Central European Journal of Urology最新文献

Introduction: Minimally-invasive partial nephrectomy (MIPN) is the standard treatment for kidney tumors with a diameter smaller than 4 cm. It is also performed in selected cases of tumors reaching 7 cm, but it may lead to potential complications. We investigated the current literature for simulators that could be used to teach urologists alone or within the boundaries of a course or a curriculum.

Material and methods: We performed a literature search using PubMed (Ovid Medline Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE [R] Daily, and Ovid MEDLINE [R]). Search terms included: simulation, simulation training, education, curricul*, partial nephrectomy, and nephron-sparing surgery. The primary endpoints were the efficacy of different simulators and the impact of different devices, curricula, or courses in training and trainee learning curves.

Results: We identified 16 studies evaluating simulation with 3D reconstruction, ex vivo, in vivo, synthetic models, and virtual reality simulators. Additionally, we identified one study presenting a training curriculum. The results appeared promising, although currently available studies are scarce. Regardless of the type of simulator, participants stated that, to some degree, their skills were improved and their confidence was elevated.

Conclusions: Simulation-based training can help novice surgeons familiarize themselves with complex procedure steps and reduce learning curves. A specific validated curriculum for this operation still needs to be included. Validating simulators or curricula for MIPN could be essential to enable more urologists to treat patients safely and effectively.

Introduction: The MemoKath™-051 (MK) is a thermo-expandable spiral stent for the treatment of benign or malignant ureteral obstruction. Existing studies on outcome measurements, like complication rate or time to stent exchange for MK differ significantly. In this retrospective analysis, we investigated the supposed superiority of the MK over conventional tumor ureteral stent (TUS) insertion.

Material and methods: In this monocentric retrospective analysis, 72 consecutive patients with benign or malignant extrinsic ureteral stenosis who either underwent insertion of a MK or TUS between 03/2008 and 12/2018 were analyzed. Indications for stent insertion were either chronic benign or malignant extrinsic obstruction in patients who were unsuitable for or refused definitive surgery. Patients who underwent urinary diversion were excluded. We compared the indwelling time, the complication rates and the time to occurrence of complications using Mann-Whitney-U-test and χ² test for categorical variables. Complication rates of both, the MK and the TUS were compared using Fisher´s test. Complications were classified according to Clavien-Dindo Classification (CDC).

Results: The total number of ureteral units analyzed was 171, including 89 MK stents and 82 TUSs. No significant differences between both groups regarding age, stent indications, and stricture characteristics occurred. At a median follow-up of 32 and 27 months in the MK and TUS groups, postoperative complications occurred in 82 (92%) and 19 (23%) patients, respectively (p = 0.01). Almost all complications were major (CDC grade 3b) that required stent removal or replacement, with the exception of one patient in the MK group. Median time to complications was significantly longer for the MK group, 5.6 months, compared to 3.5 months in the TUS group (p = 0.01), and median time to stent replacement was 8 months for the MK group vs 5.2 months for the TUS group (p <0.001).

Conclusions: Although the MemoKath™ is designed for a long indwelling time of up to years, it is associated with higher complication rates and premature replacement. However, compared to the TUS, the MK still has a significantly longer indwelling time. Further studies are needed to determine the predictors of failure and the best candidates for both stents.

Introduction: To compare the surgical outcomes of holmium laser enucleation of the prostate (HoLEP) and robotic single-port transvesical enucleation of the prostate (STEP) for the treatment of benign prostatic hyperplasia (BPH) during early adoption at a single center.

Material and methods: Data about consecutive BPH patients who underwent HoLEP and STEP at our Center from July 2023 to September 2024 were retrospectively analyzed. Both procedures were performed by surgeons at the beginning of their experience with the procedures.

Results: Thirty HoLEP and 20 STEP cases were included in the analysis. STEP patients had larger prostate volume (median 101.5 vs 78.5 cc; p = 0.003). Median operative time was longer for STEP (286 vs 124 min, p <0.001). Median catheterization time was shorter for HoLEP (3 vs 7 days, p <0.001). Transient post-operative incontinence was higher for HoLEP (31% vs 5.3%, p = 0.032). There was no difference in median length of stay (30 hours for HoLEP and 31 hours for STEP; p = 0.108).

Conclusions: Both HoLEP and STEP can be safely implemented for the minimally invasive treatment of BPH. Each of the procedures presents some appealing features that can be tailored to different subgroups of patients. HoLEP is appealing for higher surgical risk patients, while STEP allows to effectively manage larger glands even at the beginning of the surgeon's learning curve. As experience with SP robotic surgery matures, it is likely that STEP becomes a competitive alternative to the well-established HoLEP.

Introduction: Cancer, next to cardiovascular diseases, remains the primary concern of modern medicine in developed countries. Despite the unprecedented progress in targeted therapies and personalised medicine, including immunotherapy and gene therapy, we are still unable to efficiently treat many malignancies. One of the major obstacles to treating cancer is its ability to metastasise. Hence, a better understanding of cancer biology with emphasis on the metastasis formation may hold the key to further ameliorating cancer treatment. Nowadays, there is a growing body of evidence for the common denominator of neoplasia, which seems to be universal - cancer stem cells which are being found in a growing number of cancers.

Material and methods: We conducted a Web of Science and Medline database search using the terms "cancer stem cells", "carcinogenesis", and "stem cells" in conjunction with "metastasis", without setting time limits.

