Interventional Imaging Systems in Radiology, Cardiology, and Urology: Energy Consumption, Carbon Emissions, and Electricity Costs.

BACKGROUND. The energy demand of interventional imaging systems has historically been estimated using manufacturer-provided specifications rather than directly measured. OBJECTIVE. The purpose of this study was to investigate the energy consumption of interventional imaging systems and estimate potential savings in the carbon emissions and electricity costs of such systems through hypothetical operational adjustments. METHODS. An interventional radiology suite, neurointerventional suite, radiology fluoroscopy unit, two cardiology laboratories, and two urology fluoroscopy units were equipped with power sensors. Power measurement logs were extracted for a single 4-week period for each radiology and cardiology system (all between June 1, 2022, and November 28, 2022) and for the 2-week period from July 31, 2023, to August 13, 2023, for each urology system. Power statuses, procedure time stamps, and fluoroscopy times were extracted from various sources. System activity was divided into off, idle (no patient in room), active (patient in room for procedure), and net-imaging (active fluoroscopic image acquisition) states. Projected annual energy consumption was calculated. Potential annual savings in carbon emissions and electricity costs through hypothetical operational adjustments were estimated using published values for Switzerland. RESULTS. Across the seven systems, the mean power draw was 0.3-1.1, 0.7-7.4, 0.9-7.6, and 1.9-12.5 kW in the off, idle, active, and net-imaging states, respectively. Across systems, the off state, in comparison with the idle state, showed a decrease in the mean power draw of 0.2-6.9 kW (relative decrease, 22.2-93.2%). The systems had a combined projected annual energy consumption of 115,684 kWh (range, 3646-26,576 kWh per system). The systems' combined projected energy consumption occurring outside the net-imaging state accounted for 93.3% (107,978/115,684 kWh) of projected total energy consumption (range, 89.2-99.4% per system). A hypothetical operational adjustment whereby all systems would be switched from the idle state to the off state overnight and on weekends (versus being operated in idle mode 24 hours a day, 7 days a week) would yield the following potential annual savings: for energy consumption, 144,640 kWh; for carbon emissions, 18.6 metric tons of CO2 equivalent; and for electricity costs, US$37,896. CONCLUSION. Interventional imaging systems are energy intensive, having high consumption outside of image acquisition periods. CLINICAL IMPACT. Strategic operational adjustments (e.g., powering down idle systems) can substantially decrease the carbon emissions and electricity costs of interventional imaging systems.

Water vapor thermal therapy of lower urinary tract symptoms due to benign prostatic obstruction: efficacy and safety analysis of a real-world cohort of 211 patients.

PURPOSE: This study assessed the efficacy, safety and durability outcomes of water vapor thermal therapy with Rezum in a real-world cohort of patients with lower urinary tract symptoms due to benign prostate obstruction. METHODS: Consecutive, unselected patients undergoing Rezum treatment between January 2014 and August 2022 were candidates for this pragmatic, observational, longitudinal, single-center cohort study. Pre- and perioperative data were descriptively summarized. The primary outcome was surgical efficacy, determined by International Prostate Symptom Score (IPSS), Quality of Life (QoL) Score, maximum urinary flow rate (Qmax), post-void residual (PVR) volume and prostate volume (PV) at baseline, 2 months, 6 months, 1 year, 2 years, and > 2 years. RESULTS: A total of 211 patients were enrolled for analysis. Overall, catheter removal was successful in 92.4% of patients after a median of 5 days. A preoperative catheter and the presence of a median lobe increased the risk of unsuccessful catheter removal. In total, 5.7% of patients were reoperated after a median of 407 days. Comparing baseline to the longest median follow-up, the postoperative IPSS decreased significantly by 65.7%, the QoL Score declined by 66.7% (both until a maximum median of 4.5 years) and Qmax improved by 66.7% (until 3.9 years). Post-void residual volume and PV were reduced by 85.7% (3.7 years) and 47% (4.0 years), respectively. Clavien-Dindo complication ≤ II occurred in 11.8%. CONCLUSION: Rezum is a safe minimally invasive treatment option in a real-world patient cohort with a beneficial improvement of micturition symptoms and voiding function during follow-up.

Patterns of stemness-associated markers in the development of castration-resistant prostate cancer.

