BJUI compass最新文献

Objectives

A range of techniques have been described for robotic-assisted intracorporeal neobladder construction. The pyramid neobladder has now been performed for over 10 years. We now describe the long-term outcomes, including the impact of function preservation through nerve and prostate capsule sparing in the male population.

Subjects/Patients and Methods

All patients who underwent pyramid neobladder construction between January 2015 and December 2023 at the University College London Hospital (UK) were reviewed. Patients were selected for function preservation based on baseline sexual function/wishes, PSA ± multiparametric prostate MRI. Selected oncological, functional and patient reported outcomes were assessed.

Results

A total of 71 patients were included; 87% (61/71) were men. About 65% (40/61) underwent either nerve- or prostate capsule-sparing surgery. Median follow-up was 57.8 months (IQR 48.3). In male patients, there was no difference between the 12- and 24-month cancer specific and overall survival rates between the function sparing groups. There were no positive prostate cancer margins. Daytime continence was 75% (39/52) and 67% (6/9), and nighttime was 17% (9/52) and 11% (1/9), in men and women, respectively. There was no significant difference between the male function sparing groups (p < 0.342). About 94% of men (29/31) were sexually active before surgery, falling to 55% (17/31) after, with 76% (13/17) using treatment for erectile dysfunction. The median change in SHIM score was 4.5 (SD 5.3) in prostate capsule-sparing, 6 (SD 7.7) in nerve-sparing and 17 (SD 2.8) in standard groups.

About 45% (30/66) of patients had a significant reduction in eGFR (>10 mL/min/1.73m²). Uretero–ileal strictures were confirmed in 4.2% (3/71). About 28% (19/67) of patients reported recurrent UTIs and 7% (5/71) reported neobladder rupture.

Conclusion

Sexual function had the largest impact on quality of life and may be improved with function-sparing techniques. The burden of additional complications including neobladder rupture and urinary tract infections was also highlighted.

Objectives

To evaluate the efficacy and safety of bilateral vas deferens sutures in preventing postoperative inguinal hernia after prostatectomy for clinically localized prostate cancer.

Materials and Methods

This retrospective study included 282 patients with localized prostate cancer who underwent open or laparoscopic radical prostatectomy between July 2012 and July 2023. The inguinal hernia incidence rates were compared between the vas deferens suture group (141 patients, May 2017 to July 2023) and the control group (141 patients, July 2012 to April 2017). We further determined the risk factors for inguinal hernia after prostatectomy using a multivariate regression analysis.

Results

Among the 282 patients analysed, postoperative inguinal hernia was observed in 10 (7.1%) and 37 (26.2%) patients in the vas deferens suture and control groups, respectively. The incidence differed significantly between patients who did and did not undergo radical prostatectomy with a prophylactic procedure (P = 0.006). The 2-year inguinal hernia-free rates were 93.4% and 85.1% in the vas deferens suture and control groups, respectively. The median duration for inguinal hernia development was 15 months. Multivariate analysis identified the vas deferens suture procedure as a single factor associated with protection against inguinal hernia development after radical prostatectomy (hazard ratio, 0.36; 95% confidence interval, 0.177–0.734; P = 0.005).

Conclusions

The vas deferens suture is a simple and safe prophylactic procedure to decrease the risk of inguinal hernia after radical prostatectomy.

Objectives

To evaluate the outcomes of partial gland ablation (PGA) according to prostate cancer (PCa) visibility on magnetic resonance imaging (MRI).

Subjects and Methods

Consecutive patients with localized PCa diagnosed by MRI-informed prostate biopsy (PBx), who underwent hemi-gland Cryoablation (CRYO) or hemi-gland High-Intensity Focused Ultrasound (HIFU), were identified from a multicentric database. High-visibility was defined as Prostate Imaging–Reporting and Data System (PIRADS) ≥ 4. The primary endpoint was treatment failure (TF), defined as Grade Group (GG) ≥ 2 on follow-up PBx (FU-PBx), any whole-gland treatment, systemic therapy, metastases or PCa-specific mortality. Kaplan–Meier and Cox regression analyses were performed. Statistically significant if p < 0.05.

Results

A total of 156 patients met the inclusion criteria being 96 (62%) high-visibility and 59 (38%) low-visibility groups on baseline MRI. The baseline characteristics were as follows: median age 65yo, prostate-specific antigen (PSA) 6.0 ng/ml, 22% with PIRADS 1–2, 16% with PIRADS 3, 44% with PIRADS 4 and 17% with PIRADS 5. The 3-year free-survival rates for high-visible vs low-visible were: TF 57% vs 83% (p = 0.002); biochemical failure (PSA nadir + 2 ng/ml) 81% vs 72% (p = 0.5); GG ≥ 2 on FU-PBx 57% vs 85% (p < 0.001); and Radical Treatment 87% vs 85% (p = 0.9), respectively. After adjusting for confounders, the independent predictors for TF were PSA density, PSA reduction and high visibility (hazard ratio 4.83, 95% confidence interval 1.81–12.90).

