Endoscopic intervention versus radical nephroureterectomy for the management of localized upper urinary tract urothelial carcinoma: a systematic review and meta-analysis of comparative studies.

OBJECTIVE: Localized Upper Urinary Tract Urothelial Carcinoma (UTUC) is an uncommon cancer typically detected at an advanced stage. Currently, radical nephroureterectomy (RNU) with bladder cuff excision is the standard treatment for high-risk UTUC. This meta-analysis aims to evaluate the 5-year overall and cancer-specific survival and bladder recurrence rates in studies comparing endoscopic kidney-sparing surgeries (E-KSS) with RNU in localized UTUC. EVIDENCE ACQUISITION: We performed a literature search on 20th April 2023 through PubMed, Web of Science, and Scopus. The PICOS model was used for study inclusion: P: adult patients with localized UTUC; I: E-KSS. C: RNU; O: primary: overall survival (OS); secondary: cancer-specific survival (CSS), bladder recurrence rate, and metastasis-free survival (MFS). S: retrospective, prospective, and randomized studies. EVIDENCE SYNTHESIS: Overall, 11 studies involving 2284 patients were eligible for this meta-analysis, 737 in the E-KSS group and 1547 in the RNU group. E-KSS showed a similar overall 5-year OS between E-KSS and RNU, and for low-grade tumors, while 5-year OS favored RNU for high-grade tumors (RR 1.84, 95% CI 1.26-2.69, p = 0.002). No difference emerged for 5-year CSS between the two groups, even when the results were stratified for low- and high grade tumors. Bladder recurrence rate and 5-year MFS were also similar between the two groups. CONCLUSIONS: Our review showed that E-KSS is a viable option for patients with localized UTUC with non-inferior oncological outcomes as compared with RNU, except for 5-year OS in high-grade tumors which favoured RNU.

Cost-effectiveness and health economics for ureteral and kidney stone disease: a systematic review of literature.

PURPOSE OF REVIEW: To systematically review costs associated with endourological procedures (ureteroscopy, URS; shockwave lithotripsy, SWL; and percutaneous nephrolithotomy, PCNL) for kidney stone disease (KSD), providing an overview of cost-effectiveness and health economics strategies. RECENT FINDINGS: A systematic review of the literature was performed, retrieving 83 English-written full-text studies for inclusion. Papers were labelled according to the respective area of interest: 'costs of different procedures: SWL, URS, PCNL', 'costs of endourological devices and new technologies: reusable and disposable scopes, lasers, other devices', 'costs of KSD treatment in the emergency setting: emergency stenting versus primary URS'. Forty-three papers reported on associated cost for different procedures, revealing URS to be the most cost-effective. PCNL follows with higher hospitalization costs, while SWL appears to be least cost effective due to high need of additional procedures. The role of disposable and reusable scope is investigated by 15 articles, while other 16 reported on the role of different lasers, devices and techniques. The last nine studies included discussed the best and more cost-effective treatment for acute stone presentation, with promising results for primary URS versus emergency stenting and delayed URS. SUMMARY: Cost-effective and cost-conscious intervention is equally imperative to consider whilst weighing in clinical efficacy for endourological procedures. When a decision-making choice of SWL, URS or PCNL is offered to a patient, the outcomes must be balanced with a deeper understanding of additional cost burden of retreatment, reimbursement, repeated interventions, and recurrence. In todays' practice, investing in endourological devices for KSD management must consider carefully the direct and hidden costs of using reusable and disposable technology. Cost control measures should not in any way compromise the quality of life or safety of the patient.

Radiomics vs radiologist in prostate cancer. Results from a systematic review.

