Unilateral Pelvic Lymph Node Dissection in Prostate Cancer Patients Diagnosed in the Era of Magnetic Resonance Imaging-targeted Biopsy: A Study That Challenges the Dogma.

PURPOSE: Bilateral extended pelvic lymph node dissection at the time of radical prostatectomy is the current standard of care if pelvic lymph node dissection is indicated; often, however, pelvic lymph node dissection is performed in pN0 disease. With the more accurate staging achieved with magnetic resonance imaging-targeted biopsies for prostate cancer diagnosis, the indication for bilateral extended pelvic lymph node dissection may be revised. We aimed to assess the feasibility of unilateral extended pelvic lymph node dissection in the era of modern prostate cancer imaging. MATERIALS AND METHODS: We analyzed a multi-institutional data set of men with cN0 disease diagnosed by magnetic resonance imaging-targeted biopsy who underwent prostatectomy and bilateral extended pelvic lymph node dissection. The outcome of the study was lymph node invasion contralateral to the prostatic lobe with worse disease features, ie, dominant lobe. Logistic regression to predict lymph node invasion contralateral to the dominant lobe was generated and internally validated. RESULTS: Overall, data from 2,253 patients were considered. Lymph node invasion was documented in 302 (13%) patients; 83 (4%) patients had lymph node invasion contralateral to the dominant prostatic lobe. A model including prostate-specific antigen, maximum diameter of the index lesion, seminal vesicle invasion on magnetic resonance imaging, International Society of Urological Pathology grade in the nondominant side, and percentage of positive cores in the nondominant side achieved an area under the curve of 84% after internal validation. With a cutoff of contralateral lymph node invasion of 1%, 602 (27%) contralateral pelvic lymph node dissections would be omitted with only 1 (1.2%) lymph node invasion missed. CONCLUSIONS: Pelvic lymph node dissection could be omitted contralateral to the prostate lobe with worse disease features in selected patients. We propose a model that can help avoid contralateral pelvic lymph node dissection in almost one-third of cases.

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.

Mechanical characterization of porcine ureter for the evaluation of tissue-engineering applications.

Introduction: Clinics increasingly require readily deployable tubular substitutes to restore the functionality of structures like ureters and blood vessels. Despite extensive exploration of various materials, both synthetic and biological, the optimal solution remains elusive. Drawing on abundant literature experiences, there is a pressing demand for a substitute that not only emulates native tissue by providing requisite signals and growth factors but also exhibits appropriate mechanical resilience and behaviour. Methods: This study aims to assess the potential of porcine ureters by characterizing their biomechanical properties in their native configuration through ring and membrane flexion tests. In order to assess the tissue morphology before and after mechanical tests and the eventual alteration of tissue microstructure that would be inserted in material constitutive description, histological staining was performed on samples. Corresponding computational analyses were performed to mimic the experimental campaign to identify the constitutive material parameters. Results: The absence of any damages to muscle and collagen fibres, which only compacted after mechanical tests, was demonstrated. The experimental tests (ring and membrane flexion tests) showed non-linearity for material and geometry and the viscoelastic behaviour of the native porcine ureter. Computational models were descriptive of the mechanical behaviour ureteral tissue, and the material model feasible. Discussion: This analysis will be useful for future comparison with decellularized tissue for the evaluation of the aggression of cell removal and its effect on microstructure. The computational model could lay the basis for a reliable tool for the prediction of solicitation in the case of tubular substitutions in subsequent simulations.

The Prognostic Role of Preoperative PSMA PET/CT in cN0M0 pN+ Prostate Cancer: A Multicenter Study.

CONTEXT: Despite negative preoperative conventional imaging, up to 10% of patients with prostate cancer (PCa) harbor lymph-node involvement (LNI) at radical prostatectomy (RP). The advent of more accurate imaging modalities such as PET/CT improved the detection of LNI. However, their clinical impact and prognostic value are still unclear. We aimed to investigate the prognostic value of preoperative PET/CT in patients node positive (pN+) at RP. EVIDENCE SYNTHESIS: We retrospectively identified cN0M0 patients at conventional imaging (CT and/or MRI, and bone scan) who had pN+ PCa at RP at 17 referral centers. Patients with cN+ at PSMA/Choline PET/CT but cN0M0 at conventional imaging were also included. Systemic progression/recurrence was the primary outcome; Cox proportional hazards models were used for multivariate analysis. EVIDENCE ACQUISITION: We included 1163 pN+ men out of whom 95 and 100 had preoperative PSMA and/or Choline PET/CT, respectively. ISUP grade ≥4 was detected in 66.6%. Overall, 42% of patients had postoperative PSA persistence (≥0.1 ng/mL). Postoperative management included initial observation (34%), ADT (22.7%) and adjuvant RT+/-ADT (42.8%). Median follow-up was 42 months. Patients with cN+ on PSMA PET/CT had an increased risk of systemic progression (52.9% vs. 13.6% cN0 PSMA PET/CT vs. 21.5% cN0 at conventional imaging; P < .01). This held true at multivariable analysis: (HR 6.184, 95% CI: 3.386-11-295; P < .001) whilst no significant results were highlighted for Choline PET/CT. No significant associations for both PET types were found for local progression, BCR, and overall mortality (all P > .05). Observation as an initial management strategy instead of adjuvant treatments was related with an increased risk of metastases (HR 1.808; 95% CI: 1.069-3.058; P < .05). CONCLUSIONS: PSMA PET/CT cN+ patients with negative conventional imaging have an increased risk of systemic progression after RP compared to their counterparts with cN0M0 disease both at conventional and/or molecular imaging.

An updated model for predicting side-specific extraprostatic extension in the era of MRI-targeted biopsy.

PURPOSE: Accurate prediction of extraprostatic extension (EPE) is pivotal for surgical planning. Herein, we aimed to provide an updated model for predicting EPE among patients diagnosed with MRI-targeted biopsy. MATERIALS AND METHODS: We analyzed a multi-institutional dataset of men with clinically localized prostate cancer diagnosed by MRI-targeted biopsy and subsequently underwent prostatectomy. To develop a side-specific predictive model, we considered the prostatic lobes separately. A multivariable logistic regression analysis was fitted to predict side-specific EPE. The decision curve analysis was used to evaluate the net clinical benefit. Finally, a regression tree was employed to identify three risk categories to assist urologists in selecting candidates for nerve-sparing, incremental nerve sparing and non-nerve-sparing surgery. RESULTS: Overall, data from 3169 hemi-prostates were considered, after the exclusion of prostatic lobes with no biopsy-documented tumor. EPE was present on final pathology in 1,094 (34%) cases. Among these, MRI was able to predict EPE correctly in 568 (52%) cases. A model including PSA, maximum diameter of the index lesion, presence of EPE on MRI, highest ISUP grade in the ipsilateral hemi-prostate, and percentage of positive cores in the ipsilateral hemi-prostate achieved an AUC of 81% after internal validation. Overall, 566, 577, and 2,026 observations fell in the low-, intermediate- and high-risk groups for EPE, as identified by the regression tree. The EPE rate across the groups was: 5.1%, 14.9%, and 48% for the low-, intermediate- and high-risk group, respectively. CONCLUSION: In this study we present an update of the first side-specific MRI-based nomogram for the prediction of extraprostatic extension together with updated risk categories to help clinicians in deciding on the best approach to nerve-preservation.

Impact of peritoneal reconfiguration on lymphocele formation after robot-assisted radical prostatectomy with pelvic lymph node dissection: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Different strategies have been proposed to prevent lymphocele (LC) formation after radical prostatectomy (RARP) with pelvic lymph node dissection (PLND). According to several recently published randomized control trials (RCTs) on the topic, peritoneal reconfiguration appears to be associated with promising results. This systematic review aimed to assess the impact of peritoneal reconfiguration on LC formation in patients undergoing RARP and PLND. METHODS: A comprehensive bibliographic search was conducted in August 2023. Studies assessing patients with prostate cancer undergoing RARP with PLND (P) and concomitant peritoneal reconfiguration (I) compared or not with other techniques (C) to prevent LC formation (O) were included. Original prospective and retrospective studies (S) were selected. LC and symptomatic LC rates were chosen as co-primary outcomes. Only RCTs were included in the meta-analysis. RESULTS: Eleven studies investigating 2991 patients were included in the systematic review, and five RCTs evaluating 1712 subjects were deemed eligible for meta-analysis. Peritoneal flap (PF) was the most common surgical technique used for LC prevention (9 studies). A significantly lower likelihood of LC was observed after PF (OR 0.82, 95% CI 0.27-1.37, I2 = 74.54%), with no significant difference in terms of symptomatic LC (OR 0.21, 95% CI -0.41-0.84, I2 = 0%). Probability of LC-related complications (OR 0.36, 95% CI 0.04-0.67, I2 = 0%), Clavien-Dindo ≥ 3 overall complications (OR 0.61, 95% CI 0.21-1.0, I2 = 0%), and Clavien-Dindo ≥ 3 LC-related complications (OR 0.98, 95% CI 0.29-1.67, I2 = 0%) were significantly lower after PF. CONCLUSIONS: PF after RARP with PLND reduces LC formation, LC-related complications, and severe postoperative adverse events.

The bladder-flap ureteral augmentation: An original solution in case of complex distal stricture.

An original surgical solution for complex stenosis of the distal ureter is presented. A young, single-kidney male patient developed a stricture of the pelvic ureter after ureteroscopy and laser lithotripsy. Surgical repair was planned after the failure of conservative management. The ureter was sectioned prevesically and spatulated; a bladder flap with the same dimensions of the ureteral plate was taken from the anterior wall, and used to augment the ureter; finally an omental flap was wrapped around the reconstructed tract. Further radiological and ureteroscopic controls showed a largely patent reconstructed ureter, and follow up proved a regularly maintained kidney function.

The impact of COVID-19 pandemic on pornography habits: a global analysis of Google Trends.

As the COVID-19 spread globally, social distancing, self-isolation/quarantine, and national lockdowns have become crucial to control the pandemic. However, these measures may also lead to increases in social isolation, loneliness, and stress, which can alter the consumption of pornography habits. The aim of the study was thus to explore the interest pattern in pornography and coronavirus-themed pornography during the COVID-19 outbreak. Google Trends® was employed to determine the most popular porn websites (Porn, XNXX, PornHub, xVideos, and xHamster), and coronavirus-themed pornography worldwide and in six nations with different COVID-19 outbreak and self-isolation recommendations. We analyzed every search trend on Google® from January 9, 2020 to May 25, 2020 using "joint point regression analysis". Comparisons of week relative search volume (WRSV) and temporal patterns were analyzed to assess the change of interest in search terms during nations lockdowns. Paired t-test was used to compare WRSV values among the porn websites during the national lockdowns and the equivalent timespan of the weeks in the previous 4 years. The research trend of almost every keyword increased with significant inflection points for those nations with a straight "stay at home orders" (China, Italy, Spain, and France). "PornHub" and "Porn" showed the highest increase of interest worldwide with an average weekend percentage change (AWPC) of 4.9 and 3.8, respectively. The mean WRSV for keywords in USA and Sweden did not show a similar increase as the other nations. The WRSV percentage change with the historical data had a peak during the straight nations' lockdowns (p < 0.01). All the nations had a significant increase in WRSV coronavirus-themed pornography for each keyword (p < 0.01) with an AWPC, ranging worldwide between 18.5 and 61.8 (p < 0.01), after the beginning of self-quarantine. As strengths this study uses a big data technology to collect worldwide trend of interest, however, data are anonymous and do not allow analysis of subpopulation groups. In conclusion, we demonstrated an increased interest in pornography and coronavirus-themed pornography after the outbreak of COVID-19 in nations with a straight "stay at home orders".

Can anastomotic urinary leakage in robotic prostatectomy be considered as a marker of surgical skill?

INTRODUCTION: The study was conducted to analyze whether the anastomotic urinary leakage (AUL) rate in robot-assisted radical prostatectomy (RARP) can be considered as a marker of surgical skill. MATERIAL AND METHODS: Post-operative cystograms taken after RARP, performed between 2006 and 2016 at a third-level university urology center, were prospectively collected. Cystograms were scheduled for all patients on post-operative day 6, but were performed over a range from days 4 to 10 (median 6). In cases of mild, moderate or excessive AUL (according to Han's classification), catheters were maintained; in the other cases, they were removed. RESULTS: Data from 1366 consecutive patients undergoing RARP were collected. The incidence of AUL at first check-up was 18.1%, with a descending trend when RARP were performed by the same surgeon. Evaluating the influence of differing technical modifications on leakage, the AUL rate was significantly lower after the introduction of posterior reconfigurations and a single posterior stitch. The introduction of barbed sutures was initially associated with an increase of leakage, but only in the first year. CONCLUSIONS: This study describes the effect of increasing experience and technical modifications in RARP on the AUL rate in a third-level university Italian center over a 10-year period; by stratifying data, we demonstrated a strong correlation between robotic surgical skill and AUL rate, which can therefore be used as an indicator of surgical proficiency.

Frailty and elderly in urology: Is there an impact on post-operative complications?

INTRODUCTION: Frailty used as predictive tool is still not carried out in daily practice, although many studies confirm the great clinical importance of the frailty syndrome in surgical outcomes. There is no standardized method of measuring the physiological reserves of older surgical patients. The aim of this study was to analyze a cohort of older urological patients according to various frailty indices, in order to evaluate whether they are predictors of post-operative complications after urological procedures. MATERIAL AND METHODS: This is a prospective observational study on 78 consecutive older (≥70 years) patients, subjected to major urological (both endoscopic and 'open surgical') procedures. Frailty was defined according to the Edmonton Frail Scale. Several risk models and biochemical parameters were evaluated. Post-operative outcomes were surgical and medical complications, mortality and rehospitalisation within 3 months. RESULTS: An overall prevalence of frailty of 21.8% was found. Patients with complications were frailer than those without complications (univariate analysis), considering both total patients (p = 0.002) and endoscopic (p = 0.04) and 'open surgical' patients (p = 0.013). However, in multivariate analysis, a significant correlation was not found between all frailty indices tested and the risk of major complications. Limitation of the study: the small sample size (lack of statistical power), although this is a prospective study focused on older urological patients. CONCLUSIONS: New urology-tailored pre-operative assessment tools may prove beneficial when calculating the risks/benefits of urological procedures, so that objective data can guide surgical decision- making and patient counselling. Further large clinical studies specifically focusing on elderly in urology will be needed.

Anesthesiologic Effects of Transperitoneal Versus Extraperitoneal Approach During Robot-Assisted Radical Prostatectomy: Results of a Prospective Randomized Study

To compare the effects of CO₂ insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses.

Athermal bladder neck dissection during robot-assisted radical prostatectomy

Introduction With improved understanding of the precise anatomy, surgical techniques during robot-assisted radical prostatectomy (RARP) have been refined, with the aim of improving functional outcomes without compromising oncological adequacy and results. Nevertheless, postoperative urinary incontinence remains a frustrating side-effect. Anatomically, bladder neck (BN) serves as an internal sphincter. The longitudinal fibres of BN may be identified and isolated with a meticulous dissection at the prostato-vesical junction, contributing to earlier return of urinary continence. The purpose of this video is to show an anatomical athermal dissection of BN during RARP.Materials and Methods After incision of endopelvic fascia and anterior defatting, the morphology of prostate not only laterally, but also at the level of bladder-prostatic junction is well visualized. With an athermal dissection of the plane between prostate and bladder we can minimize the traumatic effects on the longitudinal fibres of BN. A cold section of the preserved BN permits the complete preservation of integrity of this sphincteric structure.Results With this technique we preserve the longitudinal fibres of BN, allowing the sparing of the sphincteric mechanism of BN. The finding of a difficult athermal dissection of these plans may make you suspect the presence of an infiltration, suggesting to sacrifice BN in order to avoid a positive surgical margin. In our series no increase of PSM has been recorded using this technique.Conclusions This surgical technique preserving the natural BN mechanism appears to improve urinary continence, allowing at the same time an easy identification of a neoplastic infiltration.