Frailty and elderly in urology: Is there an impact on post-operative complications?

INTRODUCTION: Frailty used as predictive tool is still not carried out in daily practice, although many studies confirm the great clinical importance of the frailty syndrome in surgical outcomes. There is no standardized method of measuring the physiological reserves of older surgical patients. The aim of this study was to analyze a cohort of older urological patients according to various frailty indices, in order to evaluate whether they are predictors of post-operative complications after urological procedures. MATERIAL AND METHODS: This is a prospective observational study on 78 consecutive older ( 6570 years) patients, subjected to major urological (both endoscopic and 'open surgical') procedures. Frailty was defined according to the Edmonton Frail Scale. Several risk models and biochemical parameters were evaluated. Post-operative outcomes were surgical and medical complications, mortality and rehospitalisation within 3 months. RESULTS: An overall prevalence of frailty of 21.8% was found. Patients with complications were frailer than those without complications (univariate analysis), considering both total patients (p = 0.002) and endoscopic (p = 0.04) and 'open surgical' patients (p = 0.013). However, in multivariate analysis, a significant correlation was not found between all frailty indices tested and the risk of major complications. Limitation of the study: the small sample size (lack of statistical power), although this is a prospective study focused on older urological patients. CONCLUSIONS: New urology-tailored pre-operative assessment tools may prove beneficial when calculating the risks/benefits of urological procedures, so that objective data can guide surgical decision- making and patient counselling. Further large clinical studies specifically focusing on elderly in urology will be needed

Surgical strategies for lymphocele prevention in minimally-invasive radical prostatectomy and lymph-node dissection: a systematic review

PURPOSE: Pelvic lymph node dissection (PLND) is an important step during robotic radical prostatectomy (RARP). The collection of lymphatic fluid (lymphocele) is the most common complication with potentially severe impact; therefore different strategies have been proposed to reduce its incidence. MATERIAL AND METHODS: In this systematic review EMBASE, MEDLINE, Cochrane Library and NIH Registry of Clinical Trials were searched for papers including the following interventions: transperitoneal vs extraperitoneal approach, any reconfiguration of the peritoneum, the use of pelvic drains and the use of different sealing techniques and sealing agents. The outcome evaluated was the incidence of symptomatic lymphocele. Both randomized and non-randomized and/or retrospective studies. RESULTS: Twelve studies were included (including one ongoing RCT). Due to the heterogeneity of included studies no meta-analysis was performed. No significant impact was reported by different sealing techniques and agents or by surgical approach. Three retrospective, non-randomized studies showed a potential benefit of peritoneal reconfiguration in order to maximize the peritoneal surface of reabsorption. CONCLUSION: Lymphocele formation is a multi-step and multifactorial event, high quality literature analyzing risk factors and preventive measures is rather scarce. Peritoneal reconfiguration could represent a reasonable option that deserves further evaluation; no other preventive measure is supported by current evidence

Prostate cancer: more effective use of underutilized postoperative radiation therapy

Introduction: Adverse pathological features at radical prostatectomy such as extracapsular extension, seminal-vesicle involvement, positive surgical margins and/or lymph node invasion define a particular subgroup of patients that might benefit from additional treatment after surgery, in particular radiation therapy.Areas covered: Post-prostatectomy radiation is intended as adjuvant, early-salvage or salvage depending on the timing and PSA levels at the treatment. After providing the most used definitions, the high-level evidence supporting adjuvant radiation is reviewed together with the limitations affecting its utilization. In recent years early-salvage radiation was hypothesized to be a non-inferior alternative based on good-quality retrospective data. Recently, preliminary results of ongoing trials provide additional evidence. In light of the need to identify patients that will truly benefit from adjuvant radiation, clinically based and molecular tools available for this purpose are reviewed.Expert opinion: In order to tailor treatment for the patient after radical prostatectomy, there is a need for a tool that could both improve the oncological outcomes and be cost-effective. To date, genomic testing provides the most promising results that will be reasonably improved in the coming years

Transforming growth factor-\u3b2/Smad - signalling pathway and conjunctival remodelling in vernal keratoconjunctivitis.

