Retzius-sparing Robot-assisted Simple Prostatectomy: Perioperative and Short-term Functional Outcomes Assessed via Validated Questionnaires.

Background and objective: Several surgical procedures have been reported for treatment of male patients with lower urinary tract symptoms (LUTS) secondary to large benign outlet obstruction (BOO). The diffusion of robotic surgery offers the possibility to perform open simple prostatectomy (SP) with a minimally-invasive approach. Our aim was to report outcomes of the Retzius-sparing robot-assisted SP (RS-RASP) technique. Methods: This was a single centre, prospective study. Patients with LUTS secondary to BOO and a prostate volume of >100 ml underwent RS-RASP performed with a da Vinci surgical system in four-arm configuration for a transperitoneal approach. Data for intraoperative and perioperative complications were collected. Functional outcomes were assessed via validated patient questionnaires. Univariable and multivariable regression analyses were used to identify predictors of complications and achievement of a trifecta composite outcome. Key findings and limitations: The median patient age was 69 yr and the median prostate volume was 150 ml. The median operative time was 175 min, with estimated blood loss of 350 ml. The median in-hospital stay and median catheterisation time were 3 d and 9 d, respectively. Within 90 d, the incidence of complications was 3% for grade 1, 19% for grade 2, and 2% for grade 3 complications. At 7-mo follow-up, statistically significant improvements in International Prostate Symptom Scores (total score and quality of life), International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) scores, and the maximum flow rate were observed (all p < 0.0001). According to ICIQ-UI SF scores, 20%, 6%, and 3% of the patients had slight, moderate, or severe urinary incontinence (UI), respectively. Urgency UI was experienced by 14% of the patients and stress UI by 10%. Most of the patients with UI reported leakage of a small amount of urine and they did not wear pads. Conclusions: RS-RASP was associated with good perioperative outcomes and a low prevalence of high-grade complications. Significant LUTS relief was achieved, but some patients experienced slight urgency or stress UI at short-term follow-up. Patient summary: We explored a surgical technique called Retzius-sparing robot-assisted simple prostatectomy to treat men with bothersome urinary symptoms caused by a large prostate. The technique led to good results, with minimal bleeding and few complications during surgery. This surgery could be a beneficial choice for patients with stubborn urinary symptoms and a large prostate gland.

Role of targeted biopsy, perilesional biopsy, and random biopsy in prostate cancer diagnosis by mpMRI/transrectal ultrasonography fusion biopsy.

PURPOSE: It is still not clear the role of perilesional biopsy (PL) and the extension of the random biopsy (RB) scheme to be adopted during mpMRI-guided ultrasound fusion biopsy (FB). To evaluate the increase in diagnostic accuracy achieved by PL and different RB schemes over target biopsy (TB). METHODS: We collected prospectively 168 biopsy-naïve patients with positive mpMRI receiving FB and concurrent 24-core RB. The diagnostic yields of the different possible biopsy schemes (TB only; TB + 4 PL cores; TB + 12-core RB; TB + 24-core RB) were compared by the McNemar test. Clinically significant (CS) prostate cancer (PCA) was defined according to the definition of the PROMIS trial. Regression analyses were used to identify independent predictors of the presence of any cancer, csPCA. RESULTS: The detection rate of CS cancers increased to 35%, 45%, and 49% by adding 4 PL cores, 12, and 24 RB cores, respectively (all p < 0.02). Notably, the largest scheme including 3 TB and 24 RB cores identified a small but statistically significant 4% increase in detection rate of CS cancer, as compared with the second largest scheme. TB alone identified only 62% of the CS cancers. Such figure increased to 72% by adding 4 PL cores, and to 91% by adding 14 RB cores. CONCLUSIONS: We found that PL biopsy increased the detection rate of CS cancers as compared with TB alone. However, the combination of those cores missed about 30% of the CS cancers identified with larger RB cores, notably including a considerable 15% of cases located contralaterally to the index tumor.

Diagnosis of clinically significant prostate cancer after negative multiparametric magnetic resonance imaging.

