Central European Journal of Urology最新文献

Introduction: Historically, the anal canal plays a substantial role in both screening and diagnosis of pro-state cancer with digital rectal examination (DRE) and transrectal ultrasound (TRUS) guided biopsy, respectively. However, in patients with a prior history of abdominoperineal resection the transrectal route towards the prostate capsule cannot be utilized and thus alternative approaches have to be employed. The aim of this systematic review and proportional meta-analysis is to evaluate the available alternative prostate biopsy techniques in patients without rectal access.

Material and methods: The systematic literature review was performed using MEDLINE, Scopus, EMBASE, and the CENTRAL register for randomized controlled trials (RCTs). The following search algorithm was used: "resection of rectum" OR "abdominoperineal resection" OR "without rectal access" AND "prostate biopsy" (PROSPERO 2023 CRD42023459080).

Results: A total of 21 studies and 203 patients were included in this systematic review and meta-analysis, while 6 different prostate biopsy techniques were detected in the current literature. The transperineal approach under transperineal US (TPUS) and the transgluteal approach guided by computed tomography (CT) were associated with 0.74 [0.48; 0.94] and 0.70 [0.49; 0.89] pooled diagnostic yield estimates as well as 0.01 [0.00; 0.01] and 0 [0.00; 0.01] pooled complication rate estimates. The performance of multiparametric magnetic resonance imaging (mpMRI) prior to transgluteal CT-guided prostate biopsy seemed to significantly affect the biopsy result (p = 0.0002).

Conclusions: Based on current data, the TPUS-guided prostate biopsy has the highest pooled diagnostic yield estimate. However, this conclusion is based on poor evidence and more reliable and well-organized studies are needed to thoroughly explore this problem.

Introduction: The incidence of prostate cancer is increasing in Poland, particularly due to the aging population. This review explores the potential of deep learning algorithms to accelerate prostate contouring during fusion biopsies, a time-consuming but crucial process for the precise diagnosis and appropriate therapeutic decision-making in prostate cancer. Implementing convolutional neural networks (CNNs) can significantly improve segmentation accuracy in multiparametric magnetic resonance imaging (mpMRI).

Material and methods: A comprehensive literature review was conducted using PubMed and IEEE Xplore, focusing on open-access studies from the past five years, and following PRISMA 2020 guidelines. The review evaluates the enhancement of prostate contouring and segmentation in MRI for fusion biopsies using CNNs.

Results: The results indicate that CNNs, particularly those utilizing the U-Net architecture, are predominantly selected for advanced medical image analysis. All the reviewed algorithms achieved a Dice similarity coefficient (DSC) above 74%, indicating high precision and effectiveness in automatic prostate segmentation. However, there was significant heterogeneity in the methods used to evaluate segmentation outcomes across different studies.

Conclusions: This review underscores the need for developing and optimizing segmentation algorithms tailored to the specific needs of urologists performing fusion biopsies. Future research with larger cohorts is recommended to confirm these findings and further enhance the practical application of CNN-based segmentation tools in clinical settings.

Introduction: Holmium laser enucleation of the prostate (HoLEP) is a versatile treatment for benign prostatic hyperplasia (BPH), serving as an alternative to transurethral resection of the prostate (TURP) and open/robotic-assisted prostatectomy. Recent advancements have focused on evaluating the impact of smaller (22-24 Fr) vs larger (26-28 Fr) resectoscope sheaths on procedural outcomes.The aim of this study was to assess and compare the safety, efficiency, and complication rates associated with smaller and larger resectoscope sheaths in HoLEP procedures through a meta-analysis.

Material and methods: A systematic review was conducted following PRISMA guidelines. Four studies (one RCT and three retrospective) comprising 633 patients (277 with small sheaths [SR] and 356 with large sheaths [LR]) met inclusion criteria. Outcomes assessed included operative time, enucleation/morcellation efficiency, complications (urethral strictures, transient incontinence), and recovery parameters.

Results: In terms of efficiency, no significant differences were observed in operative time, enucleation time, or enucleation efficiency. LR showed faster morcellation time (p = 0.03). As for complications, SR had significantly lower urethral dilation rates (8.0% vs 39.5%, p = 0.01). No significant differences in urethral stricture rates, catheterisation duration, complication rates or transfusion rates. In terms of recovery, similar hospital stay durations and incontinence rates were seen at 3 months postoperatively between groups, and SR might decrease incontinence rates at 1 month postoperatively.

