Urologia Internationalis最新文献

Introduction: Erectile dysfunction (ED) is a common complication following radical prostatectomy (RP). Although phosphodiesterase type 5 inhibitors (PDE5is) are used for penile rehabilitation, their efficacy post-RP is limited. Low-intensity extracorporeal shockwave therapy (Li-ESWT) has emerged as a potential noninvasive treatment, promoting tissue regeneration. This study evaluates the effectiveness of Li-ESWT, with or without PDE5i, for post-RP ED.

Methods: This prospective study included 104 patients who underwent nerve-sparing RP and received Li-ESWT. Patients were divided into two groups: group 1 received daily 5 mg tadalafil along with Li-ESWT, while group 2 received Li-ESWT alone. Erectile function was assessed using the International Index of Erectile Function (IIEF-5) at baseline, 6, 12, and 24 months postoperatively.

Results: The preoperative mean IIEF-5 score was 15.7 ± 4.7, with 54.8% of patients scoring below 17. Postoperatively, significant improvements in IIEF-5 scores were observed at 12 and 24 months in both groups compared to the 6th month. In patients with preoperative IIEF-5 <17, group 1 showed significantly greater improvement in IIEF-5 scores compared to group 2 (p = 0.008). No significant difference was observed between the groups in patients with preoperative IIEF-5 ≥17 (p = 0.893).

Conclusion: Li-ESWT is an effective treatment for ED following nerve-sparing RP, with or without PDE5i. In patients with mild-to-moderate or greater preoperative ED, the combination of PDE5i and Li-ESWT may provide additional benefits, whereas Li-ESWT alone appears sufficient for those with milder cases.

Introduction: Testicular germ cell tumor is a rare malignant tumor predominantly affecting young males. In addition to well-established risk factors like cryptorchidism, genetic factors are increasingly recognized as significant contributors. This case report highlights a patient diagnosed with seminoma associated with multiple abnormalities and explores the genetic basis behind these manifestations.

Case presentation: A 22-year-old East Asian male presented with left-sided varicocele and recent onset testicular pain. Clinical examination and imaging revealed a smaller left testicle and a testicular nodule. Surgical excision and subsequent histopathology confirmed seminoma and germ cell neoplasia in situ. Additional medical investigations identified brain dysplasia, social interaction challenges, learning impairments, and a presacral mass suggestive of teratoma. Genetic analysis using exome sequencing detected a frameshift variant in the PDE11A gene, predicted by AlphaFold3 to significantly disrupt protein structure and function. The patient later underwent orchiectomy following recurrence confirmation.

Conclusion: This report emphasizes the potential pathogenic role of the PDE11A frameshift variant in seminoma development and associated systemic abnormalities. The application of advanced computational tools like AlphaFold3 can provide deeper molecular insights into genetic variants and further elucidate their clinical implications.

Introduction: To explore the prevalence of antisperm antibodies (ASA) and its impact on the embryo culture outcomes of in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI), a retrospective analysis of the Center for Reproductive Medicine's data was conducted.

Methods: 8,265 semen samples were detected for ASA using mixed antiglobulin reaction. In addition, 934 IVF/ICSI cycles were included to compare the effects of ASA on embryo culture outcomes during IVF/ICSI, including normal fertilization rate, D3 good-quality embryo rate, available blastocyst formation rate, and available embryo rate.

Results: The positive rate of ASA in semen was relatively low, about 1.03%. We found ASA may weaken the normal fertilization rate of IVF cycles. In addition, there was no statistical difference in outcomes between the positive groups and negative groups of ICSI cycles with a threshold 10% in ASA, but ASA significantly reduced the normal fertilization rate and D3 good-quality embryo rate of ICSI cycles with a threshold 50% in ASA. It was speculated that the high ratio of rescue ICSI cycles resulted in the poor embryo culture outcomes. We supposed that the higher of the ASA-positive rate, the higher of the likelihood of fertilization failure of IVF. Comparing with IVF, ICSI is more recommended as a fertilization method for ASA-positive patients who need assisted reproductive technology.

Conclusions: ASA may have a negative impact on the embryo culture outcomes of IVF. Therefore, for ASA-positive patients who require IVF/ICSI treatment, it is suggested embryologists wash the sperm thoroughly and use short-term fertilization of IVF or conventional ICSI to assist with pregnancy.

Introduction: We examined the impact of prostate-specific antigen (PSA) response, which is associated with survival, on patients with metastatic hormone-sensitive prostate cancer (mHSPC) treated with androgen receptor signal inhibitors (ARSIs).

Methods: We retrospectively reviewed 82 patients with mHSPC who received upfront ARSI treatment. The primary endpoint was PSA progression-free survival (PFS). Patients whose PSA levels decreased to ≤0.2 ng/mL at 3 months after ARSI initiation were classified as deep early, those with >0.2-≤1.0 ng/mL as early, and others as non-PSA responders.