BACKGROUND: Vernal keratoconjunctivitis (VKC) is a chronic ocular allergic inflammation characterized by corneal complications and the formation of giant papillae. Sma- and Mad-related proteins (Smad) modulate extracellular matrix gene expression during wound healing, inflammation and tissue remodelling. OBJECTIVE: To investigate the relationship between allergic inflammation and TGF-\u3b2/Smad signalling pathway, expression in VKC patients and in primary cultured conjunctival fibroblasts exposed to mediators found previously over-expressed in VKC. METHODS: Smad-2, -3, -7, phospho-(p)Smads, TGF-\u3b21 and -\u3b22 were evaluated in the conjunctiva of normal subjects (CT) and VKC patients by immunohistochemistry. The expression of Smads, pro-collagen I (PIP), TGF-\u3b21, -\u3b22, mitogen-activated protein kinase (p38/MAPK), c-Jun N-terminal kinase (JNK) and extracellular signal-regulated kinase (ERK1/2) were also determined in conjunctival fibroblast cultures exposed to histamine, IL-4, -13, TGF-\u3b21, IFN-\u3b3 and TNF-\u3b1 using immunostaining or RT-PCR. RESULTS: Immunostaining for Smad-2, -3, pSmad-2, -3, TGF-\u3b21, -\u3b22 and PIP was significantly increased in VKC stroma compared with CT. In conjunctival fibroblast cultures, Smad-3 and PIP were stimulated by histamine, IL-4, -13 and TGF-\u3b21 exposure, while PIP was reduced by IFN-\u3b3, and TNF-\u3b1 mRNA expression of Smad-3 was increased by histamine, while Smad-7 was reduced by IL-4. In addition, histamine, IL-4 and TNF-\u3b1 increased JNK and ERK1/2 expression. CONCLUSION AND CLINICAL RELEVANCE: The TGF-\u3b2/Smad signalling pathway is over-expressed in VKC tissues and modulated in conjunctival fibroblasts by histamine, IL-4, TGF-\u3b21 and TNF-\u3b1. These mechanisms may be involved in fibrillar collagen production, giant papillae formation and tissue remodelling typical of VKC and might provide new therapeutic targets for its treatment

Nomograms in Urologic Oncology: Lights and Shadows

Decision-making in urologic oncology involves integrating multiple clinical data to provide an answer to the needs of a single patient. Although the practice of medicine has always been an "art" involving experience, clinical data, scientific evidence and judgment, the creation of specialties and subspecialties has multiplied the challenges faced every day by physicians. In the last decades, with the field of urologic oncology becoming more and more complex, there has been a rise in tools capable of compounding several pieces of information and supporting clinical judgment and experience when approaching a difficult decision. The vast majority of these tools provide a risk of a certain event based on various information integrated in a mathematical model. Specifically, most decision-making tools in the field of urologic focus on the preoperative or postoperative phase and provide a prognostic or predictive risk assessment based on the available clinical and pathological data. More recently, imaging and genomic features started to be incorporated in these models in order to improve their accuracy. Genomic classifiers, look-up tables, regression trees, risk-stratification tools and nomograms are all examples of this effort. Nomograms are by far the most frequently used in clinical practice, but are also among the most controversial of these tools. This critical, narrative review will focus on the use, diffusion and limitations of nomograms in the field of urologic oncology

The Role of Lymph Node Dissection in the Treatment of Bladder Cancer

Lymph node dissection (LND; PLND: pelvic LND) is an essential component of radical cystectomy (RC) for bladder cancer (BC). However, the optimal anatomical extent of LND and its potential therapeutic role are still controversial: as we will explain, the extent of LND dissection is a predictor of survival and local recurrence but what is an adequate extension is still unclear. Moreover, there is large uncertainty about the role of surgery in patients with clinically-positive nodes. In this review we will provide a synthesis of the available evidence on this highly debated topic. Overall, the studies presented in this work support the idea that extended lymphadenectomy could provide optimal diagnostic and possibly therapeutic results in cN- patients. In cN+ patients, post chemotherapy surgery may be considered especially in subjects who have a good response to CHT, although definitive evidence is still needed. Finally, the final results of randomized trials are eagerly awaited to draw definitive conclusions of the role of PLND in BC

Stardust: improving spatial transcriptomics data analysis through space-aware modularity optimization-based clustering

Background Spatial transcriptomics (ST) combines stained tissue images with spatially resolved high-throughput RNA sequencing. The spatial transcriptomic analysis includes challenging tasks like clustering, where a partition among data points (spots) is defined by means of a similarity measure. Improving clustering results is a key factor as clustering affects subsequent downstream analysis. State-of-the-art approaches group data by taking into account transcriptional similarity and some by exploiting spatial information as well. However, it is not yet clear how much the spatial information combined with transcriptomics improves the clustering result.Results We propose a new clustering method, Stardust, that easily exploits the combination of space and transcriptomic information in the clustering procedure through a manual or fully automatic tuning of algorithm parameters. Moreover, a parameter-free version of the method is also provided where the spatial contribution depends dynamically on the expression distances distribution in the space. We evaluated the proposed methods results by analyzing ST data sets available on the 10x Genomics website and comparing clustering performances with state-of-the-art approaches by measuring the spots' stability in the clusters and their biological coherence. Stability is defined by the tendency of each point to remain clustered with the same neighbors when perturbations are applied.ConclusionsStardust is an easy-to-use methodology allowing to define how much spatial information should influence clustering on different tissues and achieving more stable results than state-of-the-art approaches

The impact of COVID-19 pandemic on urological emergencies: a single-center experience

COVID-19 pandemic represents a novel challenge for healthcare systems, and it affects even the daily urological practice. Italy was the first country after China to experience a lock-down period. Our objective is to determine whether, during the COVID-19 period, there has been any modification in urological emergencies