Advances in Urological Diagnosis and Imaging - AUDI (Vol. 3 - n. 3 - 2020) by Edizioni Scripta Manent

ADVANCES IN UROLOGICAL DIAGNOSIS AND IMAGING

Vol. 3 - n. 3 - 2020

EDITOR IN CHIEF Andrea B. Galosi CO-EDITOR Pasquale Martino

XXII CONGRESSO NAZIONALE Ancona 30 Novembre -1 Dicembre 2020

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S.I.E.U.N. Italian Society of Integrated Diagnostic in Urology, Andrology, Nephrology

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Editorial Prostatic biopsy: Where are we going? Miano R1, Kastner C2. 1 2

Department of Surgical Sciences, UOSD Urology, University of Rome Tor Vergata, Rome (Italy); CamPARI-Clinic, Cambridge University Hospitals, Cambridge (United Kingdom).

The prostate cancer (PCa) pathway has changed immeasurably over the last 20 years. The ‘Prostate biopsy’ has been modified in terms of preprocedural imaging, approach, technique and position in the pathway itself. This all has raised the interest of the urological community. The introduction of the prostate mpMRI has completely changed our approach and has only consolidated the pre-existing evidence that 12-core TRUS biopsies were inadequate. The use of a high-quality mpMRI can avoid biopsies, if normal, and increase the rate of the detection of significant PCa, if positive (1, 2). MRI-based biopsy has now become the standard and it is recommended before any prostate biopsy (3). Transperineal vs transrectal route, targeted vs targeted and systematic approach, fusion vs cognitive technique: many dichotomies have been resolved or are now asking for a definitive reply. The TRexit movement started in UK at Guy’s in 2017 with the aim not to perform more transfaecal transrectal biopsy in favor of a clean local anesthesia transperineal route (4, 5). UK and Australia are now leading the TRexit initiative, reaching 33% and 38% of total numbers of prostate biopsy done transperineally respectively. The local National Health System is strongly supporting this effort to minimize infection rate and address antibiotic resistance. Training and tutoring are both important issues to be considered in shifting from transrectal to transperineal. Using special devices to facilitate a probe/needle in-line approach, such as the Precision Point™ (Perineologic, Cumberland, MD, US) (6) or the Koelis™ Perine Grid®, or electromagnetic needle tracking, could help the transition. A structured patient-centred international care program should be designed to support a global initiative that favors the shift from transrectal to transperineal

approach focusing on different reimbursement, outpatient procedure in local anesthesia and antibiotic-free protocol. Targeted vs targeted and systematic biopsy is now at the center of a great debate where multiple factors should be considered because of their influence on the final biopsy result. MRI quality and radiologist’s experience drive the accuracy in reporting MRI. It has been evidenced and there is well-developed consensus that MRI reporting is a specialist skill with a requirement of significant training and maintenance of expertise within a formalized MDT (7, 8). The quality of the MRI determines the quality of the biopsy and that in turn the quality of treatment outcome. Only with a high quality MRI a biopsy can be avoided and a target only approach considered. Target biopsy appears attractive to be the future, but from a quality management perspective a global recommendation appears unsafe considering the variation of standards of individuals and teams. If quality measures are taken and transparently reported locally, if a MDT framework with quality management processes is in place, it could be considered. At the moment, we are now evolving to have a saturation of the “target”, obtaining an adequate number of cores both from the target and peri-target area and decreasing the number of systematic biopsies, that are now still necessary (3, 9). It is therefore mandatory to organize a pathway that ensures the correct acquisition of the images and the quality of the radiologist’s report through a personal certification of “good prostate MRI reading and interpretation”. At the same time, we need to educate and train urologists and residents in Urology in reading prostate MRI to perform a real “cognitive” biopsy, through the use of different available online platforms (www.mripro.io, www.raiqc.com, prostatecancer.ai) in order to acquire skills in reading and interpreting MRI. This would only ever achieve a level 2 certification of the new consensus (8). Advances in Urological Diagnosis and Imaging - 2020; 3,3

EDITORIAL – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

Fusion platforms attract a lot of urologists because of the preconception of better precision by using technology. Many papers are now showing that cognitive biopsy is non-inferior to the MRI-TRUS fusion technique in terms of accuracy (10, 11), allowing for a significant economic saving. The studies have included experts in MRI and biopsies to prove that point, but we need to consider that in the majority of centres and health services prostate diagnostics are provided by trainees, their coming and going will lead to fluctuations of quality of diagnostic outcomes and fusion technology can overcome that. Further studies are thus necessary to demonstrate when software-based fusion is really useful and superior to cognitive technique for MRI-trained and experienced urologists as well as trainees. In conclusion, we have achieved a lot but there is still a lot to be done in the field of prostate biopsy to optimize the procedure, while minimizing complications and costs. BIBLIOGRAPHY 1. Drost FH, Osses DF, Nieboer D, et al. Prostate MRI, with or without MRI-targeted biopsy, and systematic biopsy for detecting prostate cancer. Cochrane Database Syst Rev. 2019; 4(4):CD012663. 2. Ahmed HU, El-Shater Bosaily A, Brown LC, et al. PROMIS study group. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet. 2017; 389(10071):815-822. 3. Mottet N, Bellmunt J, Briers E, et al. Members of the EAU – ESTRO – ESUR –SIOG Prostate Cancer Guidelines Panel. EAU – ESTRO – ESUR – SIOG Guidelines on Prostate Cancer. Edn.

Advances in Urological Diagnosis and Imaging - 2020; 3,3

presented at the EAU Annual Congress Amsterdam 2020. 978-94-92671-07-3. Publisher: EAU Guidelines Office. Place published: Arnhem, The Netherlands. 4. https://nhsaccelerator.com/trexit-initiative-transperinealprostatebiopsies-local-anaesthetic/ Accessed 9 Nov. 2019. 5. Grummet J, Gorin MA, Popert R, et al. “TREXIT 2020”: why the time to abandon transrectal prostate biopsy starts now. Prostate Cancer Prostatic Dis. 2020; 23(1):62-65. 6. Zimmerman ME, Meyer AR, Carter HB, et al. In-office Transperineal Prostate Biopsy Using Biplanar Ultrasound Guidance: A Step-by-Step Guide. Urology. 2019; 133:247. 7. Gaziev G, Wadhwa K, Barrett T, et al. Defining the learning curve for multiparametric magnetic resonance imaging (MRI) of the prostate using MRI-transrectal ultrasonography (TRUS) fusion-guided transperineal prostate biopsies as a validation tool. BJU Int. 2016; 117(1):80-6. 8. Barrett T, Padhani AR, Patel A, et al. Certification in reporting multiparametric magnetic resonance imaging of the prostate: recommendations of a UK consensus meeting. BJU Int. 2020. 9. Hansen NL, Barrett T, Lloyd T, et al. Optimising the number of cores for magnetic resonance imaging-guided targeted and systematic transperineal prostate biopsy. BJU Int. 2020;v125(2):260-269. 10.Liang L, Cheng Y, Qi F, et al. A Comparative Study of Prostate Cancer Detection Rate Between Transperineal COG-TB and Transperineal FUS-TB in Patients with PSA ≤20 ng/mL. J Endourol. 2020; 34(10):1008-1014. 11.Khoo CC, Eldred-Evans D, Peters M, et al. A Comparison of Prostate Cancer Detection Between Visual-Estimation (Cognitive Registration) and Image-Fusion (Software Registration) Targeted Transperineal Prostate Biopsy. J Urol. 2020; 18:101097JU0000000000001476.

Official Journal of S.I.E.U.N. EDITOR in CHIEF Andrea B. Galosi, Ancona (IT)

CO-EDITOR

General Information

Pasquale Martino, Bari (IT)

ASSISTANT EDITOR Lucio Dell’Atti, Ancona (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)

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Advances in Urological Diagnosis and Imaging - 2020; 3,3

III

PATROCINI RICHIESTI

Advances in Urological Diagnosis and Imaging - 2020; 3,3

XXII CONGRESSO NAZIONALE S.I.E.U.N.

Contents

Page 1

C1_ULTRASOUND SCAN IN A REFERRED PENETRATIVE THE ABILITY TO FIND A NEEDLE IN A HAYSTACK

SCROTAL TRAUMA:

Fabiani A, Pavia MP, Principi E, Biondi C, Rossi E, Servi L. 1

C2_THE ERYTHEMATOUS SCROTUM: A CASE OF RECURRENT IDIOPATHIC SCROTAL

EDEMA

Fabiani A, Pavia MP, Principi E, Servi L. 2

C3_PERINEAL

CYST EXCISON

Traunero F, Bucci S, Claps F, Rizzo M, Boltri M, Migliozzi F, Bussani R, Scozzese S, Liguori G, Trombetta C. 2

C4_PENILE REVASCULARIZATION TO TREAT ERECTILE DYSFUNCTION: TERMINO-LATERAL AND TERMINO-TERMINAL BYPASS Chiapparrone G, Liguori G, Boschian R, Bucci S, Di Marco L, Bertolotto M, Belgrano E, Trombetta C.

C5_ULTRASOUND

AND CLINICAL EVIDENCE OF BUCCAL MUCOSA GRAFT AS FIRST CHOICE IN SURGICAL MANAGEMENT OF PEYRONIE’S DISEASE

Fabiani A, Fioretti F, Pavia MP, Luca L, Principi E, Servi L. 3

C6_ULTRASOUND

INTRAOPERATIVE MANAGEMENT OF BILATERAL LEYDIG CELL TUMOR IN A YOUNG PATIENT

Fabiani A, Pavia MP, Maurelli V, Servi L. 3

C7_ULTRASOUND GUIDED RETROGRADE FEASIBILITY IN SELECTED CASES

ENDOSCOPIC URETERAL STENTING:

Fabiani A, Iacobone E, Pavia MP, Lepri L, Boncagni F, Elisei D, Servi L, Tappatà G. 4

C8_DIAGNOSIS

OF HARDENED PLASTIC PENIS AND SHEAR WAVE ELASTOSONOGRAPHY OF THE PENIS NEW NON-INVASIVE METHOD

Trama F, Ruffo A, Illiano E, Costantini E, Iacono F. 4

C9_DYNAMIC TRANSPERINEAL ULTRASOUND IN THE FOLLOW-UP OF PATIENTS UNDERGOING A TRANSOTTURATORY SLING PROCEDURE

Trama F, Illiano E, Costantini E. 5

C10_EMI-ABLATION VS FOCAL ABLATION BY HIGH-INTENSITY FOCUSED ULTRASONOGRAPHY (HIFU): IS THERE ANY DIFFERENT IMPACT ON PATIENTS’ POSTOPERATIVE FUNCTIONAL OUTCOMES AND QUALITY OF LIFE? De Luca S, Checcucci E, Peretti D, Garrou D, Cattaneo G, Amparore D, Fiori C, Porpiglia F.

C11_CLINICAL

STAGE IIA BURNED-OUT TESTICULAR CANCER WITH ATYPICAL LYMPHATIC SPREAD: A THREATENING CLINICAL SCENARIO

Agostini E, Scarcella S, Giulioni C, Milanese G, Dell’Atti L, Galosi A. 7

C12_MP-MRI

OF THE PROSTATE SIGNIFICANTLY UNDERESTIMATES TUMOR VOLUME OF SMALL VISIBLE LESIONS. IMPLICATIONS FOR TAILORED FOCAL THERAPY APPROACHES

Stabile A, Karnes JR, Motterle G, Fossati N, Gandaglia G, Barletta F, Scuderi S, Cucchiara V, Robesti D, Rosiello G, Bravi C, Dell’Oglio P, Martini A, Salonia A, Brembilla G, Esposito A, Montorsi F, De Cobelli F, Briganti A. Advances in Urological Diagnosis and Imaging - 2020; 3,3

VII

CONTENTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

C13_INITIAL NEGATIVE MULTI-PARAMETRIC MRI WITH CONCOMITANT BIOPSY: ARE TRUE NEGATIVE FINDINGS CONFIRMED OVER TIME? RESULTS FROM A SINGLE INSTITUTION SERIES

NEGATIVE

Stabile A, Scuderi S, Karnes JR, Motterle G, Fossati N, Gandaglia G, Barletta F, Cucchiara V, Robesti D, Cannoletta D, Pellegrino F, Mazzone E, Rosiello G, Bravi C, Pellegrino A, Moschini M, Brembilla G, Esposito A, Karakiewicz PI, Montorsi F, De Cobelli F, Briganti A. 8

C14_AGE

AND GLEASON SCORE UPGRADING BETWEEN PROSTATE BIOPSY AND RADICAL PROSTATECTOMY. IS THIS STILL TRUE IN THE MP-MRI ERA?

