Prevalence and Factors Associated With Prostate Cancer Among Transgender Women.

Importance: Evidence on prostate cancer (PCa) in transgender women is very limited; data are needed to reduce gender disparities in both PCa knowledge and health care. Objective: To evaluate the prevalence of PCa among transgender women in the US and assess the factors associated with PCa, and factors associated with biochemical recurrence (BCR) and bone metastases (BM) secondary to PCa in the transgender population. Design, Setting, and Participants: A retrospective cohort study was conducted in October 2023, covering the period between 2011 and 2022 (12-year analysis). The study was based on a large, all-payer claims, deidentified, US database (PearlDiver Mariner). Transgender women who were identified as male before assignment of transsexual status codes were included. Patients with PCa were detected in the transgender women population. Main Outcomes and Measures: PCa diagnosis was selected as primary outcome; BCR and BM were chosen as secondary outcomes. Results: A total of 95 460 transgender women with a mean (SD) age of 52.5 (9.4) years were included. PCa was diagnosed in 589 individuals with a mean (SD) age of 66.8 (10.0) years (estimated prevalence, 0.62%; 95% CI, 0.54%-0.77%). Age (adjusted odds ratio [OR], 1.10; 95% CI, 1.08-1.12; P < .001) and family history (adjusted OR, 2.27; 95% CI, 1.60-4.92; P < .001) were positively associated with PCa in transgender women. Gender-affirming hormone therapy (GAHT) was negatively associated with PCa in transgender women (OR, 0.60; 95% CI, 0.56-0.89; P < .001) but positively associated with BCR (OR, 1.83; 95% CI, 1.21-2.86; P < .001) and BM (OR, 3.96; 95% CI, 1.50-9.99; P < .001) in the transgender population with PCa. Conclusions and Relevance: This cohort study found that PCa appeared to be relatively uncommon in transgender women. GAHT may reduce the risk of PCa in transgender patients, but it may also increase the risk of BCR and BM in transgender women with PCa. Further studies are needed to confirm our findings.

The 2012 Briganti nomogram predicts disease progression after surgery in high-risk prostate cancer patients.

Objectives: We tested whether the 2012 Briganti nomogram for the risk of pelvic lymph node invasion (PLNI) may represent a predictor of disease progression after surgical management in high-risk (HR) prostate cancer (PCa) patients according to the European Association of Urology. Methods: Between January 2013 and December 2021, HR PCa patients treated with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND) were identified. The 2012 Briganti nomogram was evaluated as a continuous and categorical variable, which was dichotomized using the median. The risk of disease progression, defined as the event of biochemical recurrence and/or local recurrence/distant metastases was assessed by Cox regression models. Results: Overall, 204 patients were identified. The median 2012 Briganti nomogram score resulted 12.0% (IQR: 6.0-22.0%). PLNI was detected in 57 (27.9%) cases. Compared to patients who had preoperatively a 2012 Briganti nomogram score ≤12%, those with a score >12% were more likely to present with higher percentage of biopsy positive cores, palpable tumors at digital rectal examination, high-grade cancers at prostate biopsies, and unfavorable pathology in the surgical specimen. At multivariable Cox regression analyses, disease progression, which occurred in 85 (41.7%) patients, was predicted by the 2012 Briganti nomogram score (HR: 1.02; 95%CI: 1.00-1.03; p = 0.012), independently by tumors presenting as palpable (HR: 1.78; 95%CI: 1.10.2.88; p = 0.020) or the presence of PLNI in the surgical specimen (HR: 3.73; 95%CI: 2.10-5.13; p = 0.012). Conclusions: The 2012 Briganti nomogram represented an independent predictor of adverse prognosis in HR PCa patients treated with RARP and ePLND. As the score increased, so patients were more likely to experience disease progression, independently by the occurrence of PLNI. The association between the nomogram, unfavorable pathology and tumor behavior might turn out to be useful for selecting a subset of patients needing different treatment paradigms in HR disease.

Open versus Minimally Invasive Partial Nephrectomy: Trends and Outcomes from a Wide National Population-Based Database.

