We determined predictors of pelvic lymph node metastases in patients with penile cancer. We retrieved a total of 188 node positive inguinal groins from 142 patients treated for penile cancer. Logistic regression models were fitted to test for predictors of pelvic lymph node metastases. The minimum p value method was used to determine the most significant cutoff values of each predictor. Pelvic lymph node metastases were observed in 45 cases (31.7%). The 5-year cancer specific survival rate was 71.0% vs 33.2% in patients with inguinal vs pelvic lymph node metastases. The most significant cutoff values were 3 inguinal lymph node metastases and a metastasis diameter of 30 mm. According to univariable logistic regression models the number of inguinal metastases (OR 1.92, p <0.001), the diameter of the metastases (OR 1.03, p = 0.001) and extranodal extension (OR 8.01, p <0.001) were significant predictors of pelvic lymph node metastases. These variables were also independent predictors of metastases in multivariable logistic regression models (p ≤ 0.012). Patients with 3 or more inguinal lymph node metastases and those with a metastasis diameter of 30 mm or greater were at 4.77 and 2.53-fold higher risk, respectively, of harboring pelvic lymph node metastases (p ≤ 0.006). The proportion of metastases increased significantly from 0% in cases with no risk factors to 57.1% when all 3 risk factors were observed (p <0.001). The number and diameter of inguinal lymph node metastases as well as extranodal extension are significantly associated with pelvic lymph node metastases. These variables should be considered to determine the need for pelvic lymph node dissection. Patients with no risk factors may be spared this dissection.

Current guidelines recommend considering surgical excision of non-metastatic renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombosis in patients with acceptable performance status. Of note, several authors have pioneered specific techniques for laparoscopic and robotic management of renal cancer with level I-IV IVC thrombosis. A systematic review of the English-language literature on surgical techniques and perioperative outcomes of minimally-invasive radical nephrectomy (RN) and IVC thrombectomy for nonmetastatic RCC was performed without time filters using the MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials and Web of Science (WoS) databases in September 2018 according to the PRISMA statement recommendations. Overall, 28 studies were selected for qualitative analysis (N.=13 on laparoscopic surgery, N.=15 on robotic surgery). The quality of evidence according to GRADE was low. Laparoscopic techniques included hand-assisted, hybrid and pure laparoscopic approaches. Most of these series included right-sided tumors with predominantly level I or II IVC thrombi. Similarly, most robotic series reported right-sided RCC with level I-II IVC thrombosis; yet, few authors extended the indication to level III thrombi and to left-sided RCC. Surgical techniques for minimally-invasive IVC thrombectomy evolved over the years, with specific technical nuances aiming to tailor surgical strategy according to both tumor side and thrombus extent. Among the included studies, perioperative outcomes were promising. Minimally-invasive surgery is technically feasible and has been shown to achieve acceptable perioperative outcomes in selected patients with renal cancer and IVC thrombosis. The evidence is premature to draw conclusions on intermediate-long term oncologic outcomes. Robotic surgery allowed to extend surgical indications to more challenging cases with more extensive tumor thrombosis. Nonetheless, global experience on minimally-invasive IVC thrombectomy is limited to high-volume surgeons at high-volume Centers. Future research is needed to prove its non-inferiority as compared to open surgery and to define its benefits and limits.

Bladder cancer (BC) is the tenth most commonly diagnosed malignancy worldwide. In approximately 25% of cases, it presents as a muscle-invasive disease, requiring a radical treatment. Traditionally, the mainstay of treatment has been radical cystectomy (RC), but in the last decade, bladder-sparing treatments have been gaining growing interest. In particular, trimodal therapy (TMT) seems to yield survival results comparable to RC with less morbidity and better quality of life (QoL) outcomes. In this scenario, we aimed at shedding light on the role of the histological subtypes (HS) of BC and their prognostic significance in muscle-invasive BC (MIBC), treated either surgically or with TMT. We performed a narrative review to provide an overview of the current literature on this topic. When compared with patients diagnosed with conventional urothelial carcinoma (UC) of the same disease stage, survival did not appear to be significantly worse across the reports. But when sub-analyzed for separate subtype, some appeared to be independently associated with adverse survival outcomes such as the micropapillary, plasmacytoid, small-cell, and sarcomatoid subtypes, whereas others did not. Moreover, the optimal management remains to be defined, also depending on the therapeutic susceptibility of each histology. From this perspective, multi-disciplinary assessment alongside the routine inclusion of such entities in randomized clinical trials appears to be essential.

Considering the persistent controversy concerning the impact of varicocele repair on fertility, we decided to perform an update of the review of the literature with the aim to evaluate whether the most recent research in this field gives us more evidence about the indications to treat or not to treat varicocele in dyspermic or infertile men. Randomized controlled trials (RCTs) and prospective studies evaluating semen parameters before and after varicocelectomy clearly demonstrate that varicocele repair is associated with a significant improvement of sperm concentration, motility and normal morphology. Moreover, some recent studies highlighted the potential role of varicocelectomy in reduction of seminal oxidative stress and sperm DNA damage. One recent RCT showed a statistically significant advantage in favor of varicocelectomy in comparison with observations in terms of spontaneous pregnancy rate. Meta-analysis including this study confirmed the heterogeneity of pooled studies and showed a significant trend in favor of varicocele repair. This trend has become statistically significant when an 'as-treated' analysis is performed (odds ratio 2.69, 95% confidence interval 1.16-6.24). The advantages in favor of varicocele treatment were also observed in a recent RCT analyzing couples with first-term recurrent miscarriage. Varicocele repair must be proposed in young adult men with impairment of seminal parameters and not yet interested in pregnancy. Men of infertile couples should be adequately counselled concerning the high possibility of attaining a significant improvement in seminal parameters after varicocele repair. This condition can be associated with a spontaneous pregnancy rate of 30%. The main alternative remains the use of artificial reproductive techniques.