Stabile A, Scuderi S, Karnes JR, Motterle G, Fossati N, Gandaglia G, Barletta F, Cucchiara V, Robesti D, Rizzo A, Pellegrino F, Mazzone E, Rosiello G, Bravi C, Leni R, Moschini M, Brembilla G, Esposito A, Karakiewicz PI, Montorsi F, De Cobelli F, Briganti A. 9

C15_IMPORTANCE

OF FLUOROSCOPY IN RECOGNITION OF A RARE CASE OF SUBMUCOSAL URETERAL STONE COMPLICATED AFTER ENDOSCOPIC TREATMENT - CASE REPORT

Palagonia E, Scarcella S, Dell’Atti L, Tiroli M, Galosi A. 9

C16_ROBOT-ASSISTED REIMPLANTATION: USE

SEGMENTAL URETERECTOMY WITH PSOAS HITCH URETERAL OF INDOCYANINE GREEN (ICG) IN COMPLEX ONCOLOGICAL RECONSTRUCTIVE SURGERY AND EVALUATION OF ONCOLOGICAL, FUNCTIONAL AND PERIOPERATIVE OUTCOMES IN A CASE SERIES

Palagonia E, Scarcella S, Mazzone E, Dell’Oglio P, D'Hondt F, De Naeyer G, Galosi A, Mottrie A. 10

C17_EVALUATION

OF CONCORDANCE BETWEEN PATHOLOGICAL SECTIONS AND MULTIPARAMETRIC RMI OF INDEX AND NOT-INDEX LESIONS

Palagonia E, Scarcella S, Leone L, Montesi L, Dell’Atti L, Sternardi F, Cimadamore A, Montironi R, Giovagnoni A, Galosi AB. 11

C18_WHO SCORES THE GAME IN NEPHRON-SPARING SURGERY? RENAL SCORING SYSTEM REPRODUCIBILITY AMONG RESIDENTS IN UROLOGY AND RADIOLOGY Scarcella S, Dell’Atti L, Agostini E, Palagonia E, Giulioni C, Sbrollini G, Milanese G, Pierini L, Agostini A, Floridi C, Giovagnoni A, Galosi AB.

C19_REUSABLE VERSUS COSTS EVALUATION

DISPOSABLE FLEXIBLE URETEROSCOPES:

Beatrici V, Antezza A, Lacetera V, Cappa E, Zuccarini E, Cervelli B, Gabrielloni G, Montesi M, Morcellini R, Parri G, Recanatini E. 12

C20_MRI/US FUSION OUR EXPERIENCE

PROSTATE BIOPSY IN MEN ON ACTIVE SURVEILLANCE:

Lacetera V, Antezza A, Papaveri A, Cappa E, Cervelli B, Gabrielloni G, Montesi M, Morcellini R, Parri G, Recanatini E, Beatrici V. 12

C21_ITALIAN

EXPERIENCES IN THE MANAGEMENT OF ANDROLOGICAL PATIENTS AT THE TIME OF CORONAVIRUS PANDEMIC

Maretti C, Fabiani A, Colombo F, Franceschelli A, Gentile G, Palmisano F, Vagnoni V, Quaresima L, Polito M. 13

P1_THE

ECO COLOR DOPPLER IN THE ACUTE DROP

Traunero F, Bucci S, Liguori G, Benvenuto S, Ocello G, Ollandini G, Mazzon G, Zordani A, Bertolotto M, Trombetta C, Belgrano E. 14

P2_PENILE

FRACTURES:

CASES

FROM

2002

2019

Napoli R, Liguori G, Bucci S, Benvenuto S, Ollandini G, Mazzon G, Tezzot G, De Concilio B, Di Marco L, Belgrano E, Trombetta C. 14

V1_ROBOTIC

ASSISTED PARTIAL NEPHRECTOMY (RAPN) OF DOUBLE RENAL TUMORS USING INTRAOPERATIVEULTRASOUND AND INDOCYANINEGREEN LIGHT FLUORESCENCE

Lacetera V, Antezza A, Cappa E, Cervelli B, Gabrielloni G, Montesi M, Morcellini R, Parri G, Recanatini E, Beatrici V. 15

V2_ROBOTIC

ASSISTED PARTIAL NEPHRECTOMY RECONSTRUCTION: OUR EXPERIENCE

(RAPN)

WITH

DIGITAL

Beatrici V, Lacetera V, Antezza A, Cappa E, Cervelli B, Gabrielloni G, Montesi M, Morcellini R, Parri G, Recanatini E. 15

V3_ROBOT-ASSISTED

COLPOSACROPEXY WITH SUBTOTAL HYSTERECTOMY

Cappa E, Lacetera V, Antezza A, Cervelli B, Gabrielloni G, Montesi M, Morcellini R, Parri G, Recanatini E, Beatrici V.

VIII

Advances in Urological Diagnosis and Imaging - 2020; 3,3

XXII CONGRESSO NAZIONALE S.I.E.U.N.

Abstracts

C1_ULTRASOUND

SCAN IN A REFERRED PENETRATIVE SCROTAL TRAUMA: THE ABILITY TO FIND A NEEDLE IN A HAYSTACK Fabiani A1, Pavia MP2, Principi E1, Biondi C3, Rossi E3, Servi L1. 1

Urology Unit, Surgical Dpt, ASUR MARCHE Area Vasta 3, Macerata (Italy); 2 Resident, Department of Urology, Marche Polythecnic University, Ancona (Italy); 3 Emergency Department, ASUR MARCHE Area Vasta 3, Macerata (Italy).

Introduction. Isolated urologic trauma is relatively uncommon, presenting in patients with multiple traumatic injuries. These traumatic accidents include blunt injuries, bites, burns, scrotal avulsion and penetrating injuries (1). What happens when the patient reports having had a penetrating trauma to the scrotum but we are unable to detect any clinical signs of entering in the scrotum? We report a case of a referred penetrative scrotal trauma that occured during the work. Materials and Methods. In december 2019, a twentyseven years old, worker in a packaging center, referred to the emergency department complaining that he accidentally injured his scrotum with a nail gun.The patient had no medical or surgical history of note. On examination, the scrotum was normal without any signs of injuries. An ultrasound in Emergency Department was organized wich showed no pathological signs. Both testes and epidydimi were morfologically normal, however. In consideration of the anamnestic data, the patient was referred to our Urology Unit. As a our habit, after objective exam, we performed again a scrotal ultrasound (2). After a first unremarkable scan, the urologist noted a minimal ipoechoic area, with a not well defined limits, at the inferior pole of the right dydimus, and, in the longitudinal scan of the same testis, an iperechoic line without posterior shadow, measuring 1.82 centimeters in lenght, at the external lateral surface. The patients underwent a scrotal explorative surgery. After a scrotal midline incision of the scrotal rafe, the exteriorization of the testis and the section and eversion of tunica vaginalis, we found a very thin nail of about 2 cm located in the space between the vaginal sheets on the lateral right testicular surface. No lesions to the right testis were revealed. Results. The post operative cours was unremarkable. Patient was discharged with antibiotics profilaxis needed. Ultrasound testis study performed in post operative day 1 highlighted the complete integrity of testis and the scrotal wall structures. Conclusion. This case highlights the meaning of scrotal

ultrasound in any case of closed trauma of the scrotum. In particular, we consider it extremely important to carry out the examination by the urologist himself involved in decision-making on the surgical management of the case in question. References. 1. Bourke MM, Silverberg JZ. Acute scrotal emergencies. Emerg Med Clin N Am 2019; 37:593-610. 2. Barozzi L, et al. Scrotum: ultrasound anatomy and scanning methods. In Ultrasonography in Urology, Andrology and Nephrology. Martino P and Galosi AB Editors. Springer. Cap 38, part. V: 461-470.

C2_THE ERYTHEMATOUS SCROTUM: A CASE OF RECURRENT IDIOPATHIC SCROTAL EDEMA Fabiani A1, Pavia MP2, Principi E1, Servi L1. 1

Urology Unit, Surgical Dpt, ASUR MARCHE Area Vasta 3, Macerata (Italy); 2 Resident, Department of Urology, Marche Polythecnic University, Ancona (Italy).

Introduction. Ultrasound is the established first-line imaging modality for acute scrotal disease. When combined with clinical history and physical examination, ultrasound results can be used to diagnose most scrotal disorders (1, 2). We present a case of a recurrent benign acute scrotum. Case report. A Nine-year-old boy was referred from the Emergency Department to our Urologic Section for a six hours hystory of bilateral scrotal dyscomfort, swelling and redness. The patient not complain about accompanying symptoms. Pathological anamnesis received by the mother was silent. Scrotum was enlarged, not painful, the skin red and tender to palpation. The testicular work up for ischemia and suspected torsion (TWIST score) was 2 points. The boy underwent a scrotal ultrasound demonstrating an hyperemic thickened scrotal wall around the testicles, described as the â&#x20AC;&#x153;fountain signâ&#x20AC;?. In transverse color doppler both testis and epydydimis have a normal appearance. A diagnosis of acute idiopathic scrotal edema (AISE) was made. The patient was discharged with antiinflammatory therapy (Ibrupophene for pediatrics). No notice about clinical evolution was received until one month later. The little patient was again accompained to the Emergency Department because of the new onset of the same symptoms. Clinical and ultrasonographic findigs were the same. In addition, the mother reported that the boy had woken up the same morning with swollen lips. Diagnosis of AISE was confirmed. The patient was referred to pediatrics for internal evaluation work-up. Advances in Urological Diagnosis and Imaging - 2020; 3,3

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

Discussion. Idiopathic scrotal edema is a rare, self limiting cause of an acute scrotum. It occurs between the ages of 3 to 9 years. It is defined as the swelling of the scrotal skin without swelling of the deeper tissues. It is an important diagnosis to be aware of, because it needs to be differentiated from more malignant causes of scrotal edema and pain. The etiology is unclear yet. It has been hypothesized that it represents a hypersensitivity reaction related to a variant of angioneurotic edema, associated with eosinophilia in more than 65% of cases. Conclusion. Acute idiopathic scrotal edema is a benign and self limiting condition wich is a rare cause of acute scrotum. Nevertless this is often a diagnosis of exclusion, acute idiopathic scrotal edema can be identified with ultrasonography. References. 1. Sweet DE, et al. Imaging of the acute scrotum: keys to a rapid diagnosis of acute scrotal disorders. Abdominal Radiology. 2020; 45(7):2063-2081. 2. Bucci S, et al. The testicle: Trauma, inflammation and testicular torsion. In Ultrasonography in Urology, Andrology and Nephrology. Martino P and Galosi AB Editors. Springer. Cap 41, part. V: 493-510.

C3_PERINEAL

CYST EXCISON Traunero F1, Bucci S1, Claps F1, Rizzo M1, Boltri M1, Migliozzi F1, Bussani R2, Scozzese S1, Liguori G1, Trombetta C1. 1

Department of Urology, Cattinara Hospital, University of Trieste, Trieste (Italy); 2 Institute of Anatomy Pathology, Cattinara Hospital, University of Trieste, Trieste (Italy).

Introduction and Objectives. To present the case of a symptomatic perineal cyst treated with partial excision. Materials and Methods. In this video, we present the case of a 50-year-old patient with a history of recurrent urinary infections and imaging evidence (MR and CEUS) of "hourglass" perineal cysts with a small solid component anterior to the prostate gland. During the patient preparation, the magnetic resonance images were extrapolated and rendered using the Anatomage software in order to obtain a three-dimensional model of the lesion's behavior. Results. We opted for a medial peno-scrotal access with cautious sparing of the bulb-urethral muscle during mass dissection. The painful symptomatology for which the patient is admitted to our surgeries is receded in the immediate postoperative period. Histological examination revealed the presence of a keratin cysts. Conclusion. The partial excision of the cystic mass, preceded by a careful preparation and radiological evaluation, has proved to be a valid therapeutic alternative in this patient for the treatment of pain symptoms and for the sense of psychological distress felt by the emergence of a scrotal mass. For the remaining component, a radiological follow-up was chosen.

C4_PENILE

REVASCULARIZATION TO TREAT ERECTILE DYSFUNCTION: TERMINO-LATERAL AND TERMINO-TERMINAL BYPASS

Advances in Urological Diagnosis and Imaging - 2020; 3,3

Chiapparrone G1, Liguori G1, Boschian R1, Bucci S1, Di Marco L1, Bertolotto M2, Belgrano E1, Trombetta C1. 1

Department of Urology, Cattinara Hospital, University of Trieste, Trieste (Italy); 2 Department of Radiology, Cattinara Hospital, University of Trieste, Trieste (Italy).

