World Journal of Urology最新文献

Purpose: This study aimed to comprehensively evaluate the prognostic value of T1 histo-anatomic substaging (T1a/T1b) for high grade (HG) non-muscle invasive bladder cancer (NMIBC) over a large single-centre cohort.

Materials and methods: Patients with primary HG T1 NMIBC were identified from our Institutional database, between 2011 and 2022. Data from diagnosis to repeated transurethral resection of bladder tumour (RE-TURBT), bacillus Calmette-Guérin (BCG) treatment and follow-up were collected. Patients were stratified based on histo-anatomic landmark into T1a (invasion above the Muscularis Mucosa-MM) and T1b (into/beyond MM). Kaplan-Meier curves and multivariate Cox regression analyses were used to assess the impact of histo-anatomic substaging on recurrence-free survival (RFS), cancer-specific survival (CSS), and progression-free survival (PFS).

Results: Substaging was feasible in 88% of cases. The median (IQR) follow-up was 40 (17-72) months. T1b patients had larger initial tumours (> 3 cm: 43.2% vs. 26.1%, p < 0.001), while upstaging to muscle-invasive bladder cancer (MIBC) at RE-TURBT was more frequent in T1b than in T1a (5.9% vs. 1.5%, p = 0.02). T1b patients without BCG induction had worse RFS and PFS (all p ≤ 0.02) compared to T1a, while no differences were observed in patients who received complete BCG induction. At Multivariate analysis, completing at least a BCG induction course was associated with better outcomes across all endpoints.

Conclusions: Invasion of the MM in primary T1 NMIBC is associated with a higher risk of upstaging to MIBC. Patients who received full BCG induction had similar outcomes regardless of substaging, whereas T1b patients without BCG induction experienced higher recurrence and progression rates.

Background: Although shock wave lithotripsy (SWL) has been considered to be effective in treating ureteral stones, a definitive conclusion remains unclear on which patient's position is the optimal option for proximal ureteral stones. The purpose of this study is to assess the ideal position of ultrasound guided SWL for the treatment of proximal ureteral stones.

Methods: This prospective study was conducted in multi-center from June 2020 to December 2023. Patients who underwent SWL in prone or supine position for proximal stones were enrolled in this study. The primary outcome was stone-free rate (SFR); the secondary outcome was complete SFR, sessions of SWL, and complications. Propensity score-matched (PSM) analysis was performed.

Results: Finally, 1187 patients with proximal ureteral stones were enrolled in this study; of which 50.5% (599) were treated with prone position and 49.5% (588) underwent supine position. After 1:1 PSM, the prone position group was superior in SFR (85.7% vs. 77.4%, P = 0.001), and complete SFR (83.3% vs. 75.0%, P = 0.001) compared with the supine potion group. The sessions of SWL (1.27 vs. 1.20, P = 0.092) and complications rate (all P values > 0.05) were comparable between the two groups. In addition, the prone group had shorter skin-to-stone distance (SSD) on ultrasound than the supine group (50 mm vs. 101 mm, P < 0.001).

Conclusion: This multi-center prospective PSM study demonstrated that the prone position could increase the SFR and had comparable safety for ultrasound guided SWL among patients with proximal ureteral stones. Therefore, we advocate its priority application to patients with proximal ureteral stones when the prone position is possible.

Objective: To develop a three-dimensional (3D) image based extended tumor plane technique for robotic-assisted partial nephrectomy (RAPN).

Methods: We prospectively enrolled patients with a local renal tumor for RAPN between March 2019 and Mar 2022. 3D virtual model was reconstructed based on the computed tomography urography. The tumor plane was extended equidistantly (10 mm) to form a virtual plane. According to the relationship between the extended plane and the collection system, patients are divided into those with no collecting system involvement, renal medulla involvement, and renal calyx involvement. The primary endpoint was trifecta achievement, which was defined as warm ischemic time ≤ 25 min, negative surgical margins, and no major perioperative complications.

Results: This study enrolled a total of 215 patients. The median preoperative aspects and dimensions used for an anatomical (PADUA) score was 9 (6-15). The average warm ischemic time was 21.64 ± 9.35 min. Postoperative complications occurred in 26 (12.1%) patients, of whom 14 (6.5%) classified as major complication. The number of cases with trifecta failure was 1 (5.3%) in the no involvement group, 28 (20.6%) in the renal medullary involvement group, and 24 (40.0%) in the renal calyx involvement group (p < 0.001). Logistic regression indicated that renal calyx involvement was a risk factor for trifecta failure (OR = 2.639, 95% confidence interval [1.268-5.492], p = 0.009).

Conclusions: The extended tumor plane based on three-dimensional images can is useful for the evaluation of RAPN. Determining whether the extended plane involves the collecting system, particularly the renal calyx, may impact the achievement of trifecta.

