Segmental Ureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review and Meta-analysis of Comparative Studies

Radical nephroureterectomy (RNU) represents the standard of care for high-risk upper tract urothelial carcinoma (UTUC). In selected patients with ureteral UTUC, a conservative approach such as segmental ureterectomy (SU) can be considered. However, this therapeutic option remains controversial. The aim of this study was to perform a systematic review and meta-analysis of studies assessing the outcomes of SU versus RNU in patients with UTUC. Three search engines (Scopus, Embase, and Web of Science) were queried up to May 2019. The Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA Statement) was used as a guideline for study selection. The clinical question was established as stated in the PICO (Population, Intervention, Comparator, Outcome) process. Patients in the SU group were more likely to have history of bladder cancer (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.12-3.51; P = .02), but less likely to present with preoperative hydronephrosis (OR, 0.52; 95% CI: 0.31-0.88; P = .02). A higher rate of ureteral tumor location was found in the SU group (OR, 7.54; 95% CI, 4.15-13.68; P < .00001). The SU group presented with a lower rate of higher (pT ≥ 2) stage (OR, 0.66; 95% CI, 0.53-0.82; P = .0002), and high-grade tumors (OR, 0.62; 95% CI, 0.50-0.78; P < .0001). The SU group was found to have shorter 5-year relapse-free survival (OR, 0.64; 95% CI, 0.43-0.95; P = .03), but higher postoperative estimated glomular filtration rate (weighted mean difference, 10.97 mL/min; 95% CI, 2.97-18.98; P = .007). Selected patients might benefit from SU as a therapeutic option for UTUC. In advanced high-risk disease, RNU still remains the standard of care

Prostate cancer biomarkers: a practical review based on different clinical scenarios

Traditionally, diagnosis and staging of prostate cancer (PCa) have been based on prostate-specific antigen (PSA) level, digital rectal examination (DRE), and transrectal ultrasound (TRUS) guided prostate biopsy. Biomarkers have been introduced into clinical practice to reduce the overdiagnosis and overtreatment of low-grade PCa and increase the success of personalized therapies for high-grade and high-stage PCa. The purpose of this review was to describe available PCa biomarkers and examine their use in clinical practice. A nonsystematic literature review was performed using PubMed and Scopus to retrieve papers related to PCa biomarkers. In addition, we manually searched websites of major urological associations for PCa guidelines to evaluate available evidence and recommendations on the role of biomarkers and their potential contribution to PCa decision-making. In addition to PSA and its derivates, thirteen blood, urine, and tissue biomarkers are mentioned in various PCa guidelines. Retrospective studies have shown their utility in three main clinical scenarios: (1) deciding whether to perform a biopsy, (2) distinguishing patients who require active treatment from those who can benefit from active surveillance, and (3) defining a subset of high-risk PCa patients who can benefit from additional therapies after RP. Several validated PCa biomarkers have become commercially available in recent years. Guidelines now recommend offering these tests in situations in which the assay result, when considered in combination with routine clinical factors, is likely to affect management. However, the lack of direct comparisons and the unproven benefits, in terms of long-term survival and cost-effectiveness, prevent these biomarkers from being integrated into routine clinical use

Prostate cancer radiogenomics—from imaging to molecular characterization

Radiomics and genomics represent two of the most promising fields of cancer research, designed to improve the risk stratification and disease management of patients with prostate cancer (PCa). Radiomics involves a conversion of imaging derivate quantitative features using manual or automated algorithms, enhancing existing data through mathematical analysis. This could increase the clinical value in PCa management. To extract features from imaging methods such as magnetic resonance imaging (MRI), the empiric nature of the analysis using machine learning and artificial intelligence could help make the best clinical decisions. Genomics information can be explained or decoded by radiomics. The development of methodologies can create more-efficient predictive models and can better characterize the molecular features of PCa. Additionally, the identification of new imaging biomarkers can overcome the known heterogeneity of PCa, by non-invasive radio-logical assessment of the whole specific organ. In the future, the validation of recent findings, in large, randomized cohorts of PCa patients, can establish the role of radiogenomics. Briefly, we aimed to review the current literature of highly quantitative and qualitative results from well-de-signed studies for the diagnoses, treatment, and follow-up of prostate cancer, based on radiomics, genomics and radiogenomics research

