Advances in Urological Diagnosis and Imaging - AUDI (Vol. 5 - n. 1 - 2022)

IN

AND IMAGING

Official Journal of S.I.E.U.N.

EDITOR in CHIEF

Andrea B. Galosi, Ancona (IT)

CO-EDITOR

Pasquale Martino, Bari (IT)

ASSISTANT EDITOR

Lucio Dell’Atti, Ancona (IT)

ASSISTANT EDITOR JUNIOR

Carlo Giulioni, Ancona (IT)

EDITOR

Luigi Napolitano, Napoli (IT)

EDITORIAL BOARD

Urology

Ahmed Hashim, London (GB), Artibani Walter, Verona (IT) Battaglia Michele, Bari (IT), Bucci Stefano, Trieste (IT) Carini Marco, Firenze (IT), Carrieri Giuseppe, Foggia (IT)

De Nunzio Cosimo, Roma (IT), Fandella Andrea, Treviso (IT)

Ficarra Vincenzo, Messina (IT), Finazzi Agrò Enrico, Roma (IT)

Franzese Corrado, Nola (IT), Gunelli Roberta, Forlì (IT) Kastner Christof, Cambridge (GB), Lapini Alberto, Firenze (IT) Miano Roberto, Roma (IT), Mirone Vincenzo, Napoli (IT) Montorsi Francesco, Milano (IT), Morgia Giuseppe, Catania (IT) Muller Stefan, Bonn (GE), Palazzo Silvano, Bari (IT) Pavlovich Christian, Baltimore, Maryland (USA) Pepe Pietro, Catania (IT), Rocco Bernardo, Modena (IT) Salomon George, Hamburg (GE) Schiavina Riccardo, Bologna (IT), Scattoni Vincenzo, Milano (IT) Volpe Alessandro, Novara (IT), Waltz Joachen, Marseille (FR)

Andrology

Bettocchi Carlo, Bari (IT), Bitelli Marco, Roma (IT) Cai Tommaso, Trento (IT), Cormio Luigi, Foggia (IT) Fusco Ferdinando, Napoli (IT), Gontero Paolo, Torino (IT) Liguori Giovanni, Trieste (IT), Lotti Francesco, Firenze (IT) Pizzocaro Alessandro, Milano (IT), Trombetta Carlo, Trieste (IT)

Nephrology

Boscutti Giuliano, Trieste (IT), D’Amelio Alessandro, Lecce (IT) Fiorini Fulvio, Rovigo (IT), Gesualdo Loreto, Bari (IT) Granata Antonio, Agrigento (IT), Ranghino Andrea, Ancona (IT)

Radiology

Barozzi Libero, Bologna (IT), Bertolotto Michele, Trieste (IT) Giuseppetti Gian Marco, Ancona (IT) Giovagnoni Andrea, Ancona (IT), Valentino Massimo, Tolmezzo (IT)

Pathology

Beltran Antonio Lopez, Lisbon (PT), Fiorentino Michelangelo, Bologna (IT) Liang Cheng, Indianapolis (USA), Montironi Rodolfo, Ancona (IT)

Bio-Medical Engineering

Wijkstra Hessel, Eindhoven (NL)

General Information

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Contents

1 Functional outcomes of robot-assisted pudendal nerve neurolysis: results from a tertiary referral center

Carlo Giulioni, Giulia Garelli, Andrea Benedetto Galosi, Richard Pierre Gaston, Grégory Pierquet

7

Needle biopsy of renal mass: results of single center experience

Andrea Benedetto Galosi, Marco Macchini, Roberto Candelari, Virgilio De Stefano, Silvia Stramucci, Vincenzo Di Benedetto, Gabriele Gagliardini, Vanessa Cammarata, Andrea Cicconofri, Carlo Giulioni

12 Is ultrasound useful in a doubt of Fournier’s gangrene? Lesson learned from a case report

Ofir Maltzman, Carlo Brocca, Carmine Franzese, Anna Campanati, Andrea Marani, Andrea Benedetto Galosi

15

Flexible guide as landmark of bladder diverticulum during a robotic assisted diverticulectomy

Achille Aveta, Savio Domenico Pandolfo, Luigi Napolitano, Gianluca Spena, Claudia Rosati, Ciro Imbimbo, Vincenzo Mirone, Lorenzo Spirito

17 New devices for management of upper urinary tract lithiasis

Carlo Giulioni, Virgilio De Stefano

20 SIU National Congress 2021 Technological news in endourology of the upper urinary tract: from double J to the new laser Carlo Giulioni

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Advances in Urological Diagnosis and Imaging - 2022; 5, 1

Functional outcomes of robot-assisted pudendal nerve neurolysis: results from a tertiary referral center

Carlo Giulioni ¹, Giulia Garelli ², Andrea Benedetto Galosi ¹, Richard Pierre Gaston ³, Grégory Pierquet ³.

¹ Department of Urology, Azienda ospedaliero universitaria Ospedali Riuniti di Ancona, Univeristà Politecnica delle Marche, Ancona (Italy);

² Department of Urology, ASST FBF Sacco, Milano (Italy);

³ Urology Department, Clinique Saint Augustin, Bordeaux, (France).

SUMMARY

Objective. Pudendal Nerve Entrapment Syndrome can cause chronic pelvic pain and discomfort associated with symptoms related to its innervation area. This study aimed to report the postoperative outcomes of a consecutive series of patients submitted to robot-assisted pudendal nerve neurolysis (rPNN).

Methods. The patients who met the Nantes criteria and were treated with robotic rPNN in our center from January 2016 to July 2021 were included. Cases of organic natures were excluded.

Results. 32 patients with a median duration of symptoms of 7 (5,5-9) years and a median preoperative Numeric Pain Rating Scale (NPRS) of 8 (8-9) underwent rPNN. The median operative time was 74 (65-83) mins. The median length of stay was 1 (1-2) days, and there was only a minor complication (postoperative pain relieved by analgesics). After 3-months, a partial reduction of NPRS, 5 (range 5-6; p<0.001) and "minimal improvement” score according to the Patient Global impression of Change (PGIC) scale, 3 (2-3), occurred. At a 6-months follow-up visit, a further decrease in NPRS was reported, 4 (range 3-5; p<0.001), and self-rated suc cess was reported by patients, with a median "much improvement" rank of PGIC scale of 2 (1-2). Furthermore, the Pearson cor relation coefficient reported a negative relationship between the duration of pain and the improvement in NPRS score, -0.81 (p=0.01).

Conclusion. rPNN showed to be efficace in patients with pudendal neuralgia. Surgical treatment should be performed promptly to achieve better outcomes.

INTRODUCTION

Pudendal neuralgia is a rare clinical condition of chronic perineal pain caused by the perpetual microtrauma to the pudendal nerve, with its consequent damage or irritation. Patients describe most frequently burning sensation, although tingling, stabbing, and twitching may also be reported. Symptoms are usually exacerbated in sitting posi tion and relieved when standing or in recumbent position (1). The etiology is multifactorial and usually related to a direct or chronic trauma (prolonged sitting or repetitive hip flexion), viral infection, or pelvic radiotherapy or postsurgery (2). Pudendal neuropathy is a tunnel syndrome with nerve entrapment, which may occur below the piri formis muscle, at the entrance of the Alcock canal, or at the level of its branches. In most cases, it may develop between the sacrotuberous and sacrospinous ligaments (3).

Therefore, depending on the interested area, there may be a variety of clinical presentations, depending where the nociceptive stimuli affect different regions, such as the penis, scrotum, labia, perineum, and anorectal region (4). The incidence of this chronic perineal pain syndrome is unclear: according to International Pudendal Neuropathy, 1 case per 100000 of the general population occurs (5). Moreover, pudendal neuralgia seems to have a wider dif fusion, especially in men: 11% of American men reported prostatitis-like pain, and most men diagnosed with chronic prostatitis have no evidence of bacterial infection or inflammatory cells in prostatic fluid (6). Given the absence of pathognomonic radiological or electrophysiological findings, the diagnosis of Pudendal Nerve Entrapment is clinical and exclusionary, and then its nature (mechanical, inflammatory or mixed) is investigated.

Due to the low success rate of medical therapy, Robert et

KEY WORDS: Pudendal Nerve Entrapment; Neurolysis; Robotic surgery; Pudendal nerve decompression.

al. devised pudendal nerve neurolysis (PNN) for the first time in 1993 (7). According to the latest European Association of Urology (EAU) guidelines, pudendal nerve decompression is recommended in case of entrapment or injury, especially in patients with pain for less than six years (8). Several approaches were described, as trans gluteal, trans ischiorectal, transperineal, and laparoscopic. Due to the diffusion of the da Vinci surgical system, the robotassisted technique was proposed for PNN, although there is currently no case series documenting its efficacy. Therefore, this study aimed to show the feasibility and effi cacy of robotic (r) PNN in patients suffering from puden dal nerve entrapment.

MATERIALS AND METHODS

PATIENTS

An retrospective review of patients who underwent rPNN between January 2016 and July 2021 was conduct ed. Patients eligible for our dataset had chronic perineal pain associated symptoms, which lasted for more than 6months. Patients with a diagnosis of organic pathologies, such as abscess, fistula, infections, or tumor, were excluded. Surgery was offered after ineffectiveness of medical ther apy and/or pudendal nerve infiltration. Only patients who met the Nantes criteria were included (9). They are based on five elements for proper diagnosis: i) painful symptom in the territory of innervation of the pudendal nerve; ii) worsening of pain in the sitting position; iii) the absence of awakenings for pain during the night; iv) no sensory impairment on physical examination; v) pain relief after Pudendal Nerve Block.

Pain characteristics were obtained from reviews of history and physical examinations, comprehending its primary site, side, Numeric Pain Rating Scale (NPRS), and symptoms duration. We gathered the following data: surgical time (OT), console time (CT), length of stay, and postoperative complications. The latter was ranked according to ClavienDindo Classification (CD) (10). Regarding the follow-up, the first and second visits took place 3 and 6 months after surgery, respectively. To assess the “quality” of rPNN, NPRS was collected at each visit. Patient Global impression of Change (PGIC) was also recorded. The latter is a scale with a range of 1-7 and consists of classifying the patient into three categories based on the change since the first visit: improvement in symptoms (0-3 points), stable disease (4 points) or pain worsening (5-7 points). Data collection followed the principles of the Declaration of Helsinki and its amendments. This study was conducted retrospectively, collecting data obtained for daily clinical practice, and all the procedures were performed as part of routine care.

SURGICAL TECHNIQUE

Under general anesthesia, the patient is placed in dorsal decubitus. A sub-umbilical incision is made, and a Veress needle is inserted for abdominal insufflation. Then, the 8 mm optical trocar is positioned, and the abdominal cavity is explored. Subsequently, the patient is placed in the

Trendelenburg position, with a 30° of inclination. Two robotic trocars in the left latero-umbilical region and one robotic trocar in the right iliac fossa are placed, and an assistant 5 mm trocar in the latero-umbilical area is positioned. The peritoneum is incised laterally to the umbilical artery. The dissection continues into the plane between the bladder and the ilio-obturator fossa up to the pelvic floor (Figure 1A). The obturator vessels and the ischial spine are individualized. The sacrospinous liga ment is incised at the level of the obturator vessels, per forming an exsanguinated dissection ( Figure 1B ). The coccygeal bundle of the levator ani is dissected close to the bone edge of the ischial spine (Figure 1C). The final step of the decompression consists of the section of the Alcock’s canal to free the pudendal nerve completely (Figure 1D). In the case of bleeders, hemostasis is guar anteed with 5-mm metallic clips. Once released, the medi al transposition of the nerve is performed (Figure 1E).

