Ten-year functional and oncological outcomes of a prospective randomized controlled trial comparing laparoscopic versus robot-assisted radical prostatectomy.

BACKGROUND: Among prostate cancer (PCa) treatment options, mini-invasive surgical approaches have gained a wide diffusion in the last decades. The aim of this study was to present oncological, functional, and quality of life data after 10 years of follow-up of a prospective randomized controlled trial (RCT) (ISRCTN11552140) comparing robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) for the treatment of PCa. METHODS: Patients with localized PCa were randomized to undergo LRP or RARP between January 2010 and January 2011. Functional (continence and potency) and oncological (prostate-specific antigen, biochemical recurrence [BCR] and BCR-free survival [BCRFS]) variables were evaluated. BCRFS curves were estimated by the Kaplan-Meier method and compared using the log-rank test. Machine learning partial least square-discriminant analysis (PLS-DA) was used to identify the variables characterizing more the patients who underwent RARP or LRP. RESULTS: Seventy-five of the originally enrolled 120 patients remained on follow-up for 10 years; 40 (53%) underwent RARP and 35 (47%) LRP. Continence and potency recovery rates did not show significant differences (p = 0.068 and p = 0.56, respectively), despite a Δ12% for continence and Δ8% for potency in favor of the robotic approach. However, the quality of continence (in terms of International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF] score) and erection (in terms of International Index of Erectile Function-5 [IIEF-5] score) was significantly better after 10 years in the robotic group (p = 0.02 and p < 0.001). PLS-DA revealed that LRP was characterized by the worst functional-related outcomes analyzing the entire follow-up period. Four (10%) and six (17%) patients experienced BCR in RARP and LRP groups, respectively (p = 0.36), with an overall 10-year BCR-free survival of 88% and 78% (p = 0.16). CONCLUSIONS: Comparable continence and potency rates were observed between RARP and LRP after a 10-year follow-up. However, the RARP group exhibited superior totally dry rate and erection quality. No difference in terms of oncological outcomes was found.

The prognostic role of next-generation imaging-driven upstaging in newly diagnosed prostate cancer patients.

PURPOSE: Phase III evidence showed that next-generation imaging (NGI), such as prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT), provides higher diagnostic accuracy than bone scan and contrast-enhanced computed tomography (conventional imaging, CI) in the primary staging of intermediate-to-high-risk prostate cancer (PCa) patients. However, due to the lack of outcome data, the introduction of NGI in routine clinical practice is still debated. Analysing the oncological outcome of patients upstaged by NGI (though managed according to CI) might shed light on this issue, supporting the design of randomised trials comparing the effects of treatments delivered based on NGI vs. CI. METHODS: We prospectively enrolled a cohort of 100 biopsy-proven intermediate-to-high-risk PCa patients staged with CI and PSMA PET/CT (though managed according to the CI stage), to assess the frequency of the stage migration phenomenon. Stage migration was then assessed as biochemical recurrence-free survival (bRFS) predictor. RESULTS: Three patients were lost at follow-up after imaging. PSMA PET/CT upstaged 26.8% of patients compared to CI, while it downstaged 6.1% of patients. Notably, 50% of patients excluded from surgery due to the presence of bone metastases at CI would have been treated with radical-intent approaches if PSMA PET/CT had guided the treatment choice. After a median follow-up of 6 months of surgically treated patients, 22/83 (26.5%) had biochemical recurrence (BCR). PSMA PET/CT-driven upstaging determined a significant risk increase for BCR (HR:3.41, 95%CI:1.21-9.56, p = 0.019). Including stage migration in a univariable and multivariable model identified PSMA PET/CT-upstaging as an independent predictor of bRFS. CONCLUSIONS: In conclusion, implementing NGI for staging purposes improves the prediction of bRFS. Although phase III evidence is still needed, this advancement suggests that NGI may better identify patients who would benefit from local treatments than those who may achieve better oncological outcomes through systemic treatment.

Visual extended reality tools in image-guided surgery in urology: a systematic review.