BACKGROUND: Putative castration-resistant (CR) stem-like cells (CRSC) have been identified based on their ability to initiate and drive prostate cancer (PCa) recurrence following castration in vivo. Yet the relevance of these CRSC in the course of the human disease and particularly for the transition from hormone-naive (HN) to castration-resistance is unclear. In this study, we aimed at deciphering the significance of CRSC markers in PCa progression. METHODS: We constructed a tissue microarray comprising 112 matched HN and CR tissue specimens derived from 55 PCa patients. Expression of eight stemness-associated markers (ALDH1A1, ALDH1A3, ALDH3A1, BMI1, NANOG, NKX3.1, OCT4, SOX2) was assessed by immunohistochemistry and scored as a percentage of positive tumor cells. For each marker, the resulting scores were statistically analyzed and compared to pathological and clinical data associated with the samples. Unsupervised clustering analysis was performed to stratify patients according to the expression of the eight CRSC markers. Publicly-available transcriptional datasets comprising HN and CR PCa samples were interrogated to assess the expression of the factors in silico. RESULTS: Immunohistochemical assessment of paired samples revealed atypical patterns of expression and intra- and intertumor heterogeneity for a subset of CRSC markers. While the expression of particular CRSC markers was dynamic over time in some patients, none of the markers showed significant changes in expression upon the development of castration resistance (CR vs HN). Using unsupervised clustering approaches, we identified phenotypic subtypes based on the expression of specific stem-associated markers. In particular, we found (a) patterns of mutual exclusivity for ALDH1A1 and ALDH1A3 expression, which was also observed at the transcriptomic level in publicly-available PCa datasets, and (b) a phenotypic cluster associated with more aggressive features. Finally, by comparing HN and CR matched samples, we identified phenotypic cluster switches (ie, change of phenotypic cluster between the HN and CR state), that may be associated with clinical and predictive relevance. CONCLUSIONS: Our findings indicate stemness-associated patterns that are associated with the development of castration-resistance. These results pave the way toward a deeper understanding of the relevance of CRSC markers in PCa progression and resistance to androgen-deprivation therapy.

High incidence of urinary tract infections after photoselective laser vaporisation of the prostate: a risk factor analysis of 665 patients.

PURPOSE: Although photoselective laser vaporisation of the prostate (PVP) is a recognised alternative to transurethral resection in treating benign prostatic obstruction, there is limited data on the incidence and determinants of postoperative urinary tract infections (UTI). We assessed patients subjected to PVP, evaluating incidence and potential determinants of postoperative UTIs. MATERIALS AND METHODS: Consecutive patients undergoing PVP between April 2010 and August 2018 were candidates for this retrospective cohort study. The primary outcome measure was microbiologically confirmed postoperative UTI. We fitted uni- and multi-variable Cox models to identify potential risk factors. RESULTS: Among the 665 included patients, 20% developed postoperative UTIs. The overall incidence rate per 100 patient-days was 0.65 (95% confidence interval [CI] 0.55-0.77). Risk factors for postoperative UTIs were end-stage renal failure (adjusted hazard ratio [aHR] = 14.10, 95% CI 2.08-64.58; p = 0.001) and presence of at least one of the following factors in the 3 months preceding PVP: (i) placement of urinary catheter, (ii) bacteriuria, (iii) UTI, or (iv) antimicrobial treatment (composite aHR = 1.99, 95% CI 1.22-3.24; p < 0.001). There was no apparent association between choice or duration of antimicrobial prophylaxis and incident UTIs. CONCLUSIONS: Our analysis revealed a high incidence of UTIs after PVP and served to identify certain preoperative risk factors. Neither the choice of antimicrobial regimen nor its duration affected the incidence of UTIs. Prolonged antimicrobials proved to be disproportionately high, warranting further scrutiny in randomised controlled trials.

Novices in MRI-targeted prostate biopsy benefit from structured reporting of MRI findings.