PURPOSE: Radiomics in uro-oncology is a rapidly evolving science proving to be a novel approach for optimizing the analysis of massive data from medical images to provide auxiliary guidance in clinical issues. This scoping review aimed to identify key aspects wherein radiomics can potentially improve the accuracy of diagnosis, staging, and extraprostatic extension in prostate cancer (PCa). METHODS: The literature search was performed on June 2022 using PubMed, Embase, and Cochrane Central Controlled Register of Trials. Studies were included if radiomics were compared with radiological reports only. RESULTS: Seventeen papers were included. The combination of PIRADS and radiomics score models improves the PIRADS score reporting of 2 and 3 lesions even in the peripheral zone. Multiparametric MRI-based radiomics models suggest that by simply omitting diffusion contrast enhancement imaging in radiomics models can simplify the process of analysis of clinically significant PCa by PIRADS. Radiomics features correlated with the Gleason grade with excellent discriminative ability. Radiomics has higher accuracy in predicting not only the presence but also the side of extraprostatic extension. CONCLUSIONS: Radiomics research on PCa mainly uses MRI as an imaging modality and is focused on diagnosis and risk stratification and has the best future possibility of improving PIRADS reporting. Radiomics has established its superiority over radiologist-reported outcomes but the variability has to be taken into consideration before translating it to clinical practice.

Does Alexis Wound Protector/Retractor Reduce the Risk of Surgical Site Infections After Open Radical Cystectomy for Bladder Cancer? Results From a Single Center, Comparative Study.

OBJECTIVE: To assess if Alexis dual-ring wound protector/retractor reduced the incidence of superficial and deep incisional infection following open radical cystectomy (ORC). METHODS: Since January 2020, all procedures were performed using the Alexis retractor. We retrospectively reviewed our ORC database and compared patients who were operated on with Alexis with the same number of consecutive patients operated with a stainless steel retractor in the previous period. Data are presented as median and (interquartile range). RESULTS: Seventy-four patients underwent RC with Alexis (group 1) and 74 with stainless steel retractor (group 2). Median age was 73.0(13) in group 1, 73.5(14) in group 2 (P = .338). There were 59(79.7%) men in both groups. The groups were comparable in terms of comorbidities, body mass index, American Society of Anesthesiology score, and neoadjuvant chemotherapy rate. There was no statistically significant difference in type of lymph node dissection and urinary diversion, total surgical time. Postoperative stay was shorter in group 1 [8(4) days vs 9(4) in group 2, P = .012]. Group 2 had a significantly higher rate of both superficial (8.1% vs 18.9%, P = .045) and deep incisional infection (2.7% vs 14.9%, P = .009). At multivariable analysis, body mass index (OR 1.129 95% CI 1.162-1.283, P = .043) was significantly associated with higher odds of superficial incisional infection. The use of Alexis was significantly associated with lower odds of having both superficial (OR 0.274 95%CI 0.033-0.781, P = .023) and deep incisional infection (OR 0.159 95% CI 0.034-0.745, P = .020). CONCLUSION: The use of Alexis significantly reduces the rate of superficial and deep incisional infection following ORC.

Advancements in artificial intelligence for robotic-assisted radical prostatectomy in men suffering from prostate cancer: results from a scoping review.

BACKGROUND: Robotic-assisted radical prostatectomy (RARP) is currently a first-line treatment option for men with localized prostate cancer (PCa), at least 10 years of life expectancy, and candidate for curative treatment. We performed a scoping review to evaluate the role of artificial intelligence (AI) on RARP for PCa. METHODS: A comprehensive literature search was performed using EMBASE, PubMed, and Scopus. Only English papers were accepted. The PICOS (Patient Intervention Comparison Outcome Study type) model was used; P: adult men with PCa undergoing RARP; I: use of AI; C: none; O: preoperative planning improvement and postoperative outcomes; S: prospective and retrospective studies. RESULTS: Seventeen papers were included, dealing with prediction of positive surgical margins/extraprostatic extension, biochemical recurrence, patient's outcomes, intraoperative superimposition of magnetic resonance images to identify and locate lesions for nerve-sparing surgery, identification and labeling of surgical steps, and quality of surgery. All studies found improving outcomes in procedures employing AI. CONCLUSIONS: The integration of AI in RARP represents a transformative advancement in surgical practice, augmenting surgical precision, enhancing decision-making processes and facilitating personalized patient care. This holds immense potential to improve surgical outcomes and teaching, and mitigate complications. This should be balanced against the current costs of implementation of robotic platforms with such a technology.