PURPOSE: The aim of this systematic review is to assess the clinical implications of employing various Extended Reality (XR) tools for image guidance in urological surgery. METHODS: In June 2023, a systematic electronic literature search was conducted using the Medline database (via PubMed), Embase (via Ovid), Scopus, and Web of Science. The search strategy was designed based on the PICO (Patients, Intervention, Comparison, Outcome) criteria. Study protocol was registered on PROSPERO (registry number CRD42023449025). We incorporated retrospective and prospective comparative studies, along with single-arm studies, which provided information on the use of XR, Mixed Reality (MR), Augmented Reality (AR), and Virtual Reality (VR) in urological surgical procedures. Studies that were not written in English, non-original investigations, and those involving experimental research on animals or cadavers were excluded from our analysis. The quality assessment of comparative and cohort studies was conducted utilizing the Newcastle-Ottawa scale, whilst for randomized controlled trials (RCTs), the Jadad scale was adopted. The level of evidence for each study was determined based on the guidelines provided by the Oxford Centre for Evidence-Based Medicine. RESULTS: The initial electronic search yielded 1,803 papers after removing duplicates. Among these, 58 publications underwent a comprehensive review, leading to the inclusion of 40 studies that met the specified criteria for analysis. 11, 20 and 9 studies tested XR on prostate cancer, kidney cancer and miscellaneous, including bladder cancer and lithiasis surgeries, respectively. Focusing on the different technologies 20, 15 and 5 explored the potential of VR, AR and MR. The majority of the included studies (i.e., 22) were prospective non-randomized, whilst 7 and 11 were RCT and retrospective studies respectively. The included studies that revealed how these new tools can be useful both in preoperative and intraoperative setting for a tailored surgical approach. CONCLUSIONS: AR, VR and MR techniques have emerged as highly effective new tools for image-guided surgery, especially for urologic oncology. Nevertheless, the complete clinical advantages of these innovations are still in the process of evaluation.

Role of neoadjuvant chemotherapy in patients with locally advanced and clinically positive nodes Upper Tract Urothelial Carcinoma treated with Nephroureterectomy: real-world data from the ROBUUST 2.0 Registry.

PURPOSE: To assess the impact of neoadjuvant and adjuvant chemotherapy on survival outcomes, within a large multicenter cohort of Upper tract urothelial carcinoma patients treated with Nephroureterectomy. METHODS: A multicenter retrospective analysis utilizing the Robotic surgery for Upper Tract Urothelial Cancer Study registry was performed. Baseline, preoperative, perioperative, and pathologic variables of three groups of patients receiving surgery only, neoadjuvant or adjuvant chemotherapy were compared. Categorical and continuous variables among the three subgroups were compared with Chi square and ANOVA tests. The impact of perioperative chemotherapy on survival outcomes was assessed with the Kaplan Meier method. Univariable and multivariable Cox regression analyses were performed to identify predictors of survival. RESULTS: Overall, 1,994 patients were included. Overall and Clavien grade ≥3 complications rates were comparable among the three subgroups (p = 0.65 and p = 0.92). At Kaplan Meier analysis, neoadjuvant chemotherapy significantly improved cancer-specific survival (p = 0.03) and overall survival (p = 0.03) probabilities of patients with cT ≥ 3 tumors and of those with positive cN (p = 0.03 and p = 0.02). On multivariable analysis, neoadjuvant chemotherapy was independently associated with an improvement of cancer-specific survival in cT ≥ 3 patients (HR 0.44; p = 0.04), and of both cancer-specific survival (HR 0.50; p = 0.03) and overall survival (HR 0.53; p = 0.02) probabilities in positive cN patients. CONCLUSIONS: This large multicenter retrospective analysis suggests significant survival benefit in Upper tract urothelial carcinoma patients with either locally advanced or clinically positive nodes disease receiving neoadjuvant chemotherapy. These findings can be regarded as "hypothesis generating", stimulating future trials focusing on such advanced stages.

Techniques for Penile Augmentation Surgery: A Systematic Review of Surgical Outcomes, Complications, and Quality of Life.

The increase in practices related to enhancing penile size can be attributed to the belief that an improved genital appearance contributes to a man's virility, coupled with an altered self-perception of his body. It is crucial to tailor interventions to meet the genuine needs of patients by thoroughly assessing their history, psychological state, and potential surgical benefits, all while considering the associated risks of complications. This systematic review aims to summarize the available evidence on outcomes, complications, and quality of life after penile augmentation surgery, examining both minimally invasive and more radical techniques. A search of the PubMed and Scopus databases, focusing on English-language papers published in the last 15 years, was performed in December 2023. Papers discussing surgery in animal models and case reports were excluded from the present study unless further evaluated in a follow-up case series. The primary outcomes were changes in penile dimensions, specifically in terms of length and girth, as well as the incidence of surgical complications and the impact on quality of life. A total of 1670 articles were retrieved from the search and 46 were included for analysis. Procedures for penile length perceived enhancements include lipoplasty, skin reconstruction plasty, V-Y and Z plasty, flap reconstruction, scrotoplasty, ventral phalloplasty, and suspensory ligament release; techniques for increasing corporal penile length include penile disassembly, total phalloplasty, and sliding elongation. Finally, penile girth enhancement may be performed using soft tissue fillers, grafting procedures, biodegradable scaffolds, and Penuma®. In conclusion, while penile augmentation surgeries offer potential solutions for individuals concerned about genital size, the risks and complexities need to be accounted for.

