Emergency holmium laser enucleation of the prostate (HoLEP): a novel approach in the management of refractory hematuria for patients with benign prostatic hyperplasia (BPH): a single-institution experience.

INTRODUCTION: Refractory hematuria secondary to prostatic disease typically resolves with conservative management; however, this condition may require hospitalization with extensive measures to control life-threatening bleeding. The aim of this study was to report our experience using holmium laser enucleation of the prostate (HoLEP) as an emergency treatment in this clinical setting. METHODS: We conducted a retrospective review of all patients that presented to the emergency department with refractory hematuria of prostatic origin from October 2017 to September 2021, for whom hospitalization and conservative management failed to control bleeding. All emergency HoLEP procedures were performed by a single surgeon. Preoperative and intraoperative parameters, as well as perioperative outcomes, were collected and analyzed. Postoperative outcomes included duration of foley catheterization, length of postoperative hospital stay, and hospital readmissions. RESULTS: A total of 40 emergency HoLEP procedures were performed. Our cohort had a median prostate volume of 110.5 cc and a median resected weight of 81 g. Twenty-seven patients (67.5%) were on anticoagulant or antiplatelet medications on admission. The urethral catheter was removed within 1 day in 95% of patients with a successful trial of void (TOV). Moreover, 92.5% of patients were discharged home within 24 h of their procedure. Two patients (5%) experienced clot retention within one-week post-discharge with a 2.5% overall readmission rate. All postoperative parameters, including International Prostate Symptom Score (IPSS), quality of life (QoL), maximum flow rate (Qmax), and post-void residual volume (PVR), showed significant improvement at 1 year follow up. CONCLUSION: Our experience demonstrates that emergency HoLEP is an effective treatment option for patients with refractory hematuria of prostatic origin. Further studies are warranted to consolidate our results.

Age-stratified potency outcomes of bilateral nerve sparing robotic-assisted radical prostatectomy.

INTRODUCTION: This study aims to report age-stratified potency outcomes in men undergoing robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: A retrospective review was performed on a database of 1737 patients who underwent RARP for localized prostate cancer between 2007 and 2019. Inclusion criteria consisted of patients undergoing bilateral nerve-sparing RARP. Exclusion criteria were preoperative Sexual Health Inventory for Men (SHIM) score < 17 and postoperative androgen deprivation therapy or radiotherapy. Patients were divided into four cohorts based on age: ≤ 54 years (group 1); 55-59 years (group 2); 60-64 years (group 3) and ≥ 65 years (group 4). Functional outcomes were measured up to 36 months. Kaplan-Meier analysis was performed to compare the time to recovery of potency stratified by age groups using log-rank testing. RESULTS: A total of 542 patients met the selection criteria. Potency rates were significantly different between groups. Groups 1 through 4 demonstrated potency recovery rates of 64.2%, 52.3%, 36.6% and 20.7% at 1-year follow up, respectively. After 3 years, groups 1 through 4 had potency rates of 77.9%, 67.0%, 50.5% and 35.0%, respectively. Recovery of potency was achieved at a median time after surgery of 199, 340 and 853 days for groups 1-3, respectively. The Cox proportional hazard model showed that older age, higher body mass index (BMI), and lower preoperative SHIM score were associated with significantly higher rates of impotence. CONCLUSION: This study shows that RARP has acceptable potency outcomes, regardless of age. However, patient factors, including older age and preoperative SHIM were significantly associated with poorer functional recovery. This data is valuable in prognostic evaluation and patient counseling.

Global experience and progress in GreenLight-XPS 180-Watt photoselective vaporization of the prostate.