Conclusion

MRI visibility is an independent prognosticator for outcomes following focal therapy for prostate cancer. Patients with higher MRI visibility (PIRADS ≥4) are at an increased risk of treatment failure.

Objective

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic inflammatory bladder disorder with unknown aetiology and limited treatment options. Single-cell RNA-sequencing (scRNA-seq) has provided unprecedented insights into cellular heterogeneity in IC/BPS. This review summarizes recent scRNA-seq findings on bladder cell populations, emphasizing urothelial, interstitial and immune cells.

Methods

A comprehensive analysis of published scRNA-seq studies was conducted to compare bladder cell subtypes in healthy and IC/BPS-affected bladders. Differences between IC/BPS patients and mouse models, as well as sex-specific cellular variations, were examined.

Results

IC/BPS bladders exhibit significant urothelial alterations, including a reduction in UPK3A + umbrella cells and an expansion of progenitor-like cells with impaired regenerative capacity, linked to TLR3-NR2F6 signalling. Interstitial cells include three fibroblast subtypes (PDGFRA+, RGS5+ and pro-inflammatory IL6-producing fibroblasts), which contribute to fibrosis and inflammation. The immune landscape is characterized by a Th1-biased response, exhausted CD8 + T cells and reduced regulatory T cells, with HPV infection detected in most IC/BPS patients, suggesting a possible viral aetiology. Cell-to-cell interactions are compromised, with enhanced macrophage-endothelial signalling via CXCL8-ACKR1 and CXCL2/3-ACKR1 pathways, highlighting potential therapeutic targets. Notably, sex-based differences reveal stronger immune activation in females and increased urothelial proliferation in males, potentially explaining the higher IC/BPS prevalence in females.

Conclusions

scRNA-seq has advanced our understanding of IC/BPS by identifying disease-associated cell types, signalling pathways and intercellular interactions. Future research should integrate multi-omics approaches and explore non-invasive urine-based scRNA-seq for improved diagnosis and therapy.

Objective

To evaluate the carbon footprint of transperineal prostate biopsy (TPPB). Climate change is the biggest global public health threat of the 21st century. Healthcare contributes 5% to global greenhouse gas emissions. Despite growing enthusiasm for sustainable urology, there is little data on the environmental impact of urological practice.

Patients and methods

Emissions associated with TPPB (under local anaesthesia) at a hospital in Aotearoa New Zealand were estimated from electricity consumption, procurement of equipment/supplies, travel of staff and patients, waste disposal and sterilisation of linen. Emissions coefficients were used to determine CO₂ equivalents (kgCO₂e) emitted.

Results

TPPB was associated with 70 kgCO₂e of emissions per case. This equates to 280 km of travel by car, or an economy seat on a 70-minute flight. The largest contributors were procurement (76%) and travel (23%). Electricity, waste disposal and sterilisation of linen did not contribute significantly to emissions (cumulatively <1.5%).

Conclusions

This is the first study to evaluate the carbon footprint of a TPPB. Emissions were derived mostly from procurement and travel. These may be mitigated by review of standardised equipment packs, transitioning to reusables and introducing outreach biopsy clinics. Adherence to pragmatic evidence-based guidelines for prostate cancer may reduce emissions associated with overdiagnosis and unnecessary biopsies. Further research is required to characterise the broader environmental impact of urology services.

Introduction and Objectives

Cystectomy for bladder cancer (BC) in women involves removing gynaecological organs and the anterior vaginal wall, significantly impacting sexual function (SF). Gynaecological organ-preserving cystectomy (GOPC) aims to minimise toxicity, but limited studies assess its impact. We reviewed existing evidence.

Methods

A systematic review was conducted using Ovid (Medline, Embase, PsycINFO, CINAHL) and Cochrane Library. Studies assessing survival and SF outcomes of GOPC and SF outcomes of standard cystectomy were included.

Results

Fourteen studies (1049 screened) reported on small cohorts (11–41 patients). Most GOPC patients had ≤T2b N0 M0 disease, while standard cystectomy patients had up to T4/N1. In the GOPC cohort median follow-up was 36 months.

Over a 16–70 month period, Disease-Free Survival in GOPC patients was 80–100%. Due to heterogeneity in Patient-Reported Outcome Measures (PROMS), a narrative analysis was performed.

GOPC patients reported high levels of sexual activity, reduced dyspareunia and moderate-to-high satisfaction. While SF initially declined, recovery improved over time, with Female Sexual Function Index (FSFI) scores exceeding the 26.2 dysfunction threshold in two studies by 12 months.

In standard cystectomy, sexual dysfunction was common, with varying distress levels and inadequate patient counselling.

Conclusions

Understanding the outcomes of GOPC is limited by study design and measurement variability, and meta-analysis was not possible. In this narrative review, oncological outcomes in the GOPC group appears to have equivalent oncological outcomes to a standard radical cystectomy in carefully selected female patients. Sexual recovery outcomes in either complete or partial sexual organ preserving cystectomy appear to be better than a standard female radical cystectomy. Further prospective studies, particularly those involving nerve-sparing surgery, are needed. Women undergoing either standard cystectomy and GOPC commonly experience sexual dysfunction, and there is a need to improve pre- and post-operative counselling.