Objectives: To investigate temporal trends and overall complication rates among open partial nephrectomy (OPN) and minimally invasive partial nephrectomy (MIPN), including the impact of social determinants of health (SDOH) on postoperative outcomes. Methods: Patients who underwent OPN or MIPN between 2011 and 2021 were retrospectively analyzed by using PearlDiver-Mariner, an all-payer insurance claims database. The International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical operation, patient's characteristics (age, sex, region, insurance plan), postoperative complications and SDOH, categorized in education, healthcare, environmental, social, and economic domains. Outcomes were compared using multivariable regression models. Results: Overall, 65,325 patients underwent OPN (n = 23,377) or MIPN (n = 41,948). OPN adoption declined over the study period, whereas that of MIPN increased from 24% to 34% (p = 0.001). The 60-day postoperative complication rate was 15% for the open and 9% for the minimally invasive approach. Approximately 16% and 11% of patients reported at least one SDOH at baseline for OPN and MIPN, respectively. SDOH were associated with higher odds of postoperative complications (OPN = OR: 1.11, 95% CI: 1.01-1.25; MIPN = OR: 1.31, 95% CI: 1.18-1.46). The open approach showed a significantly higher risk of postoperative complications (OR: 1.62, 95% CI: 1.54-1.70) compared to the minimally invasive one. Conclusions: Our findings confirm that MIPN is gradually replacing OPN, which carries a higher risk of complications. SDOH are significant predictors of postoperative complications following PN, regardless of the approach.

The single port robotic surgical "toolbox": a primer for beginners.

BACKGROUND: The aim of this study is to provide a comprehensive overview of the da Vinci Single Port robotic platform, including instruments and tools that can aid in implementing the use of this novel platform. METHODS: Footage recorded during various Single port robotic urologic procedures and dry labs performed at two US institutions was used as video material. A step-by-step guide illustrating key points on OR set-up, platform, instruments, trocar configurations, intraoperative suctioning, bedside assistance were discussed and highlighted. RESULTS: The Single port surgeon console resembles the Xi console but includes upgraded software. The 6-mm biarticulated instruments incorporate an elbow and a wrist flexible joint. These instruments are deployed through the Access port. Access port kit includes the Access port, and a 25-mm multichannel trocar accommodating an 8-mm flexible scope, and three 6-mm robotic instruments. The 0° endoscope has two sets of articulation: a fixed one, and a distal one, allowing for three movements, selected with a hand command, the "Camera Adjust", the "Camera Control" and the "Relocation." The "Cobra mode," is an extra setting that allows the camera to wing out and move laterally relative to the working instruments. Suction is preferably performed with the Remotely Operated Suction Irrigation system. CONCLUSIONS: Herein we provide a detailed guide to the main technical nuances of the Single port platform and a practical overview of the instrumentation that is used during Single port robotic procedures. Knowledge of the toolbox that is used during Single port robotic surgery is key for those approaching for the first time this novel technology.

Pelvic Lymph Node Dissection: A Comparison Among Extraperitoneal Single-port and Transperitoneal Multiport Radical Prostatectomy-A Single-center Experience.

Background and objective: The role of pelvic lymph node dissection (PLND) for prostate cancer is still controversial. This study aims to compare the outcomes of PLND between extraperitoneal single-port (SP eRARP) and transperitoneal multiport (MP tRARP) robotic-assisted radical prostatectomy. Methods: This was a retrospective analysis from our single-center database for patients who underwent SP eRARP or MP tRARP with PLND between 2015 and 2023. The primary endpoint was to analyze and compare specific data related to PLND between the two populations by the detection of pN+ patients, the total number of lymph nodes removed, and the number of positive lymph nodes removed. The secondary endpoints included comparing major complications, lymphoceles, and biochemical recurrence between the two cohorts of the study. Key findings and limitations: A total of 293 patients were included, with 85 (29%) undergoing SP eRARP and 208 (71%) undergoing MP tRARP. SP eRARP showed significant differences in PLND extension from MP tRARP, while MP tRARP yielded more lymph nodes (p < 0.001). There were no differences in pN+ patient detection (p = 0.7) or the number of positive lymph nodes retrieved (p = 0.6). The rates of major complications (p = 0.6), lymphoceles (p = 0.2), and biochemical recurrence (p = 0.9) were similar between the two groups. Additionally, SP eRARP had shorter operative time (p = 0.045), hospital stay (p < 0.001), and less postoperative pain at discharge (p = 0.03). Limitations include a retrospective, single-center analysis. Conclusions and clinical implications: Despite the SP approach in RARP resulting in fewer retrieved lymph nodes, outcomes were comparable with the MP approach regarding the detection of patients with positive lymph nodes and the number of positive nodes. Additionally, the SP approach led to lower pain levels and shorter hospital stays. Patient summary: With this study, we demonstrate that pelvic lymph node dissection performed via the extraperitoneal approach during robotic-assisted radical prostatectomy with a single-port system provides comparable outcomes with the standard transperitoneal multiport approach in detecting patients with positive lymph nodes and retrieving positive nodes. In addition, it offers significantly reduced pain levels and shorter hospital stays.