PURPOSE: To evaluate changes in global perioperative data of GreenLight-XPS 180-Watt photo-selective vaporization of the prostate (GL-XPS) of the Global Greenlight Group (GGG) database. METHODS: 3441 men, who underwent GL-XPS for symptomatic BPH between 2011 and 2019 at seven high volume international centers, were included. Primary outcome measurements were operative time (OT; min), effective laser time (LT; min of OT), as well as intraoperative and postoperative adverse events (AEs), all analyzed by year of surgery (2011-2019) and prostate volume (PV) group (< 80 ml vs. 80-150 ml vs. > 150 ml). RESULTS: The median age was 70 years (interquartile range 64-77), the median PV was 64 ml (IQR 47-90). The OT and LT slightly increased but stayed highly efficient all in all. Median OT was 60 min (IQR 45-83) and LT was 33 min (IQR 23-46). Median energy use was 253 kJ (IQR 170-375) with an energy density of 3.94 kJ/ml (IQR 2.94-5.02). The relative probability of perioperative AEs decreased by 17% each year (p < 0.001). The relative probability of perioperative transfusion dropped significantly from 2% in 2011 to 0% in 2019 (p = 0.007). The early postoperative complications (within 30 days after surgery) decreased significantly from 48.8% (n = 106) in 2011 to 24.7% (n = 20) in 2019 (p > 0.001). CONCLUSION: These findings from the GGG demonstrate significant improvement secondary to growing experience with GL-XPS between 2011 and 2019 in intraoperative AEs, including transfusions, and postoperative AEs. While staying highly efficient in OT and LT of GL-XPS within a 9-year period of experience.

Age-stratified continence outcomes of robotic-assisted radical prostatectomy.

INTRODUCTION: Incontinence after robot-assisted radical prostatectomy (RARP) significantly impacts quality of life. This study aims to compare the age-stratified continence outcomes in Canadian men undergoing RARP. MATERIALS AND METHODS: A retrospective review was performed on a prospectively maintained database of 1737 patients who underwent RARP for localized prostate cancer between 2007 and 2019. Patients were stratified into five groups based on age: group 1, ≤ 54 years (n = 245); group 2, 55-59 years (n = 302) ; group 3, 60-64 years (n = 386); group 4, 65-69 years (n = 348); and group 5, ≥ 70 years (n = 116). Functional outcomes were assessed up to 36 months. Log-rank and multivariable Cox regression analyses were performed to compare the time to recovery of pad-free continence by age group. RESULTS: Continence rates of groups 1 to 5 were respectively 90.2%, 79.1%, 80.4%, 71.4%, and 59.8% at 1-year follow up (p < 0.001). After 3 years, groups 1 through 5 had continence rates of 97%, 91.7%, 89.3%, 81.4%, and 77.6%, respectively (p < 0.001). Median time to recovery of continence was 58, 135, 140, 152 and 228 days, respectively. Among men who remained incontinent, older patients consistently required more pads. In Cox proportional hazard model, groups 2, 3, 4 and 5 were respectively 33% (p < 0.001), 34% (p < 0.001), 33% (p = 0.001), and 41% (p = 0.005) more likely to remain incontinent compared to group 1. CONCLUSIONS: Age is associated with significantly lower rates of continence recovery, longer time to recovery of continence, and more severe cases of incontinence after RARP.

Oncological safety and functional outcomes of testosterone replacement therapy in symptomatic adult-onset hypogonadal prostate cancer patients following robot-assisted radical prostatectomy.

PURPOSE: Testosterone replacement therapy (TRT) remains controversial in men with treated prostate cancer. We assessed its safety and functional impacts in patients after definitive surgical treatment with robotic-assisted radical prostatectomy (RARP). METHODS: We performed a retrospective analysis of 1303 patients who underwent RARP during the years 2006-2019. We identified men with symptoms of andropause and low serum testosterone who received TRT post-RARP; then we divided the cohort into two groups accordingly for comparison. Biochemical recurrence (BCR) was the primary endpoint. Secondary endpoints included functional outcomes. Predictors of BCR, including the effect of TRT on BCR, were evaluated using univariable and multivariable logistic regression. RESULTS: Among the forty-seven men who received TRT, the mean age was 60.83 years with a median follow-up of 48 months. Three (6.4%) and 157 (12.56%) patients experienced BCR in TRT and non-TRT groups, respectively. Baseline characteristics were similar between both groups except for higher mean BMI in the TRT group (p = 0.03). In the multivariate analysis (MVA), higher pre-RARP prostate-specific antigen (PSA) (p = 0.043), higher International Society of Urological Pathology score (p < 0.001), seminal vesical invasion (p = 0.018) and positive surgical margin (p < 0.001) were predictors of BCR. However, TRT was not (p = 0.389). In addition, there was a significant change in the Sexual Health Inventory for Men (p = 0.022), and serum testosterone level (p < 0.001) before and 6 months after initiation of TRT. CONCLUSION: Our findings suggest that TRT, in well-selected, closely followed, symptomatic men post-RARP is an oncologically safe and functionally effective treatment in prostate cancer patients post-RARP.