Conclusions: Using smaller resectoscope sheaths in HoLEP reduces urethral dilation rates without compromising procedural efficiency or safety. Larger sheaths had shorter morcellation times. The choice of sheath size should be guided by patient anatomy, surgeon expertise, and procedural requirements. Further large-scale RCTs are needed to confirm long-term outcomes.

Introduction: Prostate cancer is a major global health concern, affecting one in every eight men over the course of their lives. Early detection and precise risk stratification are essential for distinguishing indolent types from aggressive cancer that necessitates immediate treatment. Prostate-specific antigen (PSA), although its widespread use in prostate cancer screening, lacks specificity, resulting in unnecessary biopsies and overtreatment of clinically insignificant malignancies. The SelectMDx test, a non-invasive molecular diagnostic tool, and multiparametric magnetic resonance imaging (mpMRI) have shown promise in enhancing diagnostic precision. This study compares the independent and combination diagnostic performance of SelectMDx and mpMRI in patients with intermediate PSA levels.

Material and methods: A retrospective analysis of 126 patients was conducted in an academic hospital in southern Romania from 2022 to 2023. The requirements for inclusion included PSA values ≥3 ng/ml, SelectMDx evaluation, mpMRI, and a prostate biopsy. SelectMDx used mRNA expression levels of ****HOXC6 and DLX1, in addition to clinical data, to create a risk score for clinically significant prostate cancer (PCa) (grade group ≥2). PI-RADS version 2.1 was used to rate mpMRI images. Lesions with a grade of ≥3 were considered suspicious. Logistic regression models were used to determine the predictive power of SelectMDx, PI-RADS, and their combination. The diagnostic performance was assessed using sensitivity, specificity, positive predictive value, and negative predictive value. The medical relevance of reducing unnecessary biopsies has been studied using decision curve analysis.

Results: SelectMDx showed a sensitivity of 89.2%, a specificity of 61.8%, a PPV of 49.25%, and an negative predictive value (NPV) of 93.22%. Patients with positive SelectMDx results had a 13.35-fold greater risk of clinically severe PCa (p <0.001). Using mpMRI with PI-RADS scoring improved detection of high-grade PCa. A PI-RADS score of ≥4 corresponded to a 7.13-fold higher probability of aggressive cancer (p <0.001). In multivariate analysis, adjusting for SelectMDx and patient age reduced the predictive value of PI-RADS ≥4 (adjusted OR = 1.49; p = 0.555). Standalone SelectMDx outperformed its combination with mpMRI in terms of diagnostic accuracy, as shown by higher AUC values and better DCA results.

Conclusions: The SelectMDx test is a highly effective and reliable diagnostic tool for predicting clinically severe PCa in individuals with intermediate PSA levels. Its high NPV avoids unnecessary biopsies and their associated morbidity. While integrating SelectMDx with mpMRI provides new diagnostic insights, the molecular test revealed superior accuracy when used alone, confirming its importance in precision medicine.

Introduction: Soft tissue sarcomas arise from mesenchymal tissue, with liposarcomas being the largest subgroup. These malignancies are classified into five subtypes by the WHO: atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDLPS), dedifferentiated liposarcoma (DDLPS), myxoid liposarcoma, pleomorphic liposarcoma, and myxoid pleomorphic liposarcoma. WDLPS and DDLPS are the most prevalent, the latter being associated with higher metastatic rates (15-30%) and a 5-year mortality of 28-30% if metastases are present. This report discusses three cases of rare paratesticular liposarcomas, a subgroup originating from the tunica vaginalis and spermatic cord.

Material and methods: Case 1 involved a 62-year-old man with a scrotal mass diagnosed as WDLPS after extensive examinations. Case 2 was a 72-year-old man with testicular swelling. Pathology revealed ALT/WDLPS with dedifferentiated zones, necessitating further wide resection due to positive margins. Case 3 described a 63-year-old man with a ductus deferens nodule diagnosed as WDLPS. Negative margins were achieved, and follow-up showed no recurrence.

