Fr dilator, but with no differences in the need for blood transfusions and renal embolization.

Purpose To compare the effect on sexual function of ejaculation-sparing enucleation of the prostate using Thulium: YAG laser (ES-ThuLEP) versus continuous-wave Thulium Fiber Laser (ES-ThuFLEP). Methods 112 patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia who wished to preserve ejaculation were treated. 58 patients underwent ES-ThuLEP (Group A) using the Cyber TM generator. 54 patients underwent ES-ThuFLEP (Group B) using the Fiber Dust generator. Sexual function was evaluated through the International Index of Erectile Function 5 (IIEF-5) score, the four-item Male Sexual Health Questionnaire (MSHQ-EjD), personal satisfaction and the occurrence of haemospermia and painful ejaculation 3 and 6 months after surgery. Results Mean age of patients was 65.8 years in Group A and 66.7 years in Group B. Groups were comparable according to preoperative features. Mean preoperative IIEF-5 score was 18.8 in Group A and 17.9 in Group B ( p  = 0.14). In all cases an ejaculation-sparing procedure was performed sparing the tissue around the veru montanum and near the prostate apex. Three months after surgery mean IIEF-5 score was 19.3 in Group A and 18.0 in Group B ( p  = 0.12). Six months after surgery mean IIEF-5 score was 17.8 in Group A and 18.1 in Group B ( p  = 0.09). No significant differences were observed according to anterograde ejaculation (81.0% vs. 81.5%, p  = 0.07), subjective satisfaction (72.4% vs. 74.1%, p  = 0.10), painful ejaculation (10.3% vs. 11.1%, p  = 0.14) and haemosparmia rate (12.1% vs. 14.8%, p  = 0.08). Ejaculation and satisfaction rate were significantly higher with prostates ≥ 80 ml in both groups. Conclusion Ejaculation-sparing enucleation of the prostate effectively preserved sexual function in the majority of patients, with high rate of anterograde ejaculation and subjective satisfaction, low rates of painful ejaculation and haemospermia and no significant differences between Thulium: YAG and Thulium Fiber Laser. Preservation of ejaculation and personal satisfaction were significantly higher with prostates ≥ 80 ml compared to smaller ones.

Purpose To compare vapor tunnel (VT) and virtual basket (VB) tools to reduce retropulsion in the treatment of proximal ureteral stones. Methods Patients with a single proximal ureteral stone were randomly assigned to holmium laser lithotripsy with the use of VT (Group A) or VB (Group B) tool. The 150W holmium:YAG cyber Ho generator was used. We compared operative time, dusting time, need for flexible ureteroscopy due to stone push-up and occurrence of ureteral lesions. The stone-free rate (SFR) and the occurrence of postoperative ureteral strictures were assessed. Results 186 patients were treated, of which 92 with the VT (49.5%, Group A) and 94 with the VB (50.5%, Group B). Mean stone size was 0.92 vs. 0.91 cm in Groups A vs. B ( p  = 0.32). Mean total operative time and dusting time were comparable between groups. 7 (7.6%) vs. 6 (6.4%) patients in Groups A vs. B required a flexible ureteroscope because of stone push-up ( p  = 0.12). Ureteral mucosa lesions were observed in 15 (16.3%) vs. 18 (19.1%) cases in the VT vs. VB group ( p  = 0.09). 1-Month SFR was comparable (97.8% vs. 95.7%, p  = 0.41). We observed one case (1.1%) of postoperative ureteral stricture in the VT group vs. two cases (2.1%) in the VB group ( p  = 0.19). Conclusions VT and VB are equally safe and effective tools in reducing retropulsion of ureteral stones. Operative time, dusting time and SFR were comparable. They also equally avoided stone push-up and prevented ureteral lesions, which may later occur in ureteral strictures.

According to European Association of Urology (EAU) guidelines, Bosniak I and II cysts do not require treatment or follow-up because of their benign nature [4]. Clear cell papillary RCC (ccpRCC) represents a histological subtype with indolent behaviour recently added to the World Health Organization classification of renal tumours. The aim of our study is therefore to increase evidence on the association between Bosniak IV class and favourable pathology, supporting the role of surgery as a definitive treatment and potentially suggesting the need for a low-intensity follow-up. A preoperative contrast-enhanced computed tomography (CT) scan or magnetic resonance imaging (MRI) was performed to assess size, location and features of the cyst.