Reasons to believe in vaporization: a review of the benefits of photo-selective and transurethral vaporization.

PURPOSE: In the current review, we will discuss the state of the literature of vaporization of the prostate for the treatment of benign prostatic enlargement (BPE). We discuss two methods of vaporization of the prostate: Transurethral Vaporization of the Prostate (TUVP) and Greenlight Photo-selective Vaporization of the Prostate (PVP). METHODS: A comprehensive review of the literature was performed on TUVP and PVP. The literature on transurethral resection of the prostate (TURP) was also extensively reviewed as a comparative surgical method. RESULTS: The evidence shows that TUVP appears to be the safer choice, as compared to TURP due to less intra- and peri-operative complications. PVP was associated with less bleeding complications than TURP with outpatient discharge. Importantly, PVP was not associated with serious bleeding events requiring blood transfusions or medical treatment in patients under anticoagulation or antiplatelet therapies. PVP was also shown to be a cost-effective option compared to TURP. CONCLUSION: Prostate vaporization for the treatment of BPE appears to be an efficient and safer alternative to TURP. Vaporization techniques, particularly Greenlight PVP, should be offered to most men, especially those under anticoagulation therapy, as well as patients at risk of bleeding complications.

Reasons to go for Rezum steam therapy: an effective and durable outpatient minimally invasive procedure.

PURPOSE: In this review, we will discuss the state of the literature regarding Rezum and opportunities for its application in the treatment of BPH. METHODS: A comprehensive review of original research on convective water vapor thermal therapy (Rezum) was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, Aquablation, and greenlight photoselective vaporization of the prostate were reviewed for discussion. RESULTS: Rezum distinguishes itself from other treatment options by its durable improvement in objective clinical outcomes such as IPSS and BPH Impact Index, while being cost-effective and versatile in its ability to treat a variety of prostate gland morphologies. This treatment option shows good lower urinary tract symptom relief, especially in small-to-moderate prostate sizes (30-80 cc). The use of convective heat transfer is unique and allows for localized treatment, avoiding damage to surrounding structures, thus providing an excellent safety profile and sexual function preservation. CONCLUSION: The current evidence on Rezum warrants its consideration as a therapeutic alternative to transurethral surgery in selected patients.

Detectable Prostate-specific antigen value between 0.01 and 0.1 ng/ml following robotic-assisted radical prostatectomy (RARP): does it correlate with future biochemical recurrence?

PURPOSE: The aim of the study is to evaluate the impact of having a nadir and persistently detectable ultrasensitive prostate-specific antigen (uPSA) between 0.01 and 0.1 ng/ml post-robot-assisted radical prostatectomy (RARP), on future biochemical recurrence (BCR). METHODS: We conducted a retrospective analysis of a prospectively maintained cohort of 1359 men who underwent RARP, between 2006 and 2019. Patients were followed with uPSA at 1, 3, 6, 9, 12, 18, 24, 30, 36 months and annually thereafter. We included patients with PSA nadir values between 0.01 and 0.1 ng/ml within 6 months of surgery and with at least 2 follow-up measurements within the same range. We divided patients based on their BCR status and analyzed uPSA changes. Multivariable Cox-regression models (CRMs) were used to analyze variables predicting BCR-free survival (BCR-FS). RESULTS: We identified 167 (12.3%) patients for analyses, with a mean follow-up time of 60.2 ± 31.4 months. In our cohort, 5-year BCR-FS rate was 86%. Overall, 32 (19.1%) patients had BCR, with a mean time to BCR of 43.7 ± 24.3 months. BCR-free patients had stable mean uPSA values ≤ 0.033 ng/ml, while patients who developed BCR showed a slowly rising trend over time, with a significant difference between groups starting at 9 months (p < 0.02). In multivariable CRMs, a rising uPSA starting at 9 months was an independent predictor of BCR (HR: 2.7; 95% CI 1.6-3.82; p = 0.013). CONCLUSION: In the present cohort, our results demonstrated that a considerable number of men have detectable uPSA values ranging between 0.01 and 0.1 ng/ml post-RARP. They can still be followed regularly to avoid patients' anxiety and salvage radiotherapy. Close follow-up is still required.

