Therapeutic Advances in Urology最新文献

Background: Treatment outcomes in intermediate-risk prostate cancer (PCa) may be impaired by adverse pathology misclassification including tumor upgrading and upstaging. Clinical predictors of disease progression need to be improved in this category of patients.

Objectives: To identify PCa prognostic factors to define prognostic groups in intermediate-risk patients treated with robot-assisted radical prostatectomy (RARP).

Design: Data from 1143 patients undergoing RARP from January 2013 to October 2020 were collected: 901 subjects had available follow-up, of whom 479 were at intermediate risk.

Methods: PCa progression was defined as biochemical recurrence and/or local recurrence and/or distant metastases. Study endpoints were evaluated by statistical methods including Cox's proportional hazards, Kaplan-Meyer survival curves, and binomial and multinomial logistic regression models.

Results: After a median (interquartile range) of 35 months (15-57 months), 84 patients (17.5%) had disease progression, which was independently predicted by the percentage of biopsy-positive cores ⩾ 50% and the International Society of Urological Pathology (ISUP) grade group 3 for clinical factors and by ISUP > 2, positive surgical margins and pelvic lymph node invasion for pathological features. Patients were classified into clinical and pathological groups as favorable, unfavorable (one prognostic factor), and adverse (more than one prognostic factor). The risk of PCa progression increased with worsening prognosis through groups. A significant positive association was found between the two groups; consequently, as clinical prognosis worsened, the risk of detecting unfavorable and adverse pathological prognostic clusters increased in both unadjusted and adjusted models.

Conclusion: The study identified factors predicting disease progression that allowed the computation of highly correlated prognostic groups. As the prognosis worsened, the risk of PCa progression increased. Intermediate-risk PCa needs more prognostic stratification for appropriate management.

Background: En bloc removal of the kidney with tumor thrombus excision in a multidisciplinary team remains the standard treatment for renal cell carcinoma (RCC) with tumor thrombus extension. In order to minimize the hemodynamic impact of the surgical blood loss, intraoperative cell salvage (IOCS) techniques can decrease the need for allogeneic blood and prevent blood transfusion related complications.

Objective: In this article, we evaluated the safety of IOCS during radical nephrectomy with inferior vena cava thrombectomy under cardiopulmonary bypass with or without deep hypothermic circulatory arrest.

Design and method: In this retrospective comparative multicenter analysis, clinical characteristics of 27 consecutive patients who underwent surgery with or without IOCS between 2012 and 2022 in three referral care units were collected into a database. The need for an allogenic blood transfusion (ABT) was also recorded, defined as any transfusion that occurred either intraoperatively or during the hospital stay.

Results: The need for ABT in the cell saver arm was significantly smaller due to the reinfusion of rescued blood (p < 0.015). In multivariate analysis, no cell saver usage was an independent predictor for complications ⩾3 Clavien 3a [odds ratio (OR) 18.71, 95% CI 1.056-331.703, p = 0.046]. No usage of IOCS was an independent predictor for a lower risk of death (OR 0.277, 95% CI 0.062-0.825, p = 0.024). During follow-up, patients who received salvaged blood did not experience an increased risk for developing local recurrence or distant metastases.

Conclusion: Transfusion of autologous blood is safe and can be using during nephrectomy and thrombectomy for advanced RCC.

Background: Pretreatment assessment of patients diagnosed with localized prostate cancer (PCa) is essential for therapeutic decision-making. Currently available staging systems based on prostate-specific antigen (PSA), Gleason score, and clinical stage allow for determining the prognostic characteristics of these patients. Several studies have evaluated the preoperative use of prostate-specific antigen density (PSAD) as a prognostic factor for further risk stratification. To date, the role of PSAD in this setting is still an object of debate.

Objectives: The present analysis aimed to assess the predictive potential of PSAD for adverse oncological outcomes after robot-assisted radical prostatectomy (RARP) and to compare its accuracy to preoperative PSA (pPSA).

Design and methods: We retrospectively reviewed 427 patients diagnosed with localized PCa who underwent RARP at a single institution between January 2015 and January 2020. Generating receiver operator characteristic (ROC) curves, calculating areas under the curves (AUCs), and using a linear regression model, we analyzed the association of PSAD and pPSA with postoperative positive surgical margins (PSM), Gleason score ⩾ 7, persistent PSA, and biochemical recurrence (BCR), with a median follow-up of 47 months.

Results: PSAD showed a significant association with PSM (p < 0.0001), PSA persistence (p < 0.0001), and Gleason ⩾ 7 (p < 0.0001), without being statistically significant in predicting BCR (p = 0.098). The predictive value of PSAD was comparable to pPSA for outcomes of PSA persistence (AUC 0.727 versus 0.771) and Gleason ⩾ 7 (AUC 0.683 versus 0.649).