Figure 1. Left pudendal nerve neurolysis step-by-step: A- Progressive dissection to the pelvic floor; B- Sacro-sciatic ligament incision; C- Coccygeal bundle of the levator ani opening; D- Alcock’s channel section; E- Liberation and medial transposition of the pudendal nerve. b: bladder; ov: obturator vein; ssl: sacro-sciatic ligament; la: levator ani.

C. Giulioni, G. Garelli, A.B. Galosi, R.P. Gaston, G. Pierquet

Figure 2. Correlation between the improvement in the Numeric Pain Rating Scale (NPRS) score after 6 months from surgery and baseline data: a- Age; b- BMI; c- Duration of symptoms. yrs: years. r: Pearson’s correlation coefficient; 6MPO6 months postoperative.

STATISTICAL ANALYSIS

The median and interquartile ranges were used to evalu ate contimuos variables. Absolute frequencies and per centages were used to evaluate qualitative variables. Follow-up changes in NPRS were analyzed using Wilcoxon Test. The Pearson correlation coefficient was calculated to evaluate the impact of preoperative variables on the improvement of the NPRS score.

All statistical tests were two-tailed, and P < 0.05 was con sidered statistically significant. Statistical tests were per formed using IBM SPPS (v 26) software.

RESULTS

32 patients (19 females and 13 males) who underwent rPNN were included in this study. The median age was 50 (46-76) years. As for the pain characteristics, the median duration of symptoms was 7 (5,5-9) years, and the median preoperative NPRS score was 8 (8-9). The pain was most frequent on the perineum (14/32, 44%), while the site of origin was the anus (11/32, 34%) or the vulva (7/32, 22%) in the other cases. The symptoms were bilateral in 19 patients. Two patients had already undergone trans gluteal PNN on the same side. Almost all patients suffered from concomitant anxiety syndrome (27/32, 84%), while five diagnoses of depression occurred (Table 1).

rPNN was successful in all 32 cases. Median OT and CT were 74 (65-83) and 63 (53-71) mins, respectively. The median length of stay was 1 (1-2) days. There were no major complications, while a minor one (CD-1) occurred only in one patient who reported postoperative pain relieved by analgesics. At a 3-months postoperative followup visit, the NPRS had already significantly reduced (from 8 to 6, p <0.001), although six patients still needed com plementary therapy with Duloxetine. A progressive reduc tion of this score occurred 6-months after surgery (from 6 to 4, p<0.001), and in no case medical therapy was required. In addition, there was an improvement in terms of PGIC during the follow-up: at the first visit, there was a “minimal improvement” in perceived pain [median value of 3 (2-3)], while, at the second visit, the overall status was “much improved”, [median value 2 (1-2)] (Table 2).

Finally, the Pearson correlation coefficient was calculated to evaluate the impact of baseline data on the improve ment in the NPRS score after 6 months from surgery (Figure 2). No relation with preoperative variables was reported, except a negative association with the duration of symptoms, -0.81 (p< 0.001).

DISCUSSION

Pudendal nerve entrapment syndrome is a disabling con dition with a great impact on patient’s quality of life, not only for pain but also for associated symptoms. In a recent systematic review, the total recovery of potency after PNN was achieved in most cases of pudendal neuralgia, demonstrating a possible correlation between the latter and erectile dysfunction (11). Aoun et al. also reported that pudendal nerve entrapment is a cause of premature

The efficacy of robot-assisted pudendal nerve neurolysis

Table 1. Baseline and perioperative data of patients related to PNN group. Data are presented as medians (interquartile range) and frequencies (proportions). PNN: pudendal nerve neurolysis; BMI: Body Mass Index; NPRS: Numeric Pain Rating Scale; CD: Clavien-Dindo.

Variable PNN group

Age, years

Kg/m2

Sex

Main

Pain

Associated

Repeated

(46-76)

(20-28)

(41)

(59)

(8-9)

(5,5-9)

(44)

(34)

(22)

(16)

(25)

(59)

(84)

(16)

(6)

(94)

ejaculation; all proven treatments involving the pudendal nerve (nerve block) or penile dorsal branch (neuromod ulation or resection) have ensured a satisfactory increase in the intravaginal ejaculatory latency time and sexual sat isfaction. Moreover, Persistent Genital Arousal Disorder, a newly discovered neuro-vascular dysfunction, seems to have a strong relationship with pudendal nerve disorders. Klifto et al., recruiting eight women with Persistent genital arousal disorder who underwent PNN, noted that all patients achieved successful outcomes, thanks to the dis appearance of genitals arousal symptoms and the ability to resume regular sexual intercourse (12).

Given broad spectrum of symptoms of the condition unit ed only by pain and the need for a differential diagnosis, affected patients undergo a long period of tests before undergoing treatment. In addition to the consequences of radiculopathy, many cases of concomitant anxiety-depres sive syndrome occur, in concordance with our results (84%). By the way, the latter is considered a negative pre dictor of surgical success. In a prospective study involving 55 patients who underwent open PNN, neurologic disor ders had the highest correlation with a poor outcome from surgery, p < 0.002 (13). However, in our cohort the time elapsed from the onset of symptoms to diagnosis correlated with the efficacy of surgery (p = 0.01). These two previous findings are likely compatible due to grey matter volume reduction and cerebral decline, especially maladaptive cognitive and emotional sections, induced by persistent chronic neuralgia (14).

Along with the time for diagnosis, a further period may be required for symptom resolution. Pharmacological therapy is offered as first-line treatment, and demonstrated a fun damental role in dramatically reducing the incidence and severity of chronic postsurgical pain during the periopera tive period (15). In multimodal management, they are associated with behavioral and physical therapy, such as myofascial relaxation and tension, due to the pulling of the internal obturator muscle on the pudendal nerve during some daily activities (16). In addition to its importance in diagnosis, the local anesthetic injection with or without steroids can ensure satisfactory pain regression, albeit with short-term results. Furthermore, nerve block can also identify the accurate site of entrapment along the course of the nerve (17). Nerve decompression is the only option that guarantees long-term outcomes. In a random ized controlled trial, surgical treatment determined an improvement in pain immediately after 3-months in patients compared to the control group, 57.1% vs 6.7%, and then increased the gap at 12-months of follow-up,

C. Giulioni, G. Garelli, A.B. Galosi, R.P. Gaston, G. Pierquet

71.4% vs 13.3% (18). As for the open approach, several techniques were proposed according to the site where pudendal nerve branch involvement: transischiorectal and transperineal (anterior) incision, despite a limited field of view, and trans gluteal (posterior) incision, with a higher rate of surgical trauma. Therefore, the site-specific approach choice for the surgery is preferable for optimal functional outcomes (19). Minimally invasive surgery was introduced when Possover described laparoscopic puden dal nerve neurolysis, demonstrating improvement in pelvic pain using the Visual Analogue Scale (20). In 2017 a trans gluteal laparoscopic approach was studied, which allowed visualization of the entire gluteal region and relevant anatomic structures, from the pudendal root up to the sci atic tuberosity area (21). Afterwards, Juttard et al. per formed this technique on 15 patients with chronic per ineal pain: the reduction in NPRS was from 9 to 5, while the 57% of patients had good and optimal treatment responses and the 31% and optimal one after 6-months (22). Simultaneously, the first case of rPNN was reported, showing its feasibility and effectiveness (23). Our study is the first series recruiting patients with chronic pelvic pain who underwent robot-assisted pudendal nerve decom pression.

The advantages of robotic-assisted laparoscopic surgery, such as high-definition visual and easy instrument manipu lation, are well known. The latter is particularly important in hard-to-reach areas requiring high precision of move ment, such as deep pelvic space. In our experience, Da Vinci® System provided us with an enhanced magnifica tion of the surgical, ensuring optimal operative time and requiring a low docking time. Perioperative results were also satisfactory, with only one patient (3%) requiring painkillers after surgery and a median hospital stay of 1 day. Finally, an improvement was reported by patients in terms of NPRS and PGIC during follow-up: both scores decreased, and no cases requiring additional drug therapy occurred.

However, this study is not without its limitations. First, it is a retrospective study, and the biases associated with its nature are to be expected. Relatively small sample size is involved in this analysis, not allowing to reach definitive data. At last, the limited follow-up prevents the long-term clinical course of patients from being assessed. Hibner et al. reported a case series of 10 patients who underwent repeat operations with trans gluteal decompression of the pudendal nerve with a median time between the two surgeries of 4 (1-7) years (24). Therefore, additional mon itoring time is needed to assess the definitive resolution of the pudendal neuralgia.

CONCLUSIONS

rPNN is a safe and effective approach for patients with pudendal neuralgia, with only one minor CD-1 complica tion and successful results in all surgeries. This technique has shown a significant positive impact on symptoms, as demonstrated by the overall condition “much improved” among patients after 6-months and self-rated success based on the measure of pain intensity. According to our

The efficacy of robot-assisted pudendal nerve neurolysis

results, timely nerve decompression is needed to achieve satisfactory functional outcomes in patients with chronic perineal pain syndrome.

REFERENCES

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2. Soon-Sutton TL, Feloney MP, Antolak S. Pudendal Neuralgia. 2021 Jul 31. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.

3. Kaur J, Singh P. Pudendal Nerve Entrapment Syndrome. 2021 Nov 14. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.

4. Martin R, Martin HD, Kivlan BR. Nerve entrapment in the hip region: current concepts reviw. Int J Sports Phys Ther. 2017; 12(7):1163-1173.

5. Hibner M, Desai N, Robertson LJ, Nour M. Pudendal neuralgia. J Minim Invasive Gynecol. 2010; 17(2):148-53.

6. Possover M, Forman A. Voiding Dysfunction Associated with Pudendal Nerve Entrapment. Curr Bladder Dysfunct Rep. 2012; 7(4):281-285.

7. Robert R, Labat JJ, Bensigor M, et al. Bases anatomiques de la chirurgie du neff pudendal. Consequences therapeutiques dans cer taines algies perineales. Lyon Chir. 1993; 89:183-7.

8. Engeler D, Baranowski AP, Berghmans B, et al. Chronic Pelvic Pain. EAU Annual Congress Milan 2021. ISBN 978-94-92671-13-4.

9. Labat JJ, Riant T, Robert R, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008; 27(4):306-10.

10. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo clas sification of surgical complications: five-year experience. Ann Surg. 2009; 250(2):187-196.

11. Aoun F, Alkassis M, Tayeh GA, et al. Sexual dysfunction due to pudendal neuralgia: a systematic review. Transl Androl Urol. 2021; 10(6):2500-2511.

12. Klifto K, Dellon AL. Persistent genital arousal disorder: Treatment by neurolysis of dorsal branch of pudendal nerve. Microsurgery. 2020; 40(2):160-166.