Impact of surgical wait times during summer months on the oncological outcomes following robotic-assisted radical prostatectomy: 10 years' experience from a large Canadian academic center.

PURPOSE: Most Canadian hospitals face significant reductions in operating room access during the summer. We sought to assess the impact of longer wait times on the oncological outcomes of localized prostate cancer patients following robotic-assisted radical prostatectomy (RARP). METHODS: We conducted a retrospective review of a prospectively maintained RARP database in two high-volume academic centers, between 2010 and 2019. Assessed outcomes included the difference between post-biopsy UCSF-CAPRA and post-surgical CAPRA-S scores, Gleason score upgrade and biochemical recurrence rates (BCR). Multivariable regression analyses (MVA) were used to evaluate the effect of wait times. RESULTS: A total of 1057 men were included for analysis. Consistent over a 10 year period, summer months had the lowest surgical volumes despite above average booking volumes. The lowest surgical volume occurred during the month of July (7.1 cases on average), which was 35% less than the cohort average. The longest average wait times occurred for patients booked in June (93 ± 69 days, p < 0.001). On MVA, patients booked in June had significantly more chance of having an increase in CAPRA score [HR (95% CI) 1.64 (1.02-2.63); p = 0.04] and in CAPRA risk group [HR (95% CI) 1.82 (1.04-3.19); p = 0.03]. Cohort analysis showed fair correlation between CAPRA-score difference and wait time (Pearson correlation: r = - 0.062; p = 0.044). CONCLUSION: Our cohort results demonstrate that conventional RARP wait times are significantly and consistently prolonged during summer months over the past 10 years, with worse post-RARP oncological outcomes in terms of CAPRA scores. Other compensatory mechanisms to sustain consistent yearly operative output should be considered.

Reasons to overthrow TURP: bring on Aquablation.

PURPOSE: In this review, we will discuss the state of the literature regarding Aquablation, its limitations, and opportunities for its application in the treatment of benign prostatic enlargement (BPE). METHODS: A comprehensive review of original research on Aquablation was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, greenlight photoselective vaporization of the prostate, and simple prostatectomy were reviewed for discussion. RESULTS: For small-medium prostates (30-80 mL), Aquablation's main advantages include better ejaculatory function and similar functional outcomes compared to TURP. For large prostates (80-150 mL), Aquablation demonstrates shorter operative time and superior ejaculatory function when compared to simple prostatectomy, HoLEP, and Greenlight PVP. In addition, Aquablation displays shorter hospital stays than simple prostatectomy. The integration of software programming and semi-automatic technology increases the reproducibility of the procedure and helps standardize overall outcomes, while also accelerating the learning curve. Its ability to preserve antegrade ejaculation makes Aquablation a very compelling option for sexually active patients. However cost and postoperative bleeding risks remain a concern. CONCLUSION: The current evidence suggests that Aquablation is a safe and effective alternative for BPE for small to large prostates. Further prospective clinical trials, with comparisons to other BPE modalities, and data from longer follow-up periods are still required.

Impact of the presence of a median lobe on functional outcomes of greenlight photovaporization of the prostate (PVP): an analysis of the Global Greenlight Group (GGG) Database.

OBJECTIVES: Previous analyses of the impact of median lobe presence on Greenlight photoselective vaporization of the prostate (PVP) outcomes were limited by their small sample size and the ability to adjust for important confounders. As such, we sought to investigate the impact of prostate median lobe presence on the operative outcomes of 180 W XPS GreenLight PVP using a large international database. METHODS: Data were obtained from the Global GreenLight Group (GGG) database which pools data of eight high-volume, experienced surgeons, from a total of seven international centers. All men with established benign prostatic hyperplasia who underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019 were eligible for the study. Patients were assigned to two groups based on presence or absence of median lobes. Analyses were adjusted for patient age, prostate volume, body mass index, and American Society of Anesthesia (ASA) score. RESULTS: A total of 1650 men met the inclusion criteria. A median lobe was identified in 621 (37.6%) patients. Baseline prostate volume, patient age, and ASA score varied considerably between the two groups. In adjusted analyses, the operative and lasing time of patients with median lobes was 6.72 (95% CI 3.22-10.23; p < 0.01) minutes and 2.90 (95% CI 1.02-4.78; p < 0.01) minutes longer than the control group. Men with median lobes had similar postoperative functional outcomes to those without a median lobe except for a 1.59-point greater drop in the 12-month IPSS score compared to baseline (95% CI 0.11-3.08; p = 0.04) in the median lobe group, and a decrease in PVR after 6 months which was 46.51 ml (95% CI 4.65-88.36; p = 0.03) greater in patients with median lobes compared to men without median lobes. CONCLUSIONS: Our findings suggest that the presence of a median lobe has no clinically significant impact on procedural or postoperative outcomes for patients undergoing Greenlight PVP using the XPS-180 W system.