Neurovascular structure-adjacent frozen-section examination (NeuroSAFE) during robot-assisted radical prostatectomy: a systematic review and meta-analysis of comparative studies.

BACKGROUND: To compare surgical, pathological, and functional outcomes of patients undergoing NeuroSAFE-guided RARP vs. RARP alone. METHODS: In February 2024, a literature search and assessment was conducted through PubMed®, Scopus®, and Web of Science™, to retrieve data of men with PCa (P) undergoing RARP with NeuroSAFE (I) versus RARP without NeuroSAFE (C) to evaluate surgical, pathological, oncological, and functional outcomes (O), across retrospective and/or prospective comparative studies (Studies). Surgical (operative time [OT], number of nerve-sparing [NS] RARP, number of secondary resections after NeuroSAFE), pathological (PSM), oncological (biochemical recurrence [BCR]), and functional (postoperative continence and sexual function recovery) outcomes were analyzed, using weighted mean difference (WMD) for continuous variables and odd ratio (OR) for dichotomous variables. RESULTS: Overall, seven studies met the inclusion criteria (one randomized clinical trial, one prospective non-randomized trial and five retrospective studies) and were eligible for SR and MA. A total of 4,207 patients were included in the MA, with 2247 patients (53%) undergoing RARP with the addition of NeuroSAFE, and 1 960 (47%) receiving RARP alone. The addition of NeuroSAFE enhanced the likelihood of receiving a nerve-sparing (NS) RARP (OR 5.49, 95% CI 2.48-12.12, I2 = 72%). In the NeuroSAFE cohort, a statistically significant reduction in the likelihood of PSM at final pathology (OR 0.55, 95% CI 0.39-0.79, I2 = 73%) was observed. Similarly, a reduced likelihood of BCR favoring the NeuroSAFE was obtained (OR 0.47, 95% CI 0.35-0.62, I2 = 0%). At 12-month postoperatively, NeuroSAFE led to a significantly higher likelihood of being pad-free (OR 2.01, 95% CI 1.25-3.25, I2 = 0%), and of erectile function recovery (OR 3.50, 95% CI 2.34-5.23, I2 = 0%). CONCLUSION: Available evidence suggests that NeuroSAFE might represent a histologically based approach to NVB preservation, broadening the indications of NS RARP, reducing the likelihood of PSM and subsequent BCR. In addition, it might translate into better functional postoperative outcomes. However, the current body of evidence is mostly derived from non-randomized studies with a high risk of bias.

Postoperative urinary incontinence following BPH surgery: insights from a comprehensive national database analysis.

BACKGROUND: Postoperative urinary incontinence (UI) is a feared complication of BPH surgery. Our study aims to investigate the incidence of UI among patients undergoing different procedures for BPH. METHODS: A retrospective analysis was conducted using a large national database, containing patient records between 2011 and 2022. The most employed surgical procedures for BPH were considered, including TURP, Transurethral Incision of the Prostate (TUIP), Holmium/Thulium Laser Enucleation of the Prostate (HoLEP/ThuLEP), Open Simple Prostatectomy (OSP), minimally invasive simple prostatectomy (Lap/Rob SP), Photoselective Vaporization of the Prostate (PVP), Prostatic Urethral Lift (PUL), Robotic Waterjet Treatment (RWT - Aquablation®), Water Vapor Thermal Therapy (WVTT - Rezum®) and Prostatic Artery Embolization (PAE). Rates of any type of UI, including stress UI (SUI), urge UI (UUI) and mixed UI (MUI) were assessed. Multivariate regression analysis was used to identify predictors of "persistent" postoperative UI, defined as the presence of an active UI diagnosis at 12 months post-surgery. RESULTS: Among 274,808 patients who underwent BPH surgery, 11,017 (4.01%) experienced persistent UI. UUI rates varied between 0.62% (PAE) and 2.71% (PVP), SUI ranged from 0.04% (PAE) and 2.75% (Lap/Rob SP), while MUI between 0.11% (PAE) and 1.17% (HoLEP/ThuLEP). On multivariable analysis, HoLEP/ThuLEP (OR 1.612; 95% CI: 1.508-1.721; P<0.001), PVP (OR 1.164; 95% CI:1.122-1.208; P<0.001), Open SP (OR 1.424; 95% CI:1.241- 1.624; P<0.001), and Lap/Rob SP (OR 1.667; 95% CI:1.119-2.384; P<0.01) showed significant higher likelihood of UI compared to TURP. PUL (OR 0.604; 95% CI:0.566-0.644; P<0.001), WVTT (OR 0.661; 95% CI:0.579-0.752; P<0.001), RWT (OR 0.434; 95% CI:0.216-0.767; P<0.01), and PAE (OR 0.178; 95% CI:0.111-0.269; P<0.001) were associated with lower likelihood of UI. CONCLUSIONS: UI remains a concerning complication following BPH surgery, but it is an uncommon event affecting <5% of patients. Some differences in UI rates and risk might exist among various BPH procedures. These findings underscore the need for thorough patient selection and counseling.

