Challenging cases in high-risk prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy.

OBJECTIVE: To evaluate the relationship between enlarged prostate, bulky median lobe (BML) or prior benign prostatic hyperplasia (BPH) surgery and perioperative functional, and oncological outcomes in high-risk (HR) prostate cancer (PCa) patients treated with Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). METHODS: 320 HR-PCa patients treated with RS-RARP between 2011 and 2020 at a single high-volume center. The relationship between prostate volume, BML, prior BPH surgery and perioperative outcomes, Clavien-Dindo (CD) grade ≥ 2 90-day postoperative complications, positive surgical margins (PSMs), and urinary continence (UC) recovery was evaluated respectively in multivariable linear, logistic and Cox regression models. Complications were collected according to the standardized methodology proposed by EAU guidelines. UC recovery was defined as the use of zero or one safety pad. RESULTS: Overall, 5.9% and 5.6% had respectively a BML or prior BPH surgery. Median PV was 45 g (range: 14-300). The rate of focal and non-focal PSMs was 8.4% and 17.8%. 53% and 10.9% patients had immediate UC recovery and CD ≥ 2. The 1- and 2-yr UC recovery was 84 and 85%. PV (p = 0.03) and prior BPH surgery (p = 0.02) was associated with longer operative time. BML was independent predictor of time to bladder catheter removal (p = 0.001). PV was independent predictor of PSMs (OR: 1.02; p = 0.009). Prior BPH surgery was associated with lower UC recovery (HR: 0.5; p = 0.03). CONCLUSION: HR-PCa patients with enlarged prostate have higher risk of PSMs, while patients with prior BPH surgery have suboptimal UC recovery. These findings should help physicians for accurate preoperative counseling and to improve surgical planning in case of HR-PCa patients with challenging features.

Safety and tolerability of local treatment with iloprost, a prostacyclin analogue, in patients with Peyronie's disease: a phase I study.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Peyronie's disease (PD) is an acquired curvature of the penis attributable to progressive fibromatosis of the tunica albuginea (TA). It is frequently associated with Dupuytren's contracture and those of Ledderhose. More recently it was found that patients suffering from PD also often suffer from diabetes mellitus and gout. Cigarette smoking and the intake of large amounts of alcohol are considered risk factors for PD.The exact aetiology of the disease is unknown, however, the trauma hypothesis is shared by most authors. According to this theory, repeated sexual microtrauma in people genetically predisposed could cause PD. The inflammatory process leads to the formation of fibrosis and plaques. Plaque can lead to penile curvature and may reduce its functionality. Pain is the most common symptom of early-stage disease. In the late stages the pain disappears, but erectile dysfunction may occur. Surgical treatment is available, but this exposes the patient to a greater risk of erectile dysfunction and it is most frequently associated with a reduction in the length of the penis. The rationale for local medical therapy is to use a treatment that acts on the initial phase of the disease by reducing and stopping the processes that lead to fibrosis, thus stabilizing the disease. Systemic medical therapy is usually accompanied by high rates of recurrence. Many authors consider local drug therapy more appropriate. Local treatment consists of several types of medication, but results are often sub-optimal. Anti-inflammatory or immunoregulatory therapy, either systemic or topical, has shown some efficacy when administered early in the disease by modulating the inflammatory response and attenuating the alteration of tissue repair. Unfortunately, in most cases, patients are first seen when the plaque is chronically inflamed, stabilized and sometimes already calcified. We have tested a biological drug for intralesional administration for the first time. We chose iloprost, an analogue of prostacyclin I2, for its theoretically favourable properties. If used i.v., it has been shown to be effective in treating vascular ischaemic disease such as thromboangioitis obliterans, peripheral arterial occlusive disease, Raynaud's phenomenon and systemic sclerosis. The rationale for the therapeutic use of iloprost in the late stages of PD is based on the assumption that activation of fibrinolysis induced by the drug would be able to determine a regression of the plaque with a consequent reduction of the curvature on erection. The main purpose of this phase I study was to evaluate the safety and tolerability of this drug injected in the context of the fibrous plaque on a small number of patients before designing a large-scale randomized trial. According to the results,therapy with intralesional iloprost in Peyronie's disease seems to be safe and tolerated and is a possible alternative to surgery. OBJECTIVE: To assess the safety and tolerability of intralesional injections of iloprost (an I2 prostacyclin analogue) for its ability to suppress the production of connective tissue growth factor in fibroblasts, for the treatment of Peyronie's disease (PD). PATIENTS AND METHODS: A total of 38 patients with PD were preliminarily assessed according to symptoms, the degree of penile curvature and the size and number of plaques. Each patient received weekly intralesional injections of iloprost 200 ng in 1 mL normal saline for 5 weeks. If tolerated, the single dose was increased weekly to the maximum of 400 ng (2 mL). All the patients were preliminarily evaluated using at-home photography and were re-evaluated 2 months after the end of the treatment regimen. There was no placebo control group in this phase I study. RESULTS: Almost all patients showed mild side effects (burning or pain) during the treatment at the site of injection. All patients tolerated well a iloprost dose of 200 ng; 19 patients reached a 300 ng dose and 14 tolerated a 400 ng dose without showing side effects. A total of 29% of the patients showed an improvement in curvature. CONCLUSION: The results show that therapy with intralesional iloprost is a possible alternative to surgery for Peyronie's disease.