Global Greenlight Group: largest international Greenlight experience for benign prostatic hyperplasia to assess efficacy and safety.

INTRODUCTION: Greenlight photo-selective vaporization of the prostate (GL-PVP) has gained international acceptance as a safe and effective alternative procedure for the treatment of benign prostatic hyperplasia (BPH), especially in anticoagulated men. This descriptive analysis aims to characterize the current state of GL-PVP, pooling data from international centers. METHODS: Data from 3627 patients who underwent GL-PVP with the XPS-180 W system in seven international centers performed by eight expert surgeons between 2011 and 2019 were retrospectively analyzed. Demographic, perioperative, and postoperative data were collected, including IPSS, QoL, Qmax, PVR, and PSA, and complications. RESULTS: At baseline, median age, prostate volume, PSA, and IPSS were 70 years (interquartile range 64-77), 64 (47-90), 3.1 ng/mL (1.8-6), and 22 (19-27), respectively. Median lasing and operative time were 34 (23-48) and 62 min (46-85), respectively. Median energy use was 250.0 kJ (168.4-367.9), with 92.6% of procedures being completed with one laser fiber. In 60.1% of cases, catheter was removed on postoperative day 1 with median length of 2 days. All-cause mortality within 30 days was 0.3%. Median PSA reduction at 3 months and 60 months compared to baseline was 43.9 and 46.4%, respectively (p < 0.001). All functional outcomes (IPSS, QoL, Qmax, and PVR) were significantly improved across study period when compared to baseline (p < 0.001). For those men with longer follow-up available, the observed surgical BPH retreatment rate was 1.5% CONCLUSION: Using the largest multi-user, international database of GL-PVP, Greenlight XPS laser treatment in experienced hands is a safe, effective, and durable BPH treatment option.

Functional and perioperative outcomes in elderly men after robotic-assisted radical prostatectomy for prostate cancer.

PURPOSE: We aimed to compare postoperative functional outcomes following robotic-assisted radical prostatectomy (RARP) in elderly men with localized prostate cancer. METHODS: A retrospective review of a prospectively maintained database of men who underwent RARP between January 2007 and November 2018 was performed. Patients over 65 years of age were selected (N = 302) and then stratified by age group: 66-69 years old (N = 214) and ≥ 70 years old (N = 88). Full continence was defined as strict 0-pad per day usage. Preoperative potency included those with a Sexual Health Inventory for Men score ≥ 17. Preoperative and postoperative functional outcomes were assessed. Kaplan-Meier analysis was used to estimate time to recovery of continence in both groups. RESULTS: Both groups had comparable preoperative parameters. Continence rates at 1, 3, 6, 9, 12, 18 and 24 months in the 66-69-year-old group were 6%, 34%, 61%, 70%, 74%, 80% and 87%, respectively. Comparatively in the ≥ 70-year-old group, continence rates were significantly lower at all time points (3%, 22%, 50%, 56%, 66%, 69% and 75%, respectively). Men in the 66-69-year-old group were significantly more likely to be continent after RARP when compared to patients 70 years of age and above [(Hazards ratio (HR) 0.73; 95%confidence interval 0.54-0.97, (p = 0.035)]. CONCLUSION: Our results suggest that RARP is feasible in elderly patients. Nevertheless, elderly patients in the ≥ 70-year-old group had significantly inferior postoperative continence rates compared to patients aged 66-69 years. Such information is valuable when counselling men during preoperative RARP planning to ensure that they have realistic postoperative expectations.

Long-term mortality in obese subjects undergoing malabsorptive surgery (biliopancreatic diversion and biliointestinal bypass) versus medical treatment.

