The role of robotic cystectomy in the salvage and palliative setting as new standard of care

Objective: To compare surgical and survival outcomes of robot-assisted (RARC) vs open (ORC) radical cystectomy with cutaneous ureterostomy (CU) for the treatment of frail patients with limited life expectancy diagnosed with bladder cancer (BC). Methods: Our prospectively maintained database was searched for cystectomy cases with CU, from June 2016 onwards. The study population was split into two groups, according to surgical approach. Baseline characteristics and surgical outcomes were compared: Mann-Whitney and Kruskal-Wallis tests were used for categorical variables, the χ²-test for continuous ones. Logistic regression analyses (LRA) identified predictors of major bleeding events (MBE) (which either caused a hemoglobin loss ≧ 3.5 g/dl or required blood transfusion) and re-operation within 30 days from surgery. Kaplan-Meier (KM) method estimated the impact of the robotic approach on overall survival (OS) and Cox regression analysis (CRA) assessed its predictors. Results: overall, 145 patients were included: 30% (n=43) underwent RARC. Baseline characteristics and tumor stages distribution were comparable in the two groups but those receiving a robot-assisted approach showed significantly reduced times to flatus, bowel and hospital discharge (all p < 0.001). Although operation time was longer in this cohort, MBE (60% vs 89%) and postoperative severe complications (0 vs 8%) (both p <0.001) were less frequent, compared to ORC. At LRA, RARC independently predicted MBE (OR: 0.26; 95%CI 0.09-0.72; p=0.02) but not the need for reintervention. At KM analysis, the minimally-invasive approach was associated with a significant advantage in terms of OS (LogRank = 0.03) and this result was confirmed at CRA (HR: 0.39; 95%CI 0.14-0.94; p=0.04). Conclusions: RARC with CU may represent the nove standard of care to treat highly comorbid patients with advanced BC as, compared to ORC, it provides significant advantages in terms of transfusion rate and severe post-operative complications while ensuring a prompt recovery and discharge

Robotic simple prostatectomy vs HOLEP, a 'multi single-center' experiences comparison

Introduction: The aim of this study was to compare peri-operative and mid-term outcomes of patients who underwent robot-assisted simple prostatectomy (RASP) vs holmium laser enucleation of the prostate (HOLEP). RASP and HOLEP are the treatments of choice for men with symptomatic benign prostatic obstruction (BPO) and a prostate ≥80 g, achieving comparable short and mid-term efficacy. No randomized controlled studies have proved the superiority of one technique over the other. Material and methods: The prospectively maintained databases of the participating institutions were queried for patients with a prostate volume (PV) ≥80 g, who underwent surgery for BPO between 2011 and 2021. The study population was divided into two subgroups based on surgical approach. Demographics, baseline characteristics, and 12 months outcomes were compared between groups: χ2 and Student t-tests were used for categorical and continuous variables, respectively. The Trifecta composite outcome (post-operative Q-max >15 ml/sec, International Prostate Symptom Score (IPSS) <8 and absence of complications) was used to define surgical quality and the two groups were compared accordingly. Logistic regression analyses investigated predictors of Trifecta achievement. Results: We included 97 patients with comparable pre-operative features (all p >0.30): 43 underwent RASP, 54 HOLEP. Median PV was 102 g (IQR 89-120) and Q-max was 7.2 ml/s (IQR 5.4-9.0). The Trifecta rate was 43% overall, higher in the RASP subgroup (56% vs 33%; p = 0.02). The endoscopic approach was its only independent predictor (OR 0.5; 95% CI 0.28-0.88; p = 0.016). Conclusions: At univariable regression analysis, surgical approach was the only independent predictor of Trifecta achievement, which was significantly higher in the RASP group compared to HOLEP

Diagnosis of prostate cancer with magnetic resonance imaging in men treated with 5-alpha-reductase inhibitors