13. Dellon AL, Coady D, Harris D. Pelvic pain of pudendal nerve ori gin: surgical outcomes and learning curve lessons. J Reconstr Microsurg. 2015; 31(4):283-90.

14. Malfliet A, Coppieters I, Van Wilgen P, et al. Brain changes asso ciated with cognitive and emotional factors in chronic pain: A system atic review. Eur J Pain. 2017; 21(5):769-786.

15. Carroll I, Hah J, Mackey S, et al. Perioperative interventions to reduce chronic postsurgical pain. J Reconstr Microsurg. 2013; 29(4):213-22.

16. Ilie CP, Mischianu DL, Pemberton RJ. Painful ejaculation. BJU Int. 2007; 99(6):1335-9.

17. Peng PW, Tumber PS. Ultrasound-guided interventional procedures for patients with chronic pelvic pain - a description of techniques and review of literature. Pain Physician. 2008; 11(2):215-24.

18. Robert R, Labat JJ, Bensignor M, et al. Decompression and trans position of the pudendal nerve in pudendal neuralgia: a randomized controlled trial and long-term evaluation. Eur Urol. 200; 47(3):403-8.

19. Dellon AL, Coady D, Harris D. Pelvic pain of pudendal nerve ori

in Urological Diagnosis and Imaging - 2022; 5,1

gin: surgical outcomes and learning curve lessons. J Reconstr Microsurg. 2015; 31(4):283-90.

20. Possover M. Laparoscopic management of endopelvic etiologies of pudendal pain in 134 consecutive patients. J Urol. 2009; 181(4):1732-6.

21. Ploteau S, Robert R, Bruyninx L, et al. A new endoscopic minimal invasive approach for pudendal nerve and inferior cluneal nerve neu rolysis: An anatomical study. Neurourol Urodyn. 2018; 37(3):971-977.

22. Jottard K, Bruyninx L, Bonnet P, De Wachter S. A minimally inva

sive, endoscopic transgluteal procedure for pudendal nerve and infe rior cluneal nerve neurolysis in case of entrapment: 3- and 6-month results. The ENTRAMI technique for neurolysis. Int J Colorectal Dis. 2020; 35(2):361-364.

23. Rey D, Oderda M. The first case of robotic pudendal nerve decompression in pudendal nerve entrapment syndrome. J Laparoendosc Adv Surg Tech A. 2015; 25(4):319-22.

24. Hibner M, Castellanos ME, Drachman D, Balducci J. Repeat oper ation for treatment of persistent pudendal nerve entrapment after pudendal neurolysis. J Minim Invasive Gynecol. 2012; 19(3):325-30.

CORRESPONDENCE

Carlo Giulioni

Department of Urology, Azienda ospedaliero universitaria

Ospedali Riuniti di Ancona, Univeristà Politecnica delle Marche, 71 Conca Street, 60126, Ancona – Italy Email: carlo.giulioni9@gmail.com Phone: +39 320/7011978

ORCID: 0000-0001-9934-4011

C. Giulioni, G. Garelli, A.B. Galosi, R.P. Gaston, G. Pierquet

Needle biopsy of renal mass: results of single center experience

Andrea Benedetto Galosi 1, Marco Macchini 2, Roberto Candelari 2, Virgilio De Stefano 1, Silvia Stramucci 1 , Vincenzo Di Benedetto 1, Gabriele Gagliardini 1, Vanessa Cammarata 1, Andrea Cicconofri 1, Carlo Giulioni 1

1 Department of Urology, Azienda ospedaliero universitaria Ospedali Riuniti di Ancona, Univeristà Politecnica delle Marche, Ancona, Italy;

2 Interventional Radiology Unit, Department of Radiology, Azienda ospedaliero universitaria Ospedali Riuniti di Ancona, Ancona, Italy.

Introduction. Ultrasound-guided biopsy of renal masses (RMB) is a useful and tool to evaluate sus pected renal tumors. This study aimed to assess the safety and feasibility of this technique. Material and Methods. 80 patients who underwent RMB between January 2012 and December 2020 were recruited for this retrospective study. Twelve patients were excluded due to incomplete data. Biopsy outcomes were collected through our electronic medical records system and then compared with definitive pathology. Results. RMB was diagnostic in 66 out of 68 cases. Pathological examination reported 44 (67%) malignant tumors, while RMB was not diagnostic in 15 cases. A benign lesion was present in 8 cases. One major and one minor post-procedure complication were reported among the patients. The concordance between biopsy and definitive pathology occurred in 22 out of 31 (71%) cases, with a higher rate among masses greater than 4 cm, 9/11 (82%) vs 13/20 (65%) cases. Four negative biopsies resulted to be at definitive pathology three renal cell carcinoma and one translocation renal cell carcinoma. Conclusion. RMB is a safe procedure, with good diagnostic ability, particularly for primary renal tumors. However, the negative predictive value of biopsy does not reliably guarantee the absence of tumor and, therefore, strict follow-up or repeat biopsy is war ranted.

SUMMARY

INTRODUCTION

Since the past few decades, the incidence of clear cell renal cell carcinoma has dramatically increased, and cur rently counts approximately 431,000 new cases per year. Furthermore, it is the cause of death of over 179,000 peo ple annually (1). This reflects the development of advanced diagnostic imaging, which determines an increase of small renal mass detection (<4 cm). In a retrospective study involving 3001 consecutively registered asymptomatic adults, a renal cell carcinoma (RCC) of at least 1 cm occurred in nearly 15% of examinations (2).

Nowadays, several therapeutic options may be offered. Considering the increased number of diagnoses of small renal masses (SRM), nephron-sparing surgery (NSS) is preferable over a radical nephrectomy due to the preser vation of renal function. Furthermore, NSS is associated with a decrease in cardiovascular events and overall mor

tality (3). Cryoablation is a valid option in patients with several comorbidities and short life expectancy, due to minimum effect on renal function and low post-procedure complication rate, despite the high treatment failure rates (4). Alternatively, active surveillance has demonstrated cancer-specific survival similar to primary intervention (5). The most appropriate treatment for patients is based first on the patient’s general condition (including comorbidities, renal function, and life expectancy) and the nature of the renal tumor. However, traditional diagnostic imaging pro vides data on mass characteristics, but it cannot determine whether the lesion is benign or malignant. There is evi dence for dynamic magnetic resonance imaging that may differentiate tumor subtypes (6), but tumor aggressiveness cannot be defined. In this context, ultrasound-guided renal mass biopsy (RMB) is crucial. This procedure plays a key role in approximately 60% of patients (7), guiding toward

KEY WORDS: Kidney tumors; Renal masses biopsy; Ultrasound; Small renal mass; Nephron -sparing surgery; Active surveillance.

the most appropriate therapeutic approach, whether it is medical or surgical.

This study aimed to describe our experience with RMB, evaluating its safety and diagnostic accuracy.

MATERIALS AND METHODS

A retrospective review of our prospective collected database on kidney tumors was conducted with data anal ysis of 80 patients with suspected primary or secondary kidney tumors who underwent RMB between January 2012 and December 2020. Twelve cases were excluded due to the lack of complete data. All patients had previ ously performed a contrast-enhanced computed tomog raphy (CT) scan of the abdomen, which allowed for tumor evaluation.

Two experienced radiologists performed all the ultra sound-guided RMB after the analysis of contrast-enhanced CT imaging. Specimens were obtained through an auto mated biopsy gun with an 18-Gauge needle. One to four cores were collected per kidney lesion, giving an average of two. Patients’ characteristics, including age, gender, body mass index (BMI), skin-to tumor distance and thickness of subcutaneous fat, were calculated through the radiology. Moreover, several radiological tumor characteristics were evaluated, such as size, location, endophytic growth, and the presence of cystic component. Post-procedure complications were reported and ranked according to the Clavien-Dindo (CD) Classification (8).

STATISTICAL ANALYSIS

Qualitative variables were described using absolute fre quencies and percentages. Quantitative variables were described using the median and interquartile ranges. IBM SPSS (V26) was used as statistical software.

RESULTS

The median age of the patients was 71 years (36-85), and the median BMI was 27.5, as shown in Table 1. A median of 2 needle cores were taken from each lesion. Tumor characteristics were reported in Table 2. 44 patients had a renal mass < 4cm in the largest diameter. RMB in our series was diagnostic in 66 cases. The histological findings of all biopsies are listed in Table 3. Biopsy found malignan cy in 44 (67%) cases, and renal cell cancer (RCC) was the most frequent diagnosis (36/44, 82%). Two cases of metas tasis were reported, while 15 biopsies yielded benign renal tissue (negative biopsy). Two patients experienced compli cations after the biopsy procedure: 1 case of a subcapsular renal hematoma, with no treatment (CD 1), and 1 case of renal bleeding, who required Super-Selective Embolization (CD 3). Table 4 reported the treatment offered to the patients. As for SMR, eight patients out of nine underwent NSS and only one was offered radical nephrectomy. Chemo- or immunotherapy was proposed to the seven patients with locally advanced disease or cancers metastatic to the kidney. Active surveillance was offered to

Table 1. Patient and sample characteristics. No. (%) Median (range)

Age, years 71 (36 - 85)

Gender Male Female 49 (72%) 19 (28%) Patient BMI <30 ≥30 46 (68%) 22 (32%)

27.5 (18.6-44.2)

Core needle samples, n 2 (1-4)

Skin-to-tumor distance, cm <7 cm ≥7 cm 43 (63%) 25 (37%)

Thickness of subcutaneous fat, cm <3 cm ≥ 3 cm 50 (74%) 18 (26%)

Table 2. Tumor characteristics.

5,8 (15 - 120)

1,9 (2 -54)

No. (%)

Side Left Right 25 (37) 43 (63) Tumor size < 4cm ≥4cm 44 (65) 24 (35) Mass location Mesorenal Upper pole Lower pole Renal pedicle

Cortical location Anterior cortex Posterior cortex Neither

Endophytic vs. exophytic Completely endophytic <50% exophytic ≥ 50% exophytic

Cystic vs. solid Cystic component ≥ 50% Cystic component <50% No cystic component

22 (32) 26 (38) 18 (27) 2 (3)

18 (27) 32 (47) 18 (27)

10 (15) 29 (43) 29 (43)

5 (7) 10 (15) 53 (78)

the 8 cases of oncocytoma, while 3 cases of watchful wait ing occurred. As shown in Table 5, the overall concordance between RMB and definitive pathology was 22/31, with a higher rate in masses larger than 4 cm. RBM demonstrated its reliability in diagnosing RCC, both for small and large masses. Tumor subtype was confirmed by definitive pathol ogy in 821% of cases (22/27). However, in two cases of unspecified carcinoma, after excision, one had a histologi

A.B. Galosi, M. Macchini, R. Candelari, V. De Stefano, S. Stramucci, V. Di Benedetto, G. Gagliardini, V. Cammarata, A. Cicconofri, C. Giulioni

Table

Clear

Papillary

Oncocytoma

Unspecified

Oncocytic

Lymphoma

Urothelial

Skeletal

Collecting

Translocation

Lung

Table

Nephron

RCC

Radical

RCC

Oncologic

Needle biopsy of renal mass: results of single center experience

cal outcome of skeletal muscle metastases and the other one was a urothelial carcinoma. For negative biopsies, 4 patients underwent surgery, with a final diagnosis of RCC in 3 and translocation renal cell carcinoma in one. In summary, the overall sensibility was 71%, with a higher value for masses greater than 4 cm than the smaller ones (82% vs 65%, respectively). Furthermore, the positive pre dictive value was 96%.