BACKGROUND AND AIM: Aim of this study was to analyze long-term mortality in obese patients receiving malabsorptive bariatric surgery (BS)[biliopancreatic diversion (BPD) and biliointestinal bypass (BIBP)] in comparison to medical treatment of obesity. PATIENTS AND METHODS: Medical records of 1877 obese patients [body mass index (BMI) > 35 kg/m2, aged 18-65 years, undergoing BS (n = 472, 111 with diabetes) or non-surgical medical treatment (n = 1405, 385 with diabetes), during the period 1999-2008 (visit 1)] were collected; non-surgical patients were matched for age, sex, BMI, and blood pressure, and life status and causes of death were ascertained through December 2016. Survival was compared across surgery patients and non-surgical patients using Kaplan-Meier plots and Cox regression analyses. RESULTS: Observation period was 12.1 ± 3.41 years (mean ± SD). Compared to non-surgical patients, BS patients had reduced all-cause mortality (34/472 (7.2%) vs 181/1,405 (12.9%) patients, χ2 = 11.25, p = 0.001; HR = 0.64, 95% C.I. 0.43-0.93, p = 0.019). Cardiovascular and cancer causes of death were significantly less frequent in surgery vs no-surgery (HR = 0.26, 95% C.I. 0.09-0.72, p = 0.003; HR = 0.21, 95% C.I. 0.09-0.45, p < 0.001, respectively). CONCLUSION: Patients who have undergone BPD and BIBP have lower long-term all-cause, cardiovascular-caused and cancer-caused mortality compared to non-surgical medical weight-loss treatment patients. Malabsorptive bariatric surgery significantly reduces long-term mortality in severely obese patients.

Short- and long-term survival has improved after radical cystectomy for bladder cancer in Québec during the years 2000-2015.

BACKGROUND AND OBJECTIVES: We evaluated the short- and long-term outcome in bladder cancer (BC) patients treated with radical cystectomy (RC) in Québec (Canada). METHODS: Data were collected from provincial registries on all BC patients who underwent RC in Québec province in 2000-2015. Outcomes were hospitalization rates and survival. Survival analyses were conducted using log-rank tests and Cox proportional hazards models. RESULTS: In total, 4450 patients were included in our analysis. RC was increasingly conducted by higher-volume surgeons in larger, higher-volume, academic hospitals. Comparing patients treated in 2010-2015 to 2000-2009, recently treated patients had shorter postoperative hospital stays (absolute difference, 0.9 days, P < 0.001) but also a higher readmission rate (25.0% vs 21.1% in the 30 days following discharge, P = 0.003). Overall (5-year rates 50.9% vs 42.7%, P < 0.001) and BC-specific survival (61.3% vs 55.5%, P < 0.001) had significantly improved. In multivariable analyses, overall survival was significantly better in recently treated patients (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.60-0.73), younger patients (HR, 1.16; 95% CI, 1.14-1.19), patients residing closer to the hospital (HR, 1.03; 95% CI, 1.01-1.06), and patients treated by high-volume surgeons (HR, 0.88; 95% CI, 0.82-0.94). CONCLUSIONS: Survival in BC patients after RC has improved in recent years. Other predictors for survival are younger age, shorter distance between patients' residences and hospitals, and higher surgeon's RC loads.

A 23-year study of mortality and development of co-morbidities in patients with obesity undergoing bariatric surgery (laparoscopic gastric banding) in comparison with medical treatment of obesity.