Robot-assisted nephroureterectomy: surgical and mid-term oncological outcomes in over 1100 patients (ROBUUST 2.0 collaborative group).

OBJECTIVE: To analyse surgical, functional, and mid-term oncological outcomes of robot-assisted nephroureterectomy (RANU) in a contemporary large multi-institutional setting. PATIENTS AND METHODS: Data were retrieved from the ROBotic surgery for Upper tract Urothelial cancer STtudy (ROBUUST) 2.0 database, an international, multicentre registry encompassing data of patients with upper urinary tract urothelial carcinoma undergoing curative surgery between 2015 and 2022. The analysis included all consecutive patients undergoing RANU except those with missing data in predictors. Detailed surgical, pathological, and postoperative functional data were recorded and analysed. Oncological time-to-event outcomes were: recurrence-free survival (RFS), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). Survival analysis was performed using the Kaplan-Meier method, with a 3-year cut-off. A multivariable Cox proportional hazard model was built to evaluate predictors of each oncological outcome. RESULTS: A total of 1118 patients underwent RANU during the study period. The postoperative complications rate was 14.1%; the positive surgical margin rate was 4.7%. A postoperative median (interquartile range) estimated glomerular filtration rate decrease of -13.1 (-27.5 to 0) mL/min/1.73 m2 from baseline was observed. The 3-year RFS was 59% and the 3-year MFS was 76%, with a 3-year OS and CSS of 76% and 88%, respectively. Significant predictors of worse oncological outcomes were bladder-cuff excision, high-grade tumour, pathological T stage ≥3, and nodal involvement. CONCLUSIONS: The present study contributes to the growing body of evidence supporting the increasing adoption of RANU. The procedure consistently offers low surgical morbidity and can provide favourable mid-term oncological outcomes, mirroring those of open NU, even in non-organ-confined disease.

The impact of bladder cuff excision on outcomes after nephroureterectomy for upper tract urothelial carcinoma: An analysis of the ROBUUST 2.0 registry.

OBJECTIVES: We sought to determine whether bladder cuff excision and its technique influence outcomes after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS AND MATERIALS: A multicenter, international, retrospective analysis using the ROBotic surgery for Upper tract Urothelial cancer Study (ROBUUST) 2.0 registry identified 1,718 patients undergoing RNU for UTUC between 2015 and 2023 at 17 centers across the United States, Europe, and Asia. Data was gathered on (1) whether bladder cuff excision was performed and (2) what technique was used, including formal excision or other techniques (pluck technique, stripping/intussusception technique) and outcomes. Multivariate and survival analyses were performed to compare the groups. RESULTS: Most patients (90%, 1,540/1,718) underwent formal bladder cuff excision in accordance with EAU and AUA guidelines. Only 4% (68/1,718) underwent resection using other techniques, and 6% (110/1,718) did not have a bladder cuff excised. Median follow up for the cohort was 24 months (IQR 9-44). When comparing formal bladder cuff excision to other excision techniques, there were no differences in oncologic or survival outcomes including bladder recurrence-free survival (BRFS), recurrence-free survival (RFS), metastasis-free survival (MFS), overall survival (OS), or cancer-specific survival (CSS). However, excision of any kind conferred a decreased risk of bladder-specific recurrence compared to no excision. There was no difference in RFS, MFS, OS, or CSS when comparing bladder cuff excision, other techniques, and no excision. CONCLUSIONS: Bladder cuff excision improves recurrence-free survival, particularly when considering bladder recurrence. This benefit is conferred regardless of technique, as long as the intramural ureter and ureteral orifice are excised. However, the benefit of bladder cuff excision on metastasis-free, overall, and cancer-specific survival is unclear.