Unilateral Pelvic Lymph Node Dissection in Prostate Cancer Patients Diagnosed in the Era of Magnetic Resonance Imaging-targeted Biopsy: A Study That Challenges the Dogma.

PURPOSE: Bilateral extended pelvic lymph node dissection at the time of radical prostatectomy is the current standard of care if pelvic lymph node dissection is indicated; often, however, pelvic lymph node dissection is performed in pN0 disease. With the more accurate staging achieved with magnetic resonance imaging-targeted biopsies for prostate cancer diagnosis, the indication for bilateral extended pelvic lymph node dissection may be revised. We aimed to assess the feasibility of unilateral extended pelvic lymph node dissection in the era of modern prostate cancer imaging. MATERIALS AND METHODS: We analyzed a multi-institutional data set of men with cN0 disease diagnosed by magnetic resonance imaging-targeted biopsy who underwent prostatectomy and bilateral extended pelvic lymph node dissection. The outcome of the study was lymph node invasion contralateral to the prostatic lobe with worse disease features, ie, dominant lobe. Logistic regression to predict lymph node invasion contralateral to the dominant lobe was generated and internally validated. RESULTS: Overall, data from 2,253 patients were considered. Lymph node invasion was documented in 302 (13%) patients; 83 (4%) patients had lymph node invasion contralateral to the dominant prostatic lobe. A model including prostate-specific antigen, maximum diameter of the index lesion, seminal vesicle invasion on magnetic resonance imaging, International Society of Urological Pathology grade in the nondominant side, and percentage of positive cores in the nondominant side achieved an area under the curve of 84% after internal validation. With a cutoff of contralateral lymph node invasion of 1%, 602 (27%) contralateral pelvic lymph node dissections would be omitted with only 1 (1.2%) lymph node invasion missed. CONCLUSIONS: Pelvic lymph node dissection could be omitted contralateral to the prostate lobe with worse disease features in selected patients. We propose a model that can help avoid contralateral pelvic lymph node dissection in almost one-third of cases.

Three-dimensional virtual models assistance predicts higher rates of "successful" minimally invasive partial nephrectomy: an Institutional analysis across the available trifecta definitions.

PURPOSE: 3D virtual models (3DVMs) are nowadays under scrutiny to improve partial nephrectomy (PN) outcomes. Five different Trifecta definitions have been proposed to optimize the framing of "success" in the PN field. Our aim is to analyze if the use of 3DVMs could impact the success rate of minimally invasive PN (mi-PN), according to the currently available definitions of Trifecta. MATERIALS AND METHODS: At our Institution 250 cT1-2N0M0 renal masses patients treated with mi-PN were prospectively enrolled. Inclusion criteria were the availability of contrast-enhanced CT, baseline and postoperative serum creatinine, and eGFR. These patients were then compared with a control group of 710 patients who underwent mi-PN with the same renal function assessments, but without 3DVMs. Multivariable logistic regression (MLR) models were used to predict the trifecta achievement according to the different trifecta definitions. RESULTS: Among the definitions, Trifecta rates ranged between 70.8% to 97.4% in the 3DVM group vs. 56.8% to 92.8% in the control group (all p values < 0.05). 3DVMs showed better postoperative outcomes in terms of ΔeGFR, ( - 16.6% vs. - 2.7%, p = 0.03), postoperative complications (15%, vs 22.9%, p = 0.002) and major complications (Clavien Dindo > 3, 2.8% vs 5.6%, p = 0.03). At MLR 3DVMs assistance independently predicted higher rates of successful PN across all the available definitions of Trifecta (OR: 2.7 p < 0.001, OR:2.0 p = 0.0008, OR:2.8 p = 0.02, OR 2.0 p = 0.003). CONCLUSIONS: The 3DVMs availability was found to be the constant predictive factor of successful PN, with a twofold higher probability of achieving Trifecta regardless of the different definitions available in Literature.