Introduction and Objectives. Penile revascularization represents a valid alternative to treat vasculogenic post-traumatic ED; artery by-pass secure adequate distal blood flow. We present two cases: first one with termino-lateral anastomosis and second one with termino-terminal anastomosis. Materials and Methods. First case: 67-years-old man, diagnosis of vasculogenic ED with obstruction of distal left pudendal artery and bilateral dorsal arteries, no responsive to medical treatment and intracavernous injection. He refused penile prosthesis and underwent penile revascularization with termino-lateral anastomosis of the inferior epigastric and dorsal arteries. Surgeon used a continuos suture in a 9/0 monofilament. Second case: 32 years-old man, diagnosis of vasculogenic ED with bilateral obstruction of pudendal arteries due to traumatic event. He underwent penile revascularization with termino-terminal anastomosis of right inferior epigastric and dorsal penile arteries. Surgeon used interrupted suture in a 9/0 monofilament. Results. In the first case, 3-month echocolordoppler shows valid distal blood flow; patient referred valid erection. In the second case, during a non-penetrative sexual activity after 15 days a large left inguino-scrotal hematoma showed up. He did angiography that showed anastomosis blood leakage. He did selective embolization with absorbable spirals. At follow-up, valid distal blood flow was observed with echocolordoppler and satisfactory erection was reported. Conclusions. Penile artery revascularization should be consider a valid therapeutic option to treat vasculogenic or post-traumatic ED; both termino-lateral and termino-terminal anastomosis result valid microsurgical technique.

C5_ULTRASOUND

AND CLINICAL EVIDENCE OF BUCCAL MUCOSA GRAFT AS FIRST CHOICE IN SURGICAL MANAGEMENT OF PEYRONIE’S DISEASE Fabiani A1, Fioretti F1, Pavia MP2, Luca L1, Principi E1, Servi L1. 1

Urology Unit, Surgical Dpt, ASUR MARCHE Area Vasta 3, Macerata (Italy); 2 Resident, Department of Urology, Marche Polythecnic University, Ancona (Italy).

Introduction. Plaque incision and grafting represent the best surgical approach to the Peyronie’s Disease (PD) patient. Nevertheless the wedge resection is still the gold standard for treating PD, grafting procedures must be restricted to patients with normal preoperative status, excessive curvature and/or hourglass deformities. However, the ideal graft has yet be identified (1). Buccal mucosa grafts (BMG) provided excellent short-term results, suggested by the fast return of spontaneous erections and prevented shrinkage, which is the main cause of

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

graft failure. It also proved to be safe and reproducible, thus representing a valuable treatment option for PD (2). We report our results with BMG focusing the analysis on ultrasonographic and clinical data demostrating buccal mucosa as the first choice in surgical management of PD. Materials and Methods. From 2013 to 2019 we performed at our Urology Unit 27 corporoplasty with BMG to correct complex penile curvature due to PD. Our analyses was focused on BMG as a major determinant of the surgical success. In particular, we considered the ultrasonographic aspect of the BMG in each patient, evaluated at 1, 3, 6 and 12 months from surgery and than yearly, underlying the quick and good integration time and the high cosmetics and functional success rate. Results. Mean age of 27 patients was 57 years (45-71) with a maximum follow up time of 72 months, minimum of 3. Site of penile curvature was dorsal in 18 (67%) patients, ventral in 2 (7%), complex in 7 (26%). The degree of the curvature was <60° in 11 (41%) patients, >60° in 16 (59%). Straightening of penis was reached in 100% of cases. A penile shortening results in 7,4% (2/27). De novo erectile dysfunction appear in 2/27 cases with a post operative amount of PDE5i users increasing from 12 to 14 patients (45% vs 52%). Ultrasound aspects of BMG, recorded at every follow up visit, results in an hypoechoic plaque with an iperechoic rim that become isoechoic over the time in all cases. No case of scars or seroma was registered. Small intra-graft cystic lesions was highlighted in 3 cases (11%). Discussion. BMG demonstrate an high power of inosculation (2-3 days in mean) as highlighted by the rapid time of spontaneous erection resumption, an immediate support from the cavernous tissue and a quick healing with no scar formation as revealed byultrasonographic appearence of patch over the follow up years. Conclusions. BMG may represent the first choice in grafts procedures for PD surgical management. Ultrasound is mandatory during follow up. References. 1. Hatzimouratidis K, Hatzichristou DG. Plaque incision and grafting represents the best surgical approach to Peyronie’s Disease patient: Con. Current Sexual Health Reports. 2006; 3:56-60. 2. Hatzimouratidis K, et al. EAU Giudelines on Erectile dysfunction, Premature Ejaculation, Penile curvature and Priapism. 2018.

C6_ULTRASOUND

INTRAOPERATIVE MANAGEMENT OF BILATERAL LEYDIG CELL TUMOR IN A YOUNG PATIENT Fabiani A1, Pavia MP2, Maurelli V1, Servi L1. 1

Urology Unit, Surgical Dpt, ASUR MARCHE Area Vasta 3, Macerata (Italy); 2 Resident, Department of Urology, Marche Polythecnic University, Ancona (Italy).

Introduction. Testis ultrasound increased detection of small and not palpable testicular lesions (1). In small nodular lesions, ultrasound guided excision is mandatory (2). We report a case of a 30 years old patient undergoing an ultrasound guided testis sparing surgery for small bilateral testicular lesions. Materials and Methods. In April 2015, the young patient underwent a scrotal ultrasound evaluation in follow up of

acute lymphoblastic leukemia treated by bone marrow transplantation in 2004. Two ipoechoic small testicular nodules sized 5 mm and 3 mm was diagnosed in left testis mediastinum. In october 2015, at our Urologic department, also a diagnosis of a right 5 mm nodular testicular lesion was made. Half yearly ultrasound follow up was performed until the evidence of progressive growth of one left nodules (diameter of 1,17 cm from 5 mm) in 2020. Male fertility diagnostic work up revealed a non obstructive azoospermia. The oncologic markers was negative. Surgical technique: Bilateral inguinal incisions were made and the testes delivered. The tunica albuginea was incised and an ultrasound was used to identify the lesions. The nodules was marked whit a 23 gauche needle. After incision of tunica albuginea, the testicular nodule was bluntly dissected and the surgical specimen was sent to frozen section examination. Diagnosis of Leydig cell tumor for each of three nodules was made. The tunica albuginea was closed. After tunica vaginalis eversion, both testes were replaced in the scrotum. Testis ultrasound evaluation was performed immediately after nodules excision. Results. The post operative course was unremarkable. Ultrasound testis study performed in post operative day1 highlighted the complete disappearance of the lesions without evidence of intratesticular hematoma. Hystopathologic exam diagnosed a Leydig cell tumor with surgical margins free from disease. Conclusion. This case highlights the importance of ultrasound testis follow up of small nodules, especially in young patient with infertility risk factors and, mostly, the role of intraoperative ultrasound in testicular sparing approach for small testicular lesions. References. 1. Galosi AB, Fulvi P, Fabiani A, et al. Testicular sparing surgery in small testis masses: a multinstitutional experience. Arch Ital Urol Androl. 2016; 88,4:320-324. 2. Fabiani A, Filosa A, Fioretti F, et al. Diagnostic ultrasound-guided excisioinal testicular biopsy for small (<1 cm) incidental nodules. A single institution experience. Arch Ital Urol Androl. 2014; 86,4: 373-377.

C7_ULTRASOUND

GUIDED RETROGRADE ENDOSCOPIC URETERAL STENTING: FEASIBILITY IN SELECTED CASES Fabiani A1, Iacobone E3, Pavia MP2, Lepri L1, Boncagni F3, Elisei D3, Servi L1, Tappatà G3. 1

Urology Unit, Surgical Dpt, ASUR MARCHE Area Vasta 3, Macerata (Italy); 2 Resident, Department of Urology, Marche Polythecnic University, Ancona (Italy); 3 Departmente of Intensive Care, ASUR MARCHE Area Vasta 3, Macerata (Italy).

Introduction. Stenting is a routine procedure in urology for a broad range of indications. Impending or actual ureteric obstruction is the most common indication for ureteric stenting and it can be caused by extrinsic or intrinsic compression or by changes of the ureteric wall itself. Obstructed pyelonephritis and intolerable renal colicky pain require urgent stenting (1). In case of malignant Advances in Urological Diagnosis and Imaging - 2020; 3,3

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ureteral obstruction it has been recently highlighted that the antegrade approach should be the first choice for the stent placement due to the technical success rate (2). But, especially in case of stone- or non- stone-non malignant indications to ureteral catheterism, retrograde stenting is the gold standard of ureteral obstruction relief. From a technical point of view, ultrasound guide may be a good practical approach to avoid radiation exposure for the patients and the operators. Materials and Methods. A retrospective review of consecutive patients that underwent ultrasound guided retrograde endoscopic ureteral stenting (UGREUS) from 2014 to 2019 for several non primary oncologic indications was performed. Patient data were exctracted from our internal database. Real time ultrasonic guidance was provided by an expert urologist in ultrasound with fluoroscopy available on stand by. Ultrasound was used to visualize advancement of guidewire (placed into the stent if already in site) and the ureteral stent throught the ureter and up to the renal pelvis. Procedures were performed in sedoanalgesia in the operating room. Results. Fourty-eight patients were identify that underwent 58 ureteral stenting procedures, 34 (71%) female and 14 (29%) males, bilateral in six cases (12,5%). Operative time varied from 2 to 10 minutes. No major complications related to procedure per se or to anestesia were recorded. One day surgery was applied in 62,5% of patients. Discussion. Nevertheless a retrograde contrastographic study before inserting the stent is strongly recommended in order to establish the anatomy of the ureter and the collecting system, we think that this is an optional need, being omitted in case of a patient careful selection. As in our case series, the lack of a retrograde contrastographic of the ureter and collecting system did not lead to any complications in the procedure. Conclusions. UGREUS is a safe, feasible and radiationfree option in the management of ureteral obstruction. Ultrasound could check guide wire progression through the ureter and finally verify the correct stent placement in the kidney, sparing radiation exposure to both patient and operators. References. 1. Lawrentschuk N, et al. Ureteric stenting 25 years on: routine or risky? ANZ Journal of Surgery. 2004; 74(4),243-7. 2. Turgut B, et al. Placement of double-J stent in patients with malignant ureteral obstruction: antegrade or retrograde approach? Clinical Radiology. 2019; 74(12):976.e11-976.e17.

C8_DIAGNOSIS

OF HARDENED PLASTIC PENIS AND SHEAR WAVE ELASTOSONOGRAPHY OF THE PENIS NEW NON-INVASIVE METHOD Trama F1, Ruffo A1, Illiano E2, Costantini E2, Iacono F1. 1

Department of General and Specialized Surgieries, Renal Transplantation, Nephrology, Intensive Care and Pain Management, University of Federico II, Naples (Italy); 2 Andrology and urogynecology Clinic, Santa Maria terni Hospital, University of 6 Perugia (Italy).

Objective of the study. The main objective of the study is to identify a possible relationship between penile

Advances in Urological Diagnosis and Imaging - 2020; 3,3

rigidity and pain in erection and subsequent appearance of plaques typical of La Peyronie’s disease. To this end, the use of Shear Wave Elastosonography of corpora cavernosum in clinical practice, was evaluated in order to demonstrate the presence of penile fibrosity (expressed at tissue level as stiffness) typical of the early stages of La Peyronie’s disease in patients with pain in erection, and thus to undertake specific therapy. Subjects and Methods. 85 patients with painful erection symptoms were recruited within less than six months of the first visit. The following were excluded from the study: patients with penile curvature, diabetes, previous pelvic surgery, patients who had taken PDE5i less than three months ago, or who had previously been treated for La Peyronie’s disease. All patients underwent Elastosonography shear wave of the corpora cavernosa, filling in the VAS questionnaire regarding pain and ultrasound B-Mode. Results. The results obtained reveal that the baseline VAS score correlates positively with the rigidity of the corpora cavernosa expressed in kPa (according to Young’s module) obtained by Elastosonography shear wave (p<0.05). There is no statistically significant correlation (p=0.09) between the presence of hyperecogenic plaques on Bmode ultrasound and the VAS score. At 6 months, there is a statistically significant increase in the rigidity of both corpora cavernosa with respect to baseline (p<.05) with a significant decrease in the VAS score with respect to baseline (p<0.04). In addition, there is a positive correlation between patients with a score >28kPa (expressed as an average of both corpora cavernosa) and the appearance of hyperecogenic plaques on ultrasound B-Mode (p<0.03). Conclusion. Elastosonography shear wave can be used in daily clinical practice to make an early and non-invasive diagnosis of La Peyronie’s disease in order to undertake therapies aimed at decreasing the painful symptomatology since its onset, and to slow down the evolution of the disease.