Background: Traditional grading systems have proven inadequate in stratifying chRCC patients based on recurrence risk. Recently, several novel grading schemes, including three-tiered, two-tiered, and four-tiered systems, have been proposed, but their prognostic value remains controversial and lacks external validation.

Materials and methods: We included 528 patients with pathologically proven chRCC (chromophobe renal cell carcinoma) from multiple medical institutions and the Cancer Genome Atlas-Kidney Chromophobe cohort. Three experienced pathologists independently reassessed the slides based on the three novel grading schemes. Survival outcomes, including disease-specific survival (DSS), recurrence-free survival (RFS), were analyzed using Kaplan-Meier methods and Cox proportional hazards regression models. The prognostic value of the original and adjusted Leibovich risk groups was compared using Harrell's C-index.

Results: All grading systems demonstrated significant survival differences among their respective groups (p < 0.001 for all). However, within the four-tiered system, no significant survival disparity was observed between grade 1 and grade 2 tumors (GTG2 without necrosis) (p = 0.619 for DSS). When patients with necrosis were excluded, no survival difference was detected between CTG1 and CTG2 tumors in the three-tiered system (p = 0.870 for DSS), challenging the prognostic utility of distinguishing between these two grades. The adjusted Leibovich risk stratification (C-index = 0.840 for DSS), incorporating necrosis and tumor thrombus, demonstrated superior prognostic value compared to the original model (C-index = 0.762 for DSS), with more pronounced survival distinctions and improved predictive performance.

Conclusion: Our study validates the prognostic significance of recently developed grading systems for chRCC. The observed survival difference between CTG1 and CTG2 in the three-tiered system may be attributed to varying percentages of coagulative necrosis. By integrating necrosis and tumor thrombus into the Leibovich risk groups, we enhanced the model's ability to distinguish between patients and improved its predictive performance.

Purpose: To evaluate functional and oncological outcomes in patients who underwent unilateral or bilateral nerve-sparing (NS) robot-assisted radical prostatectomy (RARP) for high-risk prostate cancer.

Methods: The cohort comprised 2683 patients with clinical stage T1-4, N0M0 high-risk prostate cancer who underwent RARP in Japanese tertiary care centers from August 2011 to April 2023. High risk was defined using the European Association of Urology risk stratification criteria. Patients were classified as high risk if they had clinical stage T2c-T4, a serum prostate-specific antigen concentration (PSA) of > 20 ng/dL, or an International Society of Urological Pathology (ISUP) grade of 4-5. Patients were grouped into NS and non-NS surgery groups. Propensity score matching was performed (1:1 ratio) to reduce confounding bias. The primary outcome was biochemical recurrence (BCR)-free survival (BCR-FS). The impact of NS surgery on BCR-FS was examined in the propensity score-matched cohort using Cox proportional hazards regression.

Results: The propensity score-matched cohort comprised 1722 patients. In the matched cohort, median follow-up was 31.9 months. The 5-year BCR-FS was 70.2% in the NS group and 71.9% in the non-NS group (HR 1.05; 95% confidence interval, 0.85-1.29). NS surgery did not increase the risk of BCR in subgroups of patients stratified according to ISUP grade, T stage, percent cancer core involvement, and PSA.

Conclusion: Neurovascular bundle preservation during RARP for high-risk prostate cancer appears feasible without increasing the BCR rate. However, the retrospective study design carries the potential influence of selection bias.

Purpose: Use of suction in flexible ureteroscopy is increasing lately. The introduction of flexible and navigable suction access sheath (FANS) has shown improved stone free rate (SFR). However, its efficacy in lower pole stone (LPS) in terms of SFR and complications is yet to be studied.

Methods: We collected data from 25 centers that included 394 adult patients undergoing ureteroscopy using FANS. Non contrast CT (NCCT) scan was done within first 30 days post operatively to access the SFR. Residual fragments were graded as A: 100% SFR; B: single fragment ≤ 2 mm; C: single fragment 2.1-4 mm; D: Single or multiple fragments > 4 mm. Post operative complications were recorded.

Results: Out of 394 patients, non LPS (group1) comprised of 268 patients, rest 126 patients had LPS (group 2). Single stage zero fragment SFR was seen in 58.6% (group 1) vs. 54.8% (group 2) (P = 0.619). Single stage grade A + B SFR was achieved in 96.6% vs. 98.4% in groups 1 and 2 respectively. On multivariate analysis Thulium fiber laser use was significantly associated with higher odds of being grade A stone-free, while stone volume with lower odds. In LPS group only two patients needed reintervention. The highest grade of complication was Clavien 2, which was seen in 3.2% LPS group.

Conclusion: Use of flexible and navigable suction ureteric access sheath for lower pole stones is effective and safe. The stone free rate of lower pole stones is comparable to non-lower pole locations with very low reintervention rate in both groups.

