Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted Prostate Biopsy: A Systematic Review and Meta-analysis of Prospective Studies.

BACKGROUND AND OBJECTIVE: The benefits of the detection of clinically significant prostate cancer (csPCa) and safety of magnetic resonance imaging (MRI)-targeted transperineal (TP) prostate biopsy (TP-Tbx) versus transrectal (TR) approaches are still a matter of debate. This review aims to compare the efficacy and safety of TP-Tbx and MRI-targeted TR biopsy (TR-Tbx). METHODS: A systematic literature search was performed in PubMed/Medline, Scopus, and Web of Science to identify records of prospective randomized controlled trials (RCTs) comparing TP-Tbx and TR-Tbx published until May 2024. The primary outcomes included detection rates of csPCa (International Society of Urological Pathology [ISUP] ≥2) and rates of complications. KEY FINDINGS AND LIMITATIONS: Three RCTs (PREVENT, ProBE-PC, and PERFECT) met the inclusion criteria. The TR technique was commonly administered with antibiotic prophylaxis to mitigate infection risks or after a rectal swab. No difference was found between TP-Tbx and TR-Tbx in terms of either csPCa (odds ratio [OR] 0.9, 95% confidence interval [CI]: 0.7-1.1) or ISUP 1 prostate cancer (PCa; OR 1.1, 95% CI: 0.8-1.4) detection. Postprocedural infection (OR 0.8, 95% CI: 0.4-1.8), sepsis (OR 0.6, 95% CI: 0.1-4.5), and urinary retention rates (OR 0.5, 95% CI: 0.1-1.6) were similar. Pain during the TP approach was slightly higher than during the TR approach, but after 7 d of follow-up, the differences between the two approaches were minimal. Variations in biopsy numbers per patient, patient selection, use of 5-alpha reductase inhibitors, needle sizes, TP techniques, and pain scores (reported in only one RCT), along with the multicenter nature of RCTs, limit the study. CONCLUSIONS AND CLINICAL IMPLICATIONS: TP-Tbx and TR-Tbx show similar results in detecting PCa, with comparable rates of infections, urinary retention, and effectiveness in managing biopsy-associated pain. TP-Tbx can safely omit antibiotics without increasing infection risk, unlike TR-Tbx. The tendency to exclude from practice TR-Tbx with prophylactic antibiotics due to infection concerns could be moderated; however, the directionality of some key outcomes, as infections and sepsis, favor the TP approach despite a lack of statistical significance. PATIENT SUMMARY: There were no significant differences in the prostate biopsy approaches (transperineal [TP] vs transrectal [TR]) for prostate cancer detection and complications. However, the MRI-targeted TP prostate biopsy approach may be advantageous as it can be performed safely without antibiotics, potentially reducing antibiotic resistance.

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, random biopsy, and their combination in the detection of clinically significant prostate cancer by mpMRI/transrectal ultrasonography fusion biopsy in confirmatory biopsy during active surveillance program.

BACKGROUND: Based on the findings of different trials in biopsy naïve patients, target biopsy (TB) plus random biopsy (RB) during mpMRI-guided transrectal ultrasound fusion biopsy (FB) are often also adopted for the biopsy performed during active surveillance (AS) programs. At the moment, a clear consensus on the extent and modalities of the procedure is lacking. OBJECTIVE: To evaluate the increase in diagnostic accuracy achieved by perilesional biopsy (PL) and different RB schemes during FB performed in AS protocol. DESIGN, SETTING, AND PARTICIPANTS: We collected prospectively the data of 112 consecutive patients with low- or very-low-risk prostate cancer; positive mpMRI underwent biopsy at a single academic institution in the context of an AS protocol. INTERVENTION(S): mpMRI/transrectal US FB with Hitachi RVS system with 3 TB and concurrent transrectal 24-core RB. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The diagnostic yield of the different possible biopsy schemes (TB only; TB + 4 perilesional (PL) cores; TB + 12-core RB; TB + 24-core RB) was compared by the McNemar test. Univariable and multivariable regression analyses were adopted to identify predictors of any cancer, Gleason grade group (GGG) ≥2 cancers, and the presence of GGG≥2 cancers in the larger schemes only. RESULTS AND LIMITATIONS: The detection rate of GGG ≥2 cancers increased to 30%, 39%, and 49% by adding 4 PL cores, 14, and 24 RB cores, respectively, to TB cores (all p values <0.01). On the whole, TB alone, 14-core RB, and 24-core-RB identified 38%, 47%, and 56% of all the GGG ≥2 cancers. Such figures increased to 62% by adding to TB 4 PL cores, and to 80% by adding 14 RB cores. Most of the differences were observed in PI-RADS 4 lesions. CONCLUSIONS: We found that PL biopsy increased the detection rate of GGG ≥2 cancers as compared with TB alone. However, the combination of those cores missed a large percentage of the CS cancers identified with larger RB cores, including a 20% of CS cancers diagnosed only by the combination of TB plus 24-core RB.