C9_DYNAMIC

TRANSPERINEAL ULTRASOUND IN THE FOLLOW-UP OF PATIENTS UNDERGOING A TRANSOTTURATORY SLING PROCEDURE Trama F1, Illiano E2, Costantini E2. 1

Introduction. Following implantation of medium urethral slinging (MUS) for the treatment of stress incontinence (SUI), approximately 5-23% of patients will have residual urinary incontinence. It has been evaluated in several studies that the recurrence of incontinence may be caused by an incorrect position of the (MUS). The aim of our study is to evaluate, by means of trans-perineal ultrasonography, the correct positioning or the possible incorrect position of the network in patients who have undergone midurethral sling transobturator (TOT). Materials and Methods. It is a prospective study per-

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formed in a single center. All patients had their medical history recorded, objective examination was performed, and transperineal ultrasound (TPU) was performed. Patients were followed up at 1, 3, 6, 12 months after surgery and annually thereafter. At 6 months after surgery, transperineal ultrasound with ISR measurement was repeated. The ultrasound was performed with the patient in supine position with full bladder. The ultrasound was performed at rest and during the valsalva maneuver. A 3.5 - 5 MHz convx probe was used. We recorded the measurement above and below the longitudinal axis of the symphysis as negative and positive, respectively. Further parameters evaluated are: a) the position of the mesh along the urethra: it was calculated by means of a mathematical formula which takes in account the urethral lenght to obtain 3 different position: 1) 0-40% proximal to the bladder neck 2) 40-60% midurethral position 3) 60-100% distal position; b) the movement and in particular the symmetry of the lateral arms of the mesh during straining and 3) the presence or absence of an open bladder neck. On the basis of the incontinence outcome patients were allocated into two main categories: dry (no leakage during clinical and/or stress test and/or reported by patients) vs. wet. We considered wet the patients with any kind or grade of leakage. The statistical analysis was performed using X2 test for categorical data comparisons. Results. From January 2013 to February 2016, 86 patients were recruited who underwent TOT. The followup - up on average 36 months (range 12-72). Following TOT 67 (77.9%) patients were completely continental and 19 (22.1%) patients had residual incontinence. It was assessed by transperineal ultrasonography that incontinent women had more distal slings compared to continental women (p=0.004); in incontinent women there was a greater prevalence of sling arm asymmetry compared to continental women (p<0.0001); incontinent women had more distal slings compared to continent patients (p<0. 0001); of women with open bladder neck openings, it was observed that sling placement was distally placed compared to patients with closed bladder neck (37.8% vs 0%, p<0.0001).With MUS, continent women had an improvement of urethrocele grade at rest (p=0.028) and during Valsalva (p=0.044), and lower movement of urethra from rest to during Valsava (p=0.041). Conclusion. Ultrasound is a non-invasive, inexpensive method that allows you to predict information about the correct position and functioning of the TOT sling.

Introduction and Objective. In precision surgery era, aimed to reduce the surgery related comorbidities with a maximization of oncological results, High-Intensity Focused Ultrasonography (HIFU) was introduced in the setting of localized low/intermediate risk prostate cancer (PCa) treatment. Traditionally, total ablation of the gland was performed to treat mono- or multi-focal PCa. Recently a new concept has emerged: the ablation can be modulated including only one half of the gland in case of unilateral positive standard biopsies, or focally at the level of index lesion with positive target biopsy. In both cases potential advantages were recorded in terms of reduction of postoperative complications and impact on patients’ quality of life respect to total ablation. The aim of this study is to assess differences between Emiablation (EA - half organ ablation) and Focal Ablation (FA – only the target area identified with MRI target biopsy was treated) HIFU treatments in terms of postoperative functional outcomes and complication rates. Materials and Methods. 42 patients affected by localized low and medium risk prostate cancer were enrolled in a dedicated prospective clinical trial approved by Ethics Committee. Among these patients, we considered only those who underwent a sub-total ablation of the gland. Patients were divided in two Groups: Group A underwent EA, while Group B underwent FA. The International Prostate Symptom Score (IPSS), Quality of Life (QoL) and International Index of Erectile Function (IIEF-5) questionnaires were administered to the patients preoperatively and at 1 and 6 months after HIFU. The comparison between Groups was executed by using T-student and Chisquare tests. Statistical significance was defined as p<0,05. Results. Between November 2018 and December 2019, 37 “naïve” (without previous therapies) patients underwent subtotal HIFU in our Centre: 12 were included in Group A, whilst 25 in Group B. No differences were found between the two Groups at the baseline in terms of demographics variables, IPSS, QoL and IIEF-5. Mean PSA was 6,7±3,3 ng/ml in Group A and 5,5±1,7 in Group B (p=0.15). Median IPSS, QoL and IIEF-5 at 1-month control after surgery were 10 (7-12) vs 7,5 (3-14), 2 (1-3) vs 1 (03), 5 (0-13) vs 2 (0-18) in Group A vs Group B, respectively (p≥0,05). Corresponding data at 6-month control were: IPSS 11 (8-13) vs 7 (3-13) and QoL 2 (1-3) vs 1 (02) in Group A vs Group B, respectively (p≥0,05). At this last time-point, we observed in both Groups a recovery in terms of sexual function in comparison to 1month control: IIEF-5 was 9 (2-12) in EA Group vs 16 (519) in FA Group (p=0,4). Considering complication rates, in Group A emerged 1 intraoperative complication (mild hematochezia), while in Group B 5 patients developed post-operative complications (1 acute orchitis, 2 cases of Hematuria and 2 cases of urinary retention) (p≥0,05). Conclusion. No significant differences were found between EA and FA HIFU treatment in terms of functional outcomes or complication rates. In our experience, EA and FA could be applied to patient depending on oncological features, without differences in terms of functional side effects. Further studies are needed in order to evaluate the oncological outcomes of the two different techniques in object. Advances in Urological Diagnosis and Imaging - 2020; 3,3

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C11_CLINICAL

STAGE IIA BURNEDOUT TESTICULAR CANCER WITH ATYPICAL LYMPHATIC SPREAD: A THREATENING CLINICAL SCENARIO Agostini E, Scarcella S, Giulioni C, Milanese G, Dell’Atti L, Galosi AB. Institute of Urology, Polythecnic University of Marche Region, University Hospital "Ospedali Riuniti", Ancona, (Italy).

Introduction. Currently optimal management of testicular germ cell tumors (GCT) with clinical stage (CS) IIA and IIB is a matter of debate, particularly for non-seminoma testicular cancers. European Association of Urology (EAU) guidelines section about non-seminoma testicular cancers recommends chemotherapy for marker-positive CS IIA and IIB, whilst marker-negative or negativized CS IIA doesn’t have a universally approved treatment path: retroperitoneal lymph node dissection (RPLND), chemotherapy and monitoring as main contender. Seminoma CS IIA can be treated both with chemotherapy and radiotherapy, whilst chemotherapy is the preferred management in CS IIB. Burned out testicular neoplasm represents itself a further intricate clinical scenario in GCT, accounting 5% of all GCT. It can be defined as a GCT that has completely or partially regressed, leaving a scar in the parenchyma with or without vestiges of GCT, mimicking a primary retroperitoneal testis cancer. Materials and Methods. We report the case of a 44 years-old man referred at our institution for a poorly-localized right scrotal pain. Ultrasound using a 10MHz linear probe was performed and revealed a well-defined highly 3 cm echogenic lesion with calcified areas in the right testis. Preoperative tumor markers were slightly raised: AFP 17 ng/mL, BHCG 52 mlU/mL, LDH 165. The patient underwent right orchiectomy, and histological specimens revealed regressed GCT. The CT scan thorax and abdomen scan showed retroperitoneal lymph node metastasis behind the jejunum, at the inferior mesenteric artery origin and on the left side of aorta, a little cranially to common iliac arteries origin. The lymph nodes measured 1.1, 1.6 and 1.3 cm respectively and presented colliquated center. The patient repeated tumor markers 10, 15 and 25 days after surgery, and showed complete remission since the first analysis. Due to atypical metastases location and uncertain histology, we advised for treating patient with systemic therapy based on bleomycin, etoposide and cisplatin (PEB), that was given every 3 weeks for 4 courses. Results. We re-staged the patient at 3 months with contrast enhanced thorax-abdomen CT scan, showing reduction of all node metastases, now measuring less than 1 cm each. As the largest part of small residual mass contain fibro-necrotic tissue, we proposed the patient for observation protocol. Discussion. Burned out or regressed tumor is a GCT that has completely or partially regressed, leaving a scar in the parenchyma with or without vestiges of GCT, and it has been reported in several cases. The mechanism behind tumor regression is still not clear but two main hypotheses have been formulated: immunological response mediated by T lymphocytes and ischemic response due to cancer disproportionate metabolic demand.

Advances in Urological Diagnosis and Imaging - 2020; 3,3

Pure seminoma is considered the main histology presenting with regressed aspect (53.5% in the testicle, 50.8% in the metastasis), followed by mixed seminoma. Teratoma is the most common pure type of GCT associated with burn-out phenomena after seminoma (14%). Diagnosis is often incidental (ultrasound) or secondary to symptoms of metastatic spread into retroperitoneum or mediastinum. About primary tumor, despite recurrent ultrasonographic signs, no pathognomonic pattern was described. A general disorganization of the sound pattern of parenchyma and focal/diffuse hypoechoic lesions are described, with or without calcifications. In 2017 Dell’Atti et al characterized a new pattern consisting of welldefined highly echogenic lesion with calcified areas resembling a pearl-oyster. Our patient showed furthermore lymphatic spread to the para-aortic nodes, while past elegant studies about retroperitoneum lymphatic supply showed that the right testis drains primarily to the interaortocaval nodes with some drainage to the right paracaval nodes. Due to the lymphatic spread, our patient was classified as CS IIA with atypical metastases (contralateral to the main lymphatic chain). Several authors propose the landing zone (metastatic lesions outside the primary landing zone) as a criterion for treatment choice. Treatment of clinical stage IIA testicular neoplasm, particularly without marker elevation, is actually one of the main concern in testicular cancer management. In the ESMO consensus conference in 2018, for CS IIA seminoma both chemotherapy and radiotherapy were advocated as possible treatment, but the evidence was weak. For CS IIA non-seminoma both chemotherapy with or without post chemotherapy RPLND and RPLND followed by adjuvant chemotherapy were pointed out as feasible treatments. There is now a general consensus in EAU, NCCN and AUA guidelines that the initial treatment should be chemotherapy. However, criteria as metastases size and location can help the clinician in the choice. Conclusion. Burned out tumors represent a rare histological variant that can worsen the prognosis of testicular neoplasm due to delay in diagnosis and atypical presentation. The typical ultrasound pattern is the “pearl oyster”, a well-defined highly echogenic lesion with calcified areas. Treatment of CS IIA GCT with negative markers represents a recurrent impasse for the clinician, with chemotherapy and retroperitoneal lymph node dissection as proposed first line effective treatment, depending on primary histopatology. In our case we present both these intricate situations, complicated by atypical lymphatic spread. We finally established the effectiveness of chemotherapy in this setting of patient, the importance of searching for burn out testicular cancer in patients presenting with enlarged retroperitoneal nodes and the usefulness of criteria as metastatic spread pattern for the choice of treatment. References. 1. Angulo JC, González J, Rodríguez N, et al. Clinicopathological study of regressed testicular tumors (apparent extragonadal germ cell neoplasms). J Urol. 2009; 182(5):2303-2310. 2. Honecker F, Aparicio J, Berney D, et al. ESMO Consensus Conference on testicular germ cell cancer: diagnosis, treatment and follow-up. Ann Oncol. 2018; 29(8):1658-1686.

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C12_MP-MRI

OF THE PROSTATE SIGNIFICANTLY UNDERESTIMATES TUMOR VOLUME OF SMALL VISIBLE LESIONS. IMPLICATIONS FOR TAILORED FOCAL THERAPY APPROACHES Stabile A1, Karnes JR2, Motterle G2, Fossati N1, Gandaglia G1, Barletta F1, Scuderi S1, Cucchiara V1, Robesti D1, Rosiello G1, Bravi C1, Dell’Oglio P1, Martini A1, Salonia A1, Brembilla G3, Esposito A3, Montorsi F1, De Cobelli F3, Briganti A1.

Figure 1. Relationship between index lesion volume at MRI and final pathology.

Division of Oncology / Unit of Urology; URI; IRCCS Ospedale San Raffaele, Milan (Italy); 2 Mayo Clinic, Department of Urology, Rochester, Minnesota (USA); 3 IRCCS Ospedale San Raffaele, Unit of Clinical Research in Radiology, Experimental Imaging Center, Milan (Italy).