Comparison of Current International Guidelines on Premature Ejaculation: 2024 Update.

Premature ejaculation (PE) is a common male sexual dysfunction that can cause significant distress in the patient and partner. This study aimed to compare the current international guidelines on PE to highlight their similarities and differences. We examined the latest guidelines from the European Association of Urology (EAU), American Urological Association/Sexual Medicine Society of North America (AUA/SMSNA), and International Society of Sexual Medicine (ISSM) by comparing definitions, classifications, epidemiology, pathophysiology, and recommendations on diagnosis and therapy. The quality of guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) Global Rating Scale (GRS). We found significant variations in the definitions of PE and recommendations on management of patients. The EAU guidelines were the most recent, the AUA/SMSNA guidelines lacked detail in some areas, and the ISSM guidelines were the most complete but also the least updated. The search for a unified definition and the development of standardized diagnostic and therapeutic pathways remain concrete issues to improve the management of patients with PE worldwide.

The Learning Curve for Holmium Laser Enucleation of the Prostate: A Single-Center Analysis of Surgical And Functional Outcomes.

Background: To report the surgical and functional outcomes of the holmium laser enucleation of the prostate (HoLEP) surgical program implemented at a high-volume tertiary referral center and to estimate the learning curve (LC) duration for this surgical procedure. Methods: Data of all consecutive patients undergoing HoLEP at the University of Verona between June 2022 and April 2024 were retrieved from a prospectively maintained institutional database of patients undergoing benign prostatic hyperplasia (BPH) surgical treatment. The primary endpoint was functional outcomes evaluation during the surgeons' LC. The secondary endpoint was to define the surgical LC for HoLEP. A multivariable test of means was performed to compare functional outcomes at different time points. After adjusting for potential confounders (age, preoperative pharmacotherapy, and prostate volume), multivariable linear regression models were fitted to evaluate the effect of experience on operative time (OT) and enucleation efficiency. To assess LCs for HoLEP surgery, the non-risk-adjusted cumulative sum (CUSUM) method was used. Results: A statistically significant improvement in International Prostate Symptoms Score (IPSS) score, delta% IPSS score, IPSS quality of life (IPSS-QoL) score, and delta% IPSS-QoL score was observed over the study period. Furthermore, the incidence of irritative symptoms (p < 0.001) and stress incontinence (p = 0.01) significantly decreased over time, with a 12-month incidence of 8.4% and 9.5%, respectively. A statistically significant association between experience and both OT and enucleation efficiency was observed in multivariable linear regression analysis. The CUSUM chart for OT and enucleation efficiency showed a steep initial upward/downward trend of ∼50 cases each, and a plateau until ∼100 procedures are reached, where the breakpoint is recognized for both variables and where the CUSUM curve goes below the locally weighted scatterplot smoothing curve in the corresponding observed-expected CUSUM plot. Conclusions: HoLEP represents an effective treatment for BPH, demonstrating significant improvement in BPH-related symptoms over the study period, despite the considerable LC of ∼50 cases associated with the procedure.

Contemporary management of ischemic priapism: A 12-year population-based analysis from a large US database.

BACKGROUND: Priapism is a urological condition characterized by a persistent erection. The management varies based on its subclassifications. Despite established clinical guidelines for ischemic priapism, there is a lack of large-scale research focused on patient characteristics and management strategies. OBJECTIVES: To analyze the contemporary management of ischemic priapism in the US, exploring patient demographics and clinical characteristics, as well as predictors of erectile dysfunction (ED) and penile prosthesis implantation (PPI). MATERIALS AND METHODS: We performed a retrospective analysis of the PearlDiver Mariner database, reviewing records from 2010-2021. Adult males diagnosed with ischemic priapism were included. Data analysis covered demographic, clinical variables, and management strategies. Predictors of de novo ED and PPI were evaluated using multivariable logistic regression analysis. RESULTS: Of 36,120 patients, most (93%) received only medical management, and a minority underwent surgical interventions (penile shunt surgery [PSS], PPI or both). Medical management was typically effective, as 67.08% of the patients in this group experienced only one episode of priapism. However, de novo ED occurred in 16.57% of these patients. The majority of patients undergoing PPI had an inflatable prosthesis (81%). Older age (odds ratio, OR 1.02), the presence of metabolic diseases (OR 1.39), neurogenic disorders (OR 1.72), solid pelvic malignancies (OR 1.09), and multiple episodes of priapism were identified as significant predictors of de novo ED (all p < 0.05). Similarly, age (OR 1.03), the presence of metabolic diseases (OR 1.23), solid pelvic malignancies (OR 1.99), and multiple episodes of priapism were associated with higher likelihood of PPI (all p < 0.05). CONCLUSION: Most cases of ischemic priapism are managed with the medical therapy. Less than 3% of patients with ischemic priapism receive PPI, and when this occurs an inflatable prosthesis is favored. Age, specific comorbidities, and multiple episodes of priapism appear to be significant predictors of ED and PPI.