BACKGROUND AND AIM: Several studies have shown that bariatric surgery reduces long term mortality compared to medical weight loss therapy. In a previous study we have demonstrated that gastric banding (LAGB) is associated with reduced mortality in patients with and without diabetes, and with reduced incidence of obesity co-morbidities (cardiovascular disease, diabetes, and cancer) at a 17 year follow-up. The aim of this study was to verify at a longer time interval (23 years) mortality and incidence of co-morbidities in patients undergoing LAGB or medical weight loss therapy. PATIENTS AND METHODS: As reported in the previous shorter-time study, medical records of obese patients [body mass index (BMI) > 35 kg/m2 undergoing LAGB (n = 385; 52 with diabetes) or medical treatment (controls, n = 681; 127 with diabetes), during the period 1995-2001 (visit 1)] were collected. Patients were matched for age, sex, BMI, and blood pressure. Identification codes of patients were entered in the Italian National Health System Lumbardy database, that contains life status, causes of death, as well as exemptions, prescriptions, and hospital admissions (proxies of diseases) from visit 1 to June 2018. Survival was compared across LAGB patients and matched controls using Kaplan-Meier plots adjusted Cox regression analyses. RESULTS: Final observation period was 19.5 ± 1.87 years (13.4-23.5). Compared to controls, LAGB was associated with reduced mortality [HR = 0.52, 95% CI 0.33-0.80, p = 0.003], significant in patients with diabetes [HR = 0.46, 95% CI 0.22-0.94, p = 0.034], borderline significant in patients without diabetes [HR = 0.61, 95% CI = 0.35-1.05, p = 0.076]. LAGB was associated with lower incidence of diabetes (15 vs 75 cases, p = 0.001), of CV diseases (61 vs 226 cases, p = 0.009), of cancer (10 vs 35, p = 0.01), and of renal diseases (0 vs 35, p = 0.001), and of hospital admissions (92 vs 377, p = 0.001). CONCLUSION: The preventive effect of LAGB on mortality is maintained up to 23 years, even with a decreased efficacy compared with the shorter-time study, while the preventive effect of LAGB on co-morbidities and on hospital admissions increases with time.

Changes in the levels of testosterone profile over time in relation to clinical parameters in a cohort of patients with prostate cancer managed by active surveillance.

OBJECTIVES: To characterize testosterone profile changes over time in a cohort of prostate cancer (PCa) patients managed with active surveillance (AS) and to assess its correlation with the initial disease characteristics and further progression. METHODS: We conducted retrospective chart review of PCa patients managed with AS. Patients were followed with PSA, total, free and bioavailable testosterone measurements, physical examination, and by repeat biopsies or periodic magnetic resonance imaging. Disease progression was identified by follow-up biopsy changes or by imaging. A Cox proportional hazard regression models were used to assess the association between testosterone profile at baseline and the risk of progression. RESULTS: For the 122 patients included in analyses, the mean age at diagnosis was 65.8 years; the mean follow-up time was 7.8 years. At baseline, 108 (88.5%) patients had a Gleason score of ≤ 6. In all, 45 (36.8%) patients had disease progression, with a mean time to progression of 4.6 years. During follow-up, PSA levels showed a rising trend, while testosterone profile levels showed a trend of decrease over time. There was no significant correlation between PSA and testosterone profile (total, free, and bioavailable) level changes over time (ρ = - 0.14, - 0.11 and - 0.16, P = 0.16, 0.34, and 0.20, respectively). In addition, multivariable analysis showed that serum-free testosterone was an independent predictor of disease progression (HR 0.93, 95% CI 0.88-0.99, P = 0.029). CONCLUSION: Our study results showed that testosterone profile measurements tended to decrease over time in PCa patients managed with AS. Free testosterone was a significant independent variable of disease progression.

Changes in the outcome of prostate biopsies after preventive task force recommendation against prostate-specific antigen screening.

BACKGROUND: The benefits of PSA-based screening for prostate cancer (PCa) are controversial. The Canadian and American Task Forces on Preventive Health Care (CTFPHC & USPSTF) have released recommendations against the use of routine PSA-based screening for any men. We thought to assess the impact of these recommendations on the outcomes and trends of prostate needle biopsies. METHODS: A complete chart review was conducted for all men who received prostate needle biopsies at McGill University Health Center between 2010 and 2016. Of those, we included 1425 patients diagnosed with PCa for analysis. We Compared 2 groups of patients (pre and post recommendations' release date) using Welch's t-tests and Chi-square test. A multivariate logistic regression model was used to analyze variables predicting worse pathological outcomes. RESULTS: When the release date of the USPSTF draft (October 2011) was used as a cut-off, we found an average annual decrease of 10.6% in the total number of biopsies. The median (IQR) baseline PSA levels were higher in post-recommendations group (n = 977) when compared to pre-recommendations group (n = 448) [8 ng/ml (5.7-12.9) versus 6.4 ng/ml (4.9-10.1), respectively. P = 0.0007]. Also, post-recommendations group's patients had higher Gleason score (G7: 35.4% versus 28.4% and G8-G10: 31.2% versus 18.1%, respectively. P < 0.0001). Moreover, they had higher intermediate and high-risk PCa classification (36.4% versus 32.8% and 35.5% versus 22.1%, respectively. P < 0.0001). The recommendations release date was an independent variable associated with higher Gleason score in prostate biopsies (OR: 2.006, 95%CI: 1.477-2.725). Using the CTFPHC recommendations release date (October 2014) as a cut-off in further analysis, revealed similar results. CONCLUSIONS: Our results revealed a reduction in the number of prostate needle biopsies performed over time after the recommendations of the preventive task forces. Furthermore, it showed a significant relative increase in the higher risk PCa diagnosis. The oncological outcomes associated with this trend need to be examined in further studies.