Introduction. MRI of the prostate is routinely used for both patient selection and treatment planning before focal therapy for prostate cancer (PCa). However, some concerns exist regarding the real accuracy of MRI in estimating the volume of the index lesion (IL). Little is known if such underestimations occur in all PI-RADS score and also in smaller index lesions which are those usually more suitable for a focal therapy approach. We then tested the association between the volume of the index lesion at mp-MRI and at radical prostatectomy (RP) and stratified it according to PI-RADS. Materials and Methods. We identified 332 men with a positive MRI (single lesion with PI-RADS≥3) who underwent systematic plus targeted biopsy and subsequent RP at two tertiary referral centres between 2014 and 2019. All MRI scan were reviewed by experienced radiologists using PI-RADS score v2. The study outcome was to assess the relationship between MRIvol (based on planimetry from MRI sequence best showing tumor) and RPvol (based on tumour involved area of each RP pathology slice). To achieve this endpoint, we performed a linear regression analysis (LRA) to predict RPvol using PI-RADS (3 vs 4 vs 5), PSA, prostate volume, age, DRE and biopsy history as covariates. Non-parametric loess function was used to graphically explore the relationship between MRIvol and RPvol, and stratifyed for PI-RADS score. Results. Overall, 24%, 49% and 27% of men had a visible PI-RADS 3, 4 and 5 lesion at MRI. The median MRIvol and RPvol were 0.67cc (IQR: 0.29-1.76) and 1.39 cc (IQR: 0.58-4.23). At LRA, MRIvol (OR: 2.80), presence of a previous negative (OR: 0.17) and positive biopsy (OR: 0.12) were independent predictors of RPvol. The non-parametric loess analysis (Figure 1) showed a non-linear relationship between MRIvol and RPvol. Significant underestimation was reported across all volumes with the highest differences between MRIvol and RPvol in the low volume range (<2 cc), where RPvol almost doubled MRIvol. A similar effect was observed across all PI-RADS scores. Conclusion. mp-MRI significantly underestimates the actual volume of the disease, especially for small visible lesions (< 2cc), regardless of PI-RADS score. This should be taken into account when planning tailored focal therapy approaches often delivered to men with smaller prostatic lesions.

Lectures. - Radtke JP, Schwab C, Wolf MB, et al. Multiparametric Magnetic Resonance Imaging (MRI) and MRI-Transrectal Ultrasound Fusion Biopsy for Index Tumor Detection: Correlation with Radical Prostatectomy Specimen. Eur Urol. 2016; 70(5):846-853. - Muller BG, Fütterer JJ, Gupta RT, et al.The role of magnetic resonance imaging (MRI) in focal therapy for prostate cancer: recommendations from a consensus panel. BJU Int. 2014; 113(2):218-227.

C13_INITIAL NEGATIVE MULTI-PARAMETRIC MRI

WITH CONCOMITANT NEGATIVE BIOPSY: ARE TRUE NEGATIVE FINDINGS CONFIRMED OVER TIME? RESULTS FROM A SINGLE INSTITUTION SERIES Stabile A1, Scuderi S1, Karnes JR2, Motterle G2, Fossati N1, Gandaglia G1, Barletta F1, Cucchiara V1, Robesti D1, Cannoletta D1, Pellegrino F1, Mazzone E1, Rosiello G1, Bravi C1, Pellegrino A1, Moschini M3, Brembilla G4, Esposito A4, Karakiewicz PI5, Montorsi F1, De Cobelli F4, Briganti A1. 1

IRCCS Ospedale San Raffaele, Division of Oncology/Unit of Urology; URI, Milan (Italy); 2 Mayo Clinic, Dept. of Urology, Rochester, MN (USA); 3 Klinik für Urologie, Luzerner Kantonsspital, Lucerne (Switzerland); 4 IRCCS Ospedale San Raffaele, Unit of Clinical Research in Radiology, Experimental Imaging Center, Milan (Italy); 5 University of Montreal Health Center, Cancer Prognostics and Health Outcomes Unit, Division of Urology, Montreal, Quebec (Canada).

Introduction and Objectives. It is well known that mpMRI of the prostate is associated with a high negative predictive value (NPV) for clinically significant prostate cancer (csPCa). However, not in all studies negative mp-MRI had negative back-up histology. Moreover, there is a lack of strong data on follow-up in men with initial negative evaluation. The aim of this study was to assess the outcome Advances in Urological Diagnosis and Imaging - 2020; 3,3

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

over time of men with negative mp-MRI and a proven absence of PCa at initial systematic biopsy. Methods. We evaluated 250 patients with negative mpMRI (PIRADS 1 or 2) and a concomitant negative systematic prostate biopsy performed at a single tertiary care referral Centre between 2016 and 2017. All patients were submitted to 1.5 MRI study using an endorectal coil which was interpreted by two expert radiologists. After negative imaging and biopsy, all patients were then followed with annual serial PSA measurement and digital rectal examination (DRE). In case of suspicion for PCa (rising PSA and/or positive DRE), follow-up mp-MRI and/or prostate biopsy (Bx) were performed. The study outcome was csPCa (defined as Gleason score at biopsy≥3+4) during followup. Kaplan Meier analysis was used to assess csPCa diagnosis-free survival. Using multivariable Cox regression analysis (MVA) we investigated eventual predictors of presence of csPCa at follow-up using the following covariates: age at biopsy, PSA density and clinical stage (T1 vs T2 vs T3). Results. Median follow-up was 30 months (IQR: 23-41). During the study period, 49 men (19.6%) underwent mpMRI and 41 (16.4%) received a follow-up Bx. Overall, 5% (13/250) patients had positive MRI (PI-RADS 3-5) over time. Of all patients, 33 (13.2%) and 13 (5.2%) had any PCa and csPCa, respectively at follow-up after initial negative mp-MRI. The 2-, 3- and 4-year csPCa diagnosis-free survival were 94.6, 87.8 and 86%, respectively. Diagnosis-free survival probability for csPCa was unchanged after 48 months of follow-up onwards. At MVA, none of the predictors investigated was significantly associated with csPCa findings during follow-up in men with initial negative mpMRI (all p>=0.1). Conclusion. We demonstrated that only a minority of patients (5%) with initial negative mpMRI and concomitant negative Bx developed csPCa at a median follow-up of 30 months, suggesting how the high initial NPV of mp-MRI is maintained over time. This data supports the importance of initial negative mp-MRI in ruling out csPCa over time provided a negative initial biopsy. Lectures. - Moldovan PC, Van den Broeck T, Sylvester R, et al. What Is the Negative Predictive Value of Multiparametric Magnetic Resonance Imaging in Excluding Prostate Cancer at Biopsy? A Systematic Review and Meta-analysis from the European Association of Urology Prostate Cancer Guidelines Panel. Eur Urol. 2017; 72(2):250-266. - Stabile A, Giganti F, Rosenkrantz AB, et al. Multiparametric MRI for prostate cancer diagnosis: current status and future directions. Nat Rev Urol. 2020; 17(1):41-61.

C14_AGE

AND GLEASON SCORE UPGRADING BETWEEN PROSTATE BIOPSY AND RADICAL PROSTATECTOMY. IS THIS STILL TRUE IN THE MP-MRI ERA? Stabile A1, Scuderi S1, Karnes JR2, Motterle G2, Fossati N1, Gandaglia G1, Barletta F1, Cucchiara V1, Robesti D1, Rizzo A1, Pellegrino F1, Mazzone E1, Rosiello G1, Bravi C1, Leni R1, Moschini M3, Brembilla G4, Esposito A4, Karakiewicz PI5, Montorsi F1, De Cobelli F4, Briganti A1.

Advances in Urological Diagnosis and Imaging - 2020; 3,3

IRCCS Ospedale San Raffaele, Division of Oncology/Unit of Urology; URI, Milan (Italy); 2 Mayo Clinic, Dept. of Urology, Rochester, MN, United States of America (Italy); 3 Klinik für Urologie, Luzerner Kantonsspital, Lucerne, Switzerland, 4 IRCCS Ospedale San Raffaele, Unit of Clinical Research in Radiology, Experimental Imaging Center, Milan (Italy); 5 University of Montreal Health Center, Cancer Prognostics and Health Outcomes Unit, Division of Urology, Montreal, Quebec (Canada).

Introduction. Several studies have invariably shown that the risk of Gleason score (GS) upgrading between biopsy and radical prostatectomy (RP) is higher in elderly men. Whether this is due to a real biological effect or to a diagnostic bias is still unknown. We hypothesized that the introduction of mp-MRI has improved the diagnostic accuracy of PCa detection in older men thus reducing the rate and the risk of Gleason score upgrading between biopsy and RP reported in the pre-MRI era. If confirmed, our hypothesis would support the theory that Gleason score upgrading in elderly is mainly a result of diagnostic biases. Materials and Methods. We identified 7831 men who underwent RP at a single tertiary referral center before the introduction of MRI for diagnostic purposes (i.e. before year 2013). We then selected 453 men who received a systematic plus targeted biopsy for a positive MRI (PI-RADS≥3) and who underwent a subsequent RP at two tertiary referral centres between 2013 and 2019. The study outcome was to compare the relationship between age and the probability of upgrading at RP across the two populations (MRI vs no MRI cohort). Upgrading was defined as an increase in GS at final pathology as compared to biopsy (from 6 to 7 and from 7 to 8-10). We used two multivariable logistic regression analyses predicting the risk of upgrading using age, PSA, prostate volume, clinical stage, GS (6 vs 7 vs ≥8), number of positive cores for both models and PI-RADS score only in the MRI cohort. Non-parametric loess function was used to graphically explore the relationship between age and rate of upgrading in the two cohorts. Results. Median age and rate of upgrading were 65 years (IQR: 60-69) and 66 years (IQR: 60-70) and 16% and 37% in the MRI and no MRI cohort, respectively. In the MRI cohort, GS was the only independent predictor of upgrading (GS 7 OR: 0.03; GS≥8 OR: 0.10; p<0.0001) while age was not (p=0.4). In the no MRI cohort, age (OR: 1.03), PSA (OR: 1.02), prostate volume (OR: 0.98), clinical stage (T2 OR: 1.53; T3 OR: 1.80), GS (GS 7 OR: 0.11; GS≥8 OR: 0.13) and number of positive cores (OR: 1.03) were independent predictors of upgrading (all p<0.01). Figure 1 shows as the overall rate of upgrading was higher in the no MRI cohort for men aged >50 yrs. The probability of upgrading slightly decreased with age in the MRI cohort while it significantly increased in the no MRI cohort. Conclusions. We showed that use of mp-MRI has obliterated the association between older age and increased risk of upgrading mainly due to improved diagnostic approaches in this group of men. Therefore, it is likely that the effect of age and Gleason score upgrading reported in previous studies in elderly men was due to misdiagnosis and lead-time bias in the pre-MRI era in this patient group.

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N. Figure 1. Relationship between upgrading and age.

Lectures. - Herlemann A, Buchner A, Kretschmer A, et al. Postoperative upgrading of prostate cancer in men ≥75 years: a propensity score-matched analysis. World J Urol. 2017; 35(10):1517-1524. - Goel S, Shoag JE, Gross MD, et al. Concordance Between Biopsy and Radical Prostatectomy Pathology in the Era of Targeted Biopsy: A Systematic Review and Meta-analysis. Eur Urol Oncol. 2020; 3(1):10-20.

C15_IMPORTANCE

OF FLUOROSCOPY IN RECOGNITION OF A RARE CASE OF SUBMUCOSAL URETERAL STONE COMPLICATED AFTER ENDOSCOPIC TREATMENT - CASE REPORT Palagonia E, Scarcella S, Dell’Atti L, Tiroli M, Galosi A. Polythecnic University of Marche Region University Hospital, Urology, Ancona (Italy).