Radical cystectomy with stentless urinary diversion: A systematic review and meta-analysis of comparative studies.

PURPOSE: To systematically compare the evidence about surgical outcomes, postoperative complications, and sequelae of Radical cystectomy with urinary diversion with or without stent placement. MATERIAL AND METHODS: A literature search was performed through PubMed, Scopus®, and Web of Science up to December 2023 in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. The study protocol was registered in PROSPERO (CRD 42023492384), and the research question was formulated according to the PICOs model. Three comparative studies were identified, 2 randomized and 1 prospective coming from a randomized cohort. RESULTS: The stent group showed higher odds of postoperative major complications (OR 3.00 - 95%CI 1.06; 8.52; P = 0.04) than the stentless group. There was no statistically significant difference between the 2 groups regarding 30-day readmission (P = 0.06), postoperative uretero-ileal anastomotis stricture (UIAS) (P = 0.09), postoperative uretero-ileal anastomotis leak (UIAL) (P = 0.20), postoperative urinary tract infections (UTIs) (P = 0.08), and postoperative ureteral obstruction (P = 0.35). No statistically significant difference between the 2 groups was found regarding UIAS management in terms of ureteral reimplantation (P = 0.28) or dilatation (P = 0.36). CONCLUSIONS: Our pooled data analysis shows no statistically significant difference between stentless and stented urinary diversion after radical cystectomy. Stentless could be a reasonable choice when performing diversion during radical cystectomy.

ASO Visual Abstract: Open Versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database.

Contemporary trend analysis of a large national data set confirms the occurrence of a significant shift toward minimally invasive nephroureterectomy (MINU), which is gradually replacing open nephroureterectomy (ONU). A minimally invasive approach is associated with a lower risk of complications. Social determinants of health (SDOH) are non-clinical factors that ultimately may have an impact on the outcomes of the nephroureterectomy (NU) procedure ( https://doi.org/10.1245/s10434-024-15565-6 ).

Upfront versus deferred cytoreductive nephrectomy following targeted or immunotherapy: a population-based propensity score-matched analysis of perioperative complications.

PURPOSE: To evaluate the incidence of postoperative complications after cytoreductive nephrectomy (CN) following first-line treatment for metastatic renal cell carcinoma (mRCC), and to compare it with postoperative complications of upfront CN. METHODS: For this population-based retrospective study, the PearlDiver Mariner database (PearlDiver Technologies, Colorado Springs, CO), a database of insurance billing records was analyzed. Using relevant ICD-9/10 and CPT codes, patients diagnosed with mRCC between 2011 and 2021, who received first-line systemic molecular therapy (SMT), either tyrosine kinase inhibitors (TKI) or immune-checkpoint inhibitors (ICI), were identified. The selected population was stratified into two cohorts according to the timing of CN (deferred: after SMT vs. upfront: before SMT). Propensity-score matching (PSM) was performed as per baseline patients' characteristics to control for potential confounders between the two cohorts. The primary outcome was to compare 30-day postoperative complications rate between patients undergoing upfront vs. deferred CN. RESULTS: After PSM, 162 patients who received upfront CN were compared with 162 patients who underwent deferred CN. The overall rate of 30-day postoperative complications was statistically significantly higher in patients undergoing deferred CN (33.9%), compared to patients treated with upfront CN (21%, p < 0.01). In addition, the rate of both medical (26.5% vs. 14.2%, p < 0.01) and surgical (14.8 vs. 7.4%, p = 0.03) complication rate was statistically significantly higher in deferred vs. upfront CN. Multivariable logistic regression analysis revealed that none of the treatment regimens significantly predicted the occurrence of postoperative complications. CONCLUSION: Patients undergoing deferred CN experience a higher rates of overall, medical, and surgical 30-day postoperative complications compared to those receiving upfront surgery. Findings from this study should be interpreted within the limitations of this type of analysis.

