BJU International最新文献

Objective: To evaluate the impact of prolonged ischaemia during partial nephrectomy (PN), which remains understudied despite its potential clinical relevance.

Patients and methods: Of 1371 patients managed with on-clamp PN (2011-2014), 759 (55%) had imaging and assessment of serum creatinine levels before and after PN within the appropriate timeframes necessary for inclusion. This timeframe was chosen to allow for a robust analysis of both warm and cold ischaemia. Recovery from ischaemia (Rec_ischaemia) was defined as ipsilateral glomerular filtration rate (GFR) preserved, normalized by percentage of parenchymal volume preserved (PPVP), and would be 100% if all nephrons recovered completely from ischaemia. Pearson correlation and multivariable linear regression models were used to assess associations between Rec_ischaemia and ischaemia type and duration.

Results: Of 759 patients, 525 (69%) were managed with warm ischaemia. The median warm/cold ischaemia times were 22 and 30 min, respectively. Overall, the median percent ipsilateral GFR preserved, PPVP and Rec_ischaemia were 79%, 83% and 96%, respectively. Segmented regression analysis demonstrated substantially greater decline in Rec_ischaemia, beginning at approximately 30 min for warm ischaemia, which was not observed for hypothermia. Prolonged ischaemia (defined as >30 min) occurred in 197 patients (26%; 88 warm/109 cold). For limited ischaemia (≤30 min), hypothermia was often used for tumours with increased tumour size and complexity (P < 0.01), while for prolonged ischaemia, the warm/cold subgroups had similar patient and tumour characteristics. For limited ischaemia and prolonged hypothermia, median Rec_ischaemia remained >95%, independent of ischaemia time. Differences in Rec_ischaemia between the warm and cold cohorts became significant only after 30 min (P < 0.05). On multivariable analysis, prolonged warm ischaemia was associated with reduced Rec_ischaemia (P = 0.02), which fell 3.9% for every additional 10 min beyond 30 min.

Conclusions: Our data suggest that Rec_ischaemia begins to decline significantly after 30 min during PN, although hypothermia was protective. Avoidance of prolonged warm ischaemia should be prioritized in patients with solitary kidneys and/or significant pre-existing chronic kidney disease.

Objective: To investigate the relationship between the prostate-specific antigen (PSA) free-to-total ratio (FTR) and International Society of Urological Pathology Grade Group ≥2, clinically significant prostate cancer (csPCa) in men with a low PSA level (≤4 ng/mL). Patients and Methods Data were obtained from the Prostate Cancer Prevention Trial. Patients with a PSA level of ≤4 ng/mL and who received a biopsy within a year of this PSA measurement were included. Associations between FTR and csPCa were investigated with logistic regression, adjusting for age and PSA, a re-scaled Brier score (index of predictive accuracy), and decision curve analysis.

Results: A total of 406 patients were analysed with 139 (34%) having csPCa and 204 (50%) having any grade PCa. For those with an FTR ≤0.15, 46% had csPCa, vs 22% for those with a ratio ≥0.20. In a regression model, the predicted probability of csPCa for a 60-year-old with a PSA of 3 ng/mL was 61% if the FTR was 0.05, falling to 18% if the FTR was 0.30. A clear negative relationship between increasing FTR and probability of csPCa was observed. A model containing FTR additional to PSA and age provides greater net benefit as per decision curve analysis and likely superior discrimination and calibration measured by a higher index of predictive accuracy.

Conclusions: In middle-aged men with a PSA level between 1.5 and 4 ng/mL but otherwise indicated for biopsy, a low FTR is associated with higher rates of csPCa. It should be utilised as an additional, readily available and inexpensive test to improve prediction of csPCa and aid in patient counselling.

Objectives: To improve precision of secondary resection (SR) after positive surgical margin (PSM) detection by frozen section (FS) during nerve-sparing (NS) robot-assisted radical prostatectomy (RARP) by employing a personalised three-dimensional (3D)-printed prostate model derived from pelvic magnetic resonance imaging (MRI). This model was used to mark positive surgical margins (PSM) and guide intraoperative SR during NS-RARP.

Patients and methods: Prospective multicentre cohort study with 100 patients undergoing NS-RARP between September 2018 and August 2021. Primary and secondary endpoints were the conversion rate of FS-identified PSM to a tumour-free margin and functional/oncological parameters within a 12-month follow-up, respectively.

Results: A PSM was identified in 23% of cases during FS, with a conversion to negative surgical margins (NSM) in 83% (19/23 cases) by model-guided SR. The tumour detection rate in SR specimens was 39% (nine of 23 cases). Among the 19 patients with converted margins, 18 (95%) achieved undetectable prostate-specific antigen levels 2 months postoperatively, with six (32%) having subsequent biochemical recurrence within 12 months. prostate-specific-membrane-antigen positron emission tomography computed tomography found one local recurrence, and five cases of metastatic disease. In converted patients, the baseline median five-item version of the International Index of Erectile Function score decreased by 16% after 1 year, with no significant difference compared to patients with primarily NSM. Limitations include the absence of a control group, the potential for false-negative FS results and limited accuracy of MRI.

Conclusion: The integration of 3D-printed prostate models into NS-RARP has the potential to positively impact surgical outcomes by improving the precision of SR and optimising pathosurgical communication.