Minimally invasive surgery for benign prostatic obstruction: new insights and future technical standards.

PURPOSE OF REVIEW: This review aims to give a brief description of the latest minimally invasive surgical techniques (MISTs) for the treatment of benign prostatic obstruction (BPO). RECENT FINDINGS: In recent years technological advances have made the implementation of MISTs in the armamentarium of BPO surgery possible and in many cases could replace standard procedures.These techniques offer many advantages -short recovery time, rapid symptomatic relief, few adverse effects, lower risk of sexual/ejaculatory dysfunction, acceptable durability and most can be performed as an outpatient procedure.Many of the newer MISTs can be performed outside the operating room under local anesthesia, hence the term office-based MIST. SUMMARY: A tailored BPO surgical treatment should not only take into account the prostate volume, but also many other factors including possible adverse events and the patient's expectations.Further studies and long-term data are necessary to standardize methods for evaluating the outcomes of these new procedures and to see which will pass the test of time and end-up replacing the gold standard procedures.

The surgical learning curve for endoscopic GreenLight™ laser enucleation of the prostate: an international multicentre study.

OBJECTIVES: To investigate the effect of surgical experience on the perioperative outcomes of endoscopic GreenLight™ (Boston Scientific Corporation, Marlborough, MA, USA) laser enucleation of the prostate (GreenLEP). SUBJECTS/PATIENTS AND METHODS: A multicentre retrospective study of the first patients treated with GreenLEP by six surgeons was conducted. For each patient, surgical experience was coded as the total number of procedures performed by the surgeons before the patient's operation. The learning curve was analysed in terms of changes over time for the following variables: enucleation time, morcellation time, occurrence of intraoperative complications (IOCs), 3-month postoperative International Prostate Symptom Score (IPSS) reduction, and the rate of Pentafecta achievement. RESULTS: In total, 922 patients were analysed. At multivariable regression analyses adjusted for case mix, surgical experience was associated with shorter enucleation and morcellation time (P < 0.001), lower IOC rate (P < 0.001), higher 3-month postoperative reduction in IPSS (P = 0.004), and higher probability of Pentafecta achievement (P < 0.001). The relationship between surgical experience and enucleation time/IOCs appeared as non-linear, with a steep slope reduction within the first 100 cases and a plateau observed after 200 cases, whilst the IPSS improved rapidly early in the learning curve process and plateaued after ~100 procedures. Finally, there was a linear improvement in Pentafecta achievement, with a plateau observed after 270 cases. CONCLUSION: Surgical experience has a significant impact on the perioperative outcomes for GreenLEP procedures. After adjusting for patient and prostate characteristics, plateau results were achieved after a long learning curve. A more intensely mentored and structured training schedule might allow quicker and safer adoption of the procedure.

Global and Regional Respiratory Mechanics During Robotic-Assisted Laparoscopic Surgery: A Randomized Study.