Predicting the Need for Biopsy to Detect Clinically Significant Prostate Cancer in Patients with a Magnetic Resonance Imaging-detected Prostate Imaging Reporting and Data System/Likert ≥3 Lesion: Development and Multinational External Validation of the Imperial Rapid Access to Prostate Imaging and Diagnosis Risk Score

BACKGROUND: Although multiparametric magnetic resonance imaging (MRI) has high sensitivity, its lower specificity leads to a high prevalence of false-positive lesions requiring biopsy. OBJECTIVE: To develop and externally validate a scoring system for MRI-detected Prostate Imaging Reporting and Data System (PIRADS)/Likert ≥3 lesions containing clinically significant prostate cancer (csPCa). DESIGN, SETTING, AND PARTICIPANTS: The multicentre Rapid Access to Prostate Imaging and Diagnosis (RAPID) pathway included 1189 patients referred to urology due to elevated age-specific prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE); April 27, 2017 to October 25, 2019. INTERVENTION: Visual-registration or image-fusion targeted and systematic transperineal biopsies for an MRI score of ≥4 or 3 + PSA density ≥0.12 ng/ml/ml. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Fourteen variables were used in multivariable logistic regression for Gleason ≥3 + 4 (primary) and Gleason ≥4 + 3, and PROMIS definition 1 (any ≥4 + 3 or ≥6 mm any grade; secondary). Nomograms were created and a decision curve analysis (DCA) was performed. Models with varying complexity were externally validated in 2374 patients from six international cohorts. RESULTS AND LIMITATIONS: The five-item Imperial RAPID risk score used age, PSA density, prior negative biopsy, prostate volume, and highest MRI score (corrected c-index for Gleason ≥3 + 4 of 0.82 and 0.80-0.86 externally). Incorporating family history, DRE, and Black ethnicity within the eight-item Imperial RAPID risk score provided similar outcomes. The DCA showed similar superiority of all models, with net benefit differences increasing in higher threshold probabilities. At 20%, 30%, and 40% of predicted Gleason ≥3 + 4 prostate cancer, the RAPID risk score was able to reduce, respectively, 11%, 21%, and 31% of biopsies against 1.8%, 6.2%, and 14% of missed csPCa (or 9.6%, 17%, and 26% of foregone biopsies, respectively). CONCLUSIONS: The Imperial RAPID risk score provides a standardised tool for the prediction of csPCa in patients with an MRI-detected PIRADS/Likert ≥3 lesion and can support the decision for prostate biopsy. PATIENT SUMMARY: In this multinational study, we developed a scoring system incorporating clinical and magnetic resonance imaging characteristics to predict which patients have prostate cancer requiring treatment and which patients can safely forego an invasive prostate biopsy. This model was validated in several other countries

Sexual Activity After Bariatric Surgery: A Prospective Monocentric Study Using the PISQ-IR Questionnaire

