Therapeutic Advances in Urology最新文献

Background: Traditionally performed as an inpatient procedure, day-case or ambulatory percutaneous nephrolithotomy (PCNL) has emerged in recent years as a promising alternative offering the potential to reduce hospital admissions and healthcare costs, without compromising patient outcomes.

Objectives: Conduct a systematic review and meta-analysis to critically evaluate the efficacy, safety and overall outcomes of day-case PCNL.

Design: The systematic review was conducted in line with PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses).

Data sources and methods: We conducted a comprehensive search of MEDLINE, Embase, Scopus, Web of Science, CENTRAL and Cochrane Databases from inception until January 2025 (CRD42024584357). The PICO statement for this systematic review is as follows: in patients with renal stones, what are the outcomes of day-case PCNL (intervention) compared with inpatient PCNL (comparator)? The authors included studies with more than 50 adult patients evaluating day-case PCNL (postoperative hospital stay ⩽ 24 h) written in the English language.

Results: From an initial literature search of 2122 articles, 16 studies were identified, from which 3133 patients were included. A variety of standard, mini and ultra-mini techniques were used, with the majority opting for tubeless (61%) or totally tubeless PCNL (16%). The mean stone size was 21.5 ± 13.5 mm, with five studies including patients with renal structural abnormalities (3.6%). The pooled mean stone-free rate (SFR) was 90% (95% CI: 0.859-0.931), with a readmission rate of 3.2% (95% CI: 0.018-0.046). The overall complication rate was 10.7% (95% CI: 0.078-0.137), with most complications classified as minor with Clavien-Dindo Grade I-II (9.1%) and III-IV (1.6%). The quality assessment of the included literature revealed that all studies were of moderate to high quality.

Conclusion: Day-case PCNL represents a safe and viable approach that has seen a growing adoption over recent years, driven in part by post-pandemic healthcare trends. Our review underscores its efficacy, marked by favourable outcomes and a low incidence of complications and readmissions. Moreover, detailed planning is paramount in order to establish clear criteria for potential surgical candidates and indications for inpatient admission, as well as a thorough follow-up plan.

Background: Data on modalities of real-world use of androgen deprivation therapy, such as triptorelin, in men with prostate cancer (PCa) are lacking.

Objectives: To describe the real-world management of triptorelin treatment over 12 months following treatment initiation in France, and to gain a better understanding of the choices being made about planned total treatment duration, formulation, and route of administration.

Design: TALISMAN was a prospective, multicenter, longitudinal, non-interventional study.

Methods: Patients with PCa eligible for triptorelin treatment for at least 12 months were enrolled and followed up for 12 months. The primary objective was to describe the proportion of patients treated continuously with triptorelin during the 12 months following treatment initiation. Planned total duration of treatment, formulation, administration route, and reasons for these choices were evaluated at baseline and at 6 and 12 months. Quality-of-life and safety data were collected.

Results: Overall, 806 patients were enrolled, of whom 787 patients were included in the analysis. Mean (standard deviation) age was 74.0 (7.9) years, the main circumstance of prescription of triptorelin was a high-risk localized tumor (41.1%). Planned total duration of treatment at baseline was most commonly 24-36 months, and the main reasons for the choice of duration were Gleason score and guideline recommendations. Most patients (72.5%) received the 3-month subcutaneous formulation at baseline; main reasons for choice of formulation and route were physician preference and planned total duration of treatment. Overall, 85.3% (95% confidence interval (82.6, 87.7)) of patients received a continuous 12-month treatment with triptorelin, and 69.1% of patients undertook at least one supportive care pathway during the study period. Patients reported an increase in hormonal treatment-related symptoms and worsening of sexual activity and functioning. There were no new or unexpected safety findings.

Conclusion: In France, compliance with continuous triptorelin treatment for 12 months is high and prescribing aligns with guideline recommendations.

Trial registration: NCT04593420.

Background: Premature ejaculation (PE) is a common sexual disorder characterized by a lack of voluntary control over ejaculation. Current treatments often fail to produce consistently satisfactory outcomes. Peripheral electrical stimulation (PES) is an emerging neuromodulation technique that applies electrical currents to targeted body areas and has shown promise across various conditions.

Objectives: Although the use of PES for PE is relatively underexplored, this study aimed to synthesize existing research to better understand its potential as a treatment option.

Design: Systematic review.

Data sources and methods: A systematic search was conducted in PubMed, Embase, Scopus, Web of Science, and Google Scholar using relevant keywords. Studies were included if they investigated PES as a treatment for PE and reported outcomes such as intravaginal ejaculatory latency time (IELT) or other clinical measures.

Results: Ten studies met the eligibility criteria. Due to the limited number and heterogeneity of studies, a meta-analysis was not feasible, and a narrative synthesis was performed. Stimulation was applied transcutaneously in various ways, including at acupuncture points, the dorsal penile nerve, and the posterior tibial nerve. Protocols varied considerably, though commonly reported parameters included a pulse frequency of 20 Hz and a pulse width of 200 µs, typically administered in 30-min sessions. Some studies lacked detailed descriptions of stimulation settings. Overall, the studies demonstrated a positive trend in favor of PES for prolonging IELT, and no consistent or significant adverse events were reported.