Objectives

To report intraoperative and early postoperative outcomes of posterior approach Robotic Assisted Radical Prostatectomy (RARP) patients and analyse a single-surgeon learning curve.

Patients & Methods

The initial 150 patients undergoing posterior approach RARP by a single surgeon were analysed in three equal cohorts. Initial postoperative follow-up was for a minimum of 3 months.

Results

A total of 150 patients were included. These cases were performed between April 2017 to June 2024. There was no significant difference in pre-operative patient age, prostate specific antigen (PSA), body mass index (BMI), prostate volume, number of biopsy positive cores, International Society of Urological Pathologists (ISUP) grade group and clinical T-stage.

Intraoperative differences between cohorts were decreasing total operative time (153 min vs 121 min vs 106 min, p < 0.001) and estimated blood loss (296 ml vs 205 ml vs 199 ml, p < 0.001), but no difference in nerve sparing status (p = 0.243).

Postoperatively, no difference was found in median length of stay, ISUP grade group, tumour volume, 30-day readmissions or complications. There were significant differences in overall pathological T stage (p = 0.004) between the cohorts, but not positive margin status, even with T2/T3 disease. There was a significant difference in early continence recovery within the first week (p = 0.022) and at 1 month (0.041) but no difference between overall continence recovery and erectile function recovery.

Conclusions

Estimated blood loss and total operative time decreased across the cohorts, despite worsening disease burden. Oncological and functional outcomes are excellent throughout when compared with published literature. The learning curve may be facilitated initially by careful patient selection. Posterior approach RARP could be safely adopted by urologists adept in standard RARP, and structured training may improve the uptake of this technique.

Objective

This study aims to assess the surgical outcomes of laparoscopic or robotic surgery for primary vesicoureteral reflux and elucidate the factors contributing to vesicoureteral reflux resolution.

Patients and Methods

We retrospectively reviewed the medical records of consecutive patients who underwent extravesical laparoscopic ureteral reimplantation or robot-assisted laparoscopic ureteral reimplantation at our institution between March 2012 and July 2020. First, we reviewed surgical outcomes in the paediatric (n = 100) and adult (n = 15) patient groups. Second, we compared the surgical findings and outcomes of both procedures in the paediatric patient group and investigated the factors contributing to surgical success in the paediatric patient group.

Results

The combined success rates for both procedures were 89.1% in the paediatric group and 70.0% in the adult group. The overall success rate among paediatric patients was not significantly different between those who underwent laparoscopic ureteral reimplantation (91.1%) and those who underwent robot-assisted laparoscopic ureteral reimplantation (85.5%). Post-operative urinary retention was observed in 5.0% and 6.7% of paediatric and adult patients, respectively. Univariate and multivariate analyses revealed that the ureteral diameter measured during surgery was significantly associated with vesicoureteral reflux resolution regardless of the use of a robotic platform (p = 0.046).

Conclusion

Both laparoscopic and robot-assisted laparoscopic ureteral reimplantation are favourable and safe procedures for paediatric patients with primary vesicoureteral reflux. To improve the success rate, a sufficient length of the submucosal tunnel must be ensured based on intraoperative measurements of ureteral diameter.

Objectives

Adjuvant pembrolizumab has improved overall survival after surgery for clear cell renal cell carcinoma (ccRCC) with an intermediate-high and high risk of recurrence according to the inclusion criteria of Keynote-564 study, but non-RCC mortality is common during postoperative follow-up. We aimed to evaluate the competing risk of death after surgery in patients with ccRCC stratified according to the risk of recurrence with Keynote-564, Three-feature and Leibovich models.

Material and Methods

A total of 1108 patients with ccRCC operated with curative intent between 2005 and 2021 before the use of adjuvant immunotherapy were identified from two academic centres in Finland and Sweden. Patients with cytoreductive nephrectomy, multiple kidney tumours or non-ccRCC were excluded. Baseline characteristics and survival outcomes were described, and the Kaplan–Meier method was used to estimate overall survival.

Results

During the median postoperative follow-up of 5.0 years, 134 (12%) patients had died from RCC with a median time to death of 3.7 years (IQR 1.6–6.6) while for 220 (20%) patients the cause of death was other than RCC, most commonly other cancers (n = 59, 5%) and cardiovascular diseases (n = 54, 5%). According to the Keynote-564 criteria, 34 (3%) patients were classified as having high risk of recurrence, 336 (30%) patients intermediate-high risk and 738 (67%) patients low risk of recurrence with 41% of RCC deaths observed in this subgroup. Limitations of this study include the lack of information on performance status, comorbidities and systemic treatments for recurrent RCC.

Conclusions

In addition to deaths from RCC, deaths from other cancers and cardiovascular diseases were common after surgery for ccRCC. As 41% of RCC deaths were observed among patients currently excluded from adjuvant therapy, more research on patient selection for perioperative immunotherapy is needed as well as interventions improving the treatment of comorbidities and lifestyle after nephrectomy.