Analysis of the Performance and Accuracy of a PSA and PSA Ratio-Based Nomogram to Predict the Probability of Prostate Cancer in a Cohort of Patients with PIRADS 3 Findings at Multiparametric Magnetic Resonance Imaging.

BACKGROUND: PIRADS score 3 represents a challenge in prostate cancer (PCa) detection with MRI. Our study aimed to evaluate the application of a nomogram on a cohort of patients with PIRADS 3. METHODS: We analyzed 286 patients undergoing fusion prostate biopsy from January 2020 to February 2024. Only PIRADS 3 patients were included. Two nomograms, previously developed and based on clinical variables such as age, total PSA (specifically 2-10 ng/mL) and PSA ratio were applied to estimate the probability (Nomograms A and B) for PCa Grade Group (GG) > 3 and GG < 3. RESULTS: Out of the 70 patients available for analysis, 14/70 patients (20%) had PCa, 4/14 were GG 1 (28.6%), 1/14 were GG 2 (7.1%), 5/14 were GG 3 (35.8%), 2/14 were GG 4 (14.3%) and 2/14 were GG 5 (14.3%). The median probability of PCa GG > 3 and GG < 3 was 5% and 33%, respectively. A significant difference (p = 0.033) was found between patients with negative versus positive biopsy for Nomogram B. There was a significant difference (p = 0.029) for Nomogram B comparing patients with GG < 3 and GG > 3. Using a cut-off of 40% for Nomogram B, sensitivity and specificity were 70% and 80%, respectively. CONCLUSIONS: This cohort has a low probability of harboring PCa especially ISUP > 3. Nomogram B has good accuracy for discriminating patients with PCa from those with negative biopsy.

Reoperation Rate for Residual/Regrowth Adenoma Following Transurethral Interventions for Benign Prostatic Enlargement: Results from a Systematic Review and Meta-Analysis of Comparative Randomized Studies.

Objective: To perform a systematic review to assess the incidence of reoperation rate for residual/regrowth adenoma after transurethral surgeries for benign prostatic enlargement. Materials and Methods: A systematic literature search was performed on November 12, 2023, using Cochrane Central Register of Controlled Trials, PubMed, and Scopus. We only included randomized studies comparing monopolar (M)/bipolar (B) transurethral resection of the prostate (TURP) vs ablation vs enucleation procedures. Incidence of reoperation was assessed using the Cochran-Mantel-Haenszel Method and reported as risk ratio (RR), 95% confidence interval (CI), and p-values. Statistical significance was set at p < 0.05. Evidence synthesis: Forty-eight studies were included. Six studies compared enucleation vs TURP, 41 ablation vs TURP, and 1 study enucleation vs ablation vs TURP, encompassing 457 patients in enucleation, 2259 in ablation, and 2517 in the TURP group. The pooled incidence of reoperation was 6.2%, 0.7%, 2.3%, and 4.3% after ablation, enucleation, M-TURP, and B-TURP, respectively. Meta-analysis showed that the incidence of reoperation was significantly lower in the enucleation group (RR 0.28, 95% CI 0.10-0.81, p = 0.02), but the difference accounted only in studies with follow-up between 1 and 3 years (RR 0.18, 95% CI 0.04-0.85, p = 0.03). The incidence of reoperation was significantly lower in the enucleation compared with the B-TURP group (RR 0.14, 95% CI 0.03-0.77, p = 0.02). Meta-analysis showed that the incidence of reoperation was significantly higher in the ablation group (RR 1.81, 95% CI 1.33-2.47, p = 0.0002), but there was no difference in studies with follow-up up to 1 year (odds ratio 1.78 95% CI 0.97-3.29, p = 0.06) longer than 5 years (RR 2.02, 95% CI 0.71-5.79, p = 0.19). The incidence of reoperation was significantly higher in the ablation compared with the M-TURP group (RR 1.91, 95% CI 1.44-2.54, p < 0.0001). Conclusions: In mid-term follow-up, reoperation rate for residual/regrowth adenoma was significantly lower after enucleation, although was significantly higher after ablation compared with TURP.