Introduction. Submucosal ureteral stone is a very rare complication related to a rupture of the ureter that occurred after endoscopic treatments. We describe a case in which multiple complications led to the formation of a submucosal ureteral stone and how imaging can help in the recognition of this condition and influencing the management in clinical practice. Materials and Methods. A 24-years-old man was referred to the urology department for evaluation of right flank pain after previous several endoscopic treatments for ureteral stones. Laboratory exam showed serum creatinine level of 1,28 and estimated glomerular filtration rate (eGFR) of 73 ml/min/1.73m2. Abdomen CT scan revealed important hydroureteronephrosis due to a ureteral stone of 1.9 cm. Double J (DJ) ureteral stent 26cm 6Ch was placed. 2 months after, retrograde pyelography showed proximal DJ stent calcification and extracorporeal shock wave lithotripsy (ESWL) of this part allowed the removal of the DJ stent. Rigid ureteroscopy showed no intraluminal stone. However, right ureteral fluoroscopy showed an imaging doubt for the presence of a stone of 2 cm at lumbar level. Considering

this and the notable symptoms, open surgery was performed. Longitudinal ureterolithotomy showed a stone into the submucosal part of the ureteral wall, after stone extraction, ureteral reconstruction was performed. Results. General condition of the patient rapidly improved with complete resolution of the symptoms, serum creatinine level of 1 mg/dl and eGFR of 98 ml/min/1,73m2. Further laboratory investigations showed a serum calcium of 11.2 mg/dl and a parathyroid hormone (PTH) of 196 pg/ml. DJ stent was removed after 20 days from the procedure. Retrograde pyelography didn’t show ureteral strictures and abdomen ultrasound after 1 months showed absence of hydronephrosis. After 1 year of follow up abdomen ultrasound shows no hydronephrosis and cortical thinning of the right kidney. Endocrinological investigation discovered a primary hyperparathyroidism, parathyroid scintigraphy showed an overcapturing area in the lower lobe of the right portion of the thyroid lodge suggestive of a hyperfunctioning parathyroid area. The patient was scheduled for surgical treatment of the hyperparathyroidism. Discussion. Submucosal ureteral stone is a very rare condition that could occur after endoscopic procedures. The peculiarity of recognizing this complication depends on the combination of ureteroscopy and fluoroscopy. In literature, there is a complete lack of experience and management of this kind of complication. Of note the major complications collected in peri and post-operative period are usually kidney lesions, arterial venous lesions, ureter avulsions, renal fistula, severe bleeding, acute sepsis with a rate of 1% overall (1, 2). The most frequent complications reported by literature are fever and sepsis, steinstrasse and ureteral lesions (1, 2). Among these the formation of submucosal ureteral stones is not mentioned. In our case the complication could be related to a condition of primary hyperparathyroidism that lead to an increased risk of calcification in the kidney and ureter, especially where other factors come together such as infections, bacteria in the urine, change in urinary pH and phlogistic reaction. Conclusion. Experience in recognizing fluoroscopic images is essential and allows identifying even major complications that need further treatment. It is a safe and replicable procedure extremely important for the management of the patient with ureteral stones. References. 1. De La Rosette J, Denstedt J, Geavlete P, et al. The clinical research office of the endourological society ureteroscopy global study: Indications, complications, and outcomes in 11,885 patients. J Endourol. 2014; 28(2):131-9. 2. Cindolo L, Castellan P, Primiceri G, et al. Life-Threatening complications after ureteroscopy for urinary stones: Survey and systematic literature review. Minerva Urol e Nefrol. 2017; 69(5):421-31.

C16_ROBOT-ASSISTED

SEGMENTAL URETERECTOMY WITH PSOAS HITCH URETERAL REIMPLANTATION: USE OF INDOCYANINE GREEN (ICG) IN COMPLEX ONCOLOGICAL RECONSTRUCTIVE SURGERY AND EVALUATION OF ONCOLOGICAL, FUNCTIONAL AND PERIOPERATIVE OUTCOMES IN A CASE SERIES Advances in Urological Diagnosis and Imaging - 2020; 3,3

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

Palagonia E1, 4, Scarcella S1, Mazzone E2, 4, Dell’Oglio P3, 4, D'Hondt F4, De Naeyer G4, Galosi AB1, Mottrie A4. 1

Department of Urology, United Hospital of Ancona (Italy); of Urology, IRCCS San Raffaele Hospital, Milano (Italy); 3 Department of Urology, Niguarda Hospital, Milano (Italy); 4 Department of Urology, Onze Lieve Vrouw Hospital, Aalst (Belgium). 2 Department

Introduction. Radical nephroureterectomy represents the reference treatment for upper tract urothelial carcinoma (UTUC) with open, laparoscopic or robot-assisted approach depending on surgeon’s preference. According to the Association of Urology guidelines, in selected cases with low grade distal ureteral tumour, robot-assisted segmental ureterectomy with bladder cuff excision and psoas hitch ureteral reimplantation (RAPHUR) can be offered. The complexity of this procedure is increased by the possibility of having non-viable tissues in the reconstruction. Indocyanin green (ICG) can be visualized using nearinfrared fluorescence (NIRF) and help the surgeon for orientation and evaluation of viability of the tissues. We describe our initial experience reporting our surgical technique and oncological, functional and perioperative outcomes of robot-assisted segmental ureterectomy with RAPHUR. Materials and Methods. We retrospectively evaluated 9 patients (pts) diagnosed with distal UTUC and treated with RAPHUR between January 2013 and October 2017 in a single institution. During surgery, the ureter is early clipped and dissected to avoid the possibility of tumour seeding. A formal bladder cuff is performed. After longitudinal incision of the bladder dome, the ureter is positioned inside of a submucosal tunnel and ICG injection help to visualise the viability of structure and not compromise the reconstruction. Ureteral-vesical anastomosis is performed in a running way. The external part of the bladder is anchored to the psoas muscle, to perform a tension-free reimplantation. Pre-, intra-, and post-operative data were recorded. Ultrasound was performed after 1 month, 3 months and 1 year from surgery. In descriptive analysis, all continuous variables were reported with median and interquartile range, while categorical variables with absolute and relative frequencies. Results. 7 (78%) pts were male and 2 (22%) female. Disease side was right in 3 (34 %) pts and left in 6 (66 %). Median age was 72 years (57-91). The median length of the ureteral defect was 21 mm (10-40 mm). Mean pre-operative creatinine level was 1,16 mg/dl (0,72-1,5) and mean estimated glomerular filtration rate (eGFR) was 50,0 ml/min/1.73m2 (32-80). 8 (88%) pts were symptomatic for haematuria and hydronephrosis before surgery. Median operative time was 160 min (120-240), with an average mean blood loss of 89 ml (50-300). All surgeries were completed without conversion to open technique. Overall 3 (34%) of the pts developed a postoperative complication classified with Clavien Dindo ≥2 and only in 1 case was higher than grade 3. Average hospital stay was 5 (2-8) days. Bladder catheter was removed after cystogram and with a mean of 10 (6-15) days while the double J ureteral stent was removed after a mean of 21 (16-44) days. Mean postoperative creatinine was 1,17 mg/dl (0,83-1,85) and mean postoperative eGFR was 62 (36-83). During a mean follow up time of 29 (9-53) months 4 (45%) pts experienced

Advances in Urological Diagnosis and Imaging - 2020; 3,3

hydronephrosis at 1 year follow up at ultrasound check.The CT scan of this 4 pts showed a urothelial cancer recurrence and 2 (22%) pts died due to its progression. Conclusion. ICG increase the safety profile in complex reconstructive cases, such RAPHUR, it’s helpful, easy to perform and reproducible (1). In our initial experience RAPHUR can be proposed to selected cases of distal ureteral carcinoma of low-grade disease with optimal perioperative and functional outcomes (2). However, cancer control may be undermined compared to nephroureterectomy. References. 1. Cadillo-Chávez R. Usefulness of indocyanine green (ICG) in robotic reconstructive surgery. Arch Esp Urol. 2019; 72(8):759-64. 2. Fang D, Seisen T, Yang K, et al. A systematic review and meta-analysis of oncological and renal function outcomes obtained after segmental ureterectomy versus radical nephroureterectomy for upper tract urothelial carcinoma. Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2016; 42(11):1625-35.

C17_EVALUATION

OF CONCORDANCE BETWEEN PATHOLOGICAL SECTIONS AND MULTIPARAMETRIC RMI OF INDEX AND NOT-INDEX LESIONS Palagonia E1, Scarcella S1, Leone L1, Montesi L1, Dell’Atti L1, Sternardi F2, Cimadamore A3, Montironi R3, Giovagnoni A2, Galosi AB1. 1

Institute of Urology, Polythecnic University of Marche Region, University Hospital “Ospedali Riuniti”, Ancona (Italy); 2 Department of Radiology, Polythecnic University of Marche Region, University Hospital “Ospedali Riuniti”, Ancona (Italy); 3 Institute of Pathological Anatomy and Histopathology, School of Medicine, Polytechnic University of the Marche Region, Ancona (Italy).

Introduction. Multiparametric Resonance Imaging (mpRMI) is used in the detection of the index lesion of prostate cancer prior to radical prostatectomy and its importance can influence the decision-making process for pelvic lymph nodes dissection. Our objective is to evaluate the reliability of multiparametric RMI (mpRMI) in identification of prostate cancer (PCa) foci through the comparison with pathological report of index and not-index lesions using graphic maps. Materials and Methods. We evaluated 65 patients (pts) underwent robot-assisted radical prostatectomy in a single centre. A single dedicated uro-pathologist reviewed all specimens. Cancer volume and Prostate cancer grade group (GG) have been evaluated for each single cancer focus. All mpRMI (1,5 T, 32 channels external coil) have been assessed by a single dedicated radiologist. Based on pathological sections (gold standard) and mpRMI findings two different maps of cancer lesions were created respectively. Results. In the pathological sections of 65 radical prostatectomies were found 87 neoplastic foci: 46 index lesions (52,8%) and 41 non index lesions (47,1%). 20 pts presented a monofocal tumor, 45 presented a multifocal tumor. GG1 was in 45 cases (51,7%), GG2 in 24 (27,5%), GG3 in 8 (9,1%), GG4 in 3 (3,4%) and GG5 in 7 (8,0%). 9 foci resulted with extra-prostatic extension (EPE). At mpRMI were found 90 areas (18 Pi-rads v2 3, 43 Pi-rads v2 4 and 29 Pi-rads v2 5). 61 of these areas corresponded to PCa,

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

29 did not. The mpRMI identified 64 (73,5%) of 87 neoplastic foci, including 37 index lesions (90,2%) of 41 total known. 27 tumoral foci (31%) were not individuated, including 21 (77,8%) clinically non significant tumor (GG1, intra-capsular, volume<0,5 cc) and 6 (22,2%) index lesions (3 GG4 and 3 GG5); no EPE was identified in these cases. The 29 false positives of mpRMI were reviewed by pathologist. In 21 cases was found inflammation (72,4%) and cysts (including 1 haemorrhagic cyst) in 8 cases (27,6%); lesions of the transition zone in 24 cases (82,7%). Conclusion. In our experience, mpRMI can individuate the 73,5% of all tumoral foci and the 90,2% of index lesions. The 77,8% of cancer lesions not individuated are clinically not significant. False positives were in 82,7% located in the transitional zone and they were found to be inflammation in 72,4% of all cases.

C18_WHO SCORES THE GAME IN NEPHRON-SPARING SURGERY? RENAL SCORING SYSTEM REPRODUCIBILITY AMONG RESIDENTS IN UROLOGY AND RADIOLOGY Scarcella S1, Dell’Atti L1, Agostini E1, Palagonia E1, Giulioni C1, Sbrollini G1, Milanese G1, Pierini L1, Agostini A1, Floridi C2, Giovagnoni A2, Galosi AB1. 1

ing the specific professional background, in UG Ns where characterized by an intra-class correlation index higher than 0.8, while in RG only the RENAL and the PADUA presented similar results. On the contrary the C-Index and ABC scores had lower ICC. The differences in score assigned between the two groups of specialists resulted respectively in 1 point and 0.6 point mean for the RENAL score (p=0.012) and the C-Index (p<0.001) while no mean differences were observed in PADUA and ABC scores (p>0.05). Conclusion. Ns are reproducible in P.A.D.U.A and R.E.N.A.L. based on anatomical characteristics, however the disagreement reach the 20 % of cases among all groups. On the other hand C-Index and ABC score tends to differ more significantly between UG and RG, even inside the same specialty. Our results suggest that Ns based on anatomical characteristics tend to show a higher reproducibility even among residents with different professional backgrounds. Since the scoring system is rarely stated in radiological report, in most studies we need to evaluate accurately who signed the RENAL score and its reproducibility.