Results: The median age of patients was 73 years old, and the median baseline PSA value was 361 ng/mL. Among 82 patients, 32 (39%), 16 (20%), and 34 (41%) were categorized into deep early, early, and non-early PSA responders, respectively. There was a significant association between PSA response status, hemoglobin, and PSA value. During follow-up (median, 23.0 months), 31 (37.8%) patients experienced PSA progression. The PSA progression rates of the deep early, early, and non-early PSA responders were 15.6%, 31.2%, and 61.8% (p < 0.001), and their 2-year PSA PFS rates were 90.5%, 70.7%, and 38.9%, respectively.

Conclusion: An early PSA response within 3 months of ARSI initiation was associated with PSA progression in patients with mHSPC.

Introduction: Metastasis-directed therapy (MDT) is a promising approach for recurrent or de novo oligo-metastatic castration-sensitive prostate cancer (omCSPC). The aim of this study was to evaluate the treatment approaches in omCSPC among German physicians.

Methods: An anonymous online questionnaire was sent via survio.com to the members of the German Societies of Urology and Radiooncology.

Results: Participants (n = 166; 33% urologists, 66% radiooncologists) define omCSPC as ≤3 (31%) or ≤4 (58%) metastases. Multimodal therapy consisting of local therapy of the primary tumor, MDT, and androgen deprivation therapy (ADT) was favored. For local therapy, radiotherapy was the preferred approach (radiotherapy: 84%, prostatectomy: 16%). Overall, 77% and 76% considered MDT as (very) highly important in synchronous and metachronous omCSPC, respectively. In total, 80% would complement MDT with time-limited ADT. Compared to urologists, radiooncologists more often include cases with ≥3 metastases (p = 0.006) and see a higher importance of radiotherapy (p = 0.023), a lower importance of prostatectomy (p < 0.001) as well as a higher importance of MDT (in de novo p = 0.038, in metachronous p = 0.010).

Conclusion: MDT with time-limited ADT is a common treatment strategy in omCSPC. Especially in synchronous omCSPC, radiotherapy as local treatment for the primary is the preferred option rather than radical prostatectomy.

Introduction: Randomized controlled trials comparing patients' experience with open (OPN) vs. robot-assisted (RAPN) partial nephrectomy showed no clear advantages for RAPN. This contradicts our clinical impression, so we analyzed a cohort that underwent both approaches for bilateral renal tumors. The aim of our study was to compare their intraindividual perceptions of OPN and RAPN.

Methods: Scar assessment and evaluation of patient-reported outcome measures were conducted. The questionnaires were retrospectively answered for postoperative day 5 after OPN and RAPN and, as a reference, for the date of presentation.

Results: Results revealed longer hospitalization and ischemia times in patients with OPN, while ratings for physical condition and quality of life were better in the RAPN group. Stress, depression, and anxiety in cancer patients scored higher in the OPN group. Scar assessment revealed less patient-reported satisfaction after OPN. Patients favored RAPN when comparing both approaches directly and were more likely to recommend RAPN to a friend.

Conclusion: This is the first study on the intraindividual perception of OPN vs. RAPN, revealing a comparative judgement clearly in favor of RAPN. Based on our findings, we designed the APPROACH trial to compare OPN and RAPN in a representative population under the conditions of routine care.

Introduction: Patients desire postoperative transurethral catheter removal as early as possible after radical prostatectomy (RP). Therefore, we strived to obtain risk factors for radiographic anastomotic leakage (AL) at postoperative day 3 (POD3) to assess whether a cystogram (CG) before removal is still necessary in all patients.

Methods: We retrospectively analyzed the data of 409 patients undergoing RP at our clinic in 01-06/2022. Out of these, 334 were included for further analysis. Patients with a robotic-assisted approach (RARP) received their CG on POD3 as standard, after open surgery (ORP) on day 5. We employed univariable analyses to examine potential risk factors for AL, such as surgical approach, intraoperative bladder neck reconstruction, obesity, or locally advanced disease stages.

Results: In total, the rate of AL was low: 22/334 (6.7%) patients showed extravasation on initial standard (POD3, 5) CG after RP. Only surgical approach (ORP 30% vs. RARP: 5.1% p < 0.001, odds ratio [OR] 0.12, 95% confidence interval [CI] 0.04-0.37, p < 0.001) and need for bladder neck reconstruction (5.6% vs. 16.7%, p = 0.02, OR 0.30, 95% CI 0.10-0.87, p = 0.027) could be determined as risk factor for AL. None of the other factors showed statistically significant associations.

Conclusion: Omitting CG at POD3 following RP would miss approximately 7% of AL. It is unclear whether this would always cause disruption and urinoma. Since catheterization time for safe removal without CG has yet to be defined, we recommend early CG for all patients. Early catheter removal has a 5% risk for acute urinary retention.