Diagnosis of prostate cancer with magnetic resonance imaging in men treated with 5-alpha-reductase inhibitors.

PURPOSE: The primary aim of this study was to evaluate if exposure to 5-alpha-reductase inhibitors (5-ARIs) modifies the effect of MRI for the diagnosis of clinically significant Prostate Cancer (csPCa) (ISUP Gleason grade ≥ 2). METHODS: This study is a multicenter cohort study including patients undergoing prostate biopsy and MRI at 24 institutions between 2013 and 2022. Multivariable analysis predicting csPCa with an interaction term between 5-ARIs and PIRADS score was performed. Sensitivity, specificity, and negative (NPV) and positive (PPV) predictive values of MRI were compared in treated and untreated patients. RESULTS: 705 patients (9%) were treated with 5-ARIs [median age 69 years, Interquartile range (IQR): 65, 73; median PSA 6.3 ng/ml, IQR 4.0, 9.0; median prostate volume 53 ml, IQR 40, 72] and 6913 were 5-ARIs naïve (age 66 years, IQR 60, 71; PSA 6.5 ng/ml, IQR 4.8, 9.0; prostate volume 50 ml, IQR 37, 65). MRI showed PIRADS 1-2, 3, 4, and 5 lesions in 141 (20%), 158 (22%), 258 (37%), and 148 (21%) patients treated with 5-ARIs, and 878 (13%), 1764 (25%), 2948 (43%), and 1323 (19%) of untreated patients (p < 0.0001). No difference was found in csPCa detection rates, but diagnosis of high-grade PCa (ISUP GG ≥ 3) was higher in treated patients (23% vs 19%, p = 0.013). We did not find any evidence of interaction between PIRADS score and 5-ARIs exposure in predicting csPCa. Sensitivity, specificity, PPV, and NPV of PIRADS ≥ 3 were 94%, 29%, 46%, and 88% in treated patients and 96%, 18%, 43%, and 88% in untreated patients, respectively. CONCLUSIONS: Exposure to 5-ARIs does not affect the association of PIRADS score with csPCa. Higher rates of high-grade PCa were detected in treated patients, but most were clearly visible on MRI as PIRADS 4 and 5 lesions. TRIAL REGISTRATION: The present study was registered at ClinicalTrials.gov number: NCT05078359.

Urinary outcomes of new ultra-minimally invasive treatments for prostate cancers.

PURPOSE OF REVIEW: The aim of this narrative review is to evaluate the current available literature on urinary outcomes following cryotherapy and high-intensity focused ultrasound (HIFU) for localized prostate cancer (PCa). RECENT FINDINGS: The available literature is heterogeneous in terms of intervention modalities and assessment of urinary outcome measures. Nevertheless, ultra-minimally invasive treatments seem to provide good urinary outcomes. Technological advancement and the adoption of more conservative ablation templates allow for a further reduction of toxicity and better preservation of urinary function. Urinary incontinence occurs in 0-10% of the patients and, is mostly transient. Voiding and storage lower urinary tract symptoms (LUTS) mostly occur in the early postoperative period and rarely require surgical treatment. Focal therapies performed with a salvage intent after external beam radiotherapy have a significantly higher impact on patient's urinary function. SUMMARY: Ultra-minimally invasive treatment for PCa show a good safety profile concerning urinary function, but consensus on when and how best to assess this is still lacking. Efforts should be made to standardize the report of preoperative and postoperative urinary function to provide higher level of evidence.

Treatment of Ureteral Stent-Related Symptoms.

BACKGROUND: The aim of the study was to assess the effectiveness of the main classes of drugs used at reducing morbidity related to ureteric stents. SUMMARY: After establishing a priori protocol, a systematic electronic literature search was conducted in July 2019. The randomized clinical trials (RCTs) selection proceeded in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and was registered (PROSPERO ID 178130). The risk of bias and the quality assessment of the included RCTs were performed. Ureteral Stent Symptom Questionnaire (USSQ), International Prostate Symptom Score (IPSS), and quality of life (QoL) were pooled for meta-analysis. Mean difference and risk difference were calculated as appropriate for each outcome to determine the cumulative effect size. Fourteen RCTs were included in the analysis accounting for 2,842 patients. Alpha antagonist, antimuscarinic, and phosphodiesterase (PDE) inhibitors significatively reduced all indexes of the USSQ, the IPSS and QoL scores relative to placebo. Conversely, combination therapy (alpha antagonist plus antimuscarinic) showed in all indexes of the USSQ, IPSS, and QoL over alpha antagonist or antimuscarinic alone. On comparison with alpha blockers, PDE inhibitors were found to be equally effective for urinary symptoms, general health, and body pain parameters, but sexual health parameters improved significantly with PDE inhibitors. Finally, antimuscarinic resulted in higher decrease in all indexes of the USSQ, the IPSS, and QoL relative to alpha antagonist. KEY MESSAGE: Relative to placebo, alpha antagonist alone, antimuscarinics alone, and PDE inhibitors alone have beneficial effect in reducing stent-related symptoms. Furthermore, there are significant advantages of combination therapy compared with monotherapy. Finally, PDE inhibitors are comparable to alpha antagonist, and antimuscarinic seems to be more effective than alpha antagonist alone.