Retzius-sparing Robot-assisted Radical Prostatectomy in High-risk Prostate Cancer Patients: Results from a Large Single-institution Series.

Background: Retzius-sparing (RS) robot-assisted radical prostatectomy represents a valid surgical treatment option for prostate cancer (PCa) patients. However, the available evidence on the role of RS in high-risk (HR) PCa setting is sparse. Objective: To describe our RS technique for HR-PCa patients and to evaluate intra-, peri-, and postoperative oncological and functional outcomes. Design setting and participants: A total of 340 D'Amico HR-PCa patients underwent RS at a single high-volume centre between 2011 and 2020. Surgical procedure: Surgical procedures were performed by five experienced robotic surgeons. Measurements: Complications were collected according to the standardised methodology proposed by the European Association of Urology guidelines. Postoperative outcomes were evaluated in patients with complete follow-up data (n = 320). Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values of ≥0.2 ng/ml. Urinary continence (UC) recovery was defined as the use of zero or one safety pad. Kaplan-Meier and multivariable logistic and Cox regression models were performed. Results and limitations: Fourteen patients (4%) experienced intraoperative complications and 52 90-d complications occurred in 44 patients (14%), of whom 24 had Clavien-Dindo 3a/b. Final pathology reported 49% International Society of Urological Pathology (ISUP) grade 4-5, 55% ≥pT3a, and 28.8% positive surgical margins (PSMs; 9.4% focal and 19.4% extended PSMs). The median follow-up was 47 mo. Overall, 35.3% and 1.3% harboured BCR and died from PCa. At 4 yr of follow-up, BCR-free survival and additional treatment-free survival were 63.6% and 56.6%, respectively. ISUP 4-5 at biopsy (odds ratio [OR]: 2.6), prostate volume (OR: 1.03), partial or full nerve sparing (OR: 1.9), and full bladder neck preservation (OR: 2.2) were independent predictors of PSMs. Pathological ISUP 4-5 (hazard ratio [HR]: 1.5) and PSMs (HR: 2.3) were independent predictors of BCR. Pathological ISUP 4-5 (HR: 1.5), PSMs (HR: 2.4), pT ≥3b (HR: 1.8), and pN ≥1 (HR: 1.8) were independent predictors of additional treatment. Immediate UC recovery was recorded in 53% patients. The 1- and 2-yr UC recovery and erectile function recovery were, respectively, 84% and 85%, and 43% and 50%. Conclusions: RS in HR-PCa patients allows optimal intra-, peri-, and postoperative outcomes. The RS approach should be considered a valid surgical treatment option for HR-PCa patients in expert hands. Patient summary: Relying on the largest cohort of high-risk prostate cancer patients treated with Retzius sparing (RS), we observed that the RS approach is safe and allows optimal cancer control, without significantly compromising functional outcomes.