BACKGROUND: Pneumoperitoneum and nonphysiological positioning required for robotic surgery increase cardiopulmonary risk because of the use of larger airway pressures (Paws) to maintain tidal volume (VT). However, the quantitative partitioning of respiratory mechanics and transpulmonary pressure (PL) during robotic surgery is not well described. We tested the following hypothesis: (1) the components of driving pressure (transpulmonary and chest wall components) increase in a parallel fashion at robotic surgical stages (Trendelenburg and robot docking); and (2) deep, when compared to routine (moderate), neuromuscular blockade modifies those changes in PLs as well as in regional respiratory mechanics. METHODS: We studied 35 American Society of Anesthesiologists (ASA) I-II patients undergoing elective robotic surgery. Airway and esophageal balloon pressures and respiratory flows were measured to calculate respiratory mechanics. Regional lung aeration and ventilation was assessed with electrical impedance tomography and level of neuromuscular blockade with acceleromyography. During robotic surgical stages, 2 crossover randomized groups (conditions) of neuromuscular relaxation were studied: Moderate (1 twitch in the train-of-four stimulation) and Deep (1-2 twitches in the posttetanic count). RESULTS: Pneumoperitoneum was associated with increases in driving pressure, tidal changes in PL, and esophageal pressure (Pes). Steep Trendelenburg position during robot docking was associated with further worsening of the respiratory mechanics. The fraction of driving pressures that partitioned to the lungs decreased from baseline (63% ± 15%) to Trendelenburg position (49% ± 14%, P < .001), due to a larger increase in chest wall elastance (Ecw; 12.7 ± 7.6 cm H2O·L) than in lung elastance (EL; 4.3 ± 5.0 cm H2O·L, P < .001). Consequently, from baseline to Trendelenburg, the component of Paw affecting the chest wall increased by 6.6 ± 3.1 cm H2O, while PLs increased by only 3.4 ± 3.1 cm H2O (P < .001). PL and driving pressures were larger at surgery end than at baseline and were accompanied by dorsal aeration loss. Deep neuromuscular blockade did not change respiratory mechanics, regional aeration and ventilation, and hemodynamics. CONCLUSIONS: In robotic surgery with pneumoperitoneum, changes in ventilatory driving pressures during Trendelenburg and robot docking are distributed less to the lungs than to the chest wall as compared to routine mechanical ventilation for supine patients. This effect of robotic surgery derives from substantially larger increases in Ecw than ELs and reduces the risk of excessive PLs. Deep neuromuscular blockade does not meaningfully change global or regional lung mechanics.

Comparison of retropubic, laparoscopic and robotic radical prostatectomy: who is the winner?

PURPOSE: This study is a systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes and the cost of open retropubic radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALP). METHODS: Summary data was abstracted from 104 original research articles representing 227,400 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE and the Cochrane Library were reviewed in December 2016. A total of 104 publications were selected for inclusion. The primary outcomes were positive surgical margin (PSM) and major complication rate according to Clavien classifications. Secondary outcomes were operative time, length of hospital stay, estimated blood loss, transfusions, conversions, rate of post-operative erectile dysfunction and incontinence and total cost of procedure. RESULTS: ORP had a significantly higher rate than RALP for PSM (OR: 1.18; 95% CI 1.05-1.32; p = 0.004), but the rate of PSM was not significantly different between ORP versus LRP (OR: 1.37; 95% CI 0.88-2.14; p = 0.17) and RALP versus LRP (OR: 0.83; 95% CI 0.40-1.72; p = 0.62). The major Clavien complication rate was significantly different between ORP and RALP (OR: 2.14; 95% CI 1.24-3.68; p = 0.006). Estimated blood loss, transfusions and length of hospital stay were low for RALP, moderate for LRP and high for ORP. The rate of erectile dysfunction (OR: 2.58; 95% CI 1.77-3.75; p < 0.001) and incontinence (OR: 3.57; 95% CI 2.28-5.58; p < 0.001) were significantly lower after RALP than LRP and equivalent for other comparisons. Total cost was highest for RALP, followed by LRP and ORP. CONCLUSIONS: For PSM and peri- and post-operative complications, RALP showed better results than ORP and LRP. In the context of the biases between the studies, one should interpret the results with caution.

Androgenic to oestrogenic switch in the human adult prostate gland is regulated by epigenetic silencing of steroid 5α-reductase 2.

Benign prostatic hyperplasia is the most common proliferative abnormality of the prostate. All men experience some prostatic growth as they age, but the rate of growth varies among individuals. Steroid 5α-reductase 2 (SRD5A2) is a critical enzyme for prostatic development and growth. Previous work indicates that one-third of adult prostatic samples do not express SRD5A2, secondary to epigenetic modifications. Here we show that the level of oestradiol is dramatically elevated, concomitant with significant upregulation of oestrogen response genes, in prostatic samples with methylation at the SRD5A2 promoter. The phosphorylation of oestrogen receptor-α in prostatic stroma is upregulated when SRD5A2 expression is absent. We show that tumour necrosis factor (TNF)-α suppresses SRD5A2 mRNA and protein expression, and simultaneously promotes expression of aromatase, the enzyme responsible for conversion of testosterone to oestradiol. Concomitant suppression of SRD5A2 and treatment with TNF-α synergistically upregulate the aromatase levels. The data suggest that, in the absence of prostatic SRD5A2, there is an androgenic to oestrogenic switch. These findings have broad implications for choosing appropriate classes of medications for the management of benign and malignant prostatic diseases. Copyright © 2017 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

DNA methyl transferase 1 reduces expression of SRD5A2 in the aging adult prostate.