Current Evidence on Utility, Outcomes, and Limitations of Endoscopic Laser Ablation for Localized Upper Urinary Tract Urothelial Carcinoma: Results from a Scoping Review.

Context: The occurrence of upper urinary tract urothelial carcinoma (UTUC) is uncommon and is usually identified at an advanced and multifocal stage. Currently, there is growing interest in utilizing endoscopic laser ablation (ELA). Objective: To evaluate the survival rates and perioperative complications of ELA. Evidence acquisition: We performed a literature search through PubMed, Web of Science, and Scopus. The analysis included observational studies that examined the oncological outcomes of patients with UTUC treated with ELA. Evidence synthesis: Neodymium and diode lasers are no longer used due to their high complication rates. Holmium:yttrium-aluminum-garnet (YAG) and thulium:YAG lasers provided excellent tumor ablation and hemostasis in both the collecting system and the ureter. These lasers offer good disease-free and cancer-specific survival, especially for low-grade tumors. Conclusions: Advancements in laser technology and ablation techniques, and understanding of UTUC tumor biology hold significant promise in improving the use of conservative UTUC treatment, with excellent safety and good oncological outcomes for low-grade diseases. Patient summary: With the advancement of technology, the conservative approach utilizing endoscopic laser ablation for upper tract urothelial tumors has been proved to be both safe and effective, showcasing promising survival rates.

Conservative approach for a giant prostatic hyperplasia of 1280 ml: a case report and literature review.

Benign Prostatic Hypertrophy (BPH) affects at least one-third of men over 60 years. A giant prostatic hyperplasia (GPH) is a prostate enlargement that exceeds 500 g. We present a case of a 72-year-old man with a GPH volume of 1280 ml, referred to our hospital for a worsening of the lower urinary tract symptoms (LUTS), bilateral loin pain and kidney failure. Although the patient had a negligible post-void residual urine, he had bilateral hydronephrosis. The patient was managed conservatory because of a high anesthesiologic risk but a bilateral percutaneous nephrostomy was placed soon due to kidney function worsening. The presence of serious comorbidities and the resolution of the loin pain and the renal failure, achieved first with the nephrostomy and then with periodic replacement of ureteral stents, along with an improvement of the LUTS obtained with medical therapy, have oriented us towards a conservative management of the patient.

Radiomics vs radiologist in bladder and renal cancer. Results from a systematic review.

Introduction: Radiomics in uro-oncology is a rapidly evolving science proving to be a novel approach for optimizing the analysis of massive data from medical images to provide auxiliary guidance in clinical issues. This scoping review aimed to identify key aspects wherein radiomics can potentially improve the accuracy of diagnosis, staging, and grading of renal and bladder cancer. Material and methods: A literature search was performed in June 2022 using PubMed, Embase, and Cochrane Central Controlled Register of Trials. Studies were included if radiomics were compared with radiological reports only. Results: Twenty-two papers were included, 4 were pertinent to bladder cancer, and 18 to renal cancer. Radiomics outperforms the visual assessment by radiologists in contrast-enhanced computed tomography (CECT) to predict muscle invasion but are equivalent to CT reporting by radiologists in predicting lymph node metastasis. Magnetic resonance imaging (MRI) radiomics outperforms radiological reporting for lymph node metastasis. Radiomics perform better than radiologists reporting the probability of renal cell carcinoma, improving interreader concordance and performance. Radiomics also helps to determine differences in types of renal pathology and between malignant lesions from their benign counterparts. Radiomics can be helpful to establish a model for differentiating low-grade from high-grade clear cell renal cancer with high accuracy just from contrast-enhanced CT scans. Conclusions: Our review shows that radiomic models outperform individual reports by radiologists by their ability to incorporate many more complex radiological features.