Parastomal hernia after ileal conduit: Incidence, natural history and risk factors.

INTRODUCTION: Parastomal hernias are a challenging complication of digestive ostomies. Ileal-conduit parastomal hernias after cystectomy have specific aspects. The aim of this study was to describe the incidence and natural history of ileal-conduit parastomal hernias in order to guide their management, as well as to identify risk factors to prevent them. PATIENTS AND METHODS: All consecutive patients undergoing cystectomy with a Bricker's ileal conduit in 3 academic centers were retrospectively identified. Data were collected regarding their medical history prior to cystectomy, the operation, the postoperative period, imaging results within 5 years of follow-up, and the onset and timing of clinically or radiologically diagnosed ICPH. RESULTS: Among 577 patients included in the study, 115 (20.6%) developed an ICPH during the study period. Most patients did not present any symptom and the diagnosis was made at imaging in 74.8% of them. Most hernias were detected between 1 and 2 years after the cystectomy, with a mean time to diagnosis of 12.4 months. At multivariate analysis, overweight and obesity were independent risk factors for developing an ICPH (adjusted hazard ratio [aHR] 1.96; p = 0.046), while a trans-rectus position of the ostomy was a significant protective factor (aHR 0.45; p = 0.011). CONCLUSIONS: A PH develops in almost 20% of patients after ileal conduit urinary diversion, with a mean time of onset of 12.4 months. It is often a subclinical condition detected at medical imaging. Obesity increases the risk, while passing the ileal-conduit through the rectus muscle can help to prevent it.

PIRADS≥4 MRI lesion: Is performing systematic biopsies still essential for detecting clinically significant prostate cancer?

INTRODUCTION: In the era of targeted prostate biopsies, the necessity of performing randomized biopsies systematically is under question. Our objective is to evaluate the rate of clinically significant prostate cancer (csPCa), defined by presence of ISUP≥2 prostate cancer, diagnosed only on randomized cores in case of a PIRADS≥4 target lesion on MRI. The secondary objective is to evaluate whether specific variables can predict the presence of undetected csPCa in targeted biopsies. METHODS: Retrospective data on targeted biopsies performed from 2015 to 2021 in our hospital were collected. Procedures were performed with MRI/Transrectal US fusion Trinity platform from Koelis®. All the MRI images were reviewed and the targets were classified using the PIRADS V2.1 classification. Inclusion criteria comprised procedures featuring at least one PIRADS≥4 targeted lesion were included. All procedures consisted 1-4 targeted cores and 12-core systematic biopsy. RESULTS: We included 358 patients. In 44 patients (12.3%) csPCa was exclusively detected in randomized cores. Among these cases, only 12 patients (27.2%) showed no cancer on the targeted biopsies. Merely 4 patients (9.09%) lacked csPCa-positive cores on the same side as the index lesion. Factors such as PSA, PSA density, prostate volume, and digital rectal examination showed no significant association with the presence of csPCa exclusively on randomized cores. Likewise, the size, location, and PIRADS classification of the target demonstrated no significant impact. CONCLUSION: Our findings indicate that in 12.3% of cases, targeted biopsies alone are insufficient for detecting the presence of csPCa. As such, systematic biopsies remain necessary to date.

Post-prostatectomy anastomotic stenosis: systematic review and meta-analysis of endoscopic treatment.

OBJECTIVE: To perform a systematic review and meta-analysis of endoscopic procedures for treating vesico-urethral anastomotic stenosis (VUAS) after prostatectomy, as initial VUAS management remains unclear. METHODS: A search of the MEDLINE database, the Cochrane database, and clinicaltrials.gov was performed (last search February 2023) using the following query: (['bladder neck' OR 'vesicourethral anastomotic' OR 'anastomotic'] AND ['stricture' OR 'stenosis' OR 'contracture'] AND 'prostatectomy'). The primary outcome was the success rate of VUAS treatment, defined by the proportion (%) of patients without VUAS recurrence at the end of follow-up. RESULTS: The literature search identified 420 studies. After the screening, 78 reports were assessed for eligibility, and 40 studies were included in the review. The pooled characteristics of the 40 studies provided a total of 1452 patients, with a median (interquartile range [IQR]) follow-up of 23.7 (13-32) months and age of 66 (64-68) years. The overall success rate (95% confidence interval [CI]) of all endoscopic procedures for VUAS treatment was 72.8% (64.4%-79.9%). Meta-regression models showed a negative influence of radiotherapy on the overall success rate (P = 0.012). After trim-and-fill (addition of 10 studies), the corrected overall success rate (95% CI) was 62.9% (53.6%-71.4%). CONCLUSION: This first meta-analysis of endoscopic treatment success rate after VUAS reported an overall success rate of 72.8%, lowered to 62.9% after correcting for significant publication bias. This study also highlighted the need for a more thorough reporting of post-prostatectomy VUAS data to understand the treatment pathway and provide higher-quality evidence-based care.

Experimental study of pedicled subcostal artery perforator (SCAP) flap: A new application in breast reconstruction.

BACKGROUND: Latissimus dorsi flap is the gold standard for pedicled breast reconstruction but is limited by donor site scarring, which is difficult to conceal, and a high rate of post-operative seroma. We investigated the anatomic characteristics and feasibility of using a subcostal artery perforator (SCAP) flap, which was taken from the flank area and vascularised by a perforator artery through a subcostal pedicle, for a breast reconstruction. METHODS: A literature review was undertaken to determine the anatomy of the SCAP flap pedicle and the vascular supply to this dermal-fat flap. Pedicled SCAP flaps were dissected on cadavers to identify the anatomy of the perforator arteries and the pedicle length. Pedicled SCAP flaps were then tunnelled through the chest area to evaluate their feasibility for breast reconstruction. RESULTS: Twelve SCAP flaps were prepared on six cadavers. Mean pedicle length was 17 cm (14.5-20 cm). Mean flap size was 13 × 18 cm (11.5 × 15.5-15 × 21 cm). For each flap, a pedicle of sufficient length was dissected to allow the tunnelling of the flap and to perform breast reconstruction with a dermal-fat flap of adequate size. In all cases, an SCAP flap was prepared, without taking muscle, to reduce the risk of parietal complications at the donor site in future clinical applications. CONCLUSION: Pedicled SCAP flap is a feasible option in breast reconstruction and could represent a less arduous surgical alternative to free flaps for some patients. Donor site scarring was acceptable. Clinical application of SCAP flaps should be investigated further.