Conclusion: The findings suggest that PES may be a promising adjunctive therapy for men with PE by prolonging IELT. Further high-quality research using validated patient-reported outcomes is needed to clarify the impact of PES on perceived ejaculatory control and sexual satisfaction.

Trial registration: The study protocol was prospectively registered in PROSPERO (ID: CRD42024551360).

Background: Stress urinary incontinence (SUI) in men, often due to radical prostatectomy or sphincter deficiency, impacts quality of life. Surgical options include artificial urinary sphincter (AUS) and male urethral slings, valued for lower risks and cost. Understanding their outcomes aids in patient care.

Objectives: To compare 30-day postoperative outcomes in AUS versus sling implantation in males.

Design: Retrospective cohort study using a multicenter database.

Methods: Male patients who underwent sling or AUS implantation between 2008 and 2022 were identified in the National Surgical Quality Improvement Program (NSQIP) database using current procedural terminology (CPT) codes. Patient characteristics, intraoperative factors, and 30-day outcomes were extracted and compared. Multivariate logistic regression adjusted for age, body mass index (BMI), race, ASA classification, anesthesia technique, smoking status, history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes, hypertension requiring medication, bleeding disorders, and chronic steroid use. A 1:1 propensity score-matched analysis was also conducted.

Results: Among 4,498 patients, 39.6% received slings and 60.4% AUS. After adjustment, AUS was associated with higher odds of 30-day complications (OR 1.48 (1.09-2.02), p = 0.012), including surgical site infections (OR 2.19), overall infections (OR 1.84), implant complications (OR 4.08), genitourinary complications (OR 2.31), unplanned reoperation (OR 2.04), Clavien-Dindo Grade I-II (OR 1.58) and Grade III complications (OR 2.10), and prolonged hospital stay (OR 4.66-5.71; all p < 0.001). The 1:1 matched analysis largely supported these findings.

Conclusion: AUS implantation is associated with higher 30-day postoperative complication rates compared to male urethral sling placement. These results may guide surgeons in their perioperative counseling regarding the short-term complication rates of both procedures, but further studies are needed to assess the long-term outcomes.

Objective: Many studies have stressed the necessity of repeat transurethral resection (reTURB) following the initial conventional transurethral resection of the bladder for non-muscle invasive bladder cancer (NMIBC) patients. However, there have been few studies focusing on the role of reTURB after en bloc resection of bladder tumor (ERBT) for NMIBC by far. This study aimed to evaluate whether reTURB can be avoided after ERBT.

Materials and methods: We conducted research in PubMed, Web of Science, EMBASE, and the Cochrane Library up to November 14, 2024, to identify studies on the reTURB after initial ERBT. For data conversion and the combined calculation of the incidence rate, we utilized R software (R Foundation for Statistical Computing, Vienna, Austria) and Cochrane Review Manager 5.4 (The Cochrane Collaboration, London, UK) along with the double arcsine method. This systematic review protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) under number 1082989.

Results: A total of 17 studies involving 1051 participants were included. The rates of residual tumor and tumor upstaging detected by reTURB or cystoscopy after ERBT were 9% (95% confidence interval (CI) = 4%-16%) and 0% (95% CI = 0%-1%). No statistically significant positive effect of reTURB after initial ERBT was exhibited in recurrence-free survival (RFS), tumor recurrence, and progression. The pooled hazard ratios of 1-year and 5-year RFS were 0.77 (95% CI = 0.41-1.44, p = 0.41) and 0.83 (95% CI = 0.58-1.20, p = 0.33). The pooled odds ratio of progression and recurrence were 1.13 (95% CI = 0.53-2.41, p = 0.75) and 0.78 (95% CI = 0.53-1.16, p = 0.23).

Conclusion: ERBT can successfully regulate the rate of tumor upstaging and residual tumor to an acceptable level. For patients with NMIBC, subsequent reTURB may not be required following the initial ERBT.

Purpose: This study was developed to compare the clinical benefits associated with the use of balloon dilatators to those of metallic telescopic dilatators when used for the establishment of tracts in patients undergoing ultrasound-guided percutaneous nephrolithotomy.

Materials and methods: This was a single-center retrospective study enrolling patients with urolithiasis who underwent ultrasound-guided percutaneous nephrolithotomy at Yuhuangding Hospital between 2011 and 2021. Patients were grouped based on the method used to establish percutaneous renal tracts, including balloon and metallic telescopic groups. The primary outcomes were overshooting rate, failure of access rate, and the efficiency of stone removal, while secondary outcomes included safety and economic benefits.