C19_REUSABLE

VERSUS DISPOSABLE FLEXIBLE URETEROSCOPES: COSTS EVALUATION Beatrici V1, Antezza A2, Lacetera V1, Cappa E1, Zuccarini E3, Cervelli B1, Gabrielloni G1, Montesi M1, Morcellini R1, Parri G1, Recanatini E1. 1

Division of Urology, Ospedali Riuniti Marche Nord, Pesaro (Italy); Institute of Urology, Polythecnic University of Marche Region, University Hospital “Ospedali Riuniti”, Ancona (Italy); 3 Unit of Pharmacy, Ospedali Riuniti Marche Nord Hospital, Pesaro (Italy). 2

Introduction. Different renal scoring systems have been tested to predict surgical complexity and post-procedural outcomes after nephron sparing surgery (NSS). To date, it has not been determined how the scoring systems vary between specialists with different backgrounds and levels of skills. The aim of this study is to evaluate the applicability of 4 different nephrometry scores (Ns) and to analyse their reproducibility comparing the scores assigned by radiology and urology residents. Patients and Methods. We enrolled 108 patients candidate to NSS with a laparoscopic or open approach between November 2017 and April 2020. All diagnostic Computed Tomography (CT) scans were retrospectively evaluated and images were consulted both in the axial and coronal planes. 6 residents in total, 3 urologists and 3 radiologist analyzed diagnostic CT scans and assigned independently the Ns for each patient. We included the R.E.N.A.L., the P.A.D.U.A., the C–Index and the ABC. In descriptive analysis all continuous variables were summarized with median and interquartile range, while categorical variables with absolute and relative frequencies. The scores given by the “Urologists group” (UG) and the “Radiologists group” (RG) were compared using the MannWhitney test and graphically with the Box Plot. Intra-class correlation coefficient (ICC) was used for continuous scores reliability while for categorical scores Cohen’s kappa (k) was used. Inter-Observer reliability was calculated, first comparing the scores among all readers. Results. Intra-class correlation coefficient among all readers was higher for the RENAL and PADUA scores while was low for the C-Index and ABC score. When consider-

Aim of the study. Endourology is a branch of the urology with rapid improving of instrumentation. The Retrograde intrarenal surgery (RIRS) utilizing flexible, actively deflectable instruments has become a valuable asset in the diagnosis of upper urinary tract pathology and the treatment of stone disease. Flexible endoscopic surgery of the proximal ureter and in the intrarenal collecting system constitutes the natural extension of rigid instrumentation in the upper urinary tract. The ureteroscopes can be reusable or disposable, with different types of problems related to their use. Our aim is to evaluate the costs of reusable and disposable ureteroscopes based on our experience over 40 months. Materials and Methods. From January 2017 to April 2020 we perform a number of 551 RIRS with both reusable and disposable ureteroscopes. The reusable are Cobra (Richard Wolf, Germany) and Boa (Richard Wolf, Germany). The disposable is Lithovue (Boston Scientific, Massachusetts,USA). The costs include the price of a single disposable instrument and the price to buy a reusable instrument or to fix it. Results. The reusable ureteroscope Boa (Richard Wolf, Germany) has a price of 11.000 euros. First break after 7 months of use, with a repair cost of 16.508 and a 15 days machine-stop. In a period of 40 month we have recorded Advances in Urological Diagnosis and Imaging - 2020; 3,3

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

3 breakages, 8 months of downtime, 11 months of use. The reusable ureteroscope Cobra (Richard Wolf, Germany) has a price of 11.000 euros. First break after 8 months of use, with a repair cost of 16.508 and a 4 months machine-stop. In a period of 24 month we have recorded 2 breakages, 2 months of downtime, 16 months of use. After 24 months of use we have recorded a second breakage, so we have decided to ask for a warranty replacement with a second Boa ureteroscope. The cost of reusable ureteroscopes for each operation was 540,67 €, this value does not include costs related to sterilization, conservation and maintenance of reusable instruments. The Lithovue (Boston Scientific, Massachusetts,USA) has a price of 1378,87 euro for each device with comparable optical capabilities, deflection and flow, making it a viable alternative to standard reusable 4th generation flexible digital and fiberoptic ureteroscopes. Several surgical and patient factors might affect stone free rates, morbidity and ureteroscope longevity. The location of the calculation is crucial for choosing a disposable or reusable ureteroscope. Conclusions. Disposable and reusable ureteroscopes are similar in terms of image quality and versatility. The cost of disposable devices can be justified by: safety in terms of lower risks of urinary tract infection after the procedure (reusable instruments needs high quality sterilization processes with related costs), in the lithotripsy of kidney stones of the lower calyxes produces a high percentage of instrument breakages, with high costs for repair and long time without instrument availability.

C20_MRI/US

FUSION PROSTATE BIOPSY IN MEN ON ACTIVE SURVEILLANCE: OUR EXPERIENCE Lacetera V, Antezza A, Papaveri A, Cappa E, Cervelli B, Gabrielloni G, Montesi M, Morcellini R, Parri G, Recanatini E, Beatrici V. Division of Urology, Ospedali Riuniti Marche Nord, Pesaro (Italy).

Aim. MRI/US fusion biopsy (targeted biopsy, TB) is associated with greater detection rate of significant prostate cancer. Our aim was to determine the rate of upgrading to Gleason score (GS) >=3+4, using imaging/ultrasound (MRI/US) fusion biopsy in men undergoing active surveillance (AS) of prostate cancer (CaP). Materials and Methods. We retrospectively analyzed 620 consecutive patients who underwent US-MRI fusion biopsy between May 2016 and Jenuary 2020. We select from our database only men on active surveillance according to strict criteria of John Hopkins Protocol (T1c, < 3 positive cores, GS=3+3=6). Monitoring consisted of PSA measurement every 3 months, a clinical examination every 6 months, confirmatory MRI-fusion biopsy within 6 months and then annual MRI-US fusion biopsy in all men. The suspicious MRI lesions were scored according to the PI-RADS classification version 2. Fusion biopsies were performed with a transrectal elastic free-hand fusion platform. A variable number of targeted biopsies (TB) and standard biopsies (SB) was performed, depending on the clinical case. The overall and clinically significant cancer detection

Advances in Urological Diagnosis and Imaging - 2020; 3,3

rate (CDR) was reported. Secondary the diagnostic role of standard biopsies was evaluated. Results. We select from our database 56 patients on active survelliance with at least 1 follow-up MRI-US fusion biopsy. Mean age was 67.4 years (CI ±8,8); mean PSA was 6.7 ng/ml ±3,1; mean prostate volume was 49.2 ± 21 ml. Lesions dectected by MRI were: PIRADS 2= 5pts; PIRADS 3= 28pts; PIRADS 4=18 pts; PIRADS 5=5pts. 46 pts had only 1 confirmatory biopsy, 7 pts had 2 follow-up biopsies, 3 pts had 3 follow-up biopsies. Mean cores from each MRI target lesion =2.1±1.1; mean total cores =13 ± 2.4. Overall PCA detection rate was 71% (40/56); Overall Significant PCA (Gleason Score >=3+4) detection rate was = 46% (26/56); PCA in target core = 62% (25/40) ; PCA in random core =28%(15/40); Significant PCA in target cores = 69% (18/26); Significant PCA in random core = 31% (8/26). Conclusion. The incidence of upgrading in 56 men on active surveillance using MRI-US fusion biopsy was 46%(26/56). A total of 31% of pathologic disease upgrades would have been missed if only the targeted biopsy were been performed. Based on our experience, we believe that among men on active surveillance MRI/US fusion target biopsy (TB) associated to standard biopsies (SB) can improve overall cancer detection rate, clinical significant cancer detection rate reducing the oncological risks of cancer misclassification (downgrading, downstaging).

C21_ITALIAN

EXPERIENCES IN THE MANAGEMENT OF ANDROLOGICAL PATIENTS AT THE TIME OF CORONAVIRUS PANDEMIC Maretti C1, Fabiani A2, Colombo F3, Franceschelli A3, Gentile G3, Palmisano F3, Vagnoni V3, Quaresima L4, Polito M5. 1

Dpt of Andrology, CIRM Medical Center, Piacenza (Italy); Urology Unit, Surgical Dpt, ASUR MARCHE Area Vasta 3, Macerata (Italy); 3 Urology and Andrology Unit- Policlinico S. Orsola, Bologna (Italy); 4 Urology Unit, Surgical Dpt, ASUR MARCHE Area Vasta 3, Civitanova M. (Italy); 5 U.O.S. UroAndrologia, Az. Ospedali Riuniti Ancona (Italy). 2

Introduction. The International Committee on Taxonomy of Viruses (ICTV), responsible for defining the official classification of viruses and the taxonomy of the Coronaviridae family, has officially classified under the name SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) the virus provisionally called by the World Health Organization (WHO) 2019-nCoV (1). Italy is still paying the price of a delay in the management of the pandemic fueled by first conflicting messages sent by virologists, epidemiologists and politicians. The high rate of contagiousness and mortality in our regions have depended both on the disinformation of the experts and the unpreparedness of the Italian health system in limiting the spread of the virus (lack of departments with dedicated personnel, lack of specific material and equipment) (2). Materials and Methods. This document analyzes the various experiences in hospital departments as well as the andrological private urgencies of Italian uro- andrologists,

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

in particular in the most affected regions, Emilia-Romagna and Marche. Results. In this Pandemic, the different governance mechanisms adopted by the various regions made the difference in terms of contagiousness and mortality together with a community strong solidarity. In fact, although the pandemic is global, its responses depend on local governance, in addition to the socio-economic and cultural context. Conclusion. The psychological impact of the COVID-19 outbreak among the whole and specifically Andrologic patients is still unknown. As expected, there was an increase in requests regarding access to out-patient consultation. Interestingly, most of the patients reported nonurgent diseases but rather conditions related to psychological burden such as penile enlargement and erectile dysfunction surgery. References. 1. Coronaviridae Study Group of the International Committee on Taxonomy of Viruses. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol. 2020; 5(4):536-544. 2. Ficarra V, Novara G, Abrate A, et al. Members of the Research Urology Network (RUN). Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020.

P1_THE

ECO COLOR DOPPLER IN THE ACUTE DROP Traunero F1, Bucci S1, Liguori G1, Benvenuto S1, Ocello G1, Ollandini G1, Mazzon G1, Zordani A1, Bertolotto M2, Trombetta C1, Belgrano E1. 1

Department of Urology, Cattinara Hospital, University of Trieste, (Italy); (Italy).

2 Department of Radiology, Cattinara Hospital, University of Trieste,

Introduction. We report some cases of patients who came to our attention with the diagnosis from the acute scrotum emergency room. All patients underwent a clinical laboratory evaluation and performed an ultrasound evaluation for diagnostic completion. Conclusions. In our clinical practice all patients who come to our attention for scrotal penile pathology undergo ecocolor Doppler control even if already performed elsewhere. In fact, we believe that the urologist must take charge of his own ultrasound evaluation in order to optimize the therapeutic choice. Not infrequently a second ultrasound evaluation differs from the first both because it is performed at different times and with different duration and because the method is operator and machine dependent. The culture of imaging associated with clinical experience is an additional weapon for a correct clinical therapeutic approach.

Figures Poster 1. The eco color doppler in the acute drop.

Advances in Urological Diagnosis and Imaging - 2020; 3,3

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

Figures Poster 2. Penile fractures: Cases from 2002 to 2019.

P2_PENILE FRACTURES: CASES FROM 2002 TO 2019 Napoli R, Liguori G, Bucci S, Benvenuto S, Ollandini G, Mazzon G, Tezzot G, De Concilio B, Di Marco L, Belgrano E, Trombetta C. Department of Urology, Cattinara Hospital, University of Trieste, Trieste (Italy).

Introduction and Objectives. Penile fracture is a rare urologic urgency; it’s the tunica albuginea rupture after contusive trauma, often during erection. Uretral lesions are associated in 10 20% of cases.This is a rewiew of our cases from 1994 to 2012. Materials and Methods. From genuary 2002 to november 2019, 20 patients were hospitalized with diagnosis of penile fracture, 2 post traumatic ED and 1 post traumatic recurvatum. 5 patients had concomitant uretral lesions with urethrorrhagia. All patients reported trauma during sexual activity, mean age was 35 years old (23-65). Clinical diagnosis was supported in half cases by radiologic imaging, in particular were perfomed: 11 echocolordoppler, 2 cavernosography, 2 MRI of the penis. 15 patients required surgical treatment (only one refused) and 8 did follow up. Results. Among patients with conservative treatment, 2 reported ED and pain during sexual activity and reduction in sensitivity of penis. Patient with post traumatic recurvatum underwent corporoplasty. In surgical treated group, there were no intraoperative or acute complications; 1 patient reported late asimptomatic recurvatum, 1 patient underwent circumcision to cure scar retraction. Among urethral traumas, 2 patients reported LUTS and 1 needed urethral dilatatons. Conclusion. Radiologic imaging is very useful, especially

Advances in Urological Diagnosis and Imaging - 2020; 3,3

echocolordoppler due to its low cost and feasibility, when clinical features are uncertain to confirm diagnosis and choose correct treatment. According to literature, our experience confirm surgical reconstruction as gold standard to treat penile fracture and uretrhal lesions with better long term functinal outcomes and lower incidence of post traumatic ED and recurvatum. Lectures. - Bertolotto M, Calderan L, Cova MA. Imaging of penile traumas therapeutic implications. Eur Radiol. 2005; 15:2475-2482. - Eke N. Fracture of the penis. British Journal of Surgery. 2002; 89:555-565. - Zargooshi J. Penile fracture in Kermanshah, Iran: the long term results of surgical treatment. BJU Int. 2002; 89:890-894. - Esposito AA, Giannitto C, Muzzupappa C, et al. MRI of penile fracture: what should be a tailored protocol in emergency? Radiol Med. 2016; 121:7118. - Zare Mehrjardi M, Darabi M, Bagheri SM, et al. The role of ultrasound (US) and magnetic resonance imag ing (MRI) in penile fracture mapping for modifed surgical repair . Int Urol Nephrol. 2017; 49:937-945.