Retroperitoneal liposarcomas(RPL) are rare malignant tumors, accounting for approximately 15% of soft tissue sarcomas and 0.07-0.2% of all cancers. The annual incidence is 0.5 to 1 per 100,000 individuals. Surgical resection is the only curative option, but recurrence rates are high, and the role of neoadjuvant radiotherapy(NRT) remains uncertain. This study aimed to assess the impact of preoperative NRT on overall survival(OS) and recurrence-free survival(RFS) in RPL patients undergoing compartmental resection, while identifying prognostic factors. A retrospective monocentric review of 94 patients with confirmed RPL treated between 2008 and 2022 was conducted. Forty-six patients received NRT, while 48 underwent surgery alone. Data on preoperative, intraoperative, and postoperative variables, including complications, recurrence, and survival, were analyzed. Kaplan-Meier analysis evaluated OS and RFS, and multivariate Cox regression identified independent prognostic factors. With a median follow-up of 46.5 months, OS did not significantly differ between the NRT and surgery-only groups (HR = 0.8; 95% CI [0.4-1.54], p = 0.48). However, RFS was significantly improved in the NRT group (HR = 0.41; 95% CI [0.21-0.83], p = 0.001), particularly in patients with dedifferentiated RPL (HR = 0.38; 95% CI [0.18-0.83], p = 0.015). Tumor rupture (HR = 5.5; p < 0.001) was a strong risk factor for recurrence, while NRT was a protective factor (HR = 0.3; p = 0.002). NRT did not improve OS but significantly enhanced RFS, particularly in dedifferentiated RPL cases. These results warrant further prospective studies to better define NRT's role in RPL management.

Purpose: The purpose of this study was to assess the feasibility of a pressure-controlled and temperature-controlled flexible ureteroscope system (PT Scope™) during flexible ureteroscopy.

Materials and methods: We developed the PT Scope™, a novel ureteroscope system with capabilities for monitoring and controlling intrarenal pressure and temperature to maintain them within set parameters. Data were retrospectively collected from 48 consecutive patients diagnosed with upper urinary tract stones who underwent flexible ureteroscopic lithotripsy using the PT Scope™ across five centers in China. Analyses focused on 24-h postoperative stone-free rates, intrarenal pressure and temperature measurements, and other procedural data.

Results: Among the 48 patients treated with the PT Scope™ system, a significant stone-free rate of 89.6% was achieved within 24 h postoperation, without any instances of intraoperative complications such as perforation or mucosal hemorrhage. Only two patients reported mild postoperative pain and were managed with NSAIDs, and there were no cases of postoperative fever or sepsis. The average maximum intrarenal pressure and temperature were recorded at 30.2 ± 4.20 mmHg and 36.6 ± 4.27 °C, respectively. Notably, during lithotripsy, both the pressure and temperature were maintained below 30 mmHg and 43 °C for 99% of the procedure duration, respectively.

Conclusion: This preliminary investigation indicates that the PT Scope™ is a safe and effective tool for the treatment of upper urinary tract stones, offering the benefit of regulating intrarenal pressure and temperature within predetermined limits. These findings support the feasibility of the system for clinical application.

Objective: To evaluate the impact of three different AEEP techniques on the training performance of novices using a realistic hydrogel prostate phantom model.

Material and methods: The experimental setup utilized realistic prostate phantom model provided by the Max Planck Institute for Intelligent Systems, Germany. For the enucleation, we utilized a new solid-state pulsed thulium laser (Thulio®, Dornier MedTech, Weßling, Germany). We explored three different AEEP techniques-bilobar, trilobar, and en-bloc-repeated ten times each, totaling 30 procedures.

Results: Median enucleation time was 9.5 min (range: 6-16), median laser time was 4.29 min (3.21-6.34), median total energy used was 25.8 kJ (19.4-38.1), and median number of laser pulses was 12.8 thousand (9.7-17). There were no significant differences in operation time, laser time, pulses, or joules among the en-bloc, two-lobe, and three-lobe techniques (p = 0.113, 0.143, 0.148, 0.141 respectively). Ultrasound evaluations showed the one-lobe technique to be superior in accuracy, smoothness, and circularity (p = 0.0002, 0.012, 0.00005 respectively) (Figs. 9, 10, 11), despite having the highest perforation rate, which was not statistically significant compared to other techniques (p = 1.4). The one-lobe technique's higher accuracy may increase the risk of perforation. In contrast, the three-lobe technique had the lowest perforation rate and removal efficiency due to its lower accuracy.

Conclusion: The en-bloc, bilobar, and trilobar enucleation techniques exhibited comparable operation times. The one-lobe method emerged as superior in terms of accuracy, smoothness, and circularity. However, it also presented the highest rate of perforation.