Health Information Technology Usability Evaluation Scale (Health-ITUES) and User-Experience Questionnaire (UEQ) for 3D Intraoperative Cognitive Navigation (ICON3DTM) System for Urological Procedures.

Backgound and objectives: In recent years, the adoption of 3D models for surgical planning and intraoperative guidance has gained a wide diffusion. The aim of this study was to evaluate the surgeons' perception and usability of ICON3DTM platform for robotic and laparoscopic urological surgical procedures. Materials and Methods: During the 10th edition of the Techno-Urology Meeting, surgeons and attendees had the opportunity to test the new ICON3DTM platform. The capability of the user to manipulate the model with hands/mouse, the software usability, the quality of the 3D model's reproduction, and the quality of its use during the surgery were evaluated with the Health Information Technology Usability Evaluation Scale (Health-ITUES) and the User-Experience Questionnaire (UEQ). Results: Fifty-three participants responded to the questionnaires. Based on the answers to the Health-ITUES questionnaire, ICON3DTM resulted to have a positive additional value in presurgical/surgical planning with 43.4% and 39.6% of responders that rated 4 (agree) and 5 (strongly agree), respectively. Regarding the UEQ questionnaire, both mouse and infrared hand-tracking system resulted to be easy to use for 99% of the responders, while the software resulted to be easy to use for 93.4% of the responders. Conclusions: In conclusion, ICON3DTM has been widely appreciated by urologists thanks to its various applications, from preoperative planning to its support for intraoperative decision-making in both robot-assisted and laparoscopic settings.

An Algorithm to Personalize Nerve Sparing in Men with Unilateral High-Risk Prostate Cancer.

PURPOSE: Current guidelines do not provide strong recommendations on preservation of the neurovascular bundles during radical prostatectomy in case of high-risk (HR) prostate cancer and/or suspicious extraprostatic extension (EPE). We aimed to evaluate when, in case of unilateral HR disease, contralateral nerve sparing (NS) should be considered or not. MATERIALS AND METHODS: Within a multi-institutional data set we selected patients with unilateral HR prostate cancer, defined as unilateral EPE and/or seminal vesicle invasion (SVI) on multiparametric (mp) magnetic resonance imaging (MRI), or unilateral International Society of Urologic Pathologists (ISUP) 4-5 or prostate specific antigen ≥20 ng/ml. To evaluate when to perform NS based on the risk of contralateral EPE, we relied on chi-square automated interaction detection, a recursive machine-learning partitioning algorithm developed to identify risk groups, which was fit to predict the presence of EPE on final pathology, contralaterally to the prostate lobe with HR disease. RESULTS: A total of 705 patients were identified. Contralateral EPE was documented in 87 patients (12%). Chi-square automated interaction detection identified 3 groups, consisting of 1) absence of SVI on mpMRI and index lesion diameter ≤15 mm, 2) index lesion diameter ≤15 mm and contralateral ISUP 2-3 or index lesion diameter >15 mm and negative contralateral biopsy or ISUP 1, and 3) SVI on mpMRI or index lesion diameter >15 mm and contralateral biopsy ISUP 2-3. We named those groups as low, intermediate and high-risk, respectively, for contralateral EPE. The rate of EPE and positive surgical margins across the groups were 4.8%, 14% and 26%, and 5.6%, 13% and 18%, respectively. CONCLUSIONS: Our study challenges current guidelines by proving that wide bilateral excision in men with unilateral HR disease is not justified. Pending external validation, we propose performing NS and incremental NS in case of contralateral low and intermediate EPE risk, respectively.