Results: Diagnosis of liposarcoma remains challenging due to overlapping imaging characteristics with benign conditions. Advanced modalities like positron emission tomography - computed tomography and magnetic resonance imaging can aid in differentiating liposarcomas based on metabolic activity and tissue characteristics. Surgical resection with negative margins remains the gold standard for treatment. Recurrence risks increase with positive margins and dedifferentiated histology. Adjuvant radiotherapy and chemotherapy show limited efficacy, emphasizing the importance of precision in surgical and pathological evaluation. Emerging therapies targeting the MDM2 and CDK4 pathways show promise for advanced or recurrent cases.

Conclusions: This report highlights the complexity of diagnosing and managing paratesticular liposarcomas, underlining the importance of multimodal approaches for improved outcomes.

Introduction: Peroneal electrical Transcutaneous NeuroModulation (peroneal eTNM®) is a non-invasive treatment for overactive bladder (OAB). In the previous randomized study in female patients with OAB, both dry and wet, peroneal eTNM® demonstrated significantly better safety and comparable efficacy to solifenacin. This subgroup analysis aimed to compare the safety and efficacy of peroneal eTNM® versus solifenacin in OAB wet population.

Material and methods: In the primary study, eligible subjects were randomized in a 2 : 1 ratio to receive either 12 weeks of daily peroneal eTNM® for 30 minutes or solifenacin 5 mg daily. This subgroup analysis included participants who presented with at least one incontinence episode at baseline and completed the study according to protocol. The primary endpoint was safety, secondary endpoint was proportion of continent subjects after treatment. Additional efficacy assessments included change in bladder diary variables, OAB V8 score, and quality of life (QoL).

Results: In the peroneal eTNM® group (n = 26), three treatment-related adverse events (TRAEs) were recorded, while nine TRAEs occured in the solifenacin group (n = 16). The proportion of patients who achieved continence after 4, 8 and 12 weeks of treatment was 50%, 62%, and 65% in the peroneal eTNM® and 56%, 50%, and 56% in the solifenacin group, respectively. Both treatments led to significant and similar improvements in all bladder diary variables, OAB V8 score, and QoL.

Conclusions: The results of this secondary analysis confirm that peroneal eTNM® has significantly better safety profile and comparable efficacy versus solifenacin in the subgroup of incontinent OAB patients.

Introduction: The da Vinci SP® Surgical System, approved by the FDA in 2018 for urological procedures and by the European Union in 2024, is now being adopted across Europe. This report presents the first Italian experience with single-port robot-assisted partial nephrectomy (RAPN) using the SP system.

Material and methods: From May 8 and May 31, 2024, ten consecutive male patients underwent single-port RAPN via a Lower Anterior retroperitoneal Access (LAA) at a single institution. Perioperative and early postoperative variables were prospectively collected and analyzed.

Results: All 10 procedures were completed without conversion to multiport or open surgery. One case was converted to radical nephrectomy for oncologic reasons. Eight procedures were performed on the right kidney and 2 on the left. Median patient age was 72 years (IQR 64-72), median BMI was 28.0 kg/m² (IQR 24.9-34), and median Charlson Comorbidity Index was 5 (IQR 4-6). Sixty percent had an ASA score of 3. Median RENAL and PADUA scores were 8 (IQR 7-9) and 7 (IQR 7-8), respectively. Tumours were <4 cm. Median warm ischaemia time was 21.5 minutes (IQR 15.25-26.5), operative time was 120 minutes (IQR 100-180), and blood loss was 60 ml (IQR 50-80). Pre- and postoperative eGFR medians were 84.9 and 84.2, respectively. Patients were discharged on postoperative day one with a median pain score of 1.3/10. No major (Clavien-Dindo ≥ III) complications occurred. One patient had a positive surgical margin.

Conclusions: Single-port RAPN with the da Vinci SP® system is safe and feasible, with promising short-term outcomes.

Introduction: Prostatic Aquablation has emerged as a minimally invasive treatment for benign prostatic hyperplasia, recognized in the European guidelines. The aim of this study is to evaluate the safety of the procedure in patients treated with this technique at a tertiary care hospital.

Material and methods: Complications during hospitalization were evaluated, as well as the reasons for emergency visits and the medium-long-term complications in patients who underwent Aquablation between February 2021 and November 2024. Clinical and laboratory variables were also assessed, along with the type of complication, using the Clavien-Dindo classification system.