PURPOSE: The aim of this study was to investigate whether structured reports (SRs) of prostate MRI results are more suitable than non-structured reports (NSRs) for promoting the more accurate assessment of the location of a single prostate cancer lesion by novices in MRI-targeted biopsy. METHODS: 50 NSRs and 50 SRs describing a single prostatic lesion were presented to 5 novices in MRI-targeted biopsy. The participants were asked to plot the tumor location in a two-dimensional prostate diagram and to answer a questionnaire on the quality of the reports. The accuracy of the plotted tumor position was evaluated with a validated 30-point scoring system that distinguished between "major" and "minor" mistakes. RESULTS: The overall mean score for the accuracy of the tumor plotting was significantly higher for SRs than for NSRs (26.4 vs. 20.7, p < 0.01). The mean numbers of major (1.4 vs. 0.48, p < 0.01) and minor (3.05 vs. 1.15, p < 0.01) mistakes were significantly higher for NSRs than for SRs. Compared with NSRs, SRs received significantly higher ratings for the perceived quality of the summary (4.0 vs. 2.4, p < 0.01) as well as for the overall satisfaction with the report (4.1 vs. 2.1, p < 0.01). CONCLUSION: Novices in MRI-targeted biopsy prefer structured reporting of prostate MRI as an information tool. SRs allow for a more accurate assessment of the location of single prostate cancer lesions. Therefore, structured reporting of prostate MRI may help to foster the learning process of novices in MRI-targeted biopsy.

Outcome of kidney function after ischaemic and zero-ischaemic laparoscopic and open nephron-sparing surgery for renal cell cancer.

BACKGROUND: Nephron-sparing surgery (NSS) remains gold standard for the treatment of localised renal cell cancer (RCC), even in case of a normal contralateral kidney. Compared to radical nephrectomy, kidney failure and cardiovascular events are less frequent with NSS. However, the effects of different surgical approaches and of zero ischaemia on the postoperative reduction in renal function remain controversial. We aimed to investigate the relative short- and long-term changes in estimated glomerular filtration rate (eGFR) after ischaemic or zero-ischaemic open (ONSS) and laparoscopic NSS (LNSS) for RCC, and to analyse prognostic factors for postoperative acute kidney injury (AKI) and chronic kidney disease (CKD) stage ≥3. METHODS: Data of 444 patients (211 LNSS, 233 ONSS), including 57 zero-ischaemic cases, were retrospectively analysed. Multiple regression models were used to predict relative changes in renal function. Natural cubic splines were used to demonstrate the association between ischaemia time (IT) and relative changes in renal function. RESULTS: IT was identified as significant risk factor for short-term relative changes in eGFR (ß = - 0.27) and development of AKI (OR, 1.02), but no effect was found on long-term relative changes in eGFR. Natural cubic splines revealed that IT had a greater effect on patients with baseline eGFR categories ≥G3 concerning short-term decrease in renal function and development of AKI. Unlike LNSS, ONSS was significantly associated with short-term decrease in renal function (ß = - 13.48) and development of AKI (OR, 3.87). Tumour diameter was associated with long-term decrease in renal function (ß = - 1.76), whereas baseline eGFR was a prognostic factor for both short- (ß = - 0.20) and long-term (ß = - 0.29) relative changes in eGFR and the development of CKD stage ≥3 (OR, 0.89). CONCLUSIONS: IT is a significant risk factor for AKI. The short-term effect of IT is not always linear, and the impact also depends on baseline eGFR. Unlike LNSS, ONSS is associated with the development of AKI. Our findings are helpful for surgical planning, and suggest either the application of a clampless NSS technique or at least the shortest possible IT to reduce the risk of short-time impairment of the renal function, which might prevent AKI, particularly regarding patients with baseline eGFR category ≥G3.

Correction to: Outcome of kidney function after ischaemic and zero-ischaemic laparoscopic and open nephron-sparing surgery for renal cell cancer.

Following publication.

The Value of Prognostic Grouping of Prostatic Carcinomas for Urologists and Pathologists.

OBJECTIVES: To improve the prognostic stratification for different therapeutic options of prostatic carcinomas (PCa) with low and intermediate grade by combining Gleason grading with cytological findings and prognostic grade grouping. METHODS: We analyzed PCa after radical prostatectomy using the combined grading of Gleason and Helpap, which allows an exact differentiation particularly of low and intermediate grade tumors. Additionally, we attached time-interval and percentage value of recurrences of prostate-specific antigen (PSA) as well as death on disease (DoD) to the prognostic grade grouping. RESULTS: Carcinomas of group I/V are very low-grade tumors with very good prognosis without biochemical recurrence and DoD predestining for active surveillance (AS). The group II/V with low progress of PSA without DoD allows the options of an active treatment or AS and shows a prognostic separation of the intermediate group III/V. Within the high-grade groups, a differentiation is necessary between GS 7b (4 + 3), 8, and 9-10 regarding TNM staging and rate of DoD. Prognosis of GS 7b (4 + 3) group III/V is more favourable without DoD in contrast to group IV and V/V with cases of DoD. CONCLUSION: Morphologically prognostic classification by using combined grading may improve the prognostic stratification of patients with PCa.

