Therapeutic Advances in Urology最新文献

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.

Gender-affirming genital reconstruction surgeries (GAGRS) are essential procedures aimed at aligning transgender individuals' physical characteristics with their gender identity. While these surgeries have been shown to improve psychological well-being and overall mental health, they often come with challenges, particularly in preserving sexual sensation and function. Despite advancements in surgical strategies, postoperative sexual rehabilitation remains an underexplored aspect of gender-affirming care. Emerging evidence suggests that transcutaneous electrical nerve stimulation (TENS) may offer a promising noninvasive approach to enhancing sexual function. This paper explores the role of TENS in sexual rehabilitation following GAGRS, emphasizing the need for a more comprehensive approach that goes beyond anatomical reconstruction.

Background: Men with chronic scrotal content pain (CSCP) commonly present to various providers within the healthcare system. Despite its prevalence, little research has been done to understand risk factors for the development of CSCP. In many cases, the cause of pain is unknown, and there are no widely accepted protocols for evaluation or management.

Objective: To characterize associated symptoms and concomitant concerns of those presenting with CSCP.

Design and methods: Retrospective review of validated questionnaires including the Chronic Orchialgia Symptom Index (COSI), the internal index of erectile function, the NIH-chronic prostatitis symptom index, the American Urological Association symptom index/international prostate symptom score, the hip dysfunction and osteoarthritis outcome score, the Oswestry low back pain questionnaire, the patient health questionnaire-9, the general anxiety disorder-7, and a comprehensive intake form on men presenting to a single urologist's office with CSCP was performed. The analysis included constructing linear best-fit lines between subjective chronic testicular pain rating and other numerical rating scales.

Results: Questionnaires from 94 male patients were reviewed. The average pain subscore on the COSI was 8.00 out of 17. When assessing the association between pain and other domains, more severe chronic scrotal pain was associated with worse pain in and around the genitourinary system (p < 0.001), worse urinary symptoms (p = 0.001), worse hip (p = 0.001) and back (p < 0.001) symptoms, worse sexual function (p = 0.025), and worse anxiety (p = 0.019) and depression (p = 0.003) symptoms. Patients in our study were found to have a wide variety of presentations with differing aggravating and relieving factors, urological and surgical histories, and interventions.

Conclusion: Men presenting with CSCP may present with many co-occurring symptoms. More severe scrotal content pain may be associated with worse symptoms in multiple other domains. In order to create a personalized treatment plan, a more comprehensive understanding of these men is critical. Future studies should focus on further developing a standardized approach for assessing these patients and how directed interventions on associated symptoms may impact outcomes.

Background: The evidence supporting personalized surveillance strategies for upper-tract urothelial carcinoma (UTUC) remains limited. This study seeks to explore how smoking habits influence the oncological outcomes of UTUC.

Methods: Data on disease characteristics from UTUC patients were gathered prospectively. Recurrence-free survival was the primary outcome measured. Patients were stratified based on smoking status for Kaplan-Meier and multivariable Cox regression analyses.

Results: A total of 1952 patients were involved, including 684 (35%) patients who never smoked, 572 (29%) that were ex-smokers, and 696 (36%) that were current smokers. For female patients, most of them were nonsmokers (n = 328). Current smokers were significantly younger and had higher American Society of Anesthesiologist (ASA) scores and Charlson Comorbidity Index. A total of 19.9% (n = 236) of patients developed tumor recurrence. Kaplan-Meier analyses showed that smoking status was associated with a greater likelihood of urothelial carcinoma recurrence (p = 0.011) and intravesical recurrence (p = 0.021). The multivariable Cox regression analysis identified the smoking status as an independent risk factor for urothelial carcinoma recurrence (p = 0.046). When compared with former smokers, current smokers showed a higher urothelial carcinoma recurrence (p = 0.016) and intravesical recurrence (p = 0.006).