Robotic salvage partial nephrectomy following surgical and ablative therapies

ABSTRACT Purpose: Partial nephrectomies in the salvage setting after ablative or surgical therapy remain challenging cases that are underreported in the literature (1-5). The aim of this video is to demonstrate techniques for robotic salvage partial nephrectomy to manage recurrent renal cell carcinoma (RCC) after failed prior partial nephrectomy and primary cryotherapy. Materials and methods: A 55-year-old man after previous robotic-assisted right partial nephrectomy presented with a 2.5 cm locally recurrent renal mass abutting the collecting system. A 59-year-old man with right renal cell carcinoma initially treated with cryoablation presented local recurrence. CT imaging demonstrated 2.6 cm right renal mass consistent with tumor recurrence at previous treatment site. Results: Both procedures were completed in under 180 minutes. Clamp time was 22 minutes after the previous partial nephrectomy and 25 minutes after previous cryotherapy. There were no perioperative complications. Pathology in both cases demonstrated pT1a clear cell RCC with negative margins. Both patients have since no evidence of recurrent disease on follow-up imaging at 1 and 2 years, respectively. Conclusions: Salvage robotic partial nephrectomy should be considered as a feasible treatment option after failure of initial therapy—surgical or ablative. A salvage procedure is often more challenging than its standard therapy-naïve counterpart due to development of dense inflammation after previous interventions. Despite this, robotic partial nephrectomies in the salvage setting can be safely carried out with good surgical outcomes, particularly when utilizing intraoperative ultrasound to identify tumor margins and key anatomy.

Long-term functional outcomes and surgical retreatment after thulium laser enucleation of the prostate: A 10-year follow-up study

ABSTRACT Background: To evaluate the 10-year functional outcomes (primary) and frequency and predictors of BPH surgical retreatment (secondary) after ThuLEP. Materials and Methods: A single-center retrospective analysis of consecutive patients undergoing ThuLEP between 2010 and 2013 was performed. Inclusion criteria were: age ≥ 40 years, prostate volume (PV) ≥ 80 mL, International Prostate Symptom Score (IPSS)-Total score ≥ 8 points. IPSS-Total score was the primary outcome, and BPH surgical retreatment rate was the secondary outcome. Paired t-test, McNemar test, and Wilcoxon signed-rank test were used to compare variables. Logistic regression analysis was performed to evaluate predictors of surgical retreatment. Results: A total of 410 patients with a mean ±SD age of 63.9 ± 9.7 years and a PV of 115.6 ± 28.6 mL were included. Mean ±SD follow-up was 108.2 ± 29.6 months. IPSS-Total score was significantly improved at 1 year compared to baseline (23.3 ± 4.7 vs. 10.3 ± 3.8; p<0.001). It was similar after 5 years (10.5 ± 3.6 vs. 10.7 ± 5.0; p=0.161), with a significant worsening at 10 years (10.3 ±4.8 vs. 13.8 ±4.5; p=0.042) but remaining statistically and clinically better than baseline (13.8 ±4.5 vs. 22.1 ±4.3; p<0.001). After 10 years, 21 (5.9%) patients had undergone BPH reoperation. Baseline PV (adjusted OR 1.27, 95% CI 1.09-1.41; p<0.001) and time from BPH surgery (adjusted OR 1.32, 95% CI 1.15-1.43; p<0.001) were predictors of BPH surgical retreatment. Conclusions: ThuLEP is associated with optimal functional outcomes and a low frequency of BPH surgical retreatment in the long-term. Baseline PV and time from surgery were predictors of BPH reoperation.

Partial nephrectomy after a period of active surveillance: Are perioperative and pathology outcomes worsened compared to immediate surgery?