5-α Reductase type 2 (SRD5A2) is a critical enzyme for prostatic development and growth. Inhibition of SRD5A2 by finasteride is used commonly for the management of urinary obstruction caused by benign prostatic hyperplasia. Contrary to common belief, we have found that expression of SRD5A2 is variable and absent in one third of benign adult prostates. In human samples, absent SRD5A2 expression is associated with hypermethylation of the SRD5A2 promoter, and in vitro SRD5A2 promoter activity is suppressed by methylation. We show that methylation of SRD5A2 is regulated by DNA methyltransferase 1, and inflammatory mediators such as tumor necrosis factor α, NF-κB, and IL-6 regulate DNA methyltransferase 1 expression and thereby affect SRD5A2 promoter methylation and gene expression. Furthermore, we show that increasing age in mice and humans is associated with increased methylation of the SRD5A2 promoter and concomitantly decreased protein expression. Artificial induction of inflammation in prostate primary epithelial cells leads to hypermethylation of the SRD5A2 promoter and silencing of SRD5A2, whereas inhibition with tumor necrosis factor α inhibitor reactivates SRD5A2 expression. Therefore, expression of SRD5A2 is not static and ubiquitous in benign adult prostate tissues. Methylation and expression of SRD5A2 may be used as a gene signature to tailor therapies for more effective treatment of prostatic diseases.

Systematic review of lower urinary tract symptoms/benign prostatic hyperplasia surgical treatments on men's ejaculatory function: Time for a bespoke approach?

Although ejaculatory dysfunction is common for patients undergoing benign prostatic hyperplasia surgery, no clear evidence is present to counsel men seeking to preserve ejaculation. Our aim was to evaluate ejaculatory dysfunction in relation to benign prostatic hyperplasia surgery. We carried out a web and manual search using MEDLINE and Embase including randomized controlled trials reporting ejaculatory dysfunction after benign prostatic hyperplasia surgery: 42 randomized controlled trials comprising a total of 3857 patients were included. Only one study had ejaculatory dysfunction as a primary outcome, and just 10 evaluated ejaculatory dysfunction before and after surgery. The definition of ejaculatory dysfunction was not standardized. Similarly, just seven studies used internationally validated questionnaires to address ejaculatory dysfunction. The reported rates of ejaculatory dysfunction after resectional electrosurgery, laser procedures, coagulation, ablation and implant techniques were assessed and compared. Transurethral resection of the prostate and recent laser procedures including holmium, thulium and GreenLight cause similar rates of ejaculatory dysfunction, occurring in almost three out of four to five men. Although providing less symptomatic benefit compared with transurethral resection of the prostate, transurethral incision of the prostate, transurethral needle ablation and transurethral microwave thermotherapy should be considered for men aiming to maintain normal ejaculation. UroLift is also a recent promising option for this category of patients. The vast majority of studies reporting ejaculatory dysfunction after benign prostatic hyperplasia surgery used poor methodology to investigate this complication. Future studies able to address clear hypothesis and considering ejaculatory dysfunction anatomical and pathophysiological features are required to develop ejaculation preserving techniques and to increase the evidence to counsel men aiming to preserve ejaculation.

Age and Obesity Promote Methylation and Suppression of 5α-Reductase 2: Implications for Personalized Therapy of Benign Prostatic Hyperplasia.