DISCUSSION

According to EAU guidelines, surgery is the first-line choice therapy for patients with a localized renal mass, preferring, whenever feasible, the NSS to radical nephrec tomy (9).

Nowadays, there is a trend toward a conservative approach for renal surgery also for increasingly challenging cases. In a multicenter study involving 410 patients with high complexity masses, partial nephrectomy showed sat isfactory long-term oncological and functional outcomes despite an acceptable rate of perioperative complications (10). However, 20-50% of the definitive pathologies of this surgery were benign, which might have been managed by active surveillance (11). On the other hand, a multidisci plinary strategy is necessary for metastatic diseases or locally advanced renal cancer, which provides a palliative cytoreductive nephrectomy and systemic treatments (9). Therefore, a histological diagnosis is essential to guide the best therapeutic management.

RMB indication occurs in several cases, such as the diagno sis of tumor metastasis, unresectable renal cancer, indeter minate cystic or multiple renal mass, and in patients not fit for surgery (12).

The biopsy was proposed for SRM, although an inverse relationship was reported between tumor size and its risk of malignancy (13). In our series, a concordance of tumor malignancy between biopsy and definitive pathology always occurred. Moreover, the concordance of RCC between RMB and definitive pathology was 96%. In a large meta-analysis involving 5228 patients, RMB sensitivity and specificity were 99.1% and 99.7%, respectively (14). Furthermore, the authors showed a concordance rate between tumor histotype on biopsy and surgical specimen of 90.3%, while concordance rates of tumor grade ranged from 43% to 93% (14). The last data raises several doubts about biopsy, especially for SMR. Similarly, Pierorazio et al reported high percentages in terms of sensitivity and

specificity, while the negative predictive value was 68.5% and non-diagnostic rates ranged from 0% to 22.6% for masses <4 cm (15). In the same way, in the present study, the concordance rate of all SRM dropped up to 61%.

The most critical aspect that emerged from our analysis is the specificity of RMB. Indeed, there was low concordance between biopsy and definitive pathology for negative or unspecified carcinoma diagnoses. Abel et al. reported that when carrying out a biopsy of a metastatic lesion or pri mary tumor, as opposed to nephrectomy specimen exam ination, it is likely that only one subpopulation of cells is sampled, and prognostic information is based on only one subpopulation of cells (16). Therefore, there is a concern regarding high false-negative rates about the reliability of the procedure. However, RMB may be repeated on all patients with unspecified masses or non-diagnostic cases to increase the diagnostic rate (17).

Furthermore, renal biopsy is not without complications, due to the procedure invasiveness, especially bleeding, although the latter is considered a rare event. According to Lane et al., minor and major complications after RMB are less than 5% and 1%, respectively (18). Of these, the most common is undoubtedly bleeding, which often tends to present subclinically and requires transfusion in about 1.5% of cases (19). Indeed, both post-procedure compli cations were related to haemorrhage in the present study too. Another frequent complication is the intrarenal arte riovenous fistulae. According to Rollino et al., the develop ment of this condition has an incidence of up to 5% when colour-coded Doppler sonography is used (20). However, no case was reported in our cohort. The limitations of the present study are evident. First, it is a retrospective study and biases linked to its nature are predictable. Second, the pathological specimens were not reviewed independently. Moreover, a considerable number of subjects were lost at follow-up, being submitted for RMB from other centers. Lastly, a relatively small sample size was involved in this analysis.

CONCLUSIONS

Ultrasound-guided RMB demonstrated satisfactory ability to distinguish benign and malignant tumors. Concordance between biopsy and definitive pathology was high for RCC, particularly for masses greater than 4 cm. However, the low negative predictive value in the negative biopsies may require a second biopsy. In any case, the procedure proved to be safe and effective in referring patients to the most appropriate therapeutic management. Considering the low prevalence of this procedure in routine clinical practice, its use is recommended whenever an indication occurs.

RESEARCH HIGHLIGHTS

• Ultrasound-guided renal mass biopsy (RMB) is a safe technique with a low incidence of postprocedural com plications.

• RMB provides good accuracy in identifying the tumor

type, thus allowing adequate information for patient’s management.

• The concordance between RMB and definitive patholo gy occurs in most cases, particularly for renal masses ≥4 cm.

• The negative predictive value is low and does not guar antee the absence of tumor cells in the suspected mass.

REFERENCES

1. Global Cancer Observatory. International Agency for Research on Cancer. World Health Organization.

2. O’Connor SD, Pickhardt PJ, Kim DH, et al. Incidental finding of renal masses at unenhanced CT: prevalence and analysis of features for guiding management. AJR Am J Roentgenol. 2011; 197(1):139-45.

3. Huang WC, Elkin EB, Levey AS, et al. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors is there a difference in mortality and cardiovascular outcomes? J Urol. 2009; 181(1):55-61.

4. Zargar H, Atwell TD, Cadeddu JA, et al. Cryoablation for Small Renal Masses: Selection Criteria, Complications, and Functional and Oncologic Results. Eur Urol. 2016; 69(1):116-28.

5. Pierorazio PM, Johnson MH, Ball MW, et al. Five-year analysis of a multi-institutional prospective clinical trial of delayed intervention and surveillance for small renal masses: the DISSRM registry. Eur Urol. 2015; 68(3):408-15.

6. Sun MR, Ngo L, Genega EM, et al. Renal cell carcinoma: dynamic contrast-enhanced MR imaging for differentiation of tumor subtypes-correlation with pathologic findings. Radiology. 2009; 250(3):793-802.

7. Maturen KE, Nghiem HV, Caoili EM, et al. Renal mass core biopsy: accuracy and impact on clinical management. AJR Am J Roentgenol. 2007; 188(2):563-70.

8. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo clas sification of surgical complications: five-year experience. Ann Surg. 2009; 250(2):187-196.

9. Ljungberg B, Albiges L, Bedke J, et al. Volpe Guidelines on Prostate Cancer. Edn. presented at the EAU Annual Congress Milan 2021. 978-94-92671-13-4. Publisher: EAU Guidelines Office. Place pub lished: Arnhem, The Netherlands.

10. Mari A, Tellini R, Porpiglia F, et al. Perioperative and Mid-term Oncological and Functional Outcomes After Partial Nephrectomy for Complex (PADUA Score ≥10) Renal Tumors: A Prospective Multicenter Observational Study (the RECORD2 Project). Eur Urol Focus. 2021; 7(6):1371-1379.

11. Russo P, Uzzo RG, Lowrance WT, et al. Incidence of benign versus malignant renal tumors in selected studies. J. Clin. Oncol. 2012; 30,92.

12. Sahni VA, Silverman SG. Biopsy of renal masses: when and why. Cancer Imaging. 2009; 6;9(1):44-55.

13. Frank I, Blute ML, Cheville JC, et al. Solid renal tumors: an analysis of pathological features related to tumor size. J Urol. 2003; 170(6 Pt 1):2217-20.

14. Marconi L, Dabestani S, Lam TB, et al. Systematic Review and Meta-analysis of Diagnostic Accuracy of Percutaneous Renal Tumour Biopsy. Eur Urol. 2016; 69(4):660-673.

15. Pierorazio PM, Johnson MH, Patel HD, et al. Management of Renal Masses and Localized Renal Cancer: Systematic Review and Meta-Analysis. J Urol. 2016; 196(4):989-99.

16. Abel EJ, Carrasco A, Culp SH, et al. Limitations of preoperative

A.B. Galosi, M. Macchini, R. Candelari, V. De Stefano, S. Stramucci, V. Di Benedetto, G. Gagliardini, V. Cammarata, A. Cicconofri, C. Giulioni

biopsy in patients with metastatic renal cell carcinoma: comparison to surgical pathology in 405 cases. BJU Int. 2012; 110(11):1742-6.

17. Lim A, O’Neil B, Heilbrun ME, et al. The contemporary role of renal mass biopsy in the management of small renal tumors. Front Oncol. 2012; 2:106.

18. Lane BR, Samplaski MK, Herts BR, et al. Renal mass biopsy a renaissance? J Urol. 2008; 179(1):20-7.

Needle biopsy of renal mass: results of single center experience

19. Tang S, Li JH, Lui SL, et al. Free-hand, ultrasound-guided percuta neous renal biopsy: experience from a single operator. Eur J Radiol. 2002; 41(1):65-9.

20. Rollino C, Garofalo G, Roccatello D, et al. Colour-coded Doppler sonography in monitoring native kidney biopsies. Nephrol Dial Transplant 1994; 9:1260-3.

CORRESPONDENCE

Carlo Giulioni

Department of Urology, Azienda ospedaliero universitaria Ospedali Riuniti di Ancona, Univeristà Politecnica delle Marche, 71 Conca Street, 60126, Ancona – Italy

Email: carlo.giulioni9@gmail.com

Phone: +39 320/7011978

ORCID: 0000-0001-9934-4011

Advances in Urological Diagnosis and Imaging - 2022; 5,1

Is ultrasound useful in a doubt of Fournier’s gangrene? Lesson learned from a case report

1 Department of Urology, Polytechnic University of Marche, School of Medicine, United Hospitals, Ancona, Italy;

2 Department of Dermatology, Polytechnic University of Marche, School of Medicine, United Hospitals, Ancona, Italy.

SUMMARY

Fournier’s gangrene is a fulminant polymicrobial necrotizing fasciitis of the urogenital and perineal areas. It is important to diagnose it as soon as possible, due to its potential complications. We present a case of a severely obese patient with a scrotal lesion, which was a suspect for Fournier’s gangrene. We used ultrasound for the diagnosis considering that computer tomography was not feasible due patient’s morbid obesity.

KEY WORDS: Fournier’s gangrene, ultrasound, computer tomography, obesity.

INTRODUCTION

Fournier’s gangrene is a fulminant form of infective necro tizing fasciitis of the perineal, genital, or perianal regions (1). The earliest clinical signs of a possible Fournier gangrene include localized tenderness, edema, and erythema involv ing the skin of the perineum, scrotum, or labia. This can be easily confused with much more common, simple infec tions such as cellulitis, erysipelas, and impetigo.

Other differential diagnosis in the early stages of Fournier gangrene should be performed with gangrenous balanitis in diabetics, and among women with gangrenous diabetic vulvitis, ulcerative and gangrenous forms of inguinal lym phogranulomatosis, soft chancre, and acute ulcers of the genitals (2-3).

Early diagnosis is essential for rapid treatment to avoid serious complications and death.

Identification of subcutaneous gas in the scrotum is the key finding. Evidence of gas within the scrotal wall may be seen by ultrasound in early stage and before the crepitus can be appreciated at clinical palpation (4).