Urology: a trip into metaverse.

PURPOSE: Metaverse is becoming an alternative world in which technology and virtual experiences are mixed with real life, and it holds the promise of changing our way of living. Healthcare is already changing thanks to Metaverse and its numerous applications. In particular, Urology and urologic patients can benefit in many ways from Metaverse. METHODS: A non-systematic literature review identified recently published studies dealing with Metaverse. The database used for this review was PubMed, and the identified studies served as the base for a narrative analysis of the literature that explored the use of Metaverse in Urology. RESULTS: Virtual consultations can enhance access to care and reduce distance and costs, and pain management and rehabilitation can find an incredible support in virtual reality, reducing anxiety and stress and improving adherence to therapy. Metaverse has the biggest potential in urologic surgery, where it can revolutionize both surgery planning, with 3D modeling and virtual surgeries, and intraoperatively, with augmented reality and artificial intelligence. Med Schools can implement Metaverse in anatomy and surgery lectures, providing an immersive environment for learning, and residents can use this platform for learning in a safe space at their own pace. However, there are also potential challenges and ethical concerns associated with the use of the metaverse in healthcare. CONCLUSIONS: This paper provides an overview of the concept of the metaverse, its potential applications, challenges, and opportunities, and discusses the implications of its development in Urology.

Neutrophil-to-lymphocyte ratio as a prognostic factor for patients with urothelial carcinoma of the bladder following radical cystectomy.

Introduction: The pre-treatment neutrophil-to-lymphocyte ratio (NLR) has been associated with adverse pathology or survival in a variety of malignancies, including urothelial carcinoma of the bladder (UCB) treated with radical cystectomy (RC). Whether the prognostic value of NLR is retained, or even increased, when measured postoperatively remains to be studied. In this study, we evaluated the association of preoperative and postoperative NLR with oncological outcomes following RC. Material and methods: The NLR was recorded in 132 consecutive patients with UCB treated with open RC: before surgery (NLR1), postoperatively within 2 days (NRL2), between 7 and 15 days after RC before discharge (NLR3), and a few days before recurrence or last available follow-up (NLR4). Results: When assessed by multivariate analysis NLR1 remained independently associated with a significantly increased risk of extravesical disease (pT 3-4) (OR = 1.4, p <0.01) and lymphovascular invasion (LVI) (OR = 1.40, 95% CI 1.09-1.83, p <0.01). NLR4 was independently associated with a significantly increased risk of cancer-specific mortality (CSM) (HR = 1.14, 95%CI 1.03-1.24, p = 0.013). In a postoperative model, NLR3 was found to be an independent predictor of all-cause mortality (ACM) [HR = 1.11, 95% CI 1.02-1.21, p = 0.01]. NLR1 was associated with a significantly increased risk of recurrence in the univariable preoperative model [HR = 1.9, 95%CI 1.00-3.65, p = 0.05], while in the postoperative model NLR4 remained independently associated with a significantly increased risk of recurrence (HR = 1.13, 95%CI 1.04-1.23, p = 0.03). Conclusions: In patients with UCB treated with RC, the NLR is associated with more advanced tumour stage, LVI, lymph node metastasis, and higher CSM. Furthermore, the variation of the NLR after surgery might play a role in predicting higher ACM and recurrence-free survival.

Colostomy Reversal following Hartmann's Procedure: The Importance of Timing in Short- and Long-Term Complications: A Retrospective Multicentric Study.

The restoration of bowel continuity following Hartmann's Procedure (HP) has been reported hitherto with high morbidity and mortality rates. No clear guidelines exist about timing in Hartmann's Reversal (HR), the literature data being conflicting. We have sought to investigate the effect of the interval time between HP and HR in short- and long-term HR outcomes through a retrospective study based on consecutive patients undergoing HR between 2009 and 2017 in two regional hospitals in Italy. Demographic characteristics, comorbidities, intra- and post-operative data, as well as early complications, were recorded. Long-term data were collected on the surgical site occurrences of Incisional Ventral Hernia (IVH). One hundred and five patients were recruited for the study. Late HR, female gender, and long operating time were related to the highest incidence of peri-operative complications. Patients who developed IVH had undergone HR at significantly shorter times and had a higher Body Mass Index (BMI). The timing of HR seems to be an important variable linked to the onset of early and late post-operative complications. The patients submitted to early HR show a significantly lower complication rate but, at the same time, a higher rate of IVH incidence after restorative surgery. These data, in our opinion, reflect the need for planning, where possible, an early restoration of bowel continuity after HP.