Purpose The primary aim of this study was to evaluate if exposure to 5-alpha-reductase inhibitors (5-ARIs) modifies the effect of MRI for the diagnosis of clinically significant Prostate Cancer (csPCa) (ISUP Gleason grade >= 2).Methods This study is a multicenter cohort study including patients undergoing prostate biopsy and MRI at 24 institutions between 2013 and 2022. Multivariable analysis predicting csPCa with an interaction term between 5-ARIs and PIRADS score was performed. Sensitivity, specificity, and negative (NPV) and positive (PPV) predictive values of MRI were compared in treated and untreated patients.Results 705 patients (9%) were treated with 5-ARIs [median age 69 years, Interquartile range (IQR): 65, 73; median PSA 6.3 ng/ml, IQR 4.0, 9.0; median prostate volume 53 ml, IQR 40, 72] and 6913 were 5-ARIs naive (age 66 years, IQR 60, 71; PSA 6.5 ng/ml, IQR 4.8, 9.0; prostate volume 50 ml, IQR 37, 65). MRI showed PIRADS 1-2, 3, 4, and 5 lesions in 141 (20%), 158 (22%), 258 (37%), and 148 (21%) patients treated with 5-ARIs, and 878 (13%), 1764 (25%), 2948 (43%), and 1323 (19%) of untreated patients (p < 0.0001). No difference was found in csPCa detection rates, but diagnosis of high-grade PCa (ISUP GG >= 3) was higher in treated patients (23% vs 19%, p = 0.013). We did not find any evidence of interaction between PIRADS score and 5-ARIs exposure in predicting csPCa. Sensitivity, specificity, PPV, and NPV of PIRADS >= 3 were 94%, 29%, 46%, and 88% in treated patients and 96%, 18%, 43%, and 88% in untreated patients, respectively.Conclusions Exposure to 5-ARIs does not affect the association of PIRADS score with csPCa. Higher rates of high-grade PCa were detected in treated patients, but most were clearly visible on MRI as PIRADS 4 and 5 lesions.Trial registration The present study was registered at ClinicalTrials.gov number: NCT05078359

Green light vaporization of the prostate. Is it an adult technique?

INTRODUCTION: Intending to overcome transurethral resection of the prostate (TURF) in terms of safety maintaining its efficacy profile, have led to the introduction of minimally invasive laser therapies to treat men with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO), each one with its unique properties. The aim of this review was to analyze and summarize all the existing data regarding the 180 W Xcelerated Performance System (XPS) photoselective vaporization of the prostate (PVP). EVIDENCE ACQUISITION: A systematic review was conducted: 45 papers were identified. After excluding those not in English language, duplicates, case reports and "expert opinion" papers, 39 articles were reviewed. EVIDENCE SYNTHESIS: The XPS emits a 532 nm wavelength generated using a lithium triborate crystal in a quasi continuous mode through a 75011111, continuously saline-cooled, metal capped MoXyTM fibre. This system has overcome the previous model in terms of surgical and functional outcomes. Although several techniques have been proposed, the IGLU modular one is considered the standard approach for 180 W PVP. Authors estimated the need for at least 120 cases to reach an expert level of competence. The GOLIATH Study has proven the non-inferiority of XPS PVP to TURP. The procedure is safe and effective also in large glands but long operative times still represent an issue. Considering the total average costs, XPS PVP provides and advantage over TURP. International guidelines consider PVP the best option to manage patients receiving anticoagulants or with a high cardiovascular risk. CONCLUSIONS: PVP should be considered an adult technique and, as suggested by the EAU Guidelines, is the best surgical option to manage patients receiving anticoagulant medication or with a high cardiovascular risk. The development of new surgical techniques such as APV, PEBE and seminal spearing approaches could represent a possibility to further implement the XPS indications. Dedicated unit could improve the management LUTS/BPO men

Young Academic Urologist benign prostatic obstruction nomogram predicts clinical outcome in patients treated with transurethral resection of prostate: an Italian cohort study

Aim of our study was to test the Young Academic Urologist nomogram for the prediction of transurethral resection of prostate outcome in patients with lower urinary tract symptoms and benign prostatic enlargement