CASE REPORT

A 30-year-old male with severe obesity (236.8 kg, BMI 73), bedridden, and poor was referred to our emergency department complaining of worsening scrotal pain, swelling and a hidden penis. The patient had been previ

ously treated with amoxicillin-clavulanate for 14 days for an acute epididymitis one month earlier. Despite antibi otics, his local and general condition deteriorated. His mic turition was in the inguinal and the scrotal area, as a result of his bedridden and hidden penis, resulting in skin infec tion. Upon presentation, the patient was afebrile, his sys temic blood pressure was 103/77 mmHg, with a heart rate of 100 beats per minute. Physical examination showed diffuse edema of the scrotum and penis with scrotal erythema, and ulcerated lesions with necrosis, (Figure 1). On palpation, there was no crepitus. However, the genital infection was suspicious for Fournier’s gangrene

Figure 1. A scrotal lesion with edema and ulcerated lesions with necrosis, at the first presentation in the Emergency Department.

Ofir Maltzman 1, Carlo Brocca 1, Carmine Franzese 1, Anna Campanati 2, Andrea Marani 2, Andrea Benedetto Galosi 1 .

and Urological consultation in emergency room was requested. The skin was wet of urine, red, edematous, and painful, with mold-like ulcerations with necrotic-fibrinous background, with absence of crepitus. The clinical derma tologic picture, given the well-demarcated border of the injured skin, combined with the appearance of the ulcers. A computed tomography (CT) scan was requested but, due to its BMI, it was not possible to perform. Therefore, he underwent a scrotal ultrasound using a linear probe (12-8 MHz), that showed absence of air foci within subcu taneous tissues (Figure 2). His C-reactive protein was 13.0 mg/dl (normal value up to 0.6 mg/dl). To avoid urine soaking a transurethral catheter was inserted with difficul ty because the penis was hidden by abdominal fat and patient was admitted in the hospital and treated with antibiotics. The day after, dermatological consultation was

requested. The clinical dermatologic picture appeared most compatible with stage I decubitus overinfection, likely due to compression, brought about by high body weight, and urinary contamination. Urine culture was negative for pathogen growths. Skin and scrotal lesion cultures identified Pseudomonas Aeruginosa and Escherichia Coli. Dermatologic consultation confirmed the appropriateness of excluding Fournier's Gangrene. Antibiotic therapy with Piperacillin-Tazobactam 4 g iv /3 die was given for 10 days together with hydrocellular foam dressings and hydrogel for debridement of necrotic tissue. Due to poor response, antibiotics therapy was changed to Meropenem 1g /3 die plus Teicoplanin 400 mg /2 die, with an improvement of local and systemic infection starting from the fifth day, (Figure 3). After 15 days, the patient was discharged home with complete healing.

DISCUSSION

CT scan is the most common imaging used to evaluate gas extension in Fournier gangrene (5) and it is more sensitive in demonstrating subcutaneous and retroperitoneal gas and fluid collections then other imaging procedures (6). However, in some circumstances CT is either not available or can be performed (i.e. in the case of morbid obesity, and pregnancy). In the latter, ultrasound is good alternative imaging to asses gas extension in the scrotum and per ineum (7).This occurred in our patient who did not under go a CT scan due to his weight. Nevertheless, ultrasounds have some limitation such as a small field of view, operator dependence, and occasionally procedure intolerance by patients given the need for direct pressure on the scro tum/perineum during the examination (8, 9). Conversely, the advantages of ultrasounds include the absence of radi ation, and speed of performance both bedside and in emergencies.

The identification of subcutaneous gas in the scrotum is the key finding for diagnosis of Fournier gangrene which usually presents as a scrotal wall thickening with echogenic foci that show dirty shadowing caused by the presence of the gas (10).

Morrison et al. have reported a series of six patients with Fournier gangrene in which diagnosis were performed by US (11). All six patients had sonographic manifestations of soft tissue gas.

In addition, Dell’Atti et al. showed a case with successful management in operating room to identify limits and dis tant spread of gas using ultrasonography (12).

In the present case, Fournier gangrene was excluded by clinical examination of absence of crepitus, confirmed by no gas at ultrasounds and a differential diagnosis was made. This allowed us to avoid surgical debridement that might have been detrimental to our patients due to his clinical condition.

CONCLUSIONS

Fournier’s gangrene is a life-threatening disease that require of an early diagnosis and a prompt surgical treatment to

Figure 2. Ultrasound of scrotal soft tissues with superficial edema showing no gas.

Figure 3. Reduce scrotal lesion after five days of antibiotics and local dressing.

decrease morbidity and mortality. In cases where the diag nosis is doubt due to the clinical presentation and is nec essary to have an early diagnosis to intervene promptly, ultrasounds is a valid option to rule out or confirm the presence of gas in the perineal and genital area. Ultrasound can serve as a reliable diagnostic alternative in all cases where CT is not possible.

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the author(s).

REFERENCES

1. Smith GL, Bunker CB, Dinneen MD. Fournier's gangrene. Br J Urol. 1998; 81(3):347-55.

2. Chernyadyev SA, Ufimtseva MA, Vishnevskaya IF, et al. Fournier’s gangrene: Literature review and clinical cases. Urologia Internationalis, 2018; 101(1):91-97.

3. Leslie SW, Rad J, Foreman J. Fournier Gangrene. 2022 Jun 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. PMID: 31747228.

4. Di Serafino M, Gullotto C, Gregorini C, Nocentini C. A clinical case

of Fournier's gangrene: imaging ultrasound. J Ultrasound. 2014; 17(4):303-6.

5. Ballard DH, Mazaheri P, Raptis CA, et al. Fournier Gangrene in Men and Women: Appearance on CT, Ultrasound, and MRI and What the Surgeon Wants to Know. Can Assoc Radiol J. 2020; 71(1):30-39.

6. Hohenfellner M, Santucci RA. Editors. Emergency in urology. ISBN 978-3-540-48603-9. Springer – Verlag Berlin Heiderberg New York, 2007. Chapter Scrotal Emergency, V. Master. P. 139-140

7. Serra AD, Hricak H, Coakley FV, et al. Inconclusive clinical and ultra sound evaluation of the scrotum: impact of magnetic resonance imaging on patient management and cost. Urology. 1998; 51(6):1018-21.

8. Parker RA 3rd, Menias CO, Quazi R, et al. MR Imaging of the Penis and Scrotum. Radiographics. 2015; 35(4):1033-50.

9. Avery LL, Scheinfeld MH. Imaging of penile and scrotal emergen cies. Radiographics. 2013; 33(3):721-40.

10. Aganovic L, Cassidy F. Imaging of the scrotum. Radiol Clin North Am. 2012; 50(6):1145-65.

11. Morrison D, Blaivas M, Lyon M. Emergency diagnosis of Fournier's gangrene with bedside ultrasound. Am J Emerg Med. 2005; 23(4):544-7.

12. Dell'Atti L, Cantoro D, Maselli G, Galosi AB. Distant subcutaneous spreading of Fournier's gangrene: An unusual clinical identification by preoperative ultrasound study. Arch Ital Urol Androl. 2017; 89(3):238-239.

CORRESPONDENCE

Carlo Brocca

Department of Urology, Polytechnic University of Marche, School of Medicine, United Hospitals, Ancona, Italy. E-mail: brocca.carlo@gmail.com

Phone: +39 3386277851

Advances in Urological Diagnosis and Imaging - 2022; 5,1

O. Maltzman, C. Brocca, C. Franzese, A. Campanati, A. Marani, A. B. Galosi

Flexible guide as landmark of bladder diverticulum during a robotic assisted diverticulectomy

1 Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy;

2 Division of Urology, VCU Health, Richmond, Virginia, USA;

3 Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy.

SUMMARY

We present a case of bladder diverticulum (BD) with extravesical robotic approach in a 72-year-old man, permantent chateter carrier, with history of recurrent urinary infection and benign prostatic hyperplasy (BPH). In this case we use for the first time a flexible guide ware to aid in intra-abdominal identification of the diverticular neck. Robotic bladder diverticulectomy (RBD) approach of the BD is a good surgical choice as alternative to open and laparoscopic surgery.

KEY WORDS: Bladder diverticulum, flexible guide, Robotic bladder diverticulectomy (RBD).

INTRODUCTION

BD are uncommon and they are classified in congenital or acquired. Congenital bladder diverticula are often solitary, more common in males and occur in a smooth wall blad der. Acquired bladder diverticula are usually multiple and affect almost males, with an high incidence at around 60 years. BD, secondary to BPH, is a complication that is mostly seen in the elderly men, with an incidence range from 1 to 6% (1). In case of BPH with recurrent urinary complaints, the possibility of presence of a BD should be investigated. The clinical problem with bladder diverticu lum is their poorly empty during micturition which results in multiple lower urinary tract symptoms as well as recur rent urinary tract infections. Their develop is due to blad der outlet obstruction or neurogenic bladder. They some times are accompanied by a trabecular bladder, with “cells and columns”. Most BD are asymptomatic and are com monly discovered during investigation for hematuria, lower urinary tract symptoms, infection or incidentally radio graphic imaging. Sometimes malignant transformation occurs, highlighting the importance of an appropriate management (2). There are several different management for bladder diverticulum including conservative nonopera tive or surgical. Regarding surgical approach, several surgi cal techniques have been described, including open, endo

scopic, laparoscopic and, more recently, robotic approach es.The first was the open bladder diverticulectomy. This report describes robotic approach of a large BD.

CASE REPORT

A 72-year-old man with BPH was referred to our urology clinic with indwelling catheter for symptoms of pelvic pain, urgency and dysuria. The patient was studied with abdomen and pelvis CT scan which demonstrated a BD on the right side of the bladder (Figure 1).

Achille Aveta1, Savio Domenico Pandolfo1,2, Luigi Napolitano1, Gianluca Spena1, Claudia Rosati3, Ciro Imbimbo1, Vincenzo Mirone1, Lorenzo Spirito1.

Figure 1. CT pelvis scan: bladder diverticulum on the right side of the bladder with its neck.

During the endoscopic time, cystoscopy demonstrated a large bladder diverticulum located on the posterior para median right wall. Cystoscopy was performed under gen eral anesthesia and in the lithotomy position. An ureteral stent (6 F double J stent) was placed into the right ureter to identify the ureter during the robotic time. The diver ticulum neck was identified in the right posterior side of the bladder and a flexible guide was placed into. A 18 F Foley catheter was placed into the bladder. Then pneu moperitoneum was established in the abdomen, six ports were placed transperitoneally similar to the robot-assisted radical prostatectomy (RARP) configuration for the robot ic time. The bladder diverticulum was immediatly found by guide imprint on the bladder wall under direct visualiza tion (zero-degree lens) (Figure 2). The peritoneum over the diverticulum was incised. Using smooth and sharp dis section, the diverticulum was circumferentially dissected untill its neck. The flexible guide and the ureteral stent are

Figure 2. Flexible guide imprint on the peritoneum as landmark of the bladder diverticulum.

removed towards the bladder incision. The diverticulum was placed in an Endo-bag. Cystotomy at the diverticulum neck was performed by 3/0 Vycril 5\8 needle continuous suture, peritoneum by 3/0 barbed V-Loc continuous suture. A drain was placed, the ports were removed and the specimen was retrieved. On the third postoperative day, the urethral catheter was removed.

