Minerva Urology and Nephrology最新文献

Background: Partial nephrectomy (PN) is the gold-standard treatment for T1 renal-cell carcinoma, which is associated with a significant risk of complications. Tumor ablation (TA) can be implemented in chosen patients with small renal masses. The aim was to evaluate perioperative outcomes and health-care costs of PN and TA.

Methods: Patients aged ≥18 with renal mass diagnosis, who underwent PN/TA in 2007-2021, were identified in the Merative^TM Marketscan^® Research Commercial and Medicare databases. Complication rates, probability and time to second surgery, as well as hospital costs (2021 US dollars) of PN and TA were evaluated. The rate of preoperative renal mass biopsies over the years was assessed. Finally, subgroup analyses for types of second surgeries (TA, PN, radical nephrectomy) were performed.

Results: Twenty-four thousand forty-five patients with kidney tumors were included. The majority (85.7%) underwent PN. Over the years, preoperative renal biopsies have become more common. TA was associated with a significantly lower risk of complications (adjusted odds ratio [aOR]: 0.56, 95% confidence interval [CI]: 0.50-0.63) and lower costs (aOR: 0.23, 95% CI: 0.20-0.26) than PN. The analysis of specific complications found that only wound-related complications had no significant difference in risk between the procedures (aOR: 0.65, 95%CI: 0.41-1.02). However, TA patients were at higher risk of a second procedure (adjusted hazard ratio: 1.25, 95%CI: 1.05-1.49).

Conclusions: TA is associated with significantly fewer complications and lower costs than PN. However, patients undergoing TA require re-operation more frequently, possibly due to higher recurrence rates. These factors need to be considered when selecting the most appropriate treatment for patients with renal tumors.

Background: Proficiency based progression (PBP) is a very effective method of training and has been adopted by the European Robotic Surgical Section (ERUS) for robotic skills training. No study has addressed whether all learners can be trained to the proficiency benchmark. In this study, we evaluated: 1) if all trainees reached a quantitatively defined proficiency benchmark for a robotic suturing and knot tying anastomosis task; and 2) the number of training trials required.

Methods: In a multi-center, prospective, randomized, study, 48 participants were randomized to: 1) a PBP group that received e-learning on the ORSI chicken anastomosis task with the requirement to reach the proficiency benchmark before starting practical training; 2) e-learning group, received the exact same curriculum as group 1, but with no proficiency requirement on the e-learning; 3) traditional group received the exact same curriculum in face-to-face lectures; 4) the apprenticeship group received a conventional preparation.

Results: All participants, except five in group 4, demonstrated the proficiency benchmark. Group 1 took ~6 trials (~3 hours); group 2 required 14% longer, group 3, 103% (P<0.001) and in group 4, 58% of trainees demonstrated the benchmark but took 162% (P<0.001) longer. This was a small-scale but robust study with substantial effect sizes.

Conclusions: All PBP trainees demonstrated the proficiency benchmark in comparison to 58% of conventional trained group. As adherence to the PBP methodology decreased, the efficiency of proficiency demonstration significantly reduced.

Introduction: Recurrent urinary tract infections (UTIs) are a common health issue that affects patients' quality of life and healthcare systems. To reduce antibiotic use, non-antimicrobial treatments, such as Uro-Vaxom (OM-89), have been proposed to prevent UTI recurrence by enhancing immune response. Still, despite being available for many years, the evidence for its effectiveness remains unclear. This updated systematic review and meta-analysis aims to evaluate the efficacy of OM-89 in reducing UTI recurrence, increasing sample size compared to previous reviews.

Evidence acquisition: A systematic review was conducted using MEDLINE, Embase, Scopus, Cochrane, Web of Science, and Google Scholar, following the PRISMA guidelines. We included randomized controlled trials (RCTs) comparing OM-89 with placebo in adult patients with a history of recurrent UTIs. Study selection and data extraction were performed by multiple reviewers, and a random-effects model was used for data pooling. Our primary outcome was the recurrence rate of symptomatic UTIs, while secondary endpoints included the rate of positive urine cultures at 3 and 6 months post-intervention. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and statistical analysis was conducted using RStudio software. Additionally, we performed a meta-regression incorporating all included studies for primary endpoint.

Evidence synthesis: We retrieved eight RCTs, comprising 674 patients in the OM-89 group and 677 patients in the placebo group. Our analysis showed a lower rate of symptomatic UTIs in the intervention group (OR 0.48; 95% CI 0.23-0.97; P<0.01; I²=81%). Similarly, bacteriuria at both 3 and 6 months after treatment was less frequent in patients treated with OM-89 compared to placebo (OR 0.23; 95% CI 0.10-0.53; P=0.03) and (OR 0.45; 95% CI 0.23-0.89; P=0.02), respectively. Meta-regression revealed a trend suggesting that the effectiveness gap between OM-89 and placebo has decreased in more recent research.

Conclusions: Although initial meta-analysis results indicated that OM-89 was effective in reducing UTI recurrence, meta-regression reveals a decline in its efficacy in more recent studies. This decreasing effectiveness over time suggests that OM-89 may no longer be a reliable option for preventing recurrent UTIs.

Background: The Versius system has emerged as a competitor of DaVinci in robot-assisted prostatectomy (RARP). Our study aimed to perform a head-to-head comparison of the two platforms, focusing on operative room setup, duration of surgical steps, troubleshooting, and surgeon's satisfaction.