Results: One hundred and ninety-two patients were operated on with Aquablation in a third-level hospital, between February 2021 and November 2024. Mean age of patients was 68.11 ±11.15 years. Mean prostatic volume was 76.58 ±26.46 ml. During the hospital stay, 30 patients (15.7%) presented some kind of complication. The main complication was haematuria requiring haemostatic resection (7 patients; 23.3%) or evacuation of clots by bladder washings (14 patients, 46.6%). Seven patients required blood transfusions. Two patients (6.66%) presented with acute urinary retention after urinary catheter removal. Additionally, two patients developed urinary tract infection during hospitalization. Two patients presented a rectal perforation. One patient presented a vesical perforation during surgery, and one of them had a false urethral passage. One patient died during hospitalization due to bronchoaspiration in the context of decompensation of multiple myeloma. Out of the total 126 patients who completed at least one year of follow-up, 10.31% (13 patients) required reintervention.

Conclusions: Despite being a robotic treatment, Aquablation is not free of serious complications and requires a learning curve. Further studies are needed to properly establish the safety profile of this procedure.

Introduction: The research aim was to determine the role of clinical, laboratory, immunological and sonographic parameters in the development of an assessment tool for the symptomatic manifestations of prostate calcifications in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).

Material and methods: All men underwent a transabdominal ultrasonographic examination using a grayscale B-mode and color Doppler mapping, the evaluation of the National Institutes of Health-Chronic Prostatitis Symptom Index and the Patient Health Questionnaire-9, spermogram. Vascular endothelial growth factor (VEGF), serotonin and gamma-aminobutyrate (GABA), interleukins 1β and 10 were determined in blood serum and ejaculate.

Results: This study included 102 men aged 18-45 years. Group 1 (n = 34) consisted of patients with CP/CPPS. Group 2 included patients (n = 34) with asymptomatic prostatitis. Group 3 consisted of healthy volunteers (n = 34). More severe symptoms of prostatitis and depression, as well as frequent exacerbations in patients with CP/CPPS, were associated with ultrasound evidence of prostate calcifications, and especially the twinkling artifact (Spearman's r = 0.481; р <0.001; Spearman's r = 0.437; р <0.001, respectively).The presence of prostate calcifications in both CP/CPPS and asymptomatic prostatitis was accompanied by a significantly higher concentration of pro-inflammatory cytokine IL-1β and a lower concentration of anti-inflammatory cytokine IL-10 in the ejaculate (p < 0.05 in both cases, Kolmogorov-Smirnov test). The clinical manifestations observed in patients with CP/CPPS and asymptomatic prostatitis were not correlated with the leukocyte count in the ejaculate or the levels of VEGF, GABA, and serotonin in both blood and ejaculate.

Conclusions: Twinkling artifact potentially could serve as a valuable tool for evaluating the condition of patients with CP/CPPS and prostate calcifications.

Introduction: The aim of this study was to retrospectively evaluate the etiology of urethral stricture disease (USD) in a large series of patients undergoing urethroplasty.

Material and methods: The multicenter retrospective cohort study was conducted at two reconstructive urology referral centers in years 2015-2022. Prior to the surgical intervention, all patients underwent diagnostic procedures including retrograde urethrography and voiding cystourethrography. We collected comprehensive demographic and medical data including the length and location of the stricture. We paid particular attention to identifying the underlying causes of USD in the medical records.

Results: The study included 949 patients meeting criteria, with a mean age of 53. The primary cause of USD was identified as iatrogenic (404 cases, 42.6%), followed by trauma (210, 22.1%), previous hypospadias repair (122, 12.9%), lichen sclerosus (32, 3.4%), and infections (12, 1.3%). Notably, 169 patients (17.8%) did not have a discernible cause for their USD and were thus classified as idiopathic. Furthermore, it was observed that 66% of idiopathic USD cases were localized in the bulbar urethra. The etiology of USD varied significantly based on its localization (p <0.01). The mean stricture length differed among different causes, with the longest in patients with USD due to lichen sclerosus (41 mm), followed by previous hypospadias repair (35 mm), and iatrogenic causes (29 mm), p <0.001.

Conclusions: Careful medical history-taking can identify the etiology of urethral stricture in over 80% of patients undergoing urethroplasty. The etiology of the USD impacts its location and length and thus can affect surgical treatment strategy and outcomes.