Ablative efficiency of 532-nm laser vaporization compared to transurethral resection of the prostate: results from a prospective three-dimensional ultrasound volumetry study.

PURPOSE: To assess and compare postoperative prostate volume changes following 532-nm laser vaporization (LV) and transurethral resection of the prostate (TURP). To investigate whether differences in volume reduction are associated with differences in clinical outcome. METHODS: In this prospective, non-randomized study, 184 consecutive patients undergoing 120 W LV (n = 98) or TURP (n = 86) were included. Transrectal three-dimensional ultrasound and planimetric volumetry of the prostate were performed preoperatively, after catheter removal, 6 weeks, 6 and 12 months. Additionally, clinical outcome parameters were recorded. Mann-Whitney U test and analysis of covariance were utilized for statistical analysis. RESULTS: Postoperatively, a significant prostate volume reduction was detectable in both groups. However, the relative volume reduction was lower following LV (18.4 vs. 34.7 %, p < 0.001). After 6 weeks, prostate volumes continued to decrease in both groups, yet differences between the groups were less pronounced. Nonetheless, the relative volume reduction remained significantly lower following LV (12 months 43.3 vs. 50.3 %, p < 0.001). All clinical outcome parameters improved significantly in both groups. However, the maximum flow rate (Q max) and prostate-specific antigen (PSA) reduction were significantly lower following LV. Subgroup analyses revealed significant differences only if the initial prostate volume was >40 ml. Re-operations were necessary in three patients following LV. CONCLUSIONS: The modest but significantly lower volume reduction following LV was associated with a lower PSA reduction, a lower Q max and more re-operations. Given the lack of long-term results after LV, our results are helpful for preoperative patient counseling. Patients with large prostates and no clear indication for the laser might not benefit from the procedure.

Expression of histone deacetylases 1, 2 and 3 in urothelial bladder cancer.

BACKGROUND: Histone deacetylases (HDACs) are known to be associated with an overexpression in different types of cancer such as colon and prostate cancer. In this study we aimed to evaluate the protein expression of class I HDACs in urothelial carcinoma of the bladder. METHODS: A tissue microarray containing 348 tissuesamples from 174 patients with a primary urothelial carcinoma of the bladder was immunohistochemically stained for HDAC 1, 2 and 3. Intensity of staining was evaluated and the association with clinico-pathological features and prognosis was assessed. RESULTS: High HDAC expression levels were found in 40 to 60% of all investigated urothelial carcinomas (HDAC-1: 40%, HDAC-2: 42%, HDAC-3: 59%).HDAC-1 and HDAC-2 were significantly associated with higher tumour grades.Although all three markers could not predict progression in univariate analyses, high HDAC-1 expression was associated with a trend toward poorer prognosis. Patients with high-grade tumours and high expression levels of HDAC-1 were more likely to progress compared to all other patients (p < 0.05). CONCLUSIONS: High-grade noninvasive papillary bladder tumours are associated with high expression levels of HDAC-1 and HDAC-2. High grade tumours in combination with high expression of HDAC-1 showed a worse prognosis than the other tumours. The high expression levels of HDACs observed particularly in high grade urothelial bladder cancer clearly warrant subsequent studies on the potential use of HDAC inhibitors as a novel therapeutic approach.

Risk factors of bladder stones in neurogenic lower urinary tract dysfunction: A real-world study.

Objective: The objective of this study is to investigate the incidence and risk factors for stone formation and recurrence in patients with neurogenic lower urinary tract dysfunction (NLUTD) in a real-world cohort. Materials and methods: A retrospective cohort study was conducted on all patients with NLUTD who underwent bladder stone treatment between 2010 and 2022. Univariate and multivariate Cox models were used to identify the potential risk factors for stone recurrence. Results: Among 114 patients included in the study, 30% experienced stone recurrence. The most common stone components were carbonate apatite phosphate and magnesium ammonium phosphate. The overall recurrence rate was 14 cases per 100 patient years. Neurogenic detrusor overactivity had the highest recurrence rate. Risk factors for stone recurrence in the multivariate analysis were intermittent and suprapubic catheterization, and recurrent urinary tract infection (rUTI). Conclusions: Patients experienced multiple bladder stone recurrences. Close monitoring of bladder pressure and UTI with restrictive catheter application may reduce the risk of stone recurrence.