PURPOSE: In men with symptomatic benign prostatic hyperplasia 5α-reductase inhibitors are a main modality of treatment. More than 30% of men do not respond to the therapeutic effects of 5α-reductase inhibitors. We have found that a third of adult prostate samples do not express 5α-reductase type 2 secondary to epigenetic modifications. We evaluated whether 5α-reductase type 2 expression in benign prostatic hyperplasia specimens from symptomatic men was linked to methylation of the 5α-reductase type 2 gene promoter. We also identified associations with age, obesity, cardiac risk factors and prostate specific antigen. MATERIALS AND METHODS: Prostate samples from men undergoing transurethral prostate resection were used. We determined 5α-reductase type 2 protein expression and gene promoter methylation status by common assays. Clinical variables included age, body mass index, hypertension, hyperlipidemia, diabetes, prostate specific antigen and prostate volume. Univariate and multivariate statistical analyses were performed followed by stepwise logistic regression modeling. RESULTS: Body mass index and age significantly correlated with methylation of the 5α-reductase type 2 gene promoter (p <0.05) whereas prostate volume, prostate specific antigen or benign prostatic hyperplasia medication did not correlate. Methylation highly correlated with 5α-reductase protein expression (p <0.0001). In a predictive model increasing age and body mass index significantly predicted methylation status and protein expression (p <0.01). CONCLUSIONS: Increasing age and body mass index correlate with increased 5α-reductase type 2 gene promoter methylation and decreased protein expression in men with symptomatic benign prostatic hyperplasia. These results highlight the interplay among age, obesity and gene regulation. Our findings suggest an individualized epigenetic signature for symptomatic benign prostatic hyperplasia, which may be important to choose appropriate personalized treatment options.

Outpatient surgery for lower urinary tract symptoms/benign prostatic hyperplasia: truth or myth?

PURPOSE OF REVIEW: Worldwide, lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) is a common medical problem for aging men. Of patients who seek help with their symptoms, almost one-third do not respond to the medical therapy. These patients need a procedure that is safe, efficient, and durable, and at the same time carries minimal risk of side-effects. Many new technologies are introduced to our medical practice with the promise of being the ideal office-based procedure. In this review, we intend to review and discuss the role of three surgical procedures in an office setting. These include thermotherapy, 532-nm laser photo-selective vaporization of prostate, and bipolar plasma vaporization of prostate. RECENT FINDINGS: There are a few recent thermotherapy studies regarding the outcome of thermotherapy in LUTS/BPH patients. Data regarding the use of 532-ng laser photo-selective vaporization of prostate are scant but promising. The use of bipolar plasma vaporization is not well studied in an office setting. SUMMARY: In a select group of patients, thermotherapy and laser prostate surgery could be safely used to treat LUTS/BPH patients. Bipolar plasma vaporization is a promising technology, but its use in an office setting has not been completely evaluated yet.

Incidental findings at initial imaging workup of patients with prostate cancer: clinical significance and outcomes.

OBJECTIVE: The purpose of this article is to evaluate the frequency and clinical relevance of incidental findings in patients with prostate cancer who underwent abdominopelvic contrast-enhanced CT examination for initial staging workup. MATERIALS AND METHODS: We retrospectively reviewed 355 initial staging abdominopelvic contrast-enhanced CT examinations conducted from January 2000 to December 2010 in patients with prostate cancer for incidental findings that were not related to prostate cancer. A finding was judged to be potentially significant if therapeutic intervention, additional imaging, or tissue sampling was deemed advisable. The rate of incidental findings was correlated to patients' age and stratified prostate cancer risk groups. RESULTS: We found 779 incidental finding in 292 patients (82.3%), of which 75 findings in 73 patients (20.6%) were potentially significant. Indeterminate masses were the most prevalent significant finding (n = 62). Synchronous malignancy was detected in 21 patients (5.9%). Kidney cancer (n = 7 [1.97%]) was the most common malignancy, followed by lymphoma (n = 4 [1.13%]). Staging of the cancers revealed that 15 patients, including all of those with renal cancer, had N0M0 disease. Significant vascular abnormalities were reported in six cases. Additionally, significant findings, synchronous malignancies in particular, were identified at a higher rate in patients older than 65 years. However, no significant differences were noticed between the different prostate cancer risk groups. CONCLUSION: Abdominal contrast-enhanced CT for initial staging of prostate cancer shows a considerable prevalence of incidental vascular events and synchronous cancers, with kidney cancers being the most common. Notably, 71.5% of these malignancies were at early stage. Our results show an incremental value of CT in prostate cancer staging, with an emphasis on focused evaluation of the kidneys.