Conclusion: PSAD is a predictive factor for postoperative oncological outcomes of PSM, Gleason score ⩾ 7, and persistence of PSA. Despite the need for further studies, PSAD could be useful as a prognostic parameter in conjunction with established staging systems.

Background: Stress urinary incontinence (SUI) presents as unintentional urine leakage associated with activities. It significantly affects quality of life (QoL) and is the most common type of incontinence in women. Current treatment options, particularly non-surgical therapies, are lacking.

Objective: To assess the efficacy of mechanotherapy provided by the Flyte^® intra-vaginal device during pelvic floor muscle training (PFMT).

Design: This was a randomized, controlled, double-blinded trial.

Materials and methods: Flyte is a repeat use device for conditioning and strengthening the pelvic floor muscles (PFMs). It provides two-part mechanotherapy. Part 1 is the stretching and preloading of the PFM from the internal wand. Part 2 integrates mechanical pulses which elicit muscle cellular and tissue level responses that trigger cellular regeneration, improve neuromuscular facilitation and motor learning. Subjects used the device for 5 min/day for 12 weeks. Subjects (144) were randomized and evaluated at 6 and 12 weeks. Arm A (72) received both Part 1 and Part 2 mechanotherapy for 12 weeks, whereas Arm B (72) received Part 1 therapy for 6 weeks, then crossed over to full therapy. Mean age was 50, 49, respectively, prior pelvic/abdominal surgery 26%, 46%, and previous incontinence treatments 13%, 22%. The primary endpoint was 24-h pad weight (24-HR PW) at 6 weeks. Secondary endpoints were 24-HR PW at 12 weeks and QoL [International Consultation on Incontinence Questionnaire (ICIQ), Urinary Incontinence Quality of Life (IQOL)].

Results: Part 1 therapy had a greater than anticipated therapeutic effect. Thus, the study was underpowered to identify differences between study arms. Therefore, data were pooled to assess the effects of mechanotherapy. Twenty four-HR PW was significantly reduced at 6 weeks (p = <0.0001), with further reduction from 6 to 12 weeks (p = <0.0001). Data were stratified based on 24-HR PW severity. Significant reductions were noted in all severity groups (mild p = <0.0001, moderate p = <0.0001, severe p = <0.01). QoL was similarly improved at 6 weeks (ICIQ p = <0.0001, IQOL p = <0.0001), and 12 weeks (ICIQ p = <0.0001, IQOL p = <0.0001). Compliance was >80% at 6 weeks and 70% at 12 weeks.

Conclusion: Two-part mechanotherapy significantly improved 24-HR PW and QoL across all severities of SUI. Improvements were noted in as little as 2 weeks and appeared to be sustained through 2-year follow up.

Trial registration: Registered on ClinTrials.gov (NCT02954042).

High-grade (HG) urothelial carcinoma (UC) with variant histology has historically been managed conservatively. The presented case details a solitary lesion of muscle-invasive bladder cancer (MIBC) with sarcomatoid variant (SV) histology treated by partial cystectomy (PC) and adjuvant chemotherapy. A 71-year-old male with a 15-pack year smoking history presented after outside transurethral resection of bladder tumor (TURBT). Computerized tomography imaging was negative for pelvic lymphadenopathy, a 2 cm broad-based papillary tumor at the bladder dome was identified on office cystoscopy. Complete staging TURBT noted a final pathology of invasive HG UC with areas of spindle cell differentiation consistent with sarcomatous changes and no evidence of lymphovascular invasion. The patient was inclined toward bladder-preserving options. PC with a 2 cm margin and bilateral pelvic lymphadenectomy was performed. Final pathology revealed HG UC with sarcomatoid differentiation and invasion into the deep muscularis propria, consistent with pathologic T2bN0 disease, a negative margin, and no lymphovascular invasion. Subsequently, the patient pursued four doses of adjuvant doxorubicin though his treatment was complicated by hand-foot syndrome. At 21 months postoperatively, the patient developed a small (<1 cm) papillary lesion near but uninvolved with the left ureteral orifice. Blue light cystoscopy and TURBT revealed noninvasive low-grade Ta UC. To date, the patient has no evidence of HG UC recurrence; 8 years after PC. Patient maintains good bladder function and voiding every 3-4 h with a bladder capacity of around 350 ml. Surgical extirpation with PC followed by adjuvant chemotherapy may represent a durable solution for muscle invasive (pT2) UC with SV histology if tumor size and location are amenable. Due to the sparse nature of sarcomatous features within UC, large multicenter studies are required to further understand the clinical significance and optimal management options for this variant histology.

Background: There is a rising prevalence of benign prostatic hyperplasia (BPH)-related urinary symptoms along with erectile dysfunction in the aging male population. Therefore, assessment of lower urinary tract symptoms (LUTS) is advised before penile prosthesis surgery with some men requiring preoperative transurethral surgical management to reduce the risk of post-procedure complications. However, less is known about the natural history of men with uncomplicated LUTS who do not require surgical management for BPH before penile prosthesis.