Dutasteride add-on therapy reduces detrusor mass in patients with benign prostatic enlargement not satisfied with alpha-adrenergic antagonist monotherapy. A single center prospective study

AIMS: The ultrasound assessment of bladder wall thickness (BWT) and intravesical prostatic protrusion (IPP) have emerged as a non-invasive, inexpensive, time-saving alternatives to pressure-flow studies to assess benign prostatic obstruction (BPO). Aim of our study was to evaluate the effect on detrusor mass of dutasteride add-on therapy in men with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE). METHODS: A consecutive series of BPE patients with a prostate volume (PV) ≥30 mL and an international prostate symptoms score (IPSS) ≥8 not satisfied with Tamsulosin monotherapy were enrolled. Free maximum flow (Qmax), PV, BWT, and IPP were recorded at baseline and at 24 weeks follow-up. RESULTS: Overall, 27 men were enrolled. Dutasteride significantly improved LUTS (-46.7%; P = 0.001) and Qmax (+18.7%; P = 0.001) and reduced PV (-13%; P = 0.002), BWT (-40.3%; P = 0.001), and IPP (-14.9%; P = 0.015). At baseline, based on BWT ≥5 mm and an IPP >10 mm, 13/27 (48%) and 15/27 (55%) patients were defined at risk for BPO, respectively; while after 24 weeks of treatment they were 3/27 (11.1%) and 11/27 (40%), respectively. CONCLUSIONS: Dutasteride add-on therapy significantly reduced IPP and detrusor mass and was effective in improving LUTS in patients with BPE not satisfied with αBs monotherapy. The possible role of BWT and IPP as proxies of medical treatment outcomes should be confirmed by further studies

Tamsulosin or silodosin adjuvant treatment is ineffective in improving shockwave lithotripsy outcome: A short-term follow-up randomized, placebo-controlled study

Abstract INTRODUCTION: The role of α-blockers after shockwave lithotripsy (SWL) is controversial. The aim of our study was to evaluate the effect of tamsulosin and silodosin after SWL for kidney stones. METHODS: From 2012 onward, a consecutive series of patients undergoing SWL were prospectively enrolled and randomized by closed envelopes in three groups receiving tamsulosin 0.4 mg (A), silodosin 8 mg (B), and placebo (C) daily for 21 days after SWL. Anthropometrics, stone size, and location were recorded before SWL. Visual analogue scale (VAS) score was collected at 6, 12, and 24 hours after treatment to evaluate patients' discomfort. Stone-free rate was assessed 1 and 3 weeks postoperatively. Complications and medical treatment-related adverse events (AEs) were recorded. Differences in VAS score, stone-free rate, and complications were compared among the groups. RESULTS: Overall, 60 patients were enrolled. Mean stone sizes were 10.28 ± 2.46 mm, 10.45 ± 1.73 mm, and 9.23 ± 2.04 mm in groups A, B, and C, respectively (p = 0.474). There was no significant difference between the three groups with regard to stone location. Comparable energy was used to treat patients from the three groups. The overall 3-week stone-free rate was 53%: 58% in the tamsulosin group, 47% in the silodosin group, and 55% in the placebo group (p = 0.399). No significant differences were observed in the VAS scores reported by the groups at 6 hours (p = 1.254), 12 hours (p = 0.075), and 24 hours (p = 0.490). Overall, 12 complications were reported: 11 patients (7 in group C and 4 in group B) needed analgesics for colic, and 1 patient (group B) was surgically treated for Steinstrasse. Tamsulosin was superior to placebo (p = 0.008) and silodosin (p = 0.021) in preventing complications; no difference between silodosin and placebo (p = 0.629) was noted. CONCLUSIONS: Tamsulosin and silodosin are ineffective in increasing stone-free rate as well as early patients' discomfort after extracorporeal lithotripsy. PMID: 27080916 DOI: 10.1089/end.2016.011