Office evaluation of male patients with lower urinary tract symptoms.

Lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) are one of the most common urologic disorders in men. Accurate history-taking and focused physical examination allows us to diagnose the majority of cases. A better understanding of risk factors helps us tailor our treatment and predict outcomes more accurately. Population studies are crucial in our understanding of LUTS/BPH natural history. Temporary prostatic urethral stents that are used for the management of urinary retention may also be used for evaluation of patients with detrusor hypo-contractility. The use of ultrasound to measure intravesical prostatic protrusion (IPP) and the Doppler study for prostate capsular artery resistive index are promising. Near-infrared spectroscopy (NIRS) examines the tissue oxygenation that may be affected by bladder outlet obstruction. The mathematical algorithm needs some fine-tuning, and its reproducibility is debatable. Serum and urinary biomarkers may help us to diagnose the disorder, and more effectively monitor patients' response to therapy. Among all, IPP is clinically more applicable at this time.

Prostate cancer imaging: what surgeons, radiation oncologists, and medical oncologists want to know.

OBJECTIVE: The purpose of this article is to discuss the information that is important to note in imaging reports of patients with prostate cancer. CONCLUSION: Accurate staging through imaging is an integral part of prostate cancer management. Ultrasound, CT, bone scanning, and MRI are used for prostate cancer patients to assess the primary tumor, lymph node status, and bone metastasis. Accurate reporting of images is crucial for effective cancer treatment.

Evaluation of In-Office MRI/US Fusion Transperineal Prostate Biopsy via Free-hand Device during Routine Clinical Practice.

OBJECTIVES: To describe our recent experience with in-office transperineal prostate biopsy, including the adoption of software-assisted MRI/US fusion technology. Technological improvements have recently allowed transperineal biopsy to be effectively integrated into outpatient practices with negligible risk of infection. METHODS: We retrospectively reviewed a cohort of men undergoing transperineal prostate biopsy from 2018-2020, at a single institution. We compared this to another cohort of men undergoing transrectal fusion biopsy from 2014-2018, matched to the first cohort based on age, PSA, and presence of prostate cancer diagnosis prior to biopsy. All patients underwent systematic transperineal templated biopsies in addition to fusion biopsies of MRI-visible lesions. Baseline characteristics, MRI findings, biopsy results, and complications were analyzed and compared between the 2 groups. RESULTS: One-hundred and thirty men underwent transperineal prostate biopsy, and 130 men underwent transrectal fusion biopsy. Of those who underwent transperineal biopsy, 30% underwent fusion biopsy while all men with the transrectal biopsy underwent fusion biopsy. Men who underwent transperineal vs transrectal biopsy demonstrated lower infection rates (0% vs 0.8%, P = .31) with fewer prophylactic antibiotics prescribed at provider's discretion (48% vs 100%), yet higher total post-biopsy complication rates (6.1% vs 0.8%, P = .036). CONCLUSION: Our initial experiences with transperineal prostate biopsy confirm prior findings demonstrating feasibility in outpatient urologic practice without infectious complication. Software-assisted MRI/US fusion technology can be successfully integrated with transperineal biopsies to target suspicious lesions. Higher rates of non-infectious complications were observed compared with transrectal biopsy. Further analysis is needed to determine whether risk profiles improve over the learning curve of this newly implemented approach.

Multicenter experience with photoselective vaporization of the prostate on men taking novel oral anticoagulants.