Catheter-associated Urinary Tract Infections-Online Questionnaire: Status Quo in Central European Urological Management of Catheter-associated Urinary Tract Infection.

Background and objective: Catheter-associated urinary tract infections (CAUTIs) represent a significant burden in health care and its management is challenging. This study aims to assess and compare central European CAUTIs regarding diagnostics, treatment, and prophylaxis. Methods: An anonymized online questionnaire was distributed among urologists in Austria, France, Germany, and Switzerland between January and October 2023, consisting of demographic questions on catheter management and diagnostics, treatment, and prophylaxis of CAUTIs. An analysis was performed per country. Comparisons were done with the Fisher's exact test (statistical significance with p < 0.05). Key findings and limitations: Out of 423 participating urologists, most regularly performed catheter changes and managed catheter-related issues, except for French urologists. Swiss urologists tended to change the catheter after a longer interval. In France, a higher estimated number of CAUTIs were observed. Diagnostic symptoms and measures varied significantly between countries. French urologists prescribed more antimicrobials per patient and administered longer treatment regimens. The choice of antimicrobial agents differed notably for nonfebrile and febrile CAUTIs, with cotrimoxazole/nitrofurantoin being common for nonfebrile cases and cephalosporin/amoxicillin for febrile ones. Follow-up protocols were similar among urologists, while prophylactic measures showed variations. Conclusions and clinical implications: CAUTI management varied notably across countries in terms of diagnostics, treatment, and prophylaxis. Discrepancies in antimicrobial therapy could be influenced by local resistance rates; yet, nonrecommended drugs and prolonged regimens, as compared with guideline recommendations, were common. This trend, along with inappropriate diagnostics and prophylaxis, may increase antimicrobial resistance and CAUTI morbidity. This study emphasizes the necessity for diagnostic and antimicrobial stewardship interventions, and proper training in CAUTI management. Patient summary: In this questionnaire-based study examining the clinical practices for managing urinary tract infections in patients with bladder catheters (CAUTIs), significant disparities were observed among European urologists regarding diagnosis, treatment, and prophylaxis. These findings underscore the critical need for clear guidelines and comprehensive training in CAUTI management.

The impact of robotic-assisted transperineal biopsy of the prostate on erectile function.

BACKGROUND: Prostate biopsy represents one of the most frequently performed urologic procedures worldwide and therefore presupposes knowledge on potential effects like on the erectile function, especially in extensive or repeated biopsies. The robotic-assisted biopsy system (Mona Lisa) offers a minimal invasive approach via only two incision points ensuring maximal accuracy combined with protection of the neurovascular bundle of the prostate. OBJECTIVE: Our purpose was to analyse the impact of robotic-assisted transperineal biopsy of the prostate on the erectile function. METHODS: Our prospective study analyses the outcomes of 210 patients, who had undergone minimal-invasive, transperineal robotic-assisted biopsy of the prostate at the University Hospital Basel from January 2020 to March 2022 and provided sufficient data. Of these, 157 (74.8%) were included in final analysis. RESULTS: Mean (range) age, prostate volume, PSA and IIEF-5 score at baseline were 63.8 years (46.1-83.6), 46.4 ml (9-310), 13.2 ng/ml (0.2-561), and 18.8 points (6-25), respectively. EF before and 1 month after intervention was assessed with the IIEF-5 questionnaire for the whole cohort. No significant change of IIEF-5 was observed for the whole cohort with a mean (± SD) decrease of 0.4 (± 3.1) points. Except for patients > 69 years, subgroup analysis revealed no change of IIEF-5 in statistically significant manner for all subgroups. Number of biopsy cores (< 20 and ≥ 20), previous biopsies and active surveillance showed no significant influence. CONCLUSION: Our results suggest that the minimally invasive and highly precise robotic technique can spare the erectile function without limiting the extent of biopsy and without compromising diagnostic accuracy.

Patient-derived organoids identify tailored therapeutic options and determinants of plasticity in sarcomatoid urothelial bladder cancer.