Long-term mortality and incidence of cardiovascular diseases and type 2 diabetes in diabetic and nondiabetic obese patients undergoing gastric banding: a controlled study.

BACKGROUND AND AIM: Aim of this retrospective study was to compare long-term mortality and incidence of new diseases [diabetes and cardiovascular (CV) disease] in morbidly obese diabetic and nondiabetic patients, undergoing gastric banding (LAGB) in comparison to medical treatment. PATIENTS AND METHODS: Medical records of obese patients [body mass index (BMI) > 35 kg/m(2) undergoing LAGB (n = 385; 52 with diabetes) or medical treatment (controls, n = 681; 127 with diabetes), during the period 1995-2001 (visit 1)] were collected. Patients were matched for age, sex, BMI, and blood pressure. Identification codes of patients were entered in the Italian National Health System Lumbardy database, that contains life status, causes of death, as well as exemptions, drug prescriptions, and hospital admissions (proxies of diseases) from visit 1 to September 2012. Survival was compared across LAGB patients and matched controls using Kaplan-Meier plots adjusted Cox regression analyses. RESULTS: Observation period was 13.9 ± 1.87 (mean ± SD). Mortality rate was 2.6, 6.6, and 10.1 % in controls at 5, 10, and 15 years, respectively; mortality rate was 0.8, 2.5, and 3.1 % in LAGB patients at 5, 10, and 15 years, respectively. Compared to controls, surgery was associated with reduced mortality [HR 0.35, 95 % CI 0.19-0.65, p < 0.001 at univariate analysis, HR 0.41, 95 % CI 0.21-0.76, p < 0.005 at adjusted analysis], similar in diabetic [HR 0.34, 95 % CI 0.13-0.87, p = 0.025] and nondiabetic [HR 0.42, 95 % CI 0.19-0.97, p = 0.041] patients. Surgery was also associated with lower incidence of diabetes (15 vs 48 cases, p = 0.035) and CV diseases (52 vs 124 cases, p = 0.048), and of hospital admissions (88 vs 197, p = 0.04). CONCLUSION: Up to 17 years, gastric banding is associated with reduced mortality in diabetic and nondiabetic patients, and with reduced incidence of diabetes and cardiovascular diseases.

Predictors of costs associated with radical cystectomy for bladder cancer: A population-based retrospective cohort study in the province of Quebec, Canada.

BACKGROUND AND OBJECTIVES: There is paucity of studies on the predictors of bladder cancer (BC) management costs. We aimed to determine predictors of costs associated with radical cystectomy (RC) for BC. METHODS: We conducted a retrospective analysis in a cohort of 2,759 patients who underwent RC for BC between 2000 and 2009. We analyzed predictors of pre-surgery, RC, post-surgery, and total costs. The following variables were considered as potential predictors: age, gender, hospital/surgeon case load, academic hospital, and geo-administrative region. Multivariate linear regression was used to determine predictors. RESULTS: Predictors of pre-surgery costs were: age (ß = 808.64, P < 0.0001) and having surgery in an academic hospital (ß = 511.42, P = 0.003). Increased RC costs were associated with age (ß = 196.73, P = 0.0006), hospital/surgeon annual load (ß = 484.45 and ß = 254.21, P < 0.0001, respectively). Having surgery in academic hospitals and geographic region were significant predictors of low RC costs (ß = -1085.82 and ß = -449.31, P < 0.0001, respectively). Increasing age and the presence of post-operative complications were predictors of high post-operative costs (ß = 623.48, ß = 5781.44, P = 0.01, respectively), while hospital load was associated with low post-surgery costs (ß = -949.79, P < 0.0001). CONCLUSION: Patients' age and surgery performed by high-volume health providers were predictive factors of high RC costs. Low RC costs were associated with surgeries performed in academic hospitals.