Introduction: The diagnostic pathway after a negative magnetic resonance imaging (nMRI) exam is not clearly defined. The aim of the present study is to define the risk of prostate adenocarcinoma (PCa) at the prostate biopsy after a negative multiparametric magnetic resonance imaging (mpMRI) exam. Material and methods: Patients with nMRI Prostate Imaging Reporting & Data System (PI-RADS) ≤2 and without a previous diagnosis of PCa were identified among all patients undergoing mpMRI in a single referral center between 01/2016-12/2019. Detailed data about prostate biopsy after nMRI were collected, including any PCa diagnosis and clinically significant PCa diagnosis. [Gleason score (GS) ≥7]. In addition to descriptive statistics, uni and multivariable logistic regression assessed the potential predictors of any PCa and clinically significant prostate cancer (csPCa) at the biopsy after a negative mpMRI. Results: Of 410 patients with nMRI, 73 underwent saturation biopsy. Only prostate-specific antigen (PSA) levels were significantly higher in patients undergoing biopsy (5.2 ng/ml vs 6.4, p <0.001), while Prostate Cancer Research Foundation (SWOP - Stichting Wetenschappelijk Onderzoek Prostaatkanker) risk score and other variables did not differ. A total of 22 biopsies (30.1%) were positive for PCa, GS 6 was diagnosed in 14 patients, GS 7 in 3, GS 8 in 1 and GS 9-10 in 4. csPCa was found in 8 (11%) patients. No significant predictors of any PCa or csPCa were identified at multivariate regression analysis. Conclusions: Despite the good negative predictive value of mpMRI in the diagnosis of prostate cancer, 11% of the patients had csPCa. Specific predictive models addressing this setting would be useful.

Robotic partial nephrectomy for complex kidney cyst in a 4-year old boy: Points of technique.

Complex kidney cysts are rarely observed in childhood. In adult patients, when radiological studies found a suspicious renal lesion, the gold standard is surgical asportation. The robotic surgery is well known as a secure procedure for treatment these patients, and is nowadays a real alternative also for pediatric patients. The challenges in children surgery are linked to anesthesiologic gestion, smaller operative fields, the need of specific instruments and more delicate tissue handling. We present a step-by-step video description of a robotic partial nephrectomy for a renal multicystic mass in a 4 year-old child.

Metabolic syndrome and risk of prostate cancer: a systematic review and meta-analysis.

INTRODUCTION: Emerging evidence supports the hypothesis that metabolic syndrome is associated with cancer pathogenesis. In particular regarding prostate cancer, observational studies from various settings report different results. This systematic review and meta-analysis aimed to provide a quantitative estimate of the association between metabolic syndrome in prostate cancer, in particular Gleason Score >6, accounting for different study designs. EVIDENCE ACQUISITION: Systematic research of available literature in English language until 2020 was conducted through in Embase, Medline, Cochrane Library and NIH Registry of Clinical Trials. For each study, information regarding the study design, the population, the definition of metabolic syndrome, data relating to prostate cancer were collected, the association between MetS and outcome of interest was determined by calculating the generic inverse variance with random effects method. EVIDENCE SYNTHESIS: In the final sample 19 studies were included with total of 114,329 patients, 29.4% met the criteria for metabolic syndrome. We report a significant association between metabolic syndrome and prostate cancer in cross-sectional studies (OR=1.30; 95% CI: 1.13-1.49) and for patients with clinically significant prostate cancer (OR=1.56; 95% CI: 1.23-1.99). Association between metabolic syndrome and prostate cancer combining all studies, in cohort studies and case-control studies was not significant. CONCLUSIONS: Growing evidence support the association between metabolic syndrome and prostate cancer, bias derived from observational studies might conceal further findings.

Metabolic syndrome and prostate cancer treatment.

Metabolic syndrome (MetS) has been linked with several human cancers. Prostate cancer is the most common neoplasm in male adults and is often treated with radical prostatectomy (RP). Given the complex hormonal and metabolic alteration present in MetS, a possible role in the development and progression of prostate cancer (PCa) has been hypothesized. Several studies have investigated the connections between MetS and the risk of developing prostate cancer, as well as the oncological outcomes of patients who already suffer from PCa and receive a radical treatment. This comprehensive review explores the available evidence dealing with MetS and the oncological and functional results of RP for PCa.