Retzius-sparing Robotic Radical Prostatectomy for Surgeons in the Learning Curve: A Propensity Score-matching Analysis.

BACKGROUND: Several authors claimed that the Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) needs a prolonged learning curve, and outcomes during this phase could be suboptimal. OBJECTIVE: To verify the safety and outcomes of RS-RARP performed by young surgeons during the learning curve. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective analysis of the pre-, intra-, and postoperative features of all the patients who underwent RS-RARP from 2013 to 2017. We divided our patients into two groups: patients operated by two experienced surgeons (ESs) with >100 procedures and patients operated on by five younger surgeons in the learning curve (LCSs). LCSs had no previous experience in radical prostatectomy, and the very first RS-RARP procedures of each LCS case are included in the analysis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Perioperative, oncological, and functional data were analyzed. Short-term oncological results were reported as positive surgical margins (PSMs) and 1-yr disease-free survival. Complications were graded according to the Clavien-Dindo system. Potency was defined as erections sufficient for intercourse; continence was defined as no pad or one safety liner. A propensity score-matching analysis was used to adjust the difference in baseline preoperative parameters between the groups. RESULTS AND LIMITATIONS: We obtained two homogeneous groups of 256 patients each. After the matching, preoperative variables were similar in the two groups. The mean console time was longer for younger surgeons (98 vs 122 min, p < 0.001). Postoperative course, complications, and functional results were similar in the two groups; the final pathological analysis showed a worse T stage in the ES group (p = 0.017). PSMs and 1-yr disease-free survival did not differ between the groups. CONCLUSIONS: RS-RARP can be safely performed by inexperienced surgeons who have received adequate training. PATIENT SUMMARY: Surgeons in the learning curve can perform Retzius-sparing robot-assisted radical prostatectomy safely, with similar early oncological results and functional outcomes.

Technical features and the demonstrated advantages of the Retzius sparing robotic prostatectomy.

OBJECTIVE: Robot-assisted laparoscopic  radical prostatectomy (RARP) is nowadays considered  the main surgical option for localized prostate cancer (PCa). We recently developed a new approach for RARP  avoiding all the Retzius structures involved in continence  and potency preservation, the so called Retzius-sparing  technique (RSP). The objective of the paper is to report technical aspects and functional results of RSP.  METHODS: We evaluated our data and available literature  regarding RSP, functional results and advantages.  RESULTS: RSP is oncologically safe and guarantee high early continence rates. CONCLUSION: Long-term, prospective, comparative,  and possibly randomized studies are needed but RSP is  now spreading all over the world thanks to the different advantages that offers to patients. The most recognized benefit is surely the achievement of early continence, as well documented in multiple studies and papers, without compromising the oncological outcomes.

ARTICULO SOLO EN INGLES. OBJETIVO: La prostatectomía radical laparoscópica  asistida por robot (PRAR) se considera hoy  en día la principal opción quirúrgica para el cáncer de próstata localizado. Recientemente desarrollamos un  nuevo abordaje para la PRAR evitando todas las estructuras  del Retzius involucradas en la conservación de la continencia y la potencia, la conocida como técnica de prostatectomía conservadora del Retzius (PCR). El objetivo  de este artículo es comunicar los aspectos técnicos  y funcionales de la PCR. MÉTODOS: Evaluamos nuestros datos y la literatura disponible  sobre PCR, resultados funcionales y ventajas. RESULTADOS: La PCR es oncológicamente segura y garantiza  unas tasas altas de continencia precoz. CONCLUSIONES: Son necesarios estudios a largo  plazo, prospectivos, comparativos y posiblemente aleatorizados pero la PCR está actualmente extendiéndose  por todo el mundo gracias a las diferentes ventajas que ofrece a los pacientes. El beneficio más reconocido es  seguramente la consecución de continencia precoz, bien documentada en múltiples estudios y artículos, sin  compromiso de los resultados oncológicos.

Pain and discomfort after Retzius-sparing robot-assisted radical prostatectomy: a comparative study between suprapubic cystostomy and urethral catheter as urinary drainage.