Diagnostic performance of fusion (US/MRI guided) prostate biopsy: propensity score matched comparison of elastic versus rigid fusion system.

PURPOSE: Many software for US/MRI guided fusion prostate biopsy (FPB), have been developed in the last years. However, there are few data comparing diagnostic accuracy of different fusion systems. We assessed diagnostic performance of elastic (EF) versus rigid fusion (RF) PB in a propensity score matched (PSM) analysis. METHODS: A total of 314 FPB were prospectively collected from two different centers. All patients were biopsy naïve and all mpMRI reported a single suspicious area. Overall, 211 PB were performed using a RF system and 103 using an EF software. The two groups were compared for the main clinical features. A 1:1 PSM analysis was employed to reduce covariate imbalance to < 10%. Detection rate (DR) for any prostate cancer (PCa) and clinically significant (cs) PCa were compared and stratified for PI-RADS Score. A per target univariable and multivariable regression analyses were applied to identity predictors of anyPCa and csPCa. RESULTS: After applying the PSM, two cohorts of 83 cases were selected. DR of any PCa cancer and csPCa were comparable between the two cohorts (all p > 0.077) as well as DR of csPCa for every PIRADS score. At univariable regression analysis lesion size, PI-RADS Score, PSA Density and EF system were predictors of any PCa (all p < 0.001); however, at multivariable analysis only PI-RADS Score was independent predictor of any PCa (p = 0.027). At multivariable analysis only PI-RADS score was independent predictor of csPCa. CONCLUSIONS: Fusion PB guarantees high diagnostic accuracy for csPCa, regardless of the fusion technology. Prospective randomized study is needed to confirm these data.

The impact of 3D models on positive surgical margins after robot-assisted radical prostatectomy.

PURPOSE: To evaluate the role of 3D models on positive surgical margin rate (PSM) rate in patients who underwent robot-assisted radical prostatectomy (RARP) compared to a no-3D control group. Secondarily, we evaluated the postoperative functional and oncological outcomes. METHODS: Prospective study enrolling patients with localized prostate cancer (PCa) undergoing RARP with mp-MRI-based 3D model reconstruction, displayed in a cognitive or augmented-reality fashion, at our Centre from 01/2016 to 01/2020. A control no-3D group was extracted from the last two years of our Institutional RARP database. PSMr between the two groups was evaluated and multivariable linear regression (MLR) models were applied. Finally, Kaplan-Meier estimator was used to calculate biochemical recurrence at 12 months after the intervention. RESULTS: 160 patients were enrolled in the 3D Group, while 640 were selected for the Control Group. A more conservative NS approach was registered in the 3D Group (full NS 20.6% vs 12.7%; intermediate NS 38.1% vs 38.0%; standard NS 41.2% vs 49.2%; p = 0.02). 3D Group patients had lower PSM rates (25 vs. 35.1%, p = 0.01). At MLR models, the availability of 3D technology (p = 0.005) and the absence of extracapsular extension (ECE, p = 0.004) at mp-MRI were independent predictors of lower PSMr. Moreover, 3D model represented a significant protective factor for PSM in patients with ECE or pT3 disease. CONCLUSION: The availability of 3D models during the intervention allows to modulate the NS approach, limiting the occurrence of PSM, especially in patients with ECE at mp-MRI or pT3 PCa.

Robotic partial nephrectomy in 3D virtual reconstructions era: is the paradigm changed?

CONTEXT: The development of a tailored, patient-specific medical and surgical approach is becoming object of intense research. In kidney oncologic surgery, where a clear understanding of case-specific surgical anatomy is considered a key point to optimize the perioperative outcomes, such philosophy gained increasing importance. Recently, important advances in 3D virtual modeling technologies have fueled the interest for their application in the field of robotic minimally invasive surgery for kidney tumors. OBJECTIVE: To provide a synthesis of current applications of 3D virtual models for robot-assisted partial nephrectomy. EVIDENCE ACQUISITION: Medline, PubMed, the Cochrane Database, and Embase were screened for Literature regarding the use of 3D virtual models for robot-assisted partial nephrectomy (RAPN). EVIDENCE SYNTHESIS: The use of 3D virtual models for RAPN has been tested in different settings, including surgical indication and planning, intraoperative guidance, and training. Currently, several studies are available on the application of this technology for surgical planning, demonstrating impact on clinical outcomes such as renal function recovery, whilst experiences concerning their intraoperative application for navigation are still experimental. One of the latest innovations in this field is represented by the development of dedicated softwares able to automatically overlap the 3D virtual models to the real anatomy, to perform augmented reality procedures. CONCLUSIONS: The available Literature suggests a potentially crucial role of 3D virtual reconstructions during RAPN. Encouraging results concerning surgical planning and indication, intraoperative navigation, and surgical training are available. In the future, artificial intelligence may represent the key to further improve the 3D virtual modeling technology during RAPN.