Results: The existence of cancer stem cells was proven both in animal models and in humans. We know beyond doubt that cancer stem cells may be found in bladder cancer, breast cancer, and colon cancer, among others. The cancer stem cells in the aforementioned cancers may initiate tumour formation ex vivo and thus theoretically lead to tumour recurrence. Their role in the formation of metastases, however, is still under investigation.

Conclusions: Although their exact role is yet to be identified, it is now obvious that cancer stem cells give rise to primary mass in solid tumours and differentiated cancer cells in leukaemias. However, the role of cancer stem cells in metastasis is still obscure.

Introduction: The combination of magnetic resonance imaging (MRI) and ultrasound (US) allows for better lesion targeting and diagnostic probability compared to random prostate biopsies. The Artemis Fusion Biopsy system and ExactVu micro-US technology capitalize on this advantage and provide higher-resolution imaging of the prostate during biopsy. Their accuracy in measuring prostate volume and resulting implications on prostate specific antigen (PSA) density and risk stratification, however, has not been evaluated. We hypothesized that PSA densities as measured by these modalities will demonstrate clinically insignificant differences compared to standard measurement.

Material and methods: We retrospectively reviewed all prostate fusion biopsy cases performed at our health system with Artemis or ExactVu systems from April 2021 to July 2023 and compared the PSA density calculated from the volume obtained with these systems to standard measurement with ellipsoid calculation from MRI. Change in National Comprehensive Cancer Network (NCCN) prostate cancer risk stratification was analyzed for each system.

Results: Artemis MRI segmentation (0.179 ng/ml, p = 0.04) and US (0.181 ng/ml, p = 0.067) underestimated and ExactVu micro-US (0.247 ng/ml, p <0.001) overestimated PSA density. Risk stratification changed in 1.2% of Artemis MRI segmentation cases, 1.6% of Artemis US cases, and 1.2% of ExactVu micro-US cases.

Conclusions: Despite differences in PSA density, choice of fusion biopsy system has minimal clinical impact on risk stratification and any of these studied systems may be used without fear of misrepresenting a patient's disease state.

Introduction: Human papillomavirus (HPV) has been implicated in the pathogenesis of several malignancies, including cervical, penile, and oropharyngeal cancers. Its role in prostate cancer (PCa), however, remains uncertain. The embryological structure known as the prostatic utricle - sharing histological features with the cervix - has been proposed as a potential reservoir for HPV in males. The aim of this study was to evaluate the presence of HPV DNA in the prostatic utricle and its possible association with prostate cancer.

Material and methods: A prospective study was conducted between 2019 and 2022 among 50 men (median age: 64 years) undergoing radical laparoscopic prostatectomy for PCa. Biological samples were obtained from the prostatic utricle in all patients. Additionally, the population was randomly divided into two subgroups. In the first subgroup, swabs were collected from under the foreskin and the external urethral meatus. In the second subgroup, washings were obtained from random intraprostatic sites. All samples were analyzed for HPV DNA using polymerase chain reaction (PCR) and genotyping.

Results: The absence of HPV DNA in prostatic and utricular tissue does not support a direct causal relationship between HPV infection and prostate cancer. However, a potential indirect role - such as promotion of chronic inflammation - cannot be excluded. These findings highlight the importance of HPV vaccination in both sexes, as well as the need for further research into the long-term impact of the virus on prostate carcinogenesis.

Conclusions: The absence of HPV DNA in prostatic and utricular tissue does not support a direct causal relationship between HPV infection and prostate cancer. However, a potential indirect role - such as promotion of chronic inflammation - cannot be excluded. These findings highlight the importance of HPV vaccination in both sexes, as well as the need for further research into the long-term impact of the virus on prostate carcinogenesis.

Introduction: Medical eponyms remain widely used in clinical practice despite ongoing debate about their accuracy, ethical implications, and relevance. Józef Dietl (1804-1878), an influential physician of the Polish-Austrian medical sphere, is best known in urology for the symptom complex later termed "Dietl's crisis," describing intermittent ureteropelvic junction obstruction associated with nephroptosis. The persistence of this eponym illustrates the intersection of historical memory and modern urological practice. This study analyzes the historical development, dissemination, and contemporary significance of "Dietl's crisis," and situates it within Dietl's broader scientific and public health legacy.

Material and methods: A narrative historical review was performed using primary publications by Dietl, archival documents, and secondary historical sources. A non-systematic analysis of major Englishlanguage urology and pediatric urology textbooks was conducted in collaboration with the W.P. Didusch Center for Urologic History to identify references to "Dietl's crisis." Additional examination of urological case literature and ICD-10 classifications provided further evidence of the eponym's persistence.

Results: The term "Dietl's crisis" appears variably but repeatedly across major urology textbooks from the late 19^th century to the present. Although its frequency declined after the 1960s, the eponym remains in use, particularly in pediatric urology and case-based reports. Historically, its prominence paralleled the evolution of nephropexy and the broader discussion of nephroptosis in the late 19^th and early 20^th centuries. Dietl's scientific work, encompassing early evidence-based reasoning, critique of harmful therapies, and public health reform, further reinforced his standing in medical memory.

Conclusions: "Dietl's crisis" remains an enduring and clinically meaningful eponym. Its continued use, free of problematic historical associations, supports the selective preservation of established eponyms as part of the cultural and scientific heritage of urology.

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.