BACKGROUND: The aim of this study is to evaluate differences in discomfort, complications and functional results after Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) according to different urinary drainage: suprapubic tube (SPT) and standard urethral catheter (UC). METHODS: Prospective, comparative, consecutive, non-randomized study. In all patients with a water-tight anastomosis, no hematuria, obesity, previous suprapubic surgery or history of bladder cancer, a SPT (two-way Foley 14-Fr catheter) was positioned instead of a Foley 18-Fr UC. One week after surgery, an institutional self-compiled questionnaire was administered. The patients were divided into two groups according to the presence of UC or SPT and were compared concerning pain, perioperative results, complications, functional outcomes. RESULTS: Fifty-six patients with UC and 135 with SPT agreed to participate to the study. Median postoperative pain score was 3 (IQR: 2-5) in UC and 3 (IQR: 1-5) in SPT group (P=0.324); urinary drain-related pain scores were 3 (IQR: 1-5) in UC and 1 (IQR: 0-3) in SPT groups (P<0.001); catheter removal related scores were 1 (IQR: 0-3) and 1 (IQR: 1-3) (P=0.317), respectively. Lastly, 17.8% (UC) and 31.1% (SPT) wore a protection (small or medium pad) while the urinary drainage was in place (P=0.061). No differences related to complications were found (P=0.085); 7.9% of patients in UC group and 4.2% in SPT group (P=0.178) used pads one year after surgery. CONCLUSIONS: We demonstrated suprapubic tube to be more comfortable than transurethral catheter after RARP, with a possible advantage concerning anastomotic postoperative problems.

Does prostate volume have an impact on the functional and oncological results of Retzius-sparing robot-assisted radical prostatectomy?

BACKGROUND: The objective of our study is to evaluate the effect of prostatic volume on the outcomes of Retzius-sparing robot-assisted radical prostatectomy (RSP). METHODS: All the consecutive patients undergoing RSP up to January 2015 were included. The series was divided into three groups based on prostate weight at radical prostatectomy specimen (<40 g, 40-60 g, >60 g). Perioperative, oncological and functional data were prospectively recorded. Potency was defined as erections sufficient for penetration; continence as no pad or one safety liner. Oncological results were reported as positive surgical margins (PSMs) and 1-year biochemical disease-free survival (PSA<0.2 ng/mL). RESULTS: We evaluated 750 patients (366 with <40 g prostates, 272 with 40-60 g prostates, 112 with >60 g prostates). Median follow-up was 22 months; PSA was higher in larger prostates (6.6 vs. 6.8 vs. 8 ng/mL). Nerve-sparing and bladder-neck sparing procedures were in similar percentages. Larger prostates required longer surgeries (90 vs. 100 vs. 100 minutes, P=0.002). Perioperative results were similar (blood loss, discharge, complications, catheter removal). Larger prostates had more frequently localized disease (pT2 in 49.5% vs. 60.7% vs. 68.5%; P=0.001); PSMs were similar both in pT2 (15.5% vs. 9.4% vs. 11.8%) and in pT3 cases (40.1% vs. 42% vs. 34%). In the three study groups, immediate continence was reached by 88%, 89.5% and 81.3% (P=0.045), while no differences were observed concerning continence (93.4%, 94.1%, 94.7%; P=0.892) or potency after follow-up. CONCLUSIONS: RSP is feasible in patients with prostates of any volume, with similar oncological and functional outcomes. Despite being inferior to the figures obtained in low volume prostates, the very high immediate continence rates observed in larger prostates encourage the use of this approach also in larger prostates.

Urology Residency Training in Italy: Results of the First National Survey.