Anastomosis quality score during robot-assisted radical prostatectomy: a new simple tool to maximize postoperative management.

PURPOSE: The urethro-vesical anastomosis represents one of the most challenging steps of robotic prostatectomy (RARP). To maximize postoperative management, we specifically designed our anastomosis quality score (AQS), based on the intraoperative characteristics of the urethra and bladder neck. METHODS: This is a prospective study, conducted from April 2019 to March 2020. All the patients were classified into three different AQS categories (low, intermediate, high) based on the quality of the anastomosis. The postoperative management was modulated accordingly. RESULTS: We enrolled 333 patients. According to AQS, no differences were recorded in intraoperative complications (p = 0.9). Median hospital stay and catheterization time were longer in AQS 1 group (p < 0.001). Additionally, the occurrence of postoperative complication was higher in AQS 1 category (p = 0.002) but, when focusing on the complications related to the quality of the anastomosis, no differences were found neither for acute urinary retention (p = 0.12) nor urine leakage (p = 0.11). Finally, concerning the continence recovery, no significant differences were found among the three groups for each time point. The highest potency recovery rate at one month of follow-up was recorded in AQS 3 category (p = 0. 03). CONCLUSION: The AQS proposed revealed to be a valid too to intraoperatively categorize patients who underwent RARP on the basis of the urethral and bladder neck features. The modulated postoperative management for each specific score category allowed to limit the occurrence of complications and to maximize the functional outcomes.

Retroperitoneal versus transepritoneal robot-assisted partial nephrectomy for postero-lateral renal masses: an international multicenter analysis.

PURPOSE: To assess the outcomes of retroperitoneal robot-assisted partial nephrectomy (r-RAPN) in a large cohort of patients with postero-lateral renal masses comparing to those of transperitoneal RAPN (t-RAPN). METHODS: Patients with posterior (R.E.N.A.L. score grading P) or lateral (grading X) renal mass who underwent RAPN in six high-volume US and European centers were identified and stratified into two groups according to surgical approach: r-RAPN ("study group") and t-RAPN ("control group"). Baseline characteristics, intraoperative, and postoperative data were collected and compared. RESULTS: Overall, 447 patients were identified for the analysis. 231 (51.7%) and 216 (48.3%) patients underwent r-RAPN and t-RAPN, respectively. Baseline characteristics were not statistically significantly different between the groups. r-RAPN group reported lower median operative time (140 vs. 170 min, p < 0.001). No difference was found in ischemia time, estimated blood loss, and intraoperative complications. Overall, 47 and 54 postoperative complications were observed in r-RAPN and t-RAPN groups, respectively (20.3 vs. 25.1%, p = 0.9). 1 and 2 patients reported major complications (Clavien-Dindo ≥ III grade) in the retroperitoneal and transperitoneal groups (0.4 vs. 0.9%, p = 0.9). There was no difference in hospital re-admission rate, median length of stay, and PSM rate. Trifecta criteria were achieved in 90.3 and 89.2% of r-RAPN and t-RAPN, respectively (p = 0.7). CONCLUSION: r-RAPN and t-RAPN offer similar postoperative, functional, and oncological outcomes for patients with postero-lateral renal tumors. Our analysis suggests an advantage for r-RAPN in terms of shorter operative time, whereas it does not confirm a difference in terms of length of stay, as suggested by previous reports.

Implementing telemedicine for the management of benign urologic conditions: a single centre experience in Italy.