Conclusion: Smoking at the time of diagnosis was significantly associated with an increased risk of tumor recurrence in the bladder but not significantly in the upper urinary tract. This study confirms that cumulative smoking exposure accelerates the risk of tumor recurrence and underlines the importance of smoking cessation.

Trial registration: NCT02281188.

Background: Urinary tract infections (UTI) are common and costly, but standard urine culture (SUC) diagnostic tests have significant limitations. Emerging molecular techniques like multiplex polymerase chain reaction (PCR) offer rapid simultaneous detection of uropathogens and antimicrobial resistance (AMR) genes allowing timely targeted therapy.

Objectives: To compare the performance of Urine-ID™ test, an expanded multiplex PCR panel designed to detect 26 uropathogens and 49 AMR markers against SUC for pathogen detection in individuals with suspected complicated UTI.

Design and methods: A total of 56 urine specimens from individuals aged 50 and older, who exhibited UTI symptoms and failed previous therapy based on SUC results, were retrospectively analyzed using Urine-ID^™ using the TaqMan^® OpenArray plates on the QuantStudio 12K Flex Real-Time PCR System. Results of simultaneously collected PCR and SUC were compared at patient follow-ups.

Results: Of the 56 suspected UTI cases, SUC failed to detect pathogens in 19.64% (N = 11/56) of the specimens while PCR yielded negative results in 7.14% (N = 4/56) of cases. SUC identified a specific organism in 50% (N = 28/56) while PCR detected at least one uropathogen in 92.86% (N = 52/56) of specimens. Data also revealed that a nonspecific result, "Mixed urogenital flora" (MUG), was the most frequent outcome (N = 18/45) obtained with SUC among positive samples. While SUC identified a single pathogen in 92.80% (N = 26/28) of positive specimens, PCR detected additional co-infecting uropathogens in 71.20% (N = 37/52) of positive samples. Of the 18 MUG and 11 negative samples using SUC, PCR identified treatable pathogens in 13 and 7 samples, respectively.

Conclusion: These results highlight the effectiveness of expanded real-time PCR panels for quickly and accurately identifying uropathogens, surpassing traditional SUC sensitivity. Adopting these advanced molecular techniques, particularly in suspected complicated UTI cases, improves diagnosis efficiency, leading to faster pathogen identification and treatment, ultimately reducing patient morbidity.

Introduction: In recent years, several preliminary reports have suggested that the robot-assisted approach may decrease the surgical morbidity of artificial urinary sphincter (AUS) implantation in female patients with stress urinary incontinence (SUI). However, for now, only short-term outcomes have been reported. The present study aimed to report the 5-year outcomes of robot-assisted AUS implantation in female patients.

Patients and methods: All female patients who underwent a robot-assisted AUS implantation between January 2014 and September 2019 at a single academic center were included in a retrospective study. All robot-assisted female AUS implantations performed after September 2019 were excluded to ensure a 5-year minimum follow-up duration. The indication for AUS implantation was SUI due to intrinsic sphincter deficiency. The primary endpoint was the explantation-free survival and revision-free survival.

Results: Forty-two patients were included. The median age was 66 years (28-84), and 83.8% of the patients had a history of previous anti-incontinence procedure. After a median follow-up of 64 months (16-110), 8 patients were lost to follow-up before the 5-year time point. The 5-year estimated revision-free survival was 89.2 and the 5-year estimated explantation-free survival was 88%. Five AUS explantations were needed (11.9%), and six revisions were required (14.3%). The median time to explantation was 14 months. Four explantations (80%) occurred within the first 18 months, and all of them within the first 27 months. Thirty patients (71.42%) had a complete or improved continence with a complete continence rate of 59.52% and an improved continence rate of 11.9%. There were 10 intraoperative complications (23.8%): 5 bladder injuries and 5 vaginal injuries. Thirteen patients had postoperative complications (30.9%), but only two were Clavien grade ⩾3.

Conclusion: The 5-year outcomes of robot-assisted AUS implantation seem to confirm the promising short-term outcomes that have been reported so far, although revision rates increased with time, which warrants further investigation.