BACKGROUND: Numerous surveys have been performed to determine the competence and the confidence of residents. However, there is no data available on the condition of Italian residents in urology. OBJECTIVE: To investigate the status of training among Italian residents in urology regarding scientific activity and surgical exposure. DESIGN, SETTING, AND PARTICIPANTS: A web-based survey that included 445 residents from all of the 25 Italian Residency Programmes was conducted between September 2015 and November 2015. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The main outcomes were represented by scientific activity, involvement in surgical procedures, and overall satisfaction. RESULTS AND LIMITATIONS: In total, 324 out of 445 (72.8%) residents completed the survey. Overall, 104 (32%) residents had not published any scientific manuscripts, 148 (46%) published ≤5, 38 (12%) ≤10, 26 (8%) ≤15, four (1%) ≤20, and four (1%) >20 manuscripts, respectively. We did not observe any differences when residents were stratified by sex (p=0.5). Stent positioning (45.7%), extracorporeal shock wave lithotripsy (30.9%), transurethral resection of bladder tumor (33.0%), hydrocelectomy (24.7%), varicocelectomy (17%), ureterolithotripsy (14.5%), and orchiectomy (12.3%) were the surgical procedures more frequently performed by residents. Overall, 272 residents (84%) expressed a good satisfaction for urology specialty, while 178 (54.9%) expressed a good satisfaction for their own residency programme. We observed a statistically decreased trend for good satisfaction for urology specialty according to the postgraduate year (p=0.02). CONCLUSIONS: Italian Urology Residency Programmes feature some heavy limitations regarding scientific activity and surgical exposure. Nonetheless, satisfaction rate for urology specialty remains high. Further improvements in Residency Programmes should be made in order to align our schools to others that are actually more challenging. PATIENT SUMMARY: In this web-based survey, Italian residents in urology showed limited scientific productivity and low involvement in surgical procedures. Satisfaction for urology specialty remains high, demonstrating continuous interest in this field of study from residents.

[Relationship between PTH and PSA values in patients with pathological finding of benign prostatic hyperplasia]. / Correlazione tra dosaggio di paratormone ed elevati valori di PSA prebioptici in pazienti con successivo esito istologico di benignità.

The functional relationship between parathyroid glands and prostatic gland is commonly very well known. The aim of our study was to investigate the relationship between serum levels of PTH and serum levels of PSA in patients with pathological finding of BPH. According to 261 transrectal ultrasound-guided prostatic biopsies performed from March 2009 to March 2010, 75 patients, responding to our inclusion criteria, were selected. 26 patients (34.6%) ended the study. All patients with high serum levels of PSA (>4 ng/mL), with histological diagnosis of benign prostatic hyperplasia, underwent the assay of serum levels of PTH. We observed high levels of PTH (> 66 pg/mL) in 9 patients (35.2%).

[Safety and tolerability of local treatment with Iloprost in patients with Peyronie's disease. A phase 1 pilot study and proposal of a new symptom questionnaire]. / Sicurezza e tollerabilità del trattamento locale con Iloprost in pazienti affetti da malattia di La Peyronie. Studio pilota di fase 1 e proposta di nuovo questionario per la valutazione sintomatologica.

PURPOSE: Intralesional therapy is a less invasive method for the treatment of Peyronie's disease. The objective of this study was to evaluate safety and tolerability of intralesional injections of Iloprost (I2 Prostacyclin analogue) for its property to suppress in fibroblasts CTFG (Connective tissue growth factor) production, which acts in concert with TGF-ß to stimulate the fibrotic process. METHODS: Nineteen patients with Peyronie's disease were preliminarily evaluated by considering the degree of penile curvature, plaque size and local and systemic symptoms. Each patient then received weekly intralesional injections of 200 ng of Iloprost in 1 ml of normal saline for 4-5 weeks. If tolerated, the single dose increased weekly to the maximum of 400 ng (2 mL). RESULTS: The treatment has shown that all patients seem to well tolerate a 200 ng Iloprost dose; 7 of them reached a 300 ng dose and 6 tolerate a 400 ng dose without showing side effects. There was no placebo control group in this study. To evaluate the efficacy of the treatment, the absence of objective parameters (except for the auto-photograph of penis in erection) led us to develop a subjective questionnaire that was given to all patients to assess sexual function, pain reduction, ecc. CONCLUSIONS: Due to the relatively small size of the sample, the efficacy evaluation has been restricted to check the questionnaire reliability. Iloprost is well tolerated to a dose of 400 ng in the local treatment of Peyronie's disease.