Results: In total, 2269 patients were enrolled in this study, of whom 1222 (54%) and 1047 (46%) were in the balloon and metallic telescopic groups, respectively. Comparisons between the two groups did not reveal any superiority of the balloon group relative to the metallic telescopic group in overshooting rate (adjusted rate ratio (RR), 0.97; 95% confidence interval (CI), 0.73-1.27), failure of access rate (adjusted RR, 0.78; 95% CI, 0.52-1.16) and stone removal efficiency (adjusted RR, 1.03; 95% CI, 0.94-1.13). However, a significantly lower postoperative hemoglobin reduction value was observed in the balloon group relative to the metallic telescopic group (adjusted beta coefficient ratio: 7.19, 95% CI, 5.68-8.70). Balloon dilatator use was associated with better transfusion, embolization, surgical time, and hospital stay outcomes, whereas it was inferior in terms of costs.

Conclusion: In patients undergoing ultrasound-guided percutaneous nephrolithotomy, balloon dilatator use for the establishment of percutaneous tracts is not superior to metallic telescopic dilatator use in terms of overshooting and failure of access and stone removal rates, but is superior in terms of the control of bleeding.

Background: Adrenal lesions, often incidentally detected, present diagnostic challenges in distinguishing benign from malignant or hormonally active lesions. Conventional imaging (computed tomography/magnetic resonance imaging (CT/MRI)) has limitations, driving interest in artificial intelligence (AI) and radiomics for enhanced accuracy.

Objectives: To systematically evaluate AI and radiomics applications in adrenal lesion characterization, focusing on diagnostic performance, methodologies, and clinical utility.

Design: PRISMA-guided systematic review of studies published up to June 2024.

Data sources and methods: PubMed, Scopus, Web of Science, and Google Scholar were searched using the keywords: adrenal lesions, AI, radiomics, and machine learning. Inclusion followed PICO criteria: patients with indeterminate lesions, AI/radiomics interventions, comparisons to standard diagnostics, and diagnostic accuracy. Two reviewers screened studies, resolving discrepancies via consensus. Eleven retrospective studies (996 patients) met eligibility.

Results: CT-based radiomics (eight studies) achieved a mean AUC of 0.88 (range: 0.84-0.94) in differentiating benign/malignant or functional/non-functional lesions. Top-performing models identified aldosterone-producing adenomas (AUC: 0.99). MRI-based radiomics (three studies) yielded mean AUC: 0.82 (0.72-0.92), with test-set performance declines (e.g., AUC: 0.72) suggesting overfitting. Nuclear medicine (four studies) demonstrated that hybrid 18F-FDG PET/CT models (SUVmax + texture features) achieved an AUC of 0.97 for metastatic versus benign lesions. AI applications extended to intraoperative navigation (AUC: 0.93) and prognostic prediction.

Conclusion: CT-based radiomics outperformed MRI, aligning with guidelines favoring CT for adrenal assessment. AI-enhanced models show promise in refining diagnostics and reducing invasive procedures. However, retrospective designs, small cohorts, and protocol variability limit generalizability. Future work requires multicenter collaboration, standardized protocols, and prospective validation to translate AI/radiomics into clinical practice.

We aim to explore the feasibility of robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RA-SCAC) for the management of adult neurogenic lower urinary tract dysfunction and to compare the functional and surgical outcomes of an intracorporeal and extracorporeal approach. A retrospective review of all patients who underwent robot-assisted supratrigonal cystectomy and augmentation cystoplasty was performed. Data was collected on age, body mass index, American Society of Anaesthesiologists (ASA) score, type and duration of neurological disease, previous abdominal surgery and renal function. Bladder diary, urodynamics and validated symptom score results were recorded at baseline and repeated postoperatively. Intraoperative details included type of diversion, concomitant surgery, duration of surgery, blood loss and conversion to open. Postoperative surgical recovery was also reviewed. The primary endpoint was the rate of major postoperative complications defined as any complication Clavien-Dindo grade ≥3 occurring within the first 90 days postoperatively. There were 26 patients in total; 7 performed extracorporeally and 19 intracorporeally. Mean age was 41.5, mean BMI 24.4 and majority were ASA score 2 (61.5%). Twelve (46.1%) patients had spinal cord injury and 6 (23.1%) spina bifida. Seven (26.9%) had a concomitant procedure including bladder neck artificial urinary sphincter (AUS) insertion, bladder neck fascial sling or creation of a continent catheterisable channel. The surgical outcomes were analysed separately for those that had RA-SCAC only versus RA-SCAC with a concomitant procedure. The operative time was shorter in the intracorporeal group, and the length of stay was similar in both groups. The total number of major postoperative complications was low (n = 3; 11.5%). All urodynamic parameters significantly improved at 6 months in the intracorporeal group. Median number of urinary incontinence episodes per 24 h decreased significantly in both groups at 3 months but the continence status and ICIQ-UI SF demonstrated statistical significance in the intracorporeal group only. In conclusion, robot-assisted supratrigonal cystectomy and augmentation cystoplasty is feasible in adult neurological patients, favouring an intracorporeal approach.