Artificial Urinary Sphincter Implants in Men: A National Health Care Data System-Based Study to Assess Reinterventions in France.

PURPOSE: Significant concerns remain regarding the long-term outcomes of AMS 800 artificial urinary sphincter (AUS) implants in men. The objective was to assess the long-term AUS reintervention (replacement or removal) rates after a first-ever AUS implantation. MATERIALS AND METHODS: This population-based retrospective cohort study included all men age ≥ 18 years in France who underwent a first-ever AUS implantation (identified using a unique device identifier) for male stress urinary incontinence (SUI) after prostate cancer (PCa) or benign prostatic hyperplasia (BPH) treatment, between January 1, 2006, and December 31, 2018. The primary outcome was reintervention-free survival rates (replacements and removals), estimated using the Kaplan-Meier method. Secondary outcomes were replacement and removal. A multivariable Cox proportional hazards model was used to assess associations between patient and hospital factors and the hazard of reintervention. RESULTS: The study included 8475 men with a median age of 69 years (IQR, 65-74) and a median follow-up time of 6 years (IQR, 3-9). Reintervention-free survival was 71% (95% CI, 70-72) at 2 years, 57% (95% CI, 55-58) at 5 years, and 40% (95% CI, 38-41) at 10 years. Reintervention-free survival was lower after BPH surgery, after radiotherapy combined with RP, and in centers performing fewer implantations. Removal-free survival was 83% (95% CI, 83%-84%) at 2 years, 75% (95% CI, 74%-76%) at 5 years, and 66% (95% CI, 65%-68%) at 10 years. CONCLUSIONS: Among men undergoing AUS implantation for SUI because of PCa or BPH treatment, the probability of reintervention was 29% within 2 years after implantation. The median time to reintervention was 6.6 years (IQR, 6.4-7.1), and the reintervention-free survival rate at 10 years was 40%. These insights can inform therapeutic decision making for patients and surgeons during the management of male SUI.

Perioperative and functionnal outcomes of robot-assisted laparoscopic versus open ureterovesical reimplantation for benign lower ureteral pathologies: a single-center comparative study.

PURPOSE: The robot-assisted laparoscopic (RALUVR) and open (OUVR) approaches have both been described for ureterovesical reimplantation to treat benign lower ureteral pathologies. Thus, we aimed to compare the perioperative and functional outcomes of RALUVR vs. OUVR. METHODS: We performed a retrospective comparative study including all consecutive patients treated with RALUVR or OUVR for benign lower ureteral pathologies between January 2013 and December 2022 at our center. Logistic regression analyses were used to assess the predictors of complication ≥ Clavien-Dindo (CD) III within 90 days, prolonged length of stay (LOS), and 90-day overall success. The Kaplan-Meier method and Cox regression analyses were used to assess vesicoureteral reflux-free (VU-RFS) and stenosis-free (SFS) survivals. RESULTS: Overall, 44 patients underwent RALUVR (n = 19; 43%) and OUVR (n = 25; 57%). In univariable logistic regression analyses, the use of RALUVR vs. OUVR was not significantly associated with postoperative complications ≥ CDIII (OR = 0.98; 95% CI=[0.17-5.09]; p = 0.98), and 90-day overall success (OR = 1.43; 95% CI=[0.24-11.28]; p = 0.7). Despite a shorter median LOS after RALUVR vs. OUVR (4 vs. 10 days, respectively; p < 0.001), multivariable logistic regression analysis showed no impact of the surgical approach on prolonged LOS (OR = 0.51, 95% CI=[0.03-13.86]; p = 0.65). No significant difference was observed in 2-year VU-RFS (72.9% vs. 100%, respectively; p = 0.2) and 2-year SFS between the RALUVR and OUVR groups (85.7% vs. 87.7%, respectively; p = 0.8). In Cox regression analysis, the use of RALUVR vs. OUVR was not significantly associated with VU-RFS (HR = 4.26; 95% CI=[0.38-47.84]; p = 0.24) or SFS (HR = 1.32; 95% CI=[0.22-8.01]; p = 0.76). CONCLUSION: We observed that RALUVR provides similar perioperative and functional outcomes as compared to OUVR, except for potentially shorter LOS.