Introduction: The objective of this study was to analyze and compare the perioperative outcomes of patients undergoing laparoscopic and robotic ureteric reimplant at our center for benign diseases.

Methods: This retrospective study included patients who underwent minimally invasive ureteric reimplant from July 2019 to July 2024. The medical records of all the patients were accessed, and perioperative data were retrieved with the current assessment done by physical follow-ups. The procedural success was defined as either symptom resolution or documentation of anatomical or functional signs of prompt urinary clearance by prudent investigations.

Results: A total of 56 patients underwent minimally invasive modified Lich-Gregoir ureteric reimplant. The total operative time (200.4 ± 58.9 min vs. 266.8 ± 92.9 min, p = 0.009), estimated blood loss (104.8 ± 62.6 mL vs. 195.9 ± 91.9 mL, p = 0.001), time to ambulation (1.2 ± 0.4 days vs. 2.2 ± 0.5, p = 0.001), and time to full oral diet (1.9 ± 0.5 days vs. 2.7 ± 0.5 days, p = 0.001) were significantly superior in the robotic arm, whereas the rest of the parameters were similar. The success rates were also similar in both arms.

Conclusion: Robotic ureteric reimplant has a shorter operating time and faster postoperative recovery, with similar success and complication rates.

Background: Partial nephrectomy (PN) has evolved from an imperative to an elective procedure, now representing the standard of care for localized renal masses. The introduction of robotic surgery has expanded the feasibility and precision of minimally invasive nephron-sparing surgery. The single-port (SP) robotic platform, specifically designed to operate through a single incision, aims to further minimize invasiveness and improve postoperative recovery and cosmetic outcomes. Early experiences with SP robot-assisted PN (SP-RAPN) demonstrated encouraging perioperative, oncological, and functional results comparable to those achieved with the multi-port (MP) approach. The retroperitoneal route, particularly through the lower anterior access (LAA), has shown anesthesiological and surgical advantages, including shorter operative times, reduced pain, and faster discharge. Comparative studies indicate similar safety and cancer-control outcomes between SP and MP-RAPN, with SP offering shorter hospital stays but slightly longer Warm Ischemia Times (WITs). Ongoing technological advancements, artificial intelligence (AI) integration, and refined patient selection tools are expected to further enhance the precision, reproducibility, and accessibility of SP-RAPN.

Summary: SP-RAPN offers comparable oncological and functional outcomes to multi-port RAPN (MP-RAPN) while further reducing surgical invasiveness and improving cosmetic results. Careful patient selection remains crucial, with low- to intermediate-complexity tumors being most suitable during the early learning phase. Among the available access routes, retroperitoneal and LAA techniques have gained particular attention for their perioperative and anesthesiological benefits. Although SP-RAPN is associated with slightly longer WITs, it provides advantages in terms of postoperative pain, length of stay, and feasibility in outpatient settings. Ongoing technological innovations, including AI, advanced imaging, and improved robotic articulation, are expected to refine surgical precision and broaden adoption.

Key messages: SP-RAPN is a safe and feasible evolution of nephron-sparing surgery with outcomes comparable to MP-RAPN. The retroperitoneal and LAA approaches offer notable perioperative and anesthesiological advantages. Proper patient selection and structured training programs are key to optimizing outcomes and overcoming technical challenges. Future advances in robotic technology and digital integration will further enhance the role of SP-RAPN in minimally invasive urologic surgery.

Introduction: This meta-analysis compares the efficacy and safety of laser lithotripsy (LL) and pneumatic lithotripsy (PL) for upper tract urolithiasis.

Methods: A systematic search of MEDLINE via PubMed, Embase, and the Cochrane Library identified trials comparing LL and PL. Primary outcomes included stone-free rate, operative time, and complications. A random-effects model was used, and heterogeneity was assessed using I2 statistics.

Results: The systematic literature search identified 6,420 studies of which 43 fulfilled the inclusion criteria. The studies reported data from 7,377 patients. Random effect meta-analysis for stone free rate included data from 36 studies and yielded statistically significant higher stone free rates for LL with a pooled OR = 2.19 (95% confidence interval [CI] = 1.63-2.94, p < 0.001). Heterogeneity was substantial (I2 = 62%; p < 0.01). Random effect meta-analysis for operative time included data from 31 studies and yielded no statistically significant difference in operative time with a pooled MD = -1.09 min (95% CI = -4.39-2. 20, p = 0.5161). Heterogeneity was considerable (I2 = 98%; p < 0.01). Random effect meta-analysis for complications included data from 14 studies and yielded statistically significant fewer complications for LL with a pooled OR = 0.68 (95% CI = 0.48-0.96, p = 0.0276). Heterogeneity was limited (I2 = 27%; p = 0.17).

Conclusions: LL might be superior to PL in upper tract urolithiasis therapy.