CONCLUSION

In the elderly men with BPH there is an high risk of devel oping bladder diverticulum (3). RBD is an excellent alter native to open surgery and conventional laparoscopy for the management of BD. The robotic procedure is mini mally invasive and provide more benefits. The diverticu lum neck could be identified in different ways, often usying a catheter. The use of a catheter shows several drawbacks: placement of the balloon may be cumbersome, it can be dislodged from the diverticulum when the diverticular mouth is wide and the balloons may cause diverticulum rupture. The urethra may not simultaneously accommo date the balloon and a urethral catheter and urologic operating rooms may not routinely stock angiographic bal loons. We use a guideware to avoid these problems to identify diverticulum during surgery.

REFERENCES

1. Burns E. Diverticula of the Urinary Bladder. Annals of surgery. 1944; 119(5):656-64.

2. Poletajew S, Krajewski W, Adamowicz J, et al. Management of Intradiverticular Bladder Tumours: A Systematic Review. Urologia inter nationalis. 2020; 104(1-2):42-7.

3. Fang CW, Liao CH, Wu SC, Muo CH. Association of benign prostat ic hyperplasia and subsequent risk of bladder cancer: an Asian pop ulation cohort study. World J Urol. 2018; 36(6):931-938.

CORRESPONDENCE

Achille Aveta

Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", 80131 Naples, Italy e-mail: achille-aveta@hotmail.it

A. Aveta, S. D. Pandolfo, L. Napolitano, G. Spena, C. Rosati, C. Imbimbo, V. Mirone, L. Spirito.

New devices for management of upper urinary tract lithiasis

Carlo Giulioni, Virgilio De Stefano.

IMPROVEMENTS IN URETERAL STENTS FOR PATIENTS’ QUALITY OF LIFE

In clinical practice, the most common use of ureteral stents is to allow urine to flow through the ureter around an obstructing kidney/ureteral stone or after instrumenta tion of the upper urinary tract. In a retrospective study, Torricelli et al. affirmed that stent position might lead to less postoperative pain after flexible ureteroscopy with a ureteral access sheath (1).

However, according to the latest European Association of Urology (EAU) guidelines, routine ureteral stenting after a stone-free URS is not necessary because of higher postop erative morbidity and costs (2). Indeed, stent permanence even for a short time leads in turn to several criticisms. In their literature review, Lange et al. have reported the ureteral stent-associated complications, including encrusta tion, infection, pain and discomfort can be caused by ureteral tissue irritation and possibly irregular peristalsis (3).

Consequentially, ureteral stents alter general health status, working and sexual activity, but how can this effect be quantified? The Ureteric Stent Symptoms Questionnaire (USSQ), a self-administered and reliable instrument, was designed to assess the impact of stent on patients’ quality of life (4). Bosio et al. have already reported using the USSQ that a double-J ureteral stent determined severe symptoms in a high percentage of patients, carefully weigh ing his insertion and minimizing his indwelling time (5).

Although a better tolerance has been demonstrated for silicone stents than those in polyurethane and in silicone hydrocoated (6), current scientific research aims to further reduce stent-related symptoms.

The rationale is to reduce as much as possible the material in contact with the urothelial mucosa, reducing ureteral aperistalsis, vesicoureteral reflux and Lower Urinary Tract Symptoms. Keeping this in mind, the Pigtail Suture Stents were designed. The latter are made with a pigtail at the proximal end and a fluted beak, and with a double surgical thread at the distal end. In a recent prospective random ized trial, Bosio et al. compared the outcomes of these stents compared with the conventional double-J one, using

the USSQ, in patients with proximal and medial ureteral stones (7). Pigtail Suture Stents showed a significantly lower incidence of urinary frequency, burning, pain inter fering with daily-activities and the need for health profes sional help two weeks after insertion. This study had a small sample size and further investigations are necessary, but the early outcomes look promising. On the other side, the research focused on solving the consequences of ureteral stent placement, such as encrus tation. This phenomenon is common, leading to possible adverse effects such as infections, urinary symptoms and obstruction (8). In addition, the encrustations may also make the removal of the ureteral stent challenging. The reason for the formation of calcium and magnesium deposits on the external surface of a stent is very complex and depends on multiple factors, such as patient's metabolism, stent indwelling time and its shape and mate rial (9). Scientific research has focused precisely on this last contributing cause, looking for suitable material and design to minimize the encrustation. Recently, a new stent has been introduced in the market. This device is a tri-layer design that incorporates with a surface technology engineered onto the outer and inner stent surfaces for optimal coverage against urine calcium and magnesium salt deposits during exposure for two weeks to artificial sterile urine and Proteus mirabilis infect ed urine (in vitro study). Its inert and non-polar copolymer material composition surrounded by super smooth and hydrophobic outer and inner surfaces makes this stent unique as the surface of the other stents have a hydrophilic gel coating. However, Yoshida et al. recently found that this stent did not seem suitable for a long indwelling time (10). These results contrast with the previous in vitro study; therefore, further investigation is necessary.

MULTI-USE VS SINGLE-USE FLEXIBLE URETEROSCOPES : WHICH ONE TO CHOOSE?

Since the introduction of the first flexible ureteroscope in 1987 (11), technological evolution has led to improve

Department of Urology, Polytechnic University of Marche Region, Umberto I Hospital "Ospedali Riuniti", Ancona, Italy.

ments in maneuverability and fiber optic vision with a decrease in the diameter of the scope. A great revolution was the advent of digital flexible ureteroscopes, with a remarkable increase in resolution compared to fiber-optic ones but with a larger diameter. In 2013, Somani B et al. reported that digital technology saved up to 30% on oper ational time with comparable success rates (12).

Another noteworthy critical issue of reusable uretero scopes is their durability, which also correlates with the performance of the operator. Indeed, Sung et al. found that the major cause of reusable ureteroscope injury was working channel damage from laser burn or instrument passage and extreme scope deflection with an indwelling instrument (13). Therefore, the first single-use, but semirigid, ureteroscopes were created in 2016. Already with the second generation, the instrument becomes flexible, determining an improvement in terms of vision due to the use of a digital camera, and maneuverability. Nowadays, both single-use and reusable digital ureteroscopes have the same profiles and both have better ergonomics than reusable fiber-optic ureteroscopes (14).

On the other hand, single-use instruments have as limits the greater areas of shadow, over-illumination, and more blood-altered vision than digital reusable ones. Therefore, which type of device is to be preferred?

In a prospective multicenter randomized controlled trial, Qi et al. showed that the single-use digital ureteroscope appears to be at least non-inferior to digital reusable one in terms of stone-free rate, high-quality of imaging, and operability (15). Regarding the cost-effective ratio, the liter ature lacks well-designed prospective randomized trials. In their comprehensive literature-based equation, Marchini et al. pointed out that the main factors involved in the cost effectiveness of a flexible ureteroscopy program were: i) purchase price; ii) repair requirement (replacement contract and insur ance); iii) scope longevity-influenced by surgical training; iv) sterilization method; v) stone burden; vi) reprocessing or recycling expenditure; and vii) operating room expense (16).

In conclusion, based on Martin’s cost-benefit analysis (17), reusable ureteroscopes seem to be more adapted for high volume centers, while single-use ones may be cost-benefi cial in institutions with a lower volume of cases per year.

THULIUM FIBER LASER, THE NEWCOMER FOR TREATMENT OF URINARY TRACT STONES

Since its first conception in the 80s, advances in laser tech nology have determined a significant improvement in terms of surgical performance for urolithiasis. Indeed, all the factors affecting lithotripsy, such as laser and stone characteristics, distance and inclination angle between the fiber tip and tissue, have been studied (18). Currently, the Holmium-YAG (Ho:YAG) laser is the most diffused world wide, due to its vaporization capacity of the tissue, with an

infrared emission wavelength of approximately 2.09 μm. Another laser developed for urological surgery is the Thulium-YAG (Tm:YAG) one, but, due to its lower peak power, it is not suitable for stone fragmentation. In their ex vivo experimental study, Proietti et al. have reported that Tm:YAG laser has an incision depth significantly lower than Ho:YAG, although the latter determines also lateral frac tures of the tissue because of its explosive energy (19).

In addition to this uncontrollable energy burst, the Ho: YAG laser has a short duration with emission interrup tions. Indeed, the latter has a pulse duration of less than 1 millisecond and an asymmetrical pulse shape.

The innovative MOSES technology improved the stone fragmentation thanks to the generation of two sub pulses: the first one generates a controlled peak of energy creat ing a vapor bubble, which is crossed by the second one (with high energy), to disperse to a minimum the lost energy and the fiber-stone distance influences the laser transmission to a lesser extent (20).

Recently, the thulium fiber laser (TFL) was launched on the market. It demonstrated greater versatility than the Ho:YAG laser, with a wider range of energy, duration and pulse shape (21). Its flat-top pulse shape has a lower power peak and greater duration, determining a lower stone retropulsion and a higher lithotripsy efficiency through the generation of smaller fragments produced (22). TFL showed promising results. Dymov et al. reported its safety and efficacy guaranteeing optimal visualization and minimal stone displacement for all types of urinary stones in the kidney, ureter, and bladder (23). Furthermore, Chiron et al. affirmed that every TFL pulse, probably due to its low energy, generates a stream of small bubbles, determining a similar MOSES effect (24).

ACKNOWLEDGMENTS

Dr. Carlo Giulioni and Dr. Viriglio De Stefano have no con flict of interests.

REFERENCES

1. Torricelli FC, De S, Hinck B, Noble M, Monga M. Flexible ureteroscopy with a ureteral access sheath: when to stent? Urology. 2014; 83(2):278-81.

2. EAU Guidelines. Edn. presented at the EAU Annual Congress Milan 2021. ISBN 978-94-92671-13-4.

3. Lange D, Bidnur S, Hoag N, et al. Ureteral stent-associated com plications where we are and where we are going. Nat Rev Urol. 2015; 12,17-25.

4. Joshi HB, Newns N, Stainthorpe A, et al. Ureteral stent symptom questionnaire: development and validation of a multi- dimensional quality of life measure. J Urol. 2003; 169:1060-1064.

5. Bosio A, Alessandria E, Dalmasso E, et al. How bothersome dou ble-J ureteral stents are after semirigid and flexible ureteroscopy: a prospective single-institution observational study. World J Urol. 2019; 37(1):201-207.

6. Wiseman O, Ventimiglia E, Doizi S, et al. Effects of silicone hydro coated double loop ureteral stent on symptoms and quality of life in

patients undergoing flexible ureteroscopy for kidney stone: a random ized multicenter clinical study. J Urol. 2020; 204:769-77.

7. Bosio A, Alessandria E, Agosti S, et al. Pigtail Suture Stents Significantly Reduce Stent-related Symptoms Compared to Conventional Double J Stents: A Prospective Randomized Trial. Eur Urol Open Sci. 2021; 29:1-9.

8. Arenas JL, Shen JK, Keheila M, et al. Kidney, Ureter, and Bladder (KUB): A Novel Grading System for Encrusted Ureteral Stents. Urology. 2016; 97:51-55.