PURPOSE: To assess the use of telemedicine with phone-call visits as a practical tool to follow-up with patients affected by urological benign diseases, whose clinic visits had been cancelled during the acute phase of the COVID-19 pandemic. METHODS: Patients were contacted via phone-call and a specific questionnaire was administered to evaluate the health status of these patients and to identify those who needed an "in-person" ambulatory visit due to the worsening of their condition. Secondarily, the patients' perception of a potential shift towards a "telemedicine" approach to the management of their condition and to indirectly evaluate their desire to return to "in-person" clinic visits. RESULTS: 607 were contacted by phone-call. 87.5% (531/607) of the cases showed stability of the symptoms so no clinic in-person or emergency visits were needed. 81.5% (495/607) of patients were more concerned about the risk of contagion than their urological condition. The median score for phone visit comprehensibility and ease of communication of exams was 5/5; whilst patients' perception of phone visits' usefulness was scored 4/5. 53% (322/607) of the interviewees didn't own the basic supports required to be able to perform a real telemedicine consult according to the required standards. CONCLUSION: Telemedicine approach limits the number of unnecessary accesses to medical facilities and represents an important tool for the limitation of the risk of transmission of infectious diseases, such as COVID-19. However, infrastructures, health workers and patients should reach out to a computerization process to allow a wider diffusion of more advanced forms of telemedicine, such as televisit.

Adrenal tumours: open surgery versus minimally invasive surgery.

PURPOSE OF REVIEW: The aim of this article is to focus on state-of-the-art minimally invasive adrenalectomy (MIA) and the most recent role of open adrenalectomy for adrenal tumours, respect to MIA and open adrenalectomy for adrenocortical cancer (ACC). RECENT FINDINGS: The laparoscopic (both transperitoneal and retroperitoneal) approach is the first-choice treatment in cases of small-to-medium benign adrenal tumours. This approach is feasible and well tolerated even for larger lesions without radiological signs of malignancy. Robotic adrenalectomy has recently increased in popularity, although the results appear to be fully comparable with those of laparoscopy. Open approach is the keystone of ACC surgery, especially when neighbour tissues, organs, or vessels are involved. Recent evidence suggests caution in treating localized ACC with laparoscopy, because of the higher rate of local or peritoneal recurrence, and shorter recurrence-free survival rates with respect to open adrenalectomy. SUMMARY: MIA has progressively replaced the traditional open approach and plays a complementary role in the treatment of adrenal tumour. It is the first option for benign lesions, whereas open adrenalectomy is a cornerstone treatment for ACC. The overlap of indications for laparoscopic adrenalectomy and open adrenalectomy is today confined to the treatment of organ-confined adrenal cancer, in which the role of laparoscopic surgery is far from being clearly defined.

Retzius-sparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes.

OBJECTIVES: To summarize the current evidence on Retzius-sparing (RS)-robot-assisted radical prostatectomy (RARP) and to compare its oncological, peri-operative and functional outcomes with those of standard retropubic RARP (S-RARP). MATERIALS AND METHODS: After establishing an a priori protocol, a systematic electronic literature search was conducted in January 2019 using the Medline (via PubMed), Embase (via Ovid) and Cochrane databases. The search strategy relied on the 'PICO' (Patient Intervention Comparison Outcome) criteria and article selection was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only studies reporting the oncological and functional outcomes of RARP (as determined by type of procedure [RS-RARP vs S-RARP]) were considered for inclusion. Risk of bias and study quality were assessed. Finally, peri-operative and functional outcomes were recorded and analysed. RESULTS: A shorter operating time was associated with RS-RARP (weighted mean difference [WMD] 14.7 min, 95% confidence interval [CI] -28.25, 1.16; P = 0.03), whereas no significant difference was found in terms of estimated blood loss (WMD 1.45 mL, 95% CI -31.18, 34.08; P = 0.93). Also, no significant difference between the two groups was observed for overall (odds ratio [OR] 0.86, 95% CI 0.40, 1.85; P = 0.71) and major (Clavien >3; OR 0.88, 95% CI 0.30, 2.57) postoperative complications; however, the likelihood of positive surgical margins (PSMs) was lower for the S-RARP group (rate 15.2% vs 24%; OR 1.71, 95% CI 1.12, 2.60; P = 0.01). The cumulative analysis showed a statistically significant advantage for RS-RARP in terms of continence recovery at 1 month (OR 2.54, 95% CI 1.16, 5.53; P = 0.02), as well as at 3 months (OR 3.86, 95% CI 2.23, 6.68; P < 0.001), 6 months (OR 3.61, 95% CI 1.88, 6.91; P = 0.001), and 12 months (OR 7.29, 95% CI 1.89, 28.13; P = 0.004). CONCLUSION: Our analysis confirms that RS-RARP is a safe and feasible alternative to S-RARP. This novel approach may be associated with faster and higher recovery of continence, without increasing the risk of complications. One caveat might be the higher risk of PSMs, and this can be regarded as a current pitfall of the technique, probably related to an expected learning curve.