Minimally invasive urologic surgery is safe during COVID-19: experience from two high-volume centers in Italy.

Potential risks of COVID-19 spread during minimally invasive procedures caused several concerns among surgeons, despite the lack of high-level evidence. Urological robotic and laparoscopic surgery is performed in elective setting in almost all occasions, thus allowing adequate planning and stratification. Two high-volume urological centers in Italy performed 77 robotic and laparoscopic surgeries during the "lockdown" period and adopted various strategies to prevent contamination. First of all, all patients were tested negative with nasopharyngeal swab before the surgical intervention. Patients and personnel were provided adequate personal protective equipment and intraoperative strategies to prevent smoke formation and pneumoperitoneum spread were adopted. No patients nor staff members tested positive for COVID-19 during a 15-day follow-up period. In conclusion, minimally invasive urologic surgery can be safely performed during the pandemic period with adequate planning. We believe that renouncing the benefits of it would be counterproductive, especially in a scenario of long-lasting cohabitation with the virus.

Surgical Strategies for Lymphocele Prevention in Minimally Invasive Radical Prostatectomy and Lymph Node Dissection: A Systematic Review.

Purpose: Pelvic lymph node dissection is an important step during robotic radical prostatectomy. The collection of lymphatic fluid (lymphocele) is the most common complication with potentially severe impact; therefore, different strategies have been proposed to reduce its incidence. Materials and Methods: In this systematic review, EMBASE, MEDLINE, Cochrane Library, and NIH Registry of Clinical Trials were searched for articles including the following interventions: transperitoneal vs extraperitoneal approach, any reconfiguration of the peritoneum, the use of pelvic drains, and the use of different sealing techniques and sealing agents. The outcome evaluated was the incidence of symptomatic lymphocele. Randomized, nonrandomized, and/or retrospective studies were included. Results: Twelve studies were included (including one ongoing randomized clinical trial). Because of heterogeneity of included studies, no meta-analysis was performed. No significant impact was reported by different sealing techniques and agents or by surgical approach. Three retrospective, nonrandomized studies showed a potential benefit of peritoneal reconfiguration to maximize the peritoneal surface of reabsorption. Conclusion: Lymphocele formation is a multistep and multifactorial event; high-quality literature analyzing risk factors and preventive measures is rather scarce. Peritoneal reconfiguration could represent a reasonable option that deserves further evaluation; no other preventive measure is supported by current evidence.

Successful repair of iatrogenic rectourinary fistulas using the posterior sagittal transrectal approach (York-Mason): 15-year experience.

INTRODUCTION: Rectourinary fistulas (RUFs) represent a challenging clinical problem. Most RUFs are secondary to lower urinary or intestinal tract surgery. Several surgical approaches have been proposed. The aim of this study was to review a 15-year experience using the York-Mason posterior sagittal transrectal approach to iatrogenic RUFs. METHODS: Seven patients with RUFs secondary to urologic surgery were operated on with the York-Mason technique at the Department of Urology, University of Padova, Italy between 1988 and 2003. The patients' data have been collected and analyzed retrospectively. RESULTS: All the patients were treated successfully (100%). In one patient with Crohn's disease the fistula recurred 11 years after the first surgery. One patient died for metastasis of prostate cancer 1 year after surgical repair of the RUF. A temporary colostomy was performed in five patients; the colostomies were subsequently closed, and the patients regained complete fecal continence with no postoperative anal strictures. The colostomy remained in place in one patient with Crohn's disease and in another with ulcerative rectocolitis. CONCLUSIONS: The posterior sagittal transrectal approach provided easy access and identification of RUFs and good surgical exposure, with no subsequent strictures or fecal incontinence. Our data show that the York-Mason technique alone is a highly effective option for treating an iatrogenic postoperative RUF.