Comparative effectiveness of robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy for bladder cancer.

OBJECTIVES: To assess the comparative effectiveness of robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) vs open radical cystectomy (ORC) for bladder cancer (BC). PATIENTS AND METHODS: We conducted a real-life monocentric study including all consecutive patients who underwent RARC with ICUD or ORC for BC at our institution from 2014 to 2023. Uni- and multivariable logistic and Cox regression analyses were used to compare perioperative, oncological and stricture outcomes between both groups by calculating odds (ORs) and hazard (HRs) ratios with their corresponding 95% confidence intervals (CIs), respectively. RESULTS: Overall, 316 patients underwent either RARC with ICUD (n = 228 [72.2%]) or ORC (n = 88 [27.8%]). The perioperative benefits of RARC vs ORC included decreased risks of major blood loss (OR 0.10, 95% CI 0.04-0.23; P < 0.001), perioperative transfusion (OR 0.30, 95% CI 0.16-0.57; P < 0.001), 90-day major complications (OR 0.56, 95% CI 0.29-0.99; P = 0.04), and prolonged initial length of hospital stay (OR 0.20, 95% CI 0.09-0.35; P < 0.001), as well as more days alive and out of the hospital within 90 days of surgery (OR 2.56, 95% CI 1.46-4.6; P < 0.01). In addition, the use of RARC vs ORC was associated with a higher lymph node (LN) count (OR 3.35, 95% CI 1.83-6.30; P < 0.001), while there was no significant difference in recurrence-free (HR 0.72, 95% CI 0.49-1.07; P = 0.1), cancer-specific (HR 0.69, 95% CI 0.43-1.10; P = 0.1), overall (HR 0.76, 95% CI 0.47-1.20; P = 0.3) and uretero-ileal stricture-free (HR 1.18, 95% CI 0.62-2.25; P = 0.6) survival between both groups after a median (interquartile range) follow-up of 42.3 (16.4-73.8) months. CONCLUSION: Our real-world study supports the effectiveness of RARC with ICUD vs ORC for BC. We generally observed better perioperative outcomes, as well as similar oncological-except for higher LN count-and uretero-ileal stricture outcomes after RARC with ICUD vs ORC.

Artificial urinary sphincter: recent developments and the way forward.

PURPOSE OF REVIEW: The AMS 800 has dominated the treatment of postprostatectomy urinary incontinence (PPUI) due to intrinsic sphincter deficiency (ISD) for five decades. A narrative review from June 2022 to June 2024 was conducted using 'artificial urinary sphincter' (AUS) MeSH terms in Embase. We extracted information on innovative AUS, randomized controlled trials (RCTs) or prospective studies, and systematic reviews. We evaluated the latest guidelines and consensus and analyzed current trends to discuss options for advancing AUS practices. RECENT FINDINGS: Of 465 papers identified, 320 were excluded (irrelevant, duplicates, non-AUS devices, non-English, veterinary), and 145 were reviewed, with 24 selected: seven on novel AUS in development, 7 with higher-level evidence (1 RCT, 1 prospective, 4 systematic reviews, 1 nonsystematic review), and 9 retrospective relevant studies [pressure regulating balloon (PRB), revision strategies, radiotherapy history, manual dexterity/cognition, transscrotal vs. transperineal approach]. The final paper summarized current guidelines from Asia & Pacific on AUS. SUMMARY: In the past 2 years, six novel AUS have emerged, two female RCTs are ongoing, the SATURN study published its 1-year outcomes, and four systematic reviews on female AUS were conducted. These findings enhance evidence levels and position novel AUS to challenge the Gold Standard.

Adult patients treated for bladder exstrophy at a young age What are their current demands?