INTRODUCTION: Active surveillance (AS) is a viable strategy for managing small renal masses (SRMs) in lieu of immediate surgery, but concerns persist regarding its impact on delayed partial nephrectomy (PN) outcomes. We aimed to compare perioperative and pathological outcomes of patients initially on AS for SRMs, later undergoing PN, against those undergoing immediate PN. MATERIALS AND METHODS: Data were extracted from a prospective institutional database (January 2018-September 2023) for patients with cT1a renal masses. Only malignancies confirmed at final pathology were included. Baseline patient and tumor characteristics and the time from AS enrollment to PN were recorded. Surgical, renal functional, and final pathology outcomes were analyzed, including histology, tumor size, pT stage, upstaging rate, and positive surgical margins. Predictors of upstaging were identified using logistic regression models. RESULTS: Analysis included 356 patients: 307 immediate PN and 49 deferred PN after a median of 18 months in AS. Groups had comparable baseline characteristics; no significant differences emerged in surgical and postoperative outcomes. Final pathology revealed no significant disparities in tumor size, histology, positive margins, or upstaging, though pT stage distribution differed (2.4 % versus 4.3 % for pT3a, immediate versus deferred, p = 0.04). Univariable analysis identified RENAL Score (OR 1.29, 95 % C.I. 1.09-1.53, p = 0.003) and clinical tumor size (OR 1.16, 95 % C.I. 1.10-1.22, p < 0.01) as upstaging predictors, confirmed by multivariable analysis (p < 0.01). CONCLUSION: Our comparative analysis found no worsened perioperative or adverse pathological outcomes in patients with deferred PN, supporting the safety of this approach in managing SRMs, at least as an initial option.

Robotic distal ureterectomy for high-risk distal ureteral urothelial carcinoma: a retrospective multicenter comparative analysis (ROBUUST 2.0 collaborative group).

BACKGROUND: The role of kidney-sparing surgery in patients with high-risk upper urinary tract urothelial carcinoma is controversial. The present study aimed to assess oncological and functional outcomes of robot-assisted distal ureterectomy in patients with high-risk distal ureteral tumors. METHODS: The ROBUUST 2.0 multicenter international (2015-2022) dataset was used for this retrospective cohort analysis. High-risk patients with distal ureteral tumors were divided based on type of surgery: robot-assisted distal ureterectomy or robot-assisted nephroureterectomy. A survival analysis was performed for local recurrence-free survival, distant metastasis-free survival, and overall survival. After adjusting for clinical features of the high-risk prognostic group, Cox proportional hazard model was plotted to evaluate significant predictors of time-to-event outcomes. RESULTS: Overall, 477 patients were retrieved, of which 58 received robot-assisted distal ureterectomy and 419 robot-assisted nephroureterectomy, respectively, with a mean (±SD) follow-up of 29.6 months (±2.6). The two groups were comparable in terms of baseline features. At survival analysis, no significant difference was observed in terms of recurrence-free survival (P=0.6), metastasis-free survival (P=0.5) and overall survival (P=0.7) between robot-assisted distal ureterectomy and robot-assisted nephroureterectomy. At Cox regression analysis, type of surgery was never a significant predictor of worse oncological outcomes. At last follow-up patients undergoing robot-assisted distal ureterectomy had significantly better postoperative renal function. CONCLUSIONS: Comparable outcomes in terms of recurrence-free survival, metastasis-free survival, and overall survival between robot-assisted distal ureterectomy and robot-assisted nephroureterectomy patients, and better postoperative renal function preservation in the former group were observed. Kidney-sparing surgery should be considered as a potential option for selected patients with high-risk distal ureteral UTUC.

Open versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database.

BACKGROUND: It is generally perceived that minimally invasive nephroureterectomy (MINU), especially in the form of robotic-assisted laparoscopy, is gaining an increasing role in many institutions. OBJECTIVE: The aim of our study was to investigate contemporary trends in the adoption of MINU in the United States compared with open nephroureterectomy (ONU). METHODS: Patients who underwent ONU or MINU between 2011 and 2021 were retrospectively analyzed using PearlDiver Mariner, an all-payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patients' characteristics, social determinants of health (SDOH), and perioperative complications. The primary objective assessed different trends and costs in NU adoption, while secondary objectives analyzed factors influencing the postoperative complications, including SDOH. Outcomes were compared using multivariable regression models. RESULTS: Overall, 15,240 patients underwent ONU (n = 7675) and MINU (n = 7565). Utilization of ONU declined over the study period, whereas that of MINU increased from 29 to 72% (p = 0.01). The 60-day postoperative complication rate was 23% for ONU and 19% for MINU (p < 0.001). At multivariable analysis, ONU showed a significantly higher risk of postoperative complications (odds ratio 1.33, 95% CI 1.20-1.48). Approximately 5% and 9% of patients reported at least one SDOH at baseline for both ONU and MINU (p < 0.001). CONCLUSIONS: Contemporary trend analysis of a large national dataset confirms that there has been a significant shift towards MINU, which is gradually replacing ONU. A minimally invasive approach is associated with lower risk of complications. SDOH are non-clinical factors that currently do not have an impact on the outcomes of nephroureterectomy.