Objective: We sought to assess the natural history of BPH-related uncomplicated LUTS in men following penile prosthesis surgery.

Design: Single institution retrospective review.

Methods: Following institutional review board approval, we performed a retrospective review of all adult males with a preoperative diagnosis of LUTS undergoing penile prosthesis surgery at our institution from January 2017 to November 2022. The primary outcome was progression to transurethral surgery.

Results: From 2017 to 2022, 211 patients with preexisting LUTS underwent penile prosthesis surgery and met all criteria for inclusion including no history of transurethral surgery. The median (interquartile range, IQR) AUA symptom score (AUA-SS) was 12 (12). Post-void residual was below 200 cc in 96.2% of patients preoperatively and 99.1% of patients after surgery. At a median (IQR) follow-up duration of 9 (23) months after surgery, 5.7% (12/211) of patients had progressed to bladder outlet surgery and 35.5% of patients endorsed LUTS bother with a median (IQR) AUA-SS of 14.5 (11.8).

Conclusion: The majority of patients with uncomplicated LUTS did not require bladder outlet surgery following penile prosthesis implantation and could be managed with conservative or pharmacologic measures alone. Prostate gland size was significantly larger in patients who progressed to bladder outlet surgery. While the results are overall reassuring, further study is needed to identify specific factors associated with pursuing bladder outlet surgery in this small subset of patients.

Background: Penile shortening, frequently resulting from end-stage Peyronie's disease (PD), has a negative impact on patients' sexual activity and overall quality of life, especially when accompanied by Erectile dysfunction (ED). Various surgical techniques have been described to manage concomitant ED and penile shortening through penile prosthesis (PP) implantation.

Objectives: To evaluate the benefits and risks of different penile length preservation techniques during PP implantation.

Design: A systematic review of the available literature on the use of penile length preservation maneuvers in conjunction with PP implantation was conducted.

Data sources and methods: For this systematic review, three databases (Medline, Embase and Cochrane) and clinical trial.gov were queried for relevant publications from 1 January 1990 to 1 September 2022. The review process followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Results: The qualitative analysis included 15 relevant articles involving 1186 adult patients who underwent penile length preservation techniques during PP implantation. Penile lengthening of 1-7 cm was reported. Overall, postoperative complications were described in up to 21.7% of cases. Only five studies reported functional outcomes, showing a significant improvement in postoperative period based on the administered questionnaire (e.g. IIEF - International Index of Erectile Function, EDITS - Erectile Dysfunction Inventory of Treatment Satisfaction).

Conclusion: Penile length preservation procedures appear to offer a viable option for managing acquired penile shortening, particularly in cases of PD. However, they are associated with a significant risk of complications. Proper patient selection, thorough discussion of risks and benefits, and referral to high-volume centers are mandatory to achieve optimal outcomes and minimizing complications.

Trial registration: PROSPERO database registration CRD42022360758.

Background: Pelvic lipomatosis (PL) is a rare condition that is characterized by excessive growth of fat in the pelvic cavity. Studies have yet to systematically review surgical treatments for PL.

Objectives: To provide a reference for selecting reasonable surgical treatments for PL patients according to previous literature on the surgical treatment of PL.

Design and methods: We conducted this systematic review in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) of Individual Participant Data guidelines. Literature on PL published from 1968 to 2022 was retrieved from the PubMed and EMBASE databases. Data were collected and analyzed independently by two independent investigators.

Results: A total of 42 studies, involving 231 patients with PL, were included in the analysis. The surgical treatments included transurethral resection (TUR) (48.5%), ureteral stent placement (11.7%), percutaneous nephrostomy (1.3%), ureterocutaneostomy (1.3%), ureteral reimplantation (10.4%), ileal conduit (13%), and allograft kidney transplantation (0.4%). After excluding patients with unclear prognoses, 42.9% of patients showed improvement in lower urinary tract symptoms (LUTS) after TUR. Ureteral stent placement provided relief of hydronephrosis in 62.5% of PL patients. Percutaneous nephrostomy resulted in stable renal function in 33.3% of PL patients, while ureterocutaneostomy led to remission of postoperative hydronephrosis in 33.3% of PL patients. After ureteral reimplantation, 70.8% of patients experienced relief of hydronephrosis or had stable renal function. Ileal conduit led to remission of hydronephrosis, alleviation of symptoms, or maintenance of stable renal function in 83.3% of PL patients. One patient with PL had stable renal function after allograft renal transplantation.

Conclusion: The surgical treatments for PL include TUR, ureteral stent placement, urinary diversion, and allograft renal transplantation. However, the choice of surgical method should be determined after comprehensive consideration of the patient's condition.