INTRODUCTION: Bladder exstrophy-epispadias complex is a rare condition that necessitates numerous surgical procedures during a patient's youth to achieve adequate urine storage and continence. This study aimed to identify the specific needs and functional challenges faced by adults who underwent pediatric bladder exstrophy reconstructions and assess the management of these issues in an adult population. METHODS: A retrospective chart review was conducted for all bladder exstrophy complex patients who underwent surgery at a young age and were subsequently referred to our center between 2005 and 2020. Inclusion criteria included patients with cloacal or classical bladder exstrophy older than 18 years. We recorded the reasons for referral, management of contemporary complaints, types of past and present urinary reconstructions, and their current functional status. RESULTS: The study included 38 patients. The primary reasons for referral were incontinence (39%) and catheterization difficulties (24%). Management typically involved partial or complete surgical revision of their urinary reservoir, occasionally combined with a bladder neck procedure. Ultimately, only three patients continued to experience incontinence, while none reported catheterization issues after undergoing treatment at our center. Long-term exstrophy-related reconstruction complications included urinary tract infections (39%), stones (29%), stenosis (24%), fistulas (13%), chronic renal disease (16%), metabolic abnormalities (3%), and cancer (3%). CONCLUSIONS: Adults who have previously undergone bladder exstrophy reconstruction exhibit a wide range of urologic reconstructions. Their needs often revolve around continence and catheterization concerns. Most patients with satisfactory functional outcomes perform self-catheterization through a continent cutaneous channel and have either a continent pouch or an augmented bladder.

Continent cutaneous diversion: Unveiling the interplay of neuro-urology and oncological challenges.

OBJECTIVES: The objective of our study is to demonstrate the practical application of continent cutaneous urinary diversion (CCUD) in oncological patients, with a focus on various aspects of the procedure: surgical challenges, functional outcomes, and quality of life. MATERIALS AND METHODS: We studied the perioperative and follow-up data of patients who underwent cystectomy for cancer associated with CCUD (Mitrofanoff, Monti or Casale). We retrospectively analyzed complications within 30days and beyond 30days post-surgery. We evaluated oncological outcomes. Patients' quality of life was assessed using the Bladder Cancer Index (BCI) questionnaire. Results are given on an intention-to-treat basis. RESULTS: A total of 24 patients were included in the study (July 2001 and May 2022), with a median follow-up of 62.5months. We report three deaths due to neoplasic recurrence. Forty-six percent had an early postoperative complication, two of whom required revision surgery. Overall, the medium-term complication rate was 70% and the reoperation rate was 62%. There were 8 stomal cutaneous stenoses (33%) and 3 uretero-ileal stenoses (12.5%). Overall satisfaction was rated at 9.2/10 on average, and body image was unaltered or slightly altered in 62.5% of patients. Of the patients who responded to the BCI, 75% had complete continence. DISCUSSION: The experience gained with continent stomas in neuro-urology has allowed, in carefully selected cases, to offer patients an alternative that can improve their quality of life in a context already burdened by the shadow of cancer. CCUD can be proposed as an alternative to Bricker diversion in cases of urethral invasion or a high risk of neobladder incontinence, in selected patients.

Adult patients treated for bladder exstrophy at a young age: What are their current demands?

INTRODUCTION: Bladder exstrophy-epispadias complex is a rare condition that necessitates numerous surgical procedures during a patient's youth to achieve adequate urine storage and continence. This study aimed to identify the specific needs and functional challenges faced by adults who underwent pediatric bladder exstrophy reconstructions and assessing the management of these issues in an adult population. METHODS: A retrospective chart review was conducted for all bladder exstrophy complex patients who underwent surgery at a young age and were subsequently referred to our center between 2005 and 2020. Inclusion criteria included patients with cloacal or classical bladder exstrophy older than 18 years. We recorded the reasons for referral, management of contemporary complaints, types of past and present urinary reconstructions, and their current functional status. RESULTS: The study included 38 patients. The primary reasons for referral were incontinence (39%) and catheterization difficulties (24%). Management typically involved partial or complete surgical revision of their urinary reservoir, occasionally combined with a bladder neck procedure. Ultimately, only three patients continued to experience incontinence, while none reported catheterization issues after they underwent treatment at our center. Long-term exstrophy-related reconstruction complications included urinary tract infections (39%), stones (29%), stenosis (24%), fistulas (13%), chronic renal disease (16%), metabolic abnormalities (3%), and cancer (3%). CONCLUSIONS: Adults who previously underwent bladder exstrophy reconstruction exhibit a wide range of urologic reconstructions. Their needs often revolve around continence and catheterization concerns. Most patients with satisfactