Phytotherapy Might Have a Role in Reducing Unnecessary Prostate Biopsies: Results from an Exploratory, Randomized Controlled Trial of Two Different Phytotherapeutic Agents.

BACKGROUND: We aimed to evaluate the impact of two different phytotherapeutic agents on decision making regarding prostate biopsy for patients with higher-than-normal prostate-specific antigen (PSA) levels. METHODS: From June 2022 to May 2023, all patients attending two urological institutions due to higher-than-normal PSA levels were randomized to receive either oral capsules of Curcuma Longa, Boswellia, Pinus pinaster and Urtica dioica (Group A) or Serenoa Repens 320 mg (Group B) for 3 months. At the follow-up visit after 3 months, all patients underwent PSA tests and multiparametric magnetic resonance imaging (mpMRI). RESULTS: In the per-protocol analysis, data from 66 patients in Group A and 76 in Group B were analyzed. Fifty patients in Group A (75.7%) showed a significant reduction in total PSA compared to forty-nine in Group B (64.4%) (p < 0.001). Twenty-eight patients had PI-RADS III or higher in mpMRI: twelve in Group A and fourteen in Group B. Twenty-three patients (34.8%) in Group A and fifty-nine (77.6%) in Group B (p < 0.001) underwent prostate biopsy based on the mpMRI findings and PSA values. Three patients in Group A showed a significant reduction in total PSA values while having positive mpMRI findings (6%) compared with nine in Group B (19.5%) (p < 0.001). On the contrary, 7 patients in Group A did not show significant reduction in total PSA values and had negative mpMRI findings (43%) compared to 22 in Group B (81.4%) (p < 0.001). CONCLUSIONS: In conclusion, a three-month course of a combination of Curcuma Longa, Boswellia, Pinus pinaster and Urtica dioica seems to be an interesting tool to avoid unnecessary prostate biopsies among men with higher-than-normal PSA levels.

The Use of Vacuum Devices as Adjuvant Therapy before and after Penile Curvature Surgery in Patients Affected by La Peyronie's Disease: Results from a Comparative Study.

BACKGROUND: Peyronie's disease (PD) represents a challenging urological disease, due to not optimal post-operative surgical outcomes. We aim to retrospectively evaluate if vacuum erection device (VED) treatment before penile curvature surgery is able to improve post-operative surgical outcomes. METHODS: All enrolled patients were assigned to the following groups: (a) the treatment group: VED treatment (three times per week) starting 3 months before surgery and (three times per week) one month after surgery; and (b) the control group: VED treatment (three times per week) one month after surgery. Follow-up urologic visits were scheduled for 3 and 6 months after surgery, and the two groups were compared. RESULTS: A total of 38 patients were enrolled (median age 67 years, 57-74, IQR): 20 in the treatment group and 18 in the control group. At the follow-up visits, the two groups were different in terms of IIEF-5 (26 vs. 24; p = 0.02), "yes" to SEP2 and 3 (85% vs. 55%; p < 0.001, 85% vs. 50%; p < 0.001, respectively), and PDQ (-16 vs. -11; p = 0.03). Complete correction of penile curvature was achieved in 36 patients (94.7%). In the treatment group, no hourglass deformity was reported, whereas one patient reported a mild hourglass deformity in the control group. In the treatment group, we obtained a longer total penile length (median +1.5 cm). The overall satisfaction rate was 98% in the treatment group and 96% in the control group. CONCLUSIONS: The VED treatment before penile curvature surgery in patients affected by PD was able to improve surgical outcomes.

Diagnostic concordance between traditional and digital workflows. A study on 1427 prostate biopsies.

Objective: To evaluate intra-observer diagnostic reproducibility using traditional slides (TS) versus whole slide images (WSI). Methods: TS and WSI of 1427 prostatic biopsies (107 consecutive patients) were evaluated by a single pathologist. Agreement between readings was evaluated with Gwet's Agreement coefficient (AC) and Landis and Koch benchmark scale. Results: The positive/negative agreement between the readings was almost perfect (AC1= 0.962; 95% CI[0.949,0.974]), with method independent distribution of discrepancies. Among positive biopsies, 212 had identical Gleason score (GS) on TS and WSI and discordant GS in 69 cases (AC2 = 0.932; 95% CI[0.907, 0.956]). Concordant negative and positive patient classification was observed in 39 and 64 cases, respectively; two cases were assigned to the positive group on TS and 2 on WSI configuring an almost perfect agreement (AC1=0.929; 95% C1[0.860, 0.998]). ISUP Grade group (ISUP GG) agreement was evaluated in the 60 concordantly positive cases: in 45 cases it was identical on TS and WSI; in 10 biopsies the discrepancy implied a modification of the assigned ISUP GG of ≤ 1 class and in 5 the discrepancy implied a modification of 2 classes. Gwet's agreement coefficient was (95% CI [0.834, 0.962]), i.e.: almost perfect agreement. Conclusions: Our data show almost perfect agreement between digital and traditional diagnostic activity in a routine setting, confirming that digital pathology can be safely introduced into routine workflows.

External Validation of a Novel Comprehensive Trifecta System in Predicting Oncologic and Functional Outcomes of Partial Nephrectomy: Results of a Multicentric Series.

BACKGROUND: To validate a novel trifecta for evaluating outcomes of partial nephrectomy (PN) on a multicentric dataset. METHODS: Between 2007 and 2020, three renal cancer databases were queried for patients with solitary renal masses who underwent PN (n = 649). Trifecta was estimated for overall cohort and contributing centers. Overall survival (OS), cancer-specific survival (CSS) and end-stage renal disease (ESRD) probabilities were assessed by Kaplan-Meier. Cox regression was used to identify predictors of OS, CSS, ESRD. For all analyses, a p < 0.05 was considered significant. RESULTS: At a median follow-up of 22.7 months (IQR 12.5-76.5) overall trifecta was 76.7% [Centre A; (n = 230; 68.6%), B (n = 68; 77.3%), C (n = 200; 88.4%); p = 0.001). On Kaplan-Meier, patients achieving trifecta exhibited higher OS (p = 0.024), higher CSS (p = 0.015) and lower ESRD rates (p = 0.024). On multivariable analysis, age (HR 1.04; 95% CI 1.01-1.08) and trifecta (HR 0.34; 95% CI 0.15-0.76) were independent predictors of OS while pT stage (HR 1.95; 95% CI 0.45-8.43) and trifecta (HR 0.33; 95% CI 0.16-0.67) were predictors of CSS (each p < 0.01). Preoperative CKD stage ≥ 3a (HR 13.1; 95% CI 4.07-42.6) and trifecta (HR 0.41; 95% CI 0.19-0.87) were independent predictors of ESRD (each p < 0.05). CONCLUSIONS: On external validation, trifecta was an independent predictor of all PN endpoints, regardless of hilar control and ischemia duration.

Robotic-assisted radical prostatectomy following colo-rectal surgery: a user's guide.

To assess the feasibility and operative outcomes of RARP following colo-rectal surgery. A prospective database of patients undergoing RARP is maintained at our Institution since January 2015. We reviewed all patients undergoing RARP after previous colo-rectal surgery. Overall, 49 (7.4%) of 658 RARPs were performed after previous pelvic surgery, 14 (2.1%) of which following colo-rectal surgery after an interval of 5 years. (a) Colo-rectal surgery. Previous colo-rectal surgery included resection of the left colon (n = 6), and right colon (n = 4), and rectum (n = 4). Histopathology showed pT0-T2N0 in 5, pT3N0-1 in 3, and benign conditions in 4. Prostate-specific antigen (PSA) was elevated (4 ng/ml or greater) or slightly elevated (3.5-4 ng/ml) in 9 (65%) of 14 cases at the time of colo-rectal surgery. (b) Prostatectomy. Overall prostatectomy and adhesiolysis median operative times were 235 and 42 min, respectively. A robotic approach was accomplished in 11 cases with previous uncomplicated colo-rectal surgery; open conversion occurred in 3 cases. Risk factors for open conversion during RARP were: history of multiple or complicated abdominal surgery, previous open conversion, and hospital stay > 10 days. Postoperative complications included: anemization (n = 2), persistent drain output (n = 1), and urinary tract infection (n = 1). The robotic approach was successful in the case of previous uncomplicated colo-rectal surgery. The risk of intestinal injury during conversion might suggest a direct retropubic approach in case of previous multiple or complicated abdominal surgery. A planned elective colo-rectal surgery should include a thorough urologic evaluation, considering the risk of a subsequent prostate surgery.

Comparison of GreenLight 180-W XPS laser vaporization versus transurethral resection of the prostate: Outcomes of a single regional center.

BACKGROUND: To evaluate the intermediate perioperative outcomes, rate of complications and functional data after XPS 180-W Greenlight photoselective laser vaporization (PVP) compared with transurethral resection of the prostate (TURP) in a prospective non-randomized single centre study. METHODS: We analyzed a prospectively-maintained database collecting data on 100 patients undergoing surgical treatment of BPH (50 consecutive PVP and 50 consecutive TURP). All complications, recorded and graduated according to the Clavien Dindo system and the clinical, operative, perioperative variables were compared. The functional outcomes, International Prostate Symptom Score (IPSS), max flow rate (Qmax) and Prostate Specific Antigen (PSA), were recorded preoperatively and at 1 year of follow up. RESULTS: Age, prostate volume, use of anticoagulants or antiplatelets, ASA score and operative time were comparable in the two groups. The reduction in the hemoglobin levels (0.46 vs 1.8 g/dL), the catheterization time (1.2 vs 3.2 days), the hospital stay (1.7 vs 3.8 days) and rate of transfused patients (0 vs 8%), were significantly lower for PVP. Transient re-catherization (6 vs 26%) was significantly lower for PVP. The IPSS and Qmax at 1 year showed no significant difference. The rate of repeat TURP/PVP was higher in the TURP group (0 vs 10%). Reduction of PSA, that reflects the major reduction of prostate volume, was statistically greater in PVP group respect TURP group (p = 0.001). CONCLUSIONS: PVP has advantages in terms of perioperative safety and major complications than TURP. Functional outcomes at 1 year of follow-up were comparable.

Sutureless laparoscopic partial nephrectomy using fibrin gel reduces ischemia time while preserving renal function.

OBJECTIVES: We evaluated the efficacy of sutureless laparoscopic partial nephrectomy (LPN), using a fibrin gel in order to minimize renal ischemia time and preserve kidney function. MATERIALS AND METHODS: Nineteen patients (mean age 58.3 ± 7.1) undergoing sutureless LPN using a fbrin gel were compared with a control group consisting of 21 patients (mean age 57.9 ± 7.5) subjected to LPN with standard suturing. Intraand post-operative data for the two groups were compared. The following parameters were recorded: patient demographics, Charlson Comorbidity Index, tumor characteristics according to the RENAL score, warm ischemia and operative times, estimated blood loss, mean hospital stay, post-operative complications referring to the Clavien-Dindo classification, renal function parameters pathologic and follow-up data. The main outcome measure was renal ischemia time and maintenance of kidney function. RESULTS: Median warm ischemia time was 13 minutes (range 11-19) in the group treated with fibrin gel and 19 (range 17- 29) in the control group, with a statistically significant difference (p < 0.001). The two groups were homogeneous in terms of the Charlson Comorbidity Index (4.6 vs 4.8) and RENAL score (9.6 vs 9.4). Median operative time differed significantly in the two groups, 183 minutes (range 145-218) in the group treated with fibrin gel and 201 (range 197-231) in the control group (p < 0.001). A negative surgical margin was reported in 18 patients (94.7%) in the group treated with fibrin gel and in 21 patients (100%) in the control group. No difference in renal function was found between the two groups. CONCLUSIONS: Sutureless LPN with fibrin gel can reduce warm ischemia and total operative time while preserving kidney function.

Robotic-assisted partial nephrectomy provides better operative outcomes as compared to the laparoscopic and open approaches: results from a prospective cohort study.

The objective of this is to compare the surgical outcomes of partial nephrectomy (PN), performed via three different approaches: robot-assisted (RAPN), laparoscopic (LPN), and open (OPN), in a single non-academic regional center. The data of patients undergoing PN at our Department from 2005 to 2016 were prospectively collected. A logistic regression model adjusted for preoperative variables (age, tumor size, creatinine and hemoglobin, ASA and Padua scores) was performed to evaluate whether transfusion, conversion, and postoperative complication rate were influenced by the surgical approach. Overall 270 patients underwent PN: analysis included 253 cases (RAPN = 110, LPN = 70, OPN = 73). Preoperative variables did not differ significantly among the three groups. Shorter operative (130 vs 180 and 200') and ischaemia (12 vs 23 and 22') times and longer hospital stay (8 vs 7 and 6 days) were found in the OPN group as compared to LPN and RAPN, respectively. The RAPN group included a higher rate of pT1b (31.8 vs 14.2 and 15%) and malignant histotype (90 vs 82.9 and 68.5%) as compared to LPN and OPN, respectively. Clavien Grade III-IV complications were lower in the RAPN (7.2%) as compared to OPN (12.3%) and LPN (17.1%) groups. Multivariate analysis showed a lower risk for conversion, transfusion and overall complications in the RAPN group versus LPN and OPN. The surgical approach affects the perioperative outcomes in a regional setting. The advantages of RAPN over OPN (lower risk of conversion, transfusion, and overall complications) are extended over LPN as well, although OPN offered faster operative and ischemia times at the expense of greater blood loss and hospital stay.

Retropubic, Laparoscopic, and Robot-Assisted Radical Prostatectomy: A Comparative Analysis of the Surgical Outcomes in a Single Regional Center.

BACKGROUND: To compare the surgical outcomes of radical prostatectomy (RP) performed via 3 different approaches: retropubic (RRP), laparoscopic-assisted (LRP), and robot-assisted (RARP), in a single non-academic regional center by a single surgeon. MATERIALS AND METHODS: The data of patients undergoing RP from 2005 to 2014 were reviewed. The standard approach changed through the years: RRP (n = 380, years 2005 to 2008), LRP (n = 240, years 2009 to 2011), and RARP (n = 262, years 2012 to 2014). Our analysis included the last consecutive 100 RP for each surgical technique by a single surgeon. A logistic regression model adjusted for pre-and postoperative variables was done to evaluate whether transfusion, conversion, and post-operative complication rates were influenced by the approach. RESULTS: RARP was associated with significantly lower blood loss (400 vs. 600 and 600 ml, respectively), transfusion (6 vs. 21 and 21%, respectively), and shorter hospital stay (6 vs. 7 and 8 days, respectively), compared to LRP and RRP, and a lower conversion rate (1 vs. 12%) compared to LRP. Multivariate analysis adjusted for confounders confirmed that the risk of transfusion and conversion was significantly lower in the RARP group compared to the LRP and RRP groups. The RARP group was also associated with a significantly lower risk of complications compared to the RRP group and with a trend in favor of the RARP group compared to the LRP group. The 1-year continence rate was significantly higher in the RARP group compared to the RRP and LRP groups (80 vs. 72 and 68%, respectively). CONCLUSION: The surgical approach affected the operative outcomes in a regional setting. The advantages of RARP over RRP (complications, transfusion, conversion, hospital stay, 1-year continence) were over LRP as well, with the only exception being complications.

Impact of novel techniques on minimally invasive adrenal surgery: trends and outcomes from a contemporary international large series in urology.

OBJECTIVE: To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide. METHODS: A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities. RESULTS: Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46 % of cases), 57 ML (8 %), 263 LESS (36 %), and 80 RA (11 %). Overall, 204 (28 %) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p = 0.05). A transperitoneal approach was preferred in all but the ML group (p < 0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6 %/year. The rate of RAL procedures increased at slower rates (2.2 %/year), similar to ML (1.7 %/year). Limitations of this study are the retrospective design and the lack of a cost analysis. CONCLUSIONS: Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.

Differential role of CD133 and CXCR4 in renal cell carcinoma.

The chemokine receptor CXCR4 and CD133, putative stem cell markers, were previously described in renal cancer (RCC). To evaluate the biological and prognostic role of CD133 and CXCR4 in RCC the expression was evaluated through qPCR and immunoblotting in human renal cancer cell lines (786-O, A498, ACHN, CAKI-1, SN12C, TK10, UO31) and patients biopsies. Renal cancer cells and surgical biopsies expressed functional CXCR4 while CD133 was not detectable. CXCR4 and CD133 expression was then evaluated in 240 renal cancer patients through immunohistochemistry. CXCR4 and CD133 were low in 19.1% and 59.6%; intermediate in 20% and 17.9%; high in 60.8% and 22.5% of the cases, respectively. CXCR4 was overexpressed in tumours (p= 0.02), while CD133 was over expressed in healthy tissues (p= 0.04). Disease free survival Kaplan Meier plots suggest that prognosis is unfavourable for patients whose primary tumours express CXCR4 (p= 0.0199) but nor CD133 (p= 0.151) neither the concomitant CXCR4-CD133 (p=0.848) high expression affected prognosis. Analysis of prognostic factors suggests that age, clinical presentation, AJCC stage and CXCR4 had a significant prognostic value at the univariate analysis. The CXCR4 predictive ability was confirmed at the multivariate analysis while no prognostic role was identified for CD133.Thus concomitant CD133 and CXCR4 evaluation is not worth in RCC patient while the CXCR4 prognostic role encourage CXCR4 antagonists as promising therapeutic option.