9. Vanderbrink BA, Rastinehad AR, Ost MC, Smith AD. Encrusted uri nary stents: evaluation and endourologic management. J Endourol. 2008; 22(5):905-12.

10.Yoshida T, Takemoto K, Sakata Y, et al. A randomized clinical trial evaluating the short-term results of ureteral stent encrustation in urolithiasis patients undergoing ureteroscopy: micro-computed tomography evaluation. Sci Rep. 2021; 11(1):10337.

11. Takayasu H, Aso Y. Recent development for pyeloureteroscopy: guide tube method for its introduction into the ureter. J Urol. 1974; 112(2):176-8.

12. Somani BK, Al-Qahtani SM, de Medina SD, Traxer O. Outcomes of flexible ureterorenoscopy and laser fragmentation for renal stones: comparison between digital and conventional ureteroscope. Urology. 2013; 82(5):1017-9.

13. Sung JC, Springhart WP, Marguet CG, et al. Location and etiology of flexible and semirigid ureteroscope damage. Urology. 2005; 66(5):958-63.

14. Proietti S, Somani B, Sofer M, et al. The “Body Mass Index” of Flexible Ureteroscopes. J Endourol. 2017; 31(10):1090-1095.

15. Qi S, Yang E, Bao J, et al. Single-Use Versus Reusable Digital Flexible Ureteroscopes for the Treatment of Renal Calculi: A Prospective Multicenter Randomized Controlled Trial. J Endourol. 2020; 34(1):18-24.

16. Marchini GS, Torricelli FC, Batagello CA, et al. A comprehensive lit erature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices. Int Braz J Urol. 2019; 45(4):658-670.

17. Martin CJ, McAdams SB, Abdul-Muhsin H, et al. The Economic Implications of a Reusable Flexible Digital Ureteroscope: A CostBenefit Analysis. J Urol. 2017; 197(3 Pt 1):730-735.

18. Verdaasdonk RM, van Swol CFP, Grimbergen MCM, et al. Imaging techniques for research and education of thermal and mechanical interactions of lasers with biological and model tissues. J. Biomed. Opt. 2006; 11:041110.

19. Proietti S, Rodríguez-Socarrás ME, Eisner BH, et al. Thulium:YAG Versus Holmium:YAG Laser Effect on Upper Urinary Tract Soft Tissue: Evidence from an Ex Vivo Experimental Study. J Endourol. 2021; 35(4):544-551.

20. Elhilali MM, Badaan S, Ibrahim A, Andonian S. Use of the Moses technology to improve holmium laser lithotripsy outcomes: a preclin ical study. J Endourol. 2017; 31:598-604.

21. Traxer O, Keller EX. Thulium fiber laser: the new player for kidney stone treatment? A comparison with holmium:YAG laser. World J Urol. 2020; 38:1883-94.

22. Ventimiglia E, Doizi S, Kovalenko A, et al. Effect of temporal pulse shape on urinary stone phantom retropulsion rate and ablation effi ciency using holmium:YAG and super-pulse thu-lium fibre lasers. BJU Int. 2020; 126:159-67.

23. Dymov A, Rapoport L, Enikeev D, et al. 383: Prospective clinical study on superpulse thulium fiber laser: Initial analysis of optimal laser settings. Eur Urol. Suppl 2019; 18:e50052.

24. Chiron PH, Berthe LL, Coninck VD, et al. MP5-4: comparison of vapor bubbles induced by an Holmium:YAG Laser and a SuperPusled Thulium Fiber Laser. Toward high speed lithotripsy at KHz repetition rate. J Endourol. 2018; 32:A42.

CORRESPONDENCE

Carlo Giulioni

Department of Urology, University Hospital “Ospedali Riuniti”.

71 Conca Street, 60126, Ancona – Italy Email: carlo.giulioni9@gmail.com

Phone: +39 320/7011978

ORCID: 0000-0001-9934-4011

SIU National Congress 2021 Technological news in endourology of the upper urinary tract: from double J to the new laser

Carlo Giulioni 1

INNOVATIONS IN URETERAL STENTS: EVOLUTION OF MATERIALS VS EVOLUTION IN DESIGN

In clinical practice, the most common use of ureteral stents is to allow urine to flow through the ureter around an obstructing kidney/ureteral stone or after instrumenta tion of the upper urinary tract. In a retrospective study, Torricelli et al. affirmed that stent position might lead to less postoperative pain after flexible ureteroscopy with a ureteral access sheath (1).

However, according to the latest EAU guidelines, routine ureteral stenting after a stone-free URS is not necessary because of higher postoperative morbidity and costs (2). Indeed, stent permanence even for a short time leads in turn to several criticisms. In their literature review, Lange et al. have reported the ureteral stent-associated complica tions, including encrustation, infection, pain and discomfort can be caused by ureteral tissue irritation and possibly irregular peristalsis (3).

Consequentially, ureteral stents alter general health status, working and sexual activity, but how can this effect be

quantified? The Ureteric Stent Symptoms Questionnaire (USSQ), a self-administered and reliable instrument, was designed to assess the impact of stent on patients’ quality of life (4). Bosio et al. have already reported using the USSQ that a double J ureteral stent determined severe symptoms in a high percentage of patients, carefully weigh ing his insertion and minimizing his indwelling time (5). Although a better tolerance has been demonstrated for silicone stents than those in polyurethane and in silicone hydrocoated (6), current scientific research aims to further reduce stent-related symptoms.

The rationale is to reduce as much as possible the material in contact with the urothelial mucosa, reducing ureteral aperistalsis, vesicoureteral reflux and Lower Urinary Tract Symptoms. Keeping this in mind, the Pigtail Suture Stents were designed. The latter are made with a pigtail at the proximal end and a fluted beak, and with a double surgical thread at the distal end. In a recent prospective random ized trial, Bosio et al. compared the outcomes of these stents and the conventional double-J one, using the USSQ, in patients with proximal and medial ureteral stones (7). Pigtail Suture Stents showed a significantly lower incidence of urinary frequency, burning at voiding, pain interfering

Department of Urology, Polytechnic University of Marche Region, Umberto I Hospital "Ospedali Riuniti", Ancona, Italy.

with daily-activities and the need for health professional help two weeks after insertion. This study had a small sam ple size and further investigations are necessary, but the early outcomes look promising. Therefore, the future research should be focused on plac ing fewer ureteral stents and ensuring a better patients’ quality of life.

INNOVATIONS IN FLEXIBLE URETEROSCOPES: MULTI-USE VS SINGLE-USE

Since the introduction of the first flexible ureteroscope back in 1987 (8), technological evolution has led to improvements in maneuverability and fiber optic vision with a decrease in the diameter of the scope. A great rev olution was the advent of digital flexible ureteroscopes, with a remarkable increase in resolution compared to fiber-optic ones but with a larger diameter. In 2013, Somani B et al. reported that digital technology saved up to 30% on operational time with comparable success rates (9). Another noteworthy critical issue of reusable uretero scopes is their durability, which also correlates with the performance of the operator. Indeed, Sung et al. found that the major cause of reusable ureteroscope injury was working channel damage from laser burn or instrument passage and extreme scope deflection with an indwelling instrument (10). Therefore, the first single-use, but semirigid, ureteroscopes were created in 2016. Already with the 2nd generation, the instrument becomes flexible, deter mining an improvement in terms of vision due to the use of a digital camera, and manoeuvrability. Nowadays, both single-use and reusable digital ureteroscopes have the same profiles and both have better ergonomics than reusable fiber-optic ureteroscopes (11).

On the other hand, single-use instruments have as limits the greater areas of shadow, over-illumination, and more blood-altered vision than digital reusable ones. Therefore, which type of device is to be preferred? In a prospective multicenter randomized controlled trial, Qi et al. showed that the single-use digital URS appears to be at least non-inferior to digital reusable one in terms of stonefree rate, high-quality of imaging, and operability (12). Regarding the cost-effective ratio, the literature lacks welldesigned prospective randomized trials.

In their comprehensive literature-based equation, Marchini et al. pointed out that the main factors involved in the cost-effectiveness of a flexible ureteroscopy program were: i) purchase price; ii) repair requirement (replacement contract and insurance); iii) scope longevity-influenced by surgical training; iv) sterilization method; v) stone burden; vi) reprocessing or recycling expenditure; and vii) operating room expense (13).

In conclusion, based on Martin’s cost-benefit analysis (14), reusable ureteroscopes seem to be more adapted for high-volume centers, while single-use ones may be costbeneficial in institutions with a lower volume of cases per year.

INNOVATIONS IN LASER: HOLMIUM VS TFL

Since its first conception in the 80s, advances in laser tech nology have determined a significant improvement in terms of surgical performance for urolithiasis. Indeed, all the factors affecting lithotripsy, such as laser and stone characteristics, distance and inclination angle between the fiber tip and tissue, have been studied (15). Currently, the Holmium-YAG (Ho:YAG) laser is the most diffused world wide, due to its vaporization capacity of the tissue, with an infrared emission wavelength of approximately 2.09 μm. Another laser developed for urological surgery is the Thulium-YAG (Tm:YAG) one, but, due to its lower peak power, it is not suitable for stone fragmentation. In their ex vivo experimental study, Proietti et al. have reported that Tm:YAG laser has an incision depth significantly lower than Ho:YAG, although the latter determines also lateral frac tures of the tissue because of its explosive energy (16).

In addition to this uncontrollable energy burst, the Ho: YAG laser has a short duration with emission interrup tions. Indeed, the latter has a pulse duration of less than 1 millisecond and an asymmetrical pulse shape.

The innovative MOSES technology improved the stone fragmentation thanks to the generation of two subpulses: the first one generates a controlled peak of energy creat ing a vapour bubble, which is crossed by the second one (with high energy), to disperse to a minimum the lost energy and the fiber-stone distance influences the laser transmission to a lesser extent (17).

Recently, the thulium fiber laser (TFL) was launched on the market. It demonstrated greater versatility than the Ho:YAG laser, with a wider range of energy, duration and pulse shape (18). Its flat-top pulse shape has a lower power peak and greater duration, determining a lower stone retropulsion and a higher lithotripsy efficiency through the generation of smaller fragments produced (19).

TFL showed promising results: Dymov et al. reported its safety and efficacy guaranteeing optimal visualization and minimal stone displacement for all types of urinary stones in the kidney, ureter, and bladder (20). Furthermore, Chiron et al. affirmed that every TFL pulse, probably due to its low energy, generates a stream of small bubbles, determining a similar MOSES effect (21).

THM

In the previous section, the topic of symptoms following stent placement and its etiopathogenesis were discussed.

Only marginally, the consequences related to ureteral stent encrustation were mentioned. This phenomenon is com mon, leading to possible adverse effects such as infections, urinary symptoms and obstruction (22). In addition, the encrustations may also make the removal of the ureteral stent challenging.