Methods: The COMPAR-P Trial (Comparison of Outcomes of Multiple Platforms for Assisted Robotic surgery-Prostate) is a prospective post-market study (clinicaltrials.org NCT05766163). Patient enrollment commenced in March 2023, assigning individuals to either DaVinci or Versius for RARP without predefined selection criteria, for a total of up to 50 consecutive cases. The procedures were performed by two experienced surgeons employing the same technique. The evaluation centered on timing, learning curves, equipment malfunctions, complications, and user satisfaction. The cumulative summation analysis assessed the learning curve with Versius.

Results: Fifty patients each were enrolled for DaVinci and Versius RARP. Baseline features were balanced. DaVinci demonstrated significantly shorter durations for both "set-up" (37 vs. 59.5 minutes) and "console" (97 vs. 152 minutes) phases (P<0.001), with most steps being quicker. The longitudinal analysis showed "console" time reductions but not "set-up" with Versius. Learning curve analysis revealed a breakpoint after 30 procedures. Malfunctions were more frequent with Versius (38 vs. 4). DaVinci had higher satisfaction. Blood loss and complications were similar between groups. The study focused on experienced DaVinci users transitioning to Versius, limiting applicability to robotic-naïve centers.

Conclusions: Versius used to perform RARP showed more malfunctions and longer operative times, but outcomes were like those of DaVinci, with trends of improvement supporting its adoption.

Background: Extended pelvic lymph node dissection (ePLND) is the standard approach for nodal staging in prostate cancer (PCa) patients undergoing radical prostatectomy (RP). However, its utility in intermediate-risk cases remains debated due to potential complications and uncertain oncologic benefits. This study aimed to assess whether incorporating prostate-specific membrane antigen positron emission tomography (PSMA PET) nodal staging into traditional nomograms could enhance the selection of patients for ePLND.

Methods: We retrospectively analyzed 110 intermediate-risk PCa patients who underwent preoperative PSMA PET and subsequently received RP with ePLND within six months at three referral centers in Italy between 2019 and 2023.

Results: PSMA PET demonstrated significantly higher specificity and positive predictive value (PPV) than nomograms in detecting lymph node invasion (LNI), potentially sparing 84% of patients from ePLND while missing only 0.9% of LNI cases. Additionally, combining PSMA PET with the Briganti 2017 nomogram improved predictive accuracy, theoretically reducing ePLND procedures by 91%.

Conclusions: Our findings suggest that integrating PSMA PET with nomograms in intermediate-risk cases could optimize patient selection for ePLND, potentially reducing unnecessary surgeries without increasing the risk of missed LNI cases. Preoperative staging with PSMA PET may play both exclusive and inclusive roles in the intermediate-risk setting. If PSMA PET shows N0, it may exclude candidates from ePLND. Additionally, when combined with nomograms, it may help select candidates for ePLND among patients who show a high risk of LNI according to risk calculators.

Background: To evaluate the surgical outcomes and the safety profile of patients treated with thulium fiber laser (TFL) for the ablation of upper tract urothelial cancer (UTUC).

Methods: Between January 2022 and May 2024, 33 patients underwent URS for UTUC ablation using TFL in a single referral center. Data were collected prospectively and analyzed retrospectively. Baseline characteristics, peri- and post-operative surgical outcomes were reviewed. All procedures were performed by the same dedicated team specializing in endourological treatments of UTUC, with a minimum follow-up of six months. Intraoperative, 30-day and 90-day postoperative complications were collected and classified according to Clavien-Dindo Classification. Residual disease was assessed in patients undergoing second-look ureteroscopy.

Results: Median age was 74 (70-83) years and 70% had an ASA score ≥3. Papillary exophytic tumors were most common (24/33), with urothelial carcinoma confirmed in 28 cases, including 20 high-grade UTUCs. Intraoperative complications occurred in four patients, with only one Grade 2 complication. Overall, 76% experienced no postoperative complications, while the 30- and 90-day complication rates were 24% and 21%, respectively, with only one major complication (3%). Residual disease was found in four of 19 patients who underwent second-look URS. Limitations include the lack of a comparison arm and small sample size.

Conclusions: This study is the largest series on TFL for UTUC ablation and confirms its safety with low major complication rates and promising oncological outcomes, supporting its inclusion in the laser armamentarium for UTUC management.

Introduction: Urolithiasis prevalence and ureteroscopic lithotripsy utilization have increased ureteral strictures' visibility. It is imperative to summarize the global epidemiological trends and investigate risk factors associated with lithotripsy itself.

Evidence acquisition: A systematic review of English literature was conducted to assess the incidence of ureteral strictures following lithotripsy across all age groups. Comprehensive analyses, including meta-regression, network meta-analysis, and Joinpoint regression, were used to investigate subgroup incidence. Machine learning algorithms identified influencing factors related to lithotripsy.

Evidence synthesis: This study included 43 studies, estimating an overall ureteral stricture (US) occurrence rate of 1.7% and 2.9% over the past decade, indicating an upward trend. Subgroup analysis showed the lowest postoperative stenosis incidence of 1.4% for flexible combined with semi-rigid ureteroscopy. Laser lithotripsy had a higher incidence (2.4%) than pneumatic lithotripsy (1.7%), with an odds ratio (OR) of 4.61 (95% CI: 2.0-10.6). Middle and proximal segment strictures had higher ORs compared to the distal segment (2.2, 95% CI: 1.1-4.1; 2.0, 95% CI: 1.1-3.5, respectively). Machine learning models indicated that operation time is a significant predictor of postoperative stenosis. Joinpoint regression identified a change point at 45 minutes of surgical time (MPC=2.18, P<0.05), with increased stenosis incidence thereafter.

Conclusions: The prevalence of US post-lithotripsy is increasing. Different endoscope types, lithotripsy methods, and locations show distinct incidence rates. Patients with urinary lithotripsy lasting longer than 45 minutes should be actively evaluated for potential stenosis.