Andrea Vitale

Renal surgery for localized renal cell carcinoma carries substantial risk of acute kidney injury (AKI) regardless of surgical approach. This prospective study evaluated early biohumoral markers for AKI detection after robotic renal surgery and assessed their prognostic value for 12-month functional outcomes. Adults undergoing robotic renal tumor surgery with a healthy contralateral kidney were enrolled; AKI followed KDIGO 2012 criteria. Biomarkers measured at baseline and 2/24/72 h were serum β2-microglobulin (sβ2) serum IL-6, as well as urinary β2-microglobulin (uβ2), cystatin C (uC), and α2-macroglobulin (uα2M). Kidney function at 12 months was staged according to KDOQI criteria. Among 170 patients (35 radical nephrectomy, RN; 135 partial nephrectomy, PN), 33 developed AKI, more frequently after RN (p < 0.001); baseline biomarkers levels were similar. sβ2 was significantly higher at 2/24/72 h, and at 2 h, it achieved an AUC of 0.78 (cut-off 0.17: sensitivity 82%, specificity 60%), remaining the earliest independent predictor of AKI (p = 0.015). IL-6 differed at 24 h (AUC 0.80), uC at 72 h (AUC 0.73) and uβ2 at 72 h (AUC 0.66). Clinical AKI predicted KDOQI stage progression at 12 months (p < 0.001). Bulldog clamps (mean ischemia time 17.2 ± 6.9 min) were not associated with AKI (p = 0.99) or with KDOQI stage progression (p = 0.54). RN confers a higher AKI risk than PN. sβ2 at 2 h is the earliest actionable marker, complemented by IL-6 (24 h) and uC (72 h); short warm ischemia during robotic PN appears safe. Sequential multimarker assessment may improve recognition of AKI and support timely nephroprotective strategies.

Traditionally, in extraperitoneal robot-assisted radical prostatectomy (EP-RARP), a pneumo-Retzius is obtained by using a CO ₂ insufflation pressure of 12–15 mmHg. However, EP surgery is associated with an increase in CO ₂ absorption and consequent hypercapnia and acidosis. This study aimed to compare the effect of low CO ₂ pressure (8 mmHg) with the conventional gas pressure in EP-RARP. We enrolled patients with low-risk prostate cancer who had undergone total nerve-sparing RARP using our PERUSIA (Posterior, Extraperitoneal, Robotic, Under Santorini, Intrafascial, Anterograde) technique. The exclusion criteria were the presence of chronic lung disease, a positive biopsy core from the anterior zone, or a shift to a transperitoneal approach. Cardiopulmonary parameters were measured at the induction of anesthesia (T0); at 5 (T1) and 60 (T2) minutes after starting CO _₂ insufflation; and immediately after dorsal venous complex dissection before urethro-vesical anastomosis (T3). Data from 120 consecutive patients were retrospectively analyzed from a prospectively maintained database. Patients were divided into two groups based on the CO ₂ insufflation pressure (8 vs. 12 mmHg). No significant differences were detected in mean operative time, time required for trocar positioning, mean estimated blood loss, or complications between the two groups. The only significant difference was in the partial pressure of carbon dioxide, which was higher at T3 in Group 2 ( p =0.005), with a consequent reduction in arterial pH. However, no significant difference ( p = 0.44) was found regarding acidosis between the two groups at all timepoints. RARP has become a standard procedure in urological surgery for the treatment of localized prostate cancer. However, the CO ₂ insufflation required to create a surgical workspace may lead to cardiopulmonary complications, especially in patients with pre-existing respiratory conditions. This study compared the effects of a lower insufflation pressure (8 mmHg) vs. the standard pressure (12 mmHg) during EP-RARP. The findings suggest that using a low and constant pressure can reduce CO ₂ absorption into the bloodstream without increasing intraoperative or postoperative complications. This approach may expand eligibility for EP-RARP to include patients with chronic pulmonary diseases by enhancing the safety and tolerability of the procedure.

Colovesical fistulas (CVFs) are abnormal connections between the colon and bladder, most commonly associated with complicated diverticular disease. The standard treatment involves bowel resection to remove the fistulous tract and reduce the risk of recurrence. This study aimed to evaluate the feasibility and safety of laparoscopic and robotic conservative surgery for CVFs, avoiding bowel resection. Between 2012 and 2019, 12 consecutive patients underwent conservative treatment: 5 with a laparoscopic approach and 7 with a robotic approach. Perioperative outcomes showed shorter operative time and lower blood loss in the robotic group (101 min vs. 144 min, p = 0.02; 47 mL vs. 176 mL, p = 0.02). No surgical conversions were required, and the complication rate was low. One recurrence occurred in the laparoscopic group due to extensive diverticular disease. Short- and long-term outcomes demonstrated favorable functional results, with a reduced risk of complications compared to traditional bowel resection. The robotic technique provided advantages in operative time and blood loss. A conservative approach is an option for selected patients, particularly those with non-extensive diverticular disease.