V1_ROBOTIC

ASSISTED PARTIAL NEPHRECTOMY (RAPN) OF DOUBLE RENAL TUMORS USING INTRAOPERATIVE ULTRASOUND AND INDOCYANINE GREEN LIGHT FLUORESCENCE Lacetera V1, Antezza A2, Cappa E1, Cervelli B1, Gabrielloni G1, Montesi M1, Morcellini R1, Parri G1, Recanatini E1, Beatrici V1. 1 2

Division of Urology, Ospedali Riuniti Marche Nord, Pesaro (Italy); Institute of Urology, Polythecnic University of Marche Region, University Hospital “Ospedali Riuniti”, Ancona (Italy).

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

Background. The Da Vinci Robot is widely used in urological surgery. It offers the possibility to use a variety of techniques to perform partial nephrectomy. The aim of our video is to describe a case in which the combine reliance on Da Vinci Xi (Intuitive Surgical, Sunnyvale, CA, USA), intraoperative ultrasound and indocyanine green was particular useful to perform a technically complex robotic nephron-sparing surgery. Materials and Methods. A 54 yo man had an incidental diagnosis at computed tomography (CT) of dual left kidney tumor: the largest one was located in the upper pole of the left kidney, maximum diameter of 23 millimeters, mostly endophitic, R.E.N.A.L. Score 6p. The other tumor was in the lower pole of the left kidney, maximum diameter of 15 millimeters, mainly exophytic, R.E.N.A.L. Score 4a. The surgical technique, warm ischemic time (WIT), and complications were reported. Results. We performed a transperitoneal approach with the 4 robotic trocars placed in linear disposition on the lateral border of the rectus muscle, leaving at least 8 cm between two consecutive ports. 2 assistant ports (a 5 mm and the air seal port) were placed. For the upper lesion, the intraoperative ultrasound was used to confirm tumor size and location, as well to determine the margins of resection. Tumor margins were marked using monopolar scissors, and renal artery was clamped with robotic bulldog clamp. After the complete excision, we performed a first layer of the renorrhaphy and defect of the collecting system using a 3-0 Monocryl suture in a running way. The renorraphy was closed externally with “sliding clip” technique using a 0 Vicryl CT-1 suture and Hem-o-lok clips. To perform the resection of the lower lesion, we administered indocyanine green, and confirmed the absence of perfusion to the renal parenchyma surrounding the tumor with nearinfrared fluorescence (NIRF) imaging and visualized using TilePro technology. Warm ischemia time (WIT) was 28 minutes. The procedure of enucleoresection was the same as for the first lesion. The patient was discharged in V post-operative day. There were no reported complications after surgery. The histopathological report indicated renal oncocytoma for both the lesions. Conclusion. Using technology like intaroperative ultrasound and indocyanine green light fluorescence can improve a technically complex robotic nephron-sparing surgery. Link video. https://www.congressare.it/hall/2020/sieun2020/abstract/Colposacr opessi_robot.mp4

V2_ROBOTIC

ASSISTED PARTIAL NEPHRECTOMY (RAPN) WITH 3D DIGITAL RECONSTRUCTION: OUR EXPERIENCE Beatrici V1, Lacetera V1, Antezza A2, Cappa E1, Cervelli B1, Gabrielloni G1, Montesi M1, Morcellini R1, Parri G1, Recanatini E1. 1 2

Division of Urology, Ospedali Riuniti Marche Nord, Pesaro (Italy); Institute of Urology, Polythecnic University of Marche Region, University Hospital “Ospedali Riuniti”, Ancona (Italy).

Aim. We report our first case of robotic assisted partial nephrectomy (RAPN) with preoperative use of 3D digital reconstruction to guide the surgical approach. Materials and Methods. A 67 years old male patient with clinical diagnose of right renal mass was selected. We employed 3D virtual reconstruction including the lesion, the renal parenchyma, the urinary collecting system and vascular anatomy. We assessed the complexity of the renal lesion using conventional contrast-enhanced CT according R.E.N.A.L. scores and 3-D digital recostruction We report the intraoperative type of clamping (main artery or secondary branch), the surgical technique, the warm ischemic time (WIT), and complications. Results. The tumor was a clinical T1a stage (2,7 cm), 79.25% endophitic; the tumor volume was 8,48 cc, and R.E.N.A.L. score was 9p. The preoperative plan included arterial selective clamping and urinary collecting system (UCS) repair. We clamped a secondary branch of main artery, but during tumor enucleoresection we observed a mild bleeding (without needing to change our plane); we had to close the UCS with a 3-0 monocryl running suture and the cortex with a 0 vicryl running suture blocked by em-o-lock (according to technique described by Mottrie et al.). Blood loss was 200 cc. Operative time was 140 min. Warm Ischemia Time (WIT) was 23 minutes. There were no complications reported after surgery. The histopathological report indicated clear cell renal cell carcinoma type 2 sec. ISUP 2004 of 2,5 diameter with negative surgical margins (pT1a). Conclusion. Our first experience of RAPN with 3D virtual reconstruction has been promising; this technology facilitated the preoperative knowledge of the tumor and the vascularization of the kidney allowing to clamp a secondary branch instead of the main artery. Link video. https://www.congressare.it/hall/2020/sieun2020/abstract/RAPN_ric ostruzione_3D.mp4

V3_ROBOT-ASSISTED COLPOSACROPEXY WITH SUBTOTAL HYSTERECTOMY Cappa E1, Lacetera V1, Antezza A2, Cervelli B1, Gabrielloni G1, Montesi M1, Morcellini R1, Parri G1, Recanatini E1, Beatrici V1. 1 2

Division of Urology, Ospedali Riuniti Marche Nord, Pesaro (Italy); Institute of Urology, Polythecnic University of Marche Region, University Hospital “Ospedali Riuniti”, Ancona (Italy).

Aim. Pelvic organ prolapse (POP) is a common condition in women older than 50 years of age with a prevalence between 40% and 60%, and an overall lifetime risk of prolapse surgery of 12.6%. The treatment for POP includes, in addition to the conventional vaginal approaches, laparoscopic and robotic assisted sacrocolpopexy with or without hysterectomy. The aim of this video is to describe our first case of robotassisted subtotal hysterectomy with sacrocolpopexy performed by a surgeon with experience in laparoscopic surgery. Materials and Methods. A 61 yo woman presented with Advances in Urological Diagnosis and Imaging - 2020; 3,3

ABSTRACTS – XXII NATIONAL CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

an anterior utero-vaginal III degree prolaps (POP-Q III stage). The preoperative urodynamic study did not reveal detrusor hyperactivity, and she had no previous comorbidities or surgery. We report the surgical technique, operative time, intra and post-operative complications, and functional results. Results. The patient underwent robotic subtotal hysterectomy with binding of ovarian vessels to the emergence of the internal iliac artery, isolation of the ureters, and sacrocolpopexy with a mesh of titanized polypropylene. Operative time was 200 min. An intraoperative complication (a lesion of an intestinal loop) was immediatly repared. Postoperative course was regular with removal of Foley’s catheter in the second day. The patient was discharged in the third post-op day. After the twelve-weeks follow-up the patient did not have urinary symptoms or urinary incontinence, the POP was cured, and she had no dysparenuria.

Advances in Urological Diagnosis and Imaging - 2020; 3,3

Conclusion. Today the mini-invasive sacrocolpopexy has a high grade of recommendation (GR:B) and a high level of favorable evidence (LE: 2A) because of the low range, greater durability and lower dysparenuria as compared with vaginal techniques for the anterior compartment. The vaginal techniques are still valid but limited because the mesh cannot be used for the risk of infection. The da Vinci Robot (Intuitive Surgical Inc., CA, USA) was used to execute a robotic-assisted laparoscopic sacrocolpopexy (RALS) in 2004. The robotic approach provides increased magnification, three-dimensional vision, tremor filtering, and seven degrees of freedom that allow for a better surgical dissection and quick suturing. In our experience, Robot-assisted supracervical hysterectomy with sacrocolpopexy can be easily performed by a surgeon with laparoscopic experience. Link video. https://www.congressare.it/hall/2020/sieun2020/abstract/RAPN_Du plice.mp4

XXII CONGRESSO NAZIONALE S.I.E.U.N.

Authors index

Name

Page

Name

Page

Agostini A. Agostini E. Amparore D. Antezza A. Barletta F. Beatrici V. Belgrano E. Benvenuto S. Bertolotto M. Biondi C. Boltri M. Boncagni F. Boschian R. Bravi C. Brembilla G. Briganti A. Bucci S. Bussani R. Cannoletta D. Cappa E. Cattaneo G. Cervelli B. Checcucci E. Chiapparrone G. Cimadamore A. Claps F. Colombo F. Costantini E. Cucchiara V. D'Hondt F. De Cobelli F. De Concilio B. De Luca S. De Naeyer G. Dellâ&#x20AC;&#x2122;Atti L. Dellâ&#x20AC;&#x2122;Oglio P. Di Marco L. Elisei D. Esposito A. Fabiani A. Fioretti F. Fiori C. Floridi C. Fossati N. Franceschelli A. Gabrielloni G.

11 6*, 11 5 11, 12, 14, 15 7, 8 11*, 12, 14, 15* 2, 13, 14 13, 14 2, 13 1 2 3 2 7, 8 7, 8 7, 8 2, 13, 14 2 7 11, 12, 14, 15* 5 11, 12, 14, 15 5 2* 10 2 12 4 7, 8 9 7, 8 14 5* 9 6, 9, 10, 11 7, 9 2, 14 3 7, 8 1*, 2*, 3*, 12 2 5 11 7, 8 12 11, 12, 14, 15

Galosi AB. Gandaglia G. Garrou D. Gentile G. Giovagnoni A. Giulioni C. Iacobone E. Iacono F. Illiano E. Karakiewicz PI. Karnes JR. Lacetera V. Leni R. Leone L. Lepri L. Liguori G. Luca L. Maretti C. Martini A. Maurelli V. Mazzon G. Mazzone E. Migliozzi F. Milanese G. Montesi L. Montesi M. Montironi R. Montorsi F. Morcellini R. Moschini M. Motterle G. Mottrie A. Napoli R. Ocello G. Ollandini G. Palagonia E. Palmisano F. Papaveri A. Parri G. Pavia MP. Pellegrino A. Pellegrino F. Peretti D. Pierini L. Polito M. Porpiglia F.

6, 9, 10, 11 7, 8 5 12 10, 11 6, 11 3 4 4 7, 8 7, 8 11, 12*, 14*, 15 8 10 3 2, 13, 14 2 12* 7 3 13, 14 7, 8, 9 2 6, 11 10 11, 12, 14, 15 10 7, 8 11, 12, 14, 15 7, 8 7, 8 9 14* 13 13, 14 9*, 10*, 11 12 12 11, 12, 14, 15 1, 2, 3 7 7, 8 5 11 12 5

* Indicates the First Author Advances in Urological Diagnosis and Imaging - 2020; 3,3

AUTHORS INDEX – NATIONAL XXII CONGRESS OF SOCIETÀ ITALIANA DI DIAGNOSTICA INTEGRATA IN UROLOGIA, ANDROLOGIA, NEFROLOGIA – S.I.E.U.N.

Name

Page

Name

Page

Principi E. Quaresima L. Recanatini E. Rizzo A. Rizzo M. Robesti D. Rosiello G. Rossi E. Ruffo A. Salonia A. Sbrollini G. Scarcella S. Scozzese S.

1, 2 12 11, 12, 14, 15 8 2 7, 8 7, 8 1 4 7 11 6, 9, 10, 11* 2

Scuderi S. Servi L. Stabile A. Sternardi F. Tappatà G. Tezzot G. Tiroli M. Trama F. Traunero F. Trombetta C. Vagnoni V. Zordani A. Zuccarini E.

7, 8 1, 2, 3 7*, 8* 10 3 14 9 4* 2*, 13* 2, 13, 14 12 13 11

Advances in Urological Diagnosis and Imaging - 2020; 3,3

NOTES ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ................................................................................................................................................................................... ...................................................................................................................................................................................

Advances in Urological Diagnosis and Imaging - 2020; 3,3

Instructions to Authors AIMS AND SCOPE

Advances in Urological Diagnosis and Imaging is a free open access journal. The Journal has the purpose of promote, 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. All accepted paper will be published after a peer reviewed process.

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