Off-clamp Versus On-clamp Partial Nephrectomy: Re-envision of a Dilemma.

We contextualize controversial evidence on the impact of warm ischemia on functional outcomes after partial nephrectomy for localized renal tumors and provide a holistic framework for re-envisioning the dilemma of off-clamp versus on-clamp surgery. The focus should shift away from the surgeon towards patient- and kidney-related characteristics.

Outcomes of a complementary and alternative medicine based on vitamins, herbal products, and amino acid as a first line treatment in idiopathic overactive bladder syndrome in men and women without bladder outlet obstruction.

OBJECTIVE: To evaluate the efficacy and tolerability of a complementary and alternative medicine (CAM) called Kubiker (Naturmed, Montegranaro, FM, Italy), consisting of vitamins (C and D), herbal products (cucurbita maxima, capsicum annum, polygonum cuspidatum), and amino acid L-Glutamine, as first line treatment of (OAB). MATERIALS AND METHODS: According to institutional protocols, data on patients addressing to a tertiary referral centre for OAB symptoms were recorded. OAB was evaluated through validated questionnaires including ICIQ-SF, USS, and OAB-q-SF. Patients with previous antimuscarinic or ß3 agonist treatment, neurological disease or pathologies which may mimic OAB, including infections, were excluded. Only unobstructed patients were considered and were given CAM twice daily for 12 weeks. After treatment, symptoms were re-evaluated repeating previous questionnaires and PGI-I was given to evaluate perceived improvement. RESULTS: A total of 41 patients were evaluated and 35 respected inclusion criteria and were enrolled. All subjects had a full compliance and adherence with CAM medication intake. The median patient's age was 65 (56-73). Male were 8 (22.9%) while females were 27 (77.1%). Median baseline OAB-q SF and ICIQ-SF scores were 18 (15-25) and 9 (6-13), respectively. After treatment, 85.7% patients had a clinical benefit, with a significant reduction of OAB symptoms, also according to USS (p < 0.01). The median OAB-q SF and ICIQ-SF scores were 10 (7-15) and 6 (0-8) (p < 0.01). CAM was successful with an improvement in subjective patient's satisfaction, with a median PGI-I score of 2 (1-3). Patients (men and women) who still had UUI after 3 months CAM medication were eight (22.8%), and among them, those who did not refer any therapeutic benefit were five (14.3%). CONCLUSIONS: According to our study, CAM may be useful medication for a first line treatment of uncomplicated idiopathic OAB cases, providing a nonnegligible effects on symptoms. However, further studies are mandatory to draw definitive conclusions.

Carboplatin-based adjuvant chemotherapy versus observation after radical cystectomy in patients with pN1-3 urothelial bladder cancer.

PURPOSE: To test the impact of carboplatin-based ACT on overall survival (OS) in patients with pN1-3 cM0 BCa. METHODS: A retrospective analysis was conducted on 1057 patients with pTany pN1-3 cM0 urothelial BCa treated with or without carboplatin-based ACT after radical cystectomy and bilateral lymph-node dissection between 2002 and 2018 at 12 European and North-American hospitals. No patient received neoadjuvant chemotherapy or radiation therapy. Only patients with negative surgical margins at surgery were included. A 3:1 propensity score matching (PSM) was performed using logistic regression to adjust for baseline characteristics. Univariable and multivariable Cox regression analyses were used to predict the effect of carboplatin-based ACT on OS. The Kaplan-Meier method was used to display OS in the matched cohort. RESULTS: Of the 1057 patients included in the study, 69 (6.5%) received carboplatin-based ACT. After PSM, 244 total patients were identified in two cohorts that did not differ for baseline characteristics. Death was recorded in 114 (46.7%) patients over a median follow-up of 19 months. In the multivariable Cox regression analyses, increasing age at surgery (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.01-1.06, p < 0.001) and increasing number of positive lymph nodes (HR 1.06, 95% CI 1.01-1.07, p = 0.02) were independent predictors of worse OS. The delivery of carboplatin-based ACT was not predictive of improved OS (HR 0.67, 95% CI 0.43-1.04, p = 0.08). The main limitations of this study are its retrospective design and the relatively low number of patients involved. CONCLUSIONS: Carboplatin-based might not improve OS in patients with pN1-3 cM0 BCa. Our results underline the need for alternative therapies for cisplatin-ineligible patients.

Current management of radiation cystitis after pelvic radiotherapy: a systematic review.

INTRODUCTION: We aimed to summarize current literature about radiation cystitis treatments, providing physician of a summary of current management options. EVIDENCE ACQUISITION: A systematic literature review searching on PubMed (Medline), Scopus, and Web of Science databases was performed in March 2021. PRISMA guidelines were followed. Population consisted of patients with a diagnosis of radiation cystitis after pelvic radiotherapy (P). We focused our attention on different treatments, such as conservative or surgical one (I). Single or multiple arms studies were deemed eligible with no mandatory comparison (C). Main outcomes of interest were symptoms control and adverse events rates (O). EVIDENCE SYNTHESIS: The search identified 1194 records. Of all, four studies focused on the use of hyperbaric oxygen therapy showing complete response rates ranging from 52% to 87% approximately. Oral administration of cranberry compounds was investigated in one study showing no superiority to placebo. Intravesical instillation of different compounds were investigated in five studies showing the highest complete response rates after alum (60%) and formalin administration (75%). Endoscopic conservative surgical treatments (fibrin glue or vaporization) also showed 75% complete response rates. In patients who did not respond to conservative treatments robotic cystectomy is feasible with overall complication rates of about 59.3% at 90 days. CONCLUSIONS: Radiotherapy induced cystitis is an under-reported condition after pelvic radiotherapy. Several treatments have been proposed, but in up to 10% of cases salvage cystectomy is necessary. A stepwise approach, with progressive treatment aggressiveness is recommended.

En-bloc endoscopic enucleation of the prostate: a systematic review of the literature.

INTRODUCTION: Transurethral resection of the prostate (TURP) remains the gold standard for treatment of benign prostatic hyperplasia (BPH). Yet, the introduction of lasers for the treatment of LUTS due to BPO has dramatically changed the surgical landscape of benign prostatic obstruction (BPO) treatment. Recently, "en-bloc" techniques have shown to prove advantageous in terms of better visualization, more prompt identification of the surgical capsule and the correct plane to dissect. Herein we provide a comprehensive overview of available series of en-bloc enucleation of the prostate, focusing on surgical techniques, perioperative and functional outcomes. EVIDENCE ACQUISITION: A systematic review of the literature was performed according to PRISMA recommendations and was conducted on surgical techniques and perioperative outcomes of minimally invasive en-bloc surgery for prostate adenoma detachment. EVIDENCE SYNTHESIS: Overall, 16 studies with 2750 patients between 2003 and 2019 were included. Specific technical nuances have been described to maximize perioperative outcomes of en-bloc prostatic enucleation, including early apical release, horse-shape incisions, inverted U-shape tractions and low power. Overall, regardless of the energy employed, en-bloc prostatic enucleation achieved favorable outcomes including low risk of major complications and quality of life improvement. However, a great heterogeneity of study design, patients' inclusion criteria, prostate volume and en-bloc surgical strategy was found. CONCLUSIONS: En-bloc endoscopic enucleation of the prostate has been shown to be technically feasible and safe, with potential technical advantages over the classic three-lobe technique. Larger comparative studies are needed to evaluate the ultimate impact of the en-bloc approach on postoperative outcomes, in light of the surgeon's learning curve.