OBJECTIVE: Photoselective vaporization of the prostate (PVP) is a widely performed surgical procedure for benign prostatic obstruction. This approach has become particular favoured for men on anti-platelet and anticoagulation agents such as clopidogrel and warfarin but there is minimal published experience in the setting of novel oral anticoagulants (NOACs). This study was to examine the perioperative outcomes in men on NOACs undergoing PVP, with particular reference to perioperative morbidity. METHODS: A retrospective analysis of PVP datasets was undertaken from three centres in Sydney (Australia), Toulouse (France) and Boston (USA). Subjects who had been treated whilst on NOACs without discontinuation or bridging were identified. Perioperative outcomes and treatment parameters were examined and morbidity recorded according to Clavien-Dindo (CD) classification. RESULTS: There were a total of 20 subjects who had undergone PVP whilst NOACs had been continued during the perioperative period. The mean age was 77±6.5 years. The mean prostate volume, energy utilization and vaporisation time was 94±56 mL, 301±211 kJ, and 35±21 min respectively. The mean postoperative duration of catheterization and duration of hospitalization was 2.2±2.4 days and 2.4±2.4 days respectively. There was a single episode of urinary tract infection and four subjects required re-catheterisation for non-hematuric retentions. CONCLUSIONS: This study supports the safety of men on NOACs undergoing PVP. Whilst this study represents the largest experience of PVP in these men, larger studies are necessary to confirm the safety of PVP in this group of men undergoing BPH-related surgery.

Obesity-associated inflammation induces androgenic to estrogenic switch in the prostate gland.

BACKGROUND AND OBJECTIVE: Our patient cohort revealed that obesity is strongly associated with steroid-5α reductase type 2 (SRD5A2) promoter methylation and reduced protein expression. The underlying mechanism of prostatic growth in this population is poorly understood. Here we addressed the question of how obesity, inflammation, and steroid hormones affect the development of benign prostatic hyperplasia (BPH). MATERIAL AND METHODS: We used preadipocytes, macrophages, primary human prostatic stromal cells, prostate tissues from high-fat diet-induced obese mice, and 35 prostate specimens that were collected from patients who underwent transurethral resection of the prostate (TURP). RNA was isolated and quantified with RT-PCR. Genome DNA was extracted and SRD5A2 promoter methylation was determined. Sex hormones were determined by high-performance liquid chromatography-tandem mass spectrometry. Protein was extracted and determined by ELISA test. RESULTS: In prostatic tissues with obesity, the levels of inflammatory mediators were elevated. SRD5A2 promoter methylation was promoted, but SRD5A2 expression was inhibited. Inflammatory mediators and saturated fatty acid synergistically regulated aromatase activity. Obesity promoted an androgenic to estrogenic switch in the prostate. CONCLUSIONS: Our findings suggest that obesity-associated inflammation induces androgenic to estrogenic switch in the prostate gland, which may serve as an effective strategy for alternative therapies for management of lower urinary tract symptoms associated with BPH in select individuals.

Molecular imaging in urologic surgery.

Recently, advances in imaging technology have made possible the ability to image noninvasively specific molecular pathways in vivo that are involved in disease processes. Molecular imaging evaluates changes in cellular physiology and function rather than anatomy, which are likely to be earlier and more sensitive manifestations of disease. In addition, as newer drugs to treat disease become increasingly molecule specific, molecular imaging has become necessary to provide noninvasive determination of patients likely to benefit from treatment and early therapy response. This article reviews current and emerging molecular imaging technologies relevant to urologic surgery.

Herbal Supplements for Prostate Enlargement: Current State of the Evidence.

OBJECTIVE: To provide a comprehensive review of the current state of herbal supplement market for lower urinary tract symptoms (LUTS) and correlate the ingredients of each product with available scientific evidence. MATERIALS AND METHODS: Twenty-seven products from Amazon.com that were advertised as herbal supplements for LUTS and had listed their active ingredients were selected. Active ingredients were reviewed on Google Scholar. Product price, warranty, and consumer review information were also collected. RESULTS: A total of 58 unique active ingredients were identified. The mean number of ingredients was 8.26 (standard deviation 5.25). Whereas 17 (63%) products had an ingredient with a systematic review to support their use, 20 (74%) had an ingredient with conflicting evidence based on systematic reviews. Out of the supplements that contained ingredients supported by literature, all (100%) products simultaneously had other ingredients with no, conflicting, or refuting evidence. There was no (0%) product that contained only scientifically proven ingredients. There is no scientific study to evaluate these supplements as a whole. CONCLUSION: Despite the widespread use of herbal supplements for LUTS, there is scant scientific evidence to support their safety and efficacy. Lack of adequate regulation and government support for research and development are some of the factors that disincentivize researchers to study safety and efficacy of these products. We encourage physicians to warn their patients on the lack of adequate evidence to support the safety and efficacy of many of these supplements.