The reason for the formation of calcium and magnesium deposits on the external surface of a stent is very complex and depends on multiple factors, such as patient's metabolism, stent indwelling time and its shape and mate rial (23). Scientific research has focused precisely on this

SIU National Congress 2021 - Technological news in endourology of the upper urinary tract: from double J to the new laser

last contributing cause, looking for suitable material and design to minimize the encrustation. Recently, a new stent has been introduced in the market. This device is a tri-layer design that incorporates with a sur face technology engineered onto the outer and inner stent surfaces for optimal coverage against urine calcium and magnesium salt deposits during exposure for two weeks to artificial sterile urine and Proteus mirabilis infected urine (in vitro study). Its inert and non-polar copolymer material composition surrounded by super smooth and hydropho bic outer and inner surfaces makes this stent unique as the surface of the other stents have a hydrophilic gel coating. However, Yoshida et al. recently found that this stent did not seem suitable for a long indwelling time (24). These results contrast with the previous in vitro study; therefore, further investigation is necessary.

REFERENCES

1. Torricelli FC, De S, Hinck B, et al. Flexible ureteroscopy with a ureteral access sheath: when to stent? Urology. 2014; 83(2):278-81.

2. EAU Guidelines. Edn. presented at the EAU Annual Congress Milan 2021. ISBN 978-94-92671-13-4.

3. Lange D, Bidnur S, Hoag N, et al. Ureteral stent-associated com plications where we are and where we are going. Nat Rev Urol. 2015; 12,17-25.

4. Joshi HB, Newns N, Stainthorpe A, et al. Ureteral stent symptom questionnaire: development and validation of a multi- dimensional quality of life measure. J Urol. 2003; 169:1060-1064.

5. Bosio A, Alessandria E, Dalmasso E, et al. How bothersome dou ble-J ureteral stents are after semirigid and flexible ureteroscopy: a prospective single-institution observational study. World J Urol. 2019; 37(1):201-207.

6. Wiseman O, Ventimiglia E, Doizi S, et al. Effects of silicone hydro coated double loop ureteral stent on symptoms and quality of life in patients undergoing flexible ureteroscopy for kidney stone: a random ized multicenter clinical study. J Urol. 2020; 204:769-77.

7. Bosio A, Alessandria E, Agosti S, et al. Pigtail Suture Stents Significantly Reduce Stent-related Symptoms Compared to Conventional Double J Stents: A Prospective Randomized Trial. Eur Urol Open Sci. 2021; 29:1-9.

8. Takayasu H, Aso Y. Recent development for pyeloureteroscopy: guide tube method for its introduction into the ureter. J Urol. 1974; 112(2):176-8.

9. Somani BK, Al-Qahtani SM, de Medina SD, Traxer O. Outcomes of flexible ureterorenoscopy and laser fragmentation for renal stones: comparison between digital and conventional ureteroscope. Urology. 2013; 82(5):1017-9.

10. Sung JC, Springhart WP, Marguet CG, et al. Location and etiology of flexible and semirigid ureteroscope damage. Urology. 2005; 66(5):958-63.

11. Proietti S, Somani B, Sofer M, et al. The “Body Mass Index” of Flexible Ureteroscopes. J Endourol. 2017; 31(10):1090-1095.

12. Qi S, Yang E, Bao J, et al. Single-Use Versus Reusable Digital Flexible Ureteroscopes for the Treatment of Renal Calculi: A Prospective Multicenter Randomized Controlled Trial. J Endourol. 2020; 34(1):18-24.

13. Marchini GS, Torricelli FC, Batagello CA, et al. A comprehensive lit erature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices. Int Braz J Urol. 2019; 45(4):658-670.

14. Martin CJ, McAdams SB, Abdul-Muhsin H, et al. The Economic Implications of a Reusable Flexible Digital Ureteroscope: A CostBenefit Analysis. J Urol. 2017; 197(3 Pt 1):730-735.

15. Verdaasdonk RM, van Swol CFP, Grimbergen MCM, et al. Imaging techniques for research and education of thermal and mechanical interactions of lasers with biological and model tissues. J. Biomed. Opt. 2006; 11:041110.

16. Proietti S, Rodríguez-Socarrás ME, Eisner BH, et al. Thulium:YAG Versus Holmium:YAG Laser Effect on Upper Urinary Tract Soft Tissue: Evidence from an Ex Vivo Experimental Study. J Endourol. 2021; 35(4):544-551.

17. Elhilali MM, Badaan S, Ibrahim A, Andonian S. Use of the Moses technology to improve holmium laser lithotripsy outcomes: a preclin ical study. J Endourol. 2017; 31:598-604.

18. Traxer O, Keller EX. Thulium fiber laser: the new player for kidney stone treatment? A comparison with holmium:YAG laser. World J Urol. 2020; 38:1883-94.

19. Ventimiglia E, Doizi S, Kovalenko A, et al. Effect of temporal pulse shape on urinary stone phantom retropulsion rate and ablation effi ciency using holmium:YAG and super-pulse thu-lium fibre lasers. BJU Int. 2020; 126:159-67.

20. Dymov A, Rapoport L, Enikeev D, et al. 383: Prospective clinical study on superpulse thulium fiber laser: Initial analysis of optimal laser settings. Eur Urol Suppl. 2019; 18:e50052.

21. Chiron PH, Berthe LL, Coninck VD, et al. MP5-4: comparison of vapor bubbles induced by an Holmium:YAG Laser and a SuperPusled Thulium Fiber Laser. Toward high speed lithotripsy at KHz repetition rate. J Endourol. 2018; 32:A42.

22. Arenas JL, Shen JK, Keheila M, et al. A Novel Grading System for Encrusted Ureteral Stents. Urology. 2016; 97:51-55.

23. Vanderbrink BA, Rastinehad AR, Ost MC, Smith AD. Encrusted uri nary stents: evaluation and endourologic management. J Endourol. 2008; 22(5):905-12.

24. Yoshida T, Takemoto K, Sakata Y, et al. A randomized clinical trial evaluating the short-term results of ureteral stent encrustation in urolithiasis patients undergoing ureteroscopy: micro-computed tomography evaluation. Sci Rep. 2021; 11(1):10337.

CORRESPONDENCE

Carlo Giulioni

Department of Urology, University Hospital “Ospedali Riuniti”.

71 Conca Street, 60126, Ancona – Italy

E-mail: carlo.giulioni9@gmail.com

Phone: +39 320/7011978

ORCID: 0000-0001-9934-4011

Advances in Urological Diagnosis and Imaging - 2022; 5,1

Instructions to Authors

AIMS AND SCOPE

Advances in Urological Diagnosis and Imaging is a free open access journal. The Journal has the purpose of pro mote, spread and favorite the scientific knowledge and research in diagnosis and imaging in Urology, Andrology and Nephrology.

Advances in Urological Diagnosis and Imaging publishes every 4 months original articles, reviews, case reports, position papers, guidelines, editorials, abstracts and congress proceedings.

To publish in Advances in Urological Diagnosis and Imaging is free The official language of the journal is English

For papers with national interest because of local con tents, in the “Italian Corner” it’s accepted their publication in Italian. The abstract must be in English. The editing of these papers follows the instructions below described.

All accepted paper will be published after a peer reviewed process.

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It must contain: a) title; b) a short (no more than 40 characters) running head title;

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For original articles concerning experimental or clinical studies, the following standard scheme must be followed: Summary - Key Words - Introduction - Material and Methods - Results - Discussion - Conclusions - References - Tables - Legends - Figures. Case Report should be divided into: SummaryIntroduction (optional) - Case report(s) - ConclusionsReferences (Discussion and Supplementary Figures, Tables and References can be submitted for publication in Supplementary Materials).

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REFERENCES

References must be sorted in order of quotation and numbered with arabic digits between parentheses. Only the references quoted in the text can be listed. Journal titles must be abbreviated as in the Index Medicus. Only studies published on easily retrieved sources can be quot ed. Unpublished studies cannot be quoted, however arti cles “in press” can be listed with the proper indication of the journal title, year and possibly volume. References must be listed as follows:

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• Books

Authors - Complete title in the original language. Edition number (if later than the first). City of publication: Publisher, Year of publication.

Example: Bergel DIA. Cardiovascular dynamics. 2nd ed. London: Academic Press Inc., 1974.

• Book chapters

Authors of the chapters - Complete chapter title. In: Book Editor, complete Book Title, Edition number. City of publication: Publisher, Publication year: first page of chapter in the book.

Example: Sagawa K. The use of central theory and sys tem analysis. In: Bergel DH (Ed), Cardiovascular dynam ics. 2nd ed. London: Academic Press Inc., 1964; 115.

TABLES

Tables must be aimed to make comprehension of the written text easier. They must be numbered in Arabic dig its and referred to in the text by progressive numbers. Every table must be accompanied by a brief title. The meaning of any abbreviations must be explained at the bottom of the table itself.

FIGURES

Figures are also graphics, algorithms, photographs, draw ings.

Figures must be numbered and quoted in the text by number.

The meaning of all symbols, abbreviations or letters must be indicated.

Histology photograph legends must include the enlarge ment ratio and the staining method. Legends must be col lected in one or more separate pages.

Please follow these instructions when preparing files:

• Do not include any illustrations as part of your text file.

• Do not prepare any figures in Word as they are not workable.

• Line illustrations must be submitted at 600 DPI.

• Halftones and color photos should be submitted at a minimum of 300 DPI.

MANUSCRIPT REVIEW

Only manuscript written according to the above men tioned rules will be considered.

All submitted manuscripts are evaluated by the Editorial Board and/or by two referees designated by the Editors.

The Authors are informed in a time as short as possible on whether the paper has been accepted, rejected or if a revision is deemed necessary.

The Editors reserve the right to make editorial and liter

ary corrections with the goal of making the article clearer or more concise, without altering its contents. Submission of a manuscript implies acceptation of all above rules.

MANUSCRIPT PRESENTATION

Authors must submit their manuscripts (MAC and WIN DOWS Microsoft Word are accepted) to the Assistant Editor (dellatti@hotmail.com).

PROOFS

Authors are responsible for ensuring that all manuscripts are accurately typed before final submission. Galley proofs will be sent to the Corresponding Author. Proofs should be returned within seven days from receipt.

IMPORTANT TO KNOW

PAPERS ON : MEDICAL AND SURGICAL DEVICES, DIAGNOSTIC INSTRUMENTS, REGISTERED DRUGS , DIET SUPPLEMENTS , NUTRACEUTICALS

S.I.E.U.N. guarantees the Authors the publication of the article for scientific purposes completely free of charge. Each of the Authors is required to declare at the bottom of their article if they have received funding or grants from Sponsors for publication / study.

Papers that contain references to devices (medical and surgical), diagnostic instruments, registered drugs, diet sup plements, nutraceuticals must not be used for commercial purposes without the authorization of Edizioni Scripta Manent.

The Authors are required to declare in the Copyright Assignment Form which possible Sponsors could be inter ested in a commercial use of the reprints.

Sponsor are requested to buy a minimum amount of 100 reprints at a cost of € 1.500 (1 to 4 pages) or € 2.000 (5 to 8 pages).

Prices for the purchase of number of reprints greater than 100 can be negotiated with Edizioni Scripta Manent. Edizioni Scripta Manent retains copyright for republishing and the distribution rights for commercial purpose.

TRANSLATION

Translation of manuscripts in Italian language is offered on payment.

Translation and reprints can be requested to Edizioni Scripta Manent by e-mail to info@edizioniscriptamanent.eu