Background: Sclerosing perivascular epithelioid cell tumors (PEComas) are rare mesenchymal neoplasms, typically benign but occasionally exhibiting aggressive behavior. This study reports a case of sclerosing PEComa of the adrenal gland that was treated with robotic partial adrenalectomy, with 13 years of follow-up and a review of the literature. Methods: A 48-year-old woman presented with abdominal pain. Imaging revealed a 10 × 9 cm adrenal mass displacing adjacent structures. MRI and 18F-FDG PET-CT suggested angiomyolipoma. Robotic partial adrenalectomy was performed. Intraoperative frozen section analysis identified the mass as angiomyolipoma, while final histopathology confirmed it as a sclerosing PEComa. Results: This case highlights the advantages of robotic surgery in the management of large adrenal tumors, allowing complete tumor removal while preserving functional adrenal tissue. The extended 13-year follow-up is significant, given the potential for recurrence or malignant transformation reported in other cases. A literature review identified 39 reported cases of sclerosing PEComas, with few documenting long-term outcomes. Conclusions: This is a documented case of robotic partial adrenalectomy for sclerosing PEComa. The findings support robotic surgery as a safe effective approach for managing this rare tumor, with excellent functional and oncological results. Extended follow-up reinforces the tumor’s benign behavior and the importance of long-term monitoring in PEComas.

Background and Objective. The significance of microRNAs (miRNAs) in relation to neoplastic diseases; such as renal carcinoma carcinoma (RCC); has been brought to light by recent studies. Analyzing the main urinary miRNAs implicated in RCC and their potential diagnostic use was the goal of this systematic review of the literature. Methods. This systematic review was performed following the PROSPERO protocol CRD42024550716. Our literature search strategies were deciding which database to include (Pubmed; EMBASE and Clinicaltrial.gov) and composing strings with words related to urinary miRNA in patients with RCC. Key findings and limitations. After screening; 10 papers were included from the 593 records that the systematic review found. No miRNA was investigated in more than one paper by different authors. The miR-210 and let-7 family were the most investigated and resulted upregulated in RCC cases compared to controls. Five papers reported different expression of miRNAs in urine samples before and after surgery: miR-15a; miR-34a-5p; miR-200a-3p; miR-205-5p; miR-210; miR-210-3p; miR-365a-3p and let-7d-5p levels decreased after nephrectomy. Meta-analysis was not performed since the included studies were heterogeneous; in terms of studied miRNA; of the normalizer used during stabilization phase; and histologic type of RCC (clear cell RCC; papillary RCC; unspecified RCC). Conclusions. Considering the variability and heterogeneity of the obtained results; as well as the vastness of the topic; expanding research in this field appears highly promising. To support further advancements; it would be useful to establish a database that consolidates international findings.

Background: In recent years, research has highlighted the importance of microRNAs (miRNAs) in the context of oncological diseases, including renal cell carcinoma (RCC). The aim of this systematic review of the literature was to analyze the main serum miRNAs involved in RCC and their potential diagnostic power. Methods: This systematic review was performed following the PROSPERO protocol CRD42024550709. Literature search strategies were developed composing strings with text words related to serum miRNA in RCC for PubMed, EMBASE and Clinicaltrial.gov. The studies enrolling adult populations with RCC and healthy controls measuring circulating miRNAs were included. Results: We found 500 records, and 26 papers were included after screening. Four studies found that miR-210, the most investigated miRNA, was overexpressed in RCC patients compared to controls, while one reported no statistical difference. The expression of some miRNAs was consistently lower in cases compared to healthy controls, such as miR-1-3p and miR-129-5p, while others (miR-221, miR-222, miR-224-5p and miR-1233) were consistently upregulated. Conclusions: Circulating miRNAs represent a promising avenue for the non-invasive diagnosis of RCC. Future research should focus on standardization, validation in larger cohorts and the development of multi-marker diagnostic panels to address these current limitations and pave the way for miRNA-based diagnostics in RCC.

Objective: Fournier's gangrene (FG) is a rare, life-threatening necrotizing fasciitis primarily affecting the perineal, genital, and perianal regions. This rapidly progressing bacterial infection predominantly affects middleaged and elderly men. This multicenter study aims to describe the management in a wide cohort of Fournier's gangrene cases that presented to three tertiary centers with early extensive surgical debridement. Materials and Methods: We retrospectively collect data from patients with FG who were referred to the Urology Clinic of the Department of Medicine and Surgery (Perugia), the Urological Andrological Surgery and Minimally Invasive Techniques Unit (Terni) of the University of Perugia, and the Urology Unit of the Surgery Department of the Macerata Civic Hospital between January 2019 and March 2024 for onset of classic signs and symptoms of FG. Extensive surgical debridement was immediately performed under general anesthesia to reach normochromic and vascularized tissue in wide and depth extension, assuring vital and healthy margins. For all patients, intravenous daptomycin plus piperacillin/tazobactam were administered. Results: 28 male patients with FG underwent early surgical debridement. In two cases, orchidectomy and partial penectomy were required during surgical debridement due to extensive necrosis. Colon diversion and urinary diversion were not necessary for any of the patients. 32.1% complications were recorded according to the Clavien Dindo classification; 6 patients died in the perioperative. Excluding death data, the average duration of antibiotic therapy was 22.0±9.1 days, and the average length of stay was 17.6±11.8 days. Conclusions: Fournier's gangrene has high mortality rates. It requires timely surgical debridement and antibiotic therapy to achieve positive outcomes. This study shows that a primary extensive debridement can help reduce the need for further intervention and shorten the hospital stay.