Comparison of Open Versus Laparoscopic Versus Hand-Assisted Laparoscopic Nephroureterectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: A systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes of open nephroureterectomy (ONU), laparoscopic nephroureterectomy (LNU), and hand-assisted laparoscopic nephroureterectomy (HALNU) was designed. METHODS: The summarized data were abstracted from 52 original research articles representing 19,195 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE, and the Cochrane Library were reviewed in March 2017, following PRISMA framework. A total of 52 publications were selected for inclusion. The primary outcomes were 2- and 5-year cancer-specific survival (CSS) rate, overall survival (OS) rate, and recurrence-free survival (RFS) rate. The secondary outcomes were operative time, lengths of hospitalization period, estimated blood loss, transfusions, major Clavien complication rate, metastasis rate, bladder recurrence rate, and positive surgical margin. RESULTS: On comparing LNU versus ONU and HALNU versus ONU, no significant differences between the 5-year CSS rate (P = .25, P = .39), OS rate (P = .06, P = .46), and RFS rate (P = .85, P = .73) were found. On comparing LNU versus ONU and HALNU versus ONU during a 2-year follow-up period, the following were found: CSS rate (P = .61, P = .04) and OS rate (P = .33, P = .19). There were no significant differences between the LNU versus ONU and HALNU versus ONU rates, regarding bladder recurrence (P = .12, P = .85) and metastasis rate (P = .07, P = .27). Significant higher operative time (P = .01, P = .0004), lower length of hospitalization period (P < .001, P < .001), and estimated blood loss (P = .0004, P < .001) were found in comparison to that of LNU versus ONU and HALNU versus ONU. CONCLUSION: Both LNU and HALNU had comparable oncological and better perioperative and postoperative outcomes, when compared with ONU.

Noninvasive detection of clinically occult lymph-node metastases in prostate cancer.

BACKGROUND: Accurate detection of lymph-node metastases in prostate cancer is an essential component of the approach to treatment. We investigated whether highly lymphotropic superparamagnetic nanoparticles, which gain access to lymph nodes by means of interstitial-lymphatic fluid transport, could be used in conjunction with high-resolution magnetic resonance imaging (MRI) to reveal small nodal metastases. METHODS: Eighty patients with presurgical clinical stage T1, T2, or T3 prostate cancer who underwent surgical lymph-node resection or biopsy were enrolled. All patients were examined by MRI before and 24 hours after the intravenous administration of lymphotropic superparamagnetic nanoparticles (2.6 mg of iron per kilogram of body weight). The imaging results were correlated with histopathological findings. RESULTS: Of the 334 lymph nodes that underwent resection or biopsy, 63 (18.9 percent) from 33 patients (41 percent) had histopathologically detected metastases. Of these 63 nodes, 45 (71.4 percent) did not fulfill the usual imaging criteria for malignancy. MRI with lymphotropic superparamagnetic nanoparticles correctly identified all patients with nodal metastases, and a node-by-node analysis had a significantly higher sensitivity than conventional MRI (90.5 percent vs. 35.4 percent, P<0.001) or nomograms. CONCLUSIONS: High-resolution MRI with magnetic nanoparticles allows the detection of small and otherwise undetectable lymph-node metastases in patients with prostate cancer.

Imaging of penile neoplasm.

Penile malignancies are rare, accounting for less than 1% of all male malignancy in the United States. The diagnosis can be very devastating psychologically to patients and often presents a challenge for physicians to accurately diagnose and treat these neoplasms. Clinical examination is known to have certain limitations and cross-sectional imaging techniques are increasingly utilized. Knowledge in imaging characteristics of the normal anatomy of the penis, vascular supply, lymphatic drainage, and pathology of penile malignancy is essential for an accurate staging. In this article, normal anatomy of the penis is briefly discussed and is followed by a review of multiple imaging approaches for characterization of the primary tumor and nodal staging.