Introduction: Obesity can lead to pelvic floor disorders, interfering with women's sexual life; Prolapse/Incontinence Sexual Questionnaire-International Urogynecology Association–Revised (PISQ-IR) is a new instrument to measure sexual life in women with pelvic floor disorders. Aims: To assess the utility of using PISQ-IR in morbidly obese women undergoing bariatric surgery and to show the improvement of bariatric surgery on sexuality. Methods: This prospective monocentric study included all women who underwent bariatric surgery from June 2016–May 2017. Sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) was performed by 1 surgeon, and data were collected by 1 researcher. Demographics, medical history, number of deliveries, and type of bariatric surgery (SG or RYGB) were collected at baseline. At the 1-year follow-up consultation, postoperative complications, percentage of total body weight loss (TWL) and percentage excess weight loss were assessed. Questionnaires were given at baseline and at 1-year follow-up. Main Outcome Measures: Postoperative complications and total weight loss were measured at the 1-year follow-up. Sexual activity, using the PISQ-IR, and pelvic organ prolapse, urinary incontinence, and anal incontinence, using the urinary symptom profile and PFDI (Pelvic Floor Distress Inventory) 20, were compared before surgery and at 1-year follow-up. Results: 72 patients were included at baseline, 54 (75%) were considered for final analysis (30 RYGB and 24 SG), and 51 patients were considered for PISQ-IR. The mean preoperative body mass index was 41 ± 5.4 kg/m2, and mean age was 43 ± 11.8 years. Both procedures induced an important weight loss (mean TWL of 33%) and had a similar percentage of TWL for each procedure: 31 (15–46) for SG vs 34 (9–51) for RYGB. 9 patients (17 [6%]) became sexually active 1 year after surgery. For the sexually inactive population after 1 year, there was no differences in the PISQ-IR in the follow-up. When body mass index loss was &gt;13 kg/m2, a higher percentage of the sexually active population improved their different scores, and there were significant results for both global quality of life and desire (P = .026 and .046). The other questionnaires showed a significant decrease in urinary incontinence symptoms (P &lt; .001) associated with weight loss, whereas there was no difference in terms of pelvic organ prolapse or anal incontinence. Conclusion: PISQ-IR is a useful instrument to measure sexual function regarding pelvic floor disorders. Bariatric surgery improves sexual activity in obese women 1 year after surgery. Treacy PJ, Mazoyer C, Falagario U, et al. Sexual Activity After Bariatric Surgery: A Prospective Monocentric Study Using the PISQ-IR Questionnaire. J Sex Med 2019;16:1930–1937

Advanced ureteroscopic techniques for the management of kidney stones

PURPOSE OF REVIEW: Recent years witnessed significant changes in the endourological management of renal tones because of the development of new, more advanced instruments. Retrograde intrarenal surgery (RIRS) has gained particular advantage from such technological progress and now tends to be considered the gold standard treatment for uncomplicated less than 20 mm renal stones. Using a step-by-step approach, this review aims to highlight current achievements but also unsolved problems in RIRS. RECENT FINDINGS: Several technical details of RIRS, including preoperative stenting, use of ureteral access sheets, lithotripsy method, and renal drainage, remain open to discussion and linked to surgeon's preference. Moreover, there is a wide range of variation in efficacy and safety data, with major complications being episodic but often under-reported. SUMMARY: RIRS has gained increased popularity among the urological community. This is certainly because of the continuous technological advancements, which have continuously improved the RIRS performance but also to the perception of ease and safety of this procedure when compared with the other available treatment modalities, particularly percutaneous nephrolitotomy. Indeed, the reported advances in RIRS technique have significantly improved the outcomes of this procedure but care should be taken not to underestimate its potential challenges

Prostatic inflammation is associated with benign prostatic hyperplasia rather than prostate cancer

Background and aims. The relationship between prostatic inflammation, benign prostatic hyperplasia and prostate cancer is controversial. The present study aimed to determine the relationship between grade and aggressiveness of prostatic inflammation and the risk of being diagnosed with prostate cancer. Methods. Grade and aggressiveness of prostatic inflammation were assessed by Irani G and A scores, respectively, in prostate biopsy specimens of men having undergone this procedure because of increased serum PSA and/or digital rectal examination. We also assessed the correlation between Irani G and A scores and clinical variables related to benign prostatic obstruction. Results. Of the 1178 eligible patients, 615 (52.2%) were diagnosed with PCa; they were older, had greater PSA, suspicious digital rectal examination and peak flow rate but lower post-void residual urine volume, prostate volume and international prostate symptoms score than those without cancer. High-grade inflammation (Irani G 2-3) was significantly more common in patients with benign prostate than in those with PCa and the same applied to highly aggressive inflammation (Irani A 2-3). Indeed, patients with high-grade inflammation had greater PSA, prostate volume, post-void residual and international prostate symptoms score, suggesting high-grade inflammation to correlate with benign prostatic obstruction. Highly-aggressive inflammation conversely correlated only with prostate volume. Conclusions. Prostatic inflammation seems to be associated with benign prostatic hyperplasia rather than prostate cancer, with benign prostatic obstruction being strictly linked to the degree of inflammation