Sarcomatoid Urothelial Bladder Cancer (SARC) is a rare and aggressive histological subtype of bladder cancer for which therapeutic options are limited and experimental models are lacking. Here, we report the establishment of a long-term 3D organoid-like model derived from a SARC patient (SarBC-01). SarBC-01 emulates aggressive morphological, phenotypical, and transcriptional features of SARC and harbors somatic mutations in genes frequently altered in sarcomatoid tumors such as TP53 (p53) and RB1 (pRB). High-throughput drug screening, using a library comprising 1567 compounds in SarBC-01 and conventional urothelial carcinoma (UroCa) organoids, identified drug candidates active against SARC cells exclusively, or UroCa cells exclusively, or both. Among those, standard-of-care chemotherapeutic drugs inhibited both SARC and UroCa cells, while a subset of targeted drugs was specifically effective in SARC cells, including agents targeting the Glucocorticoid Receptor (GR) pathway. In two independent patient cohorts and in organoid models, GR and its encoding gene NR3C1 were found to be significantly more expressed in SARC as compared to UroCa, suggesting that high GR expression is a hallmark of SARC tumors. Further, glucocorticoid treatment impaired the mesenchymal morphology, abrogated the invasive ability of SARC cells, and led to transcriptomic changes associated with reversion of epithelial-to-mesenchymal transition, at single-cell level. Altogether, our study highlights the power of organoids for precision oncology and for providing key insights into factors driving rare tumor entities.

Exploring the intratumoral heterogeneity of DNA ploidy in prostate cancer.

BACKGROUND: Prostate cancer is morphologically and molecularly heterogeneous. Genomic heterogeneity might be mirrored by variability in DNA ploidy. Aneuploidy is a hallmark of genomic instability and associated with tumor aggressiveness. Little attention has been paid to the biological significance of the diploid tumor cell population that often coexists with aneuploid populations. Here, we investigated the role of DNA ploidy in tumor heterogeneity and clonal evolution. METHODS: Three radical prostatectomy specimens with intratumoral heterogeneity based on nuclear features on H&E were selected. DNA content of each subpopulation was determined by DNA image cytometry and silver in situ hybridization (SISH). Genomic evolution was inferred from array comparative genomic hybridization (aCGH). Additionally, immunohistochemistry was used to examine the stemness-associated marker ALDH1A1. RESULTS: Nuclear morphology reliably predicted DNA ploidy status in all three cases. In one case, aCGH analysis revealed several shared deletions and one amplification in both the diploid and the aneuploid population, suggesting that these populations could be related. In the other two cases, a statement about relatedness was not possible. Furthermore, ALDH1A1 was expressed in 2/3 cases and exclusively observed in their diploid populations. CONCLUSIONS: In this proof-of-concept study, we demonstrate the feasibility to predict the DNA ploidy status of distinct populations within one tumor by H&E morphology. Future studies are needed to further investigate the clonal relationship between the diploid and the aneuploid subpopulation and test the hypothesis that the aneuploid population is derived from the diploid one. Finally, our analyses pointed to an enrichment of the stemness-associated marker ALDH1A1 in diploid populations, which warrants further investigation in future studies.

Clinical impact of 18F-choline PET/CT in patients with recurrent prostate cancer.

PURPOSE: To investigate the clinical value of (18)F-fluorocholine PET/CT (CH-PET/CT) in treatment decisions in patients with recurrent prostate cancer (rPCA). METHODS: The study was a retrospective evaluation of 156 patients with rPCA and CH-PET/CT for restaging. Questionnaires for each examination were sent to the referring physicians 14-64 months after examination. Questions included information regarding initial extent of disease, curative first-line treatment, and the treatment plan before and after CH-PET/CT. Additionally, PSA values at diagnosis, after initial treatment, before CH-PET/CT and at the end of follow-up were also obtained from the questionnaires. RESULTS: Mean follow-up was 42 months. The mean Gleason score was 6.9 at initial diagnosis. Initial treatment was: radical prostatectomy in 110 patients, radiotherapy in 39, and combined prostatectomy and radiotherapy in 7. Median PSA values before CH-PET/CT and at the end of follow-up were 3.40 ng/ml and 0.91 ng/ml. PSA levels remained stable, decreased or were below measurable levels in 108 patients. PSA levels increased in 48 patients. In 75 of the 156 patients (48%) the treatment plan was changed due to the CH-PET/CT findings. In 33 patients the therapeutic plan was changed from palliative treatment to treatment with curative intent. In 15 patients treatment was changed from curative to palliative. In 8 patients treatment was changed from curative to another strategy and in 2 patients from one palliative strategy to another. In 17 patients the treatment plan was adapted. CONCLUSION: CH-PET/CT has an important impact on the therapeutic strategy in patients with rPCA and can help to determine an appropriate treatment.

Intrafascial dissection significantly increases positive surgical margin and biochemical recurrence rates after robotic-assisted radical prostatectomy.

INTRODUCTION: Improved visualization and magnification in robot-assisted laparoscopic radical prostatectomy (RALRP) has tempted many urologists to dissect the neurovascular bundle closer to the prostate following the layers of the pseudo-capsule of the prostate. This might bear a higher risk of decreased tumor control. MATERIALS AND METHODS: An analysis of a consecutive series of 186 patients who underwent RALRP at our institution was performed. The outcome of patients with intrafascial nerve-sparing (INS) was compared with the outcome of patients who underwent interfascial, extrafascial or no nerve-sparing (non-INS). RESULTS: A total of 80 patients (43.0%) received INS. The overall R1 rate was 27.9%. For pT2 tumors the rate of R1 was 33.8% in INS versus 14.8% in non-INS (odds ratio 2.936, 95% confidence interval 1.338-6.443, p = 0.007). Recurrence-free survival was significantly shorter in INS (p = 0.05; hazard ratio 3.791). CONCLUSION: The intrafascial dissection technique for RALRP bears a high risk of incomplete resection in localized prostate cancer resulting in unfavorable outcome.

Long-Term Outcome of Non-antireflux Robotic-Assisted Robot-Assisted Laparoscopic Ureter Reimplantation in Ureteral Obstruction.

Purpose: Although robot-assisted laparoscopic ureter reimplantation (RALUR) is a recognized alternative to open and laparoscopic ureter reimplantation in treating distal ureteral obstruction, there are limited data on long-term efficacy and safety outcomes of non-antireflux RALUR. We assessed patients undergoing RALUR, evaluating operative, functional, and safety determinants. Materials and Methods: All consecutive patients undergoing non-antireflux RALUR between April 2015 and January 2020 were included in this retrospective cohort study. The primary outcome endpoint was recurrent distal ureteral obstruction. Results: Mean follow-up was 41.3 months (95% confidence interval, 33.3-49.2; range 2-82). Among the 26 included patients, none developed recurrent distal ureteral obstruction. Kidney function in terms of serum creatinine level (72.0 µmol/L vs 71.0 µmol/L, p = 0.988) and glomerular filtration rate (92.0 mL/min vs 91.0 mL/min, p = 0.831) was stable between the preoperative period and the last follow-up. Renal pelvis dilatation decreased significantly postoperatively, from grade 2 to grade 0 (p < 0.001). Most patients (73.1%) remained free from any clinical symptoms of reflux during the follow-up. No recurring urinary tract infections were reported. The rate of postoperative complications (Clavien-Dindo grade ≥II) was 23.1%. All complications resolved without sequelae. Conclusions: Non-antireflux RALUR appears to be safe and effective in the management of distal ureteral obstruction. There was no recurrent ureteral obstruction after RALUR in our cohort during a mean follow-up of more than 3 years. Non-antireflux reimplantation did not seem to have any notable impact on renal function during the follow-up period.

Safety profile of robotic-assisted transperineal MRI-US-fusion guided biopsy of the prostate.

Introduction: Robotic-assisted transperineal MRI-US-fusion guided biopsy of the prostate is a novel and highly accurate procedure. The aim of this study was to evaluate the MonaLisa prostate biopsy system in terms of safety, tolerability, and patient-related outcomes. Methods: This prospective study included 228 patients, who had undergone Robotic-assisted transperineal MRI-US-fusion guided biopsy of the prostate at the University Hospital Basel between January 2020 and June 2022. Peri-operative side effects, functional outcomes and patient satisfaction were assessed. Results: Mean pain score on the day of biopsy was 1.3 points on VAS, which remained constant on the day after biopsy. Overall, 32 of 228 patients (14%) developed grade I complications according to Clavien-Dindo classification. No higher-grade complications occurred. Gross haematuria, hematospermia and acute urinary retention occurred in 145/228 (63.6%), 98/228 (43%) and 32/228 (14%) patients, respectively. One patient (0.4%) developed urinary tract infection. Conclusions: Robotic-assisted transperineal MRI-US-fusion guided biopsy of the prostate performed under general anesthesia is a safe and well tolerated procedure. This technique allows to omit perioperative prophylaxis and at the same time minimizes the risk of infectious complications. We attribute the favorable risk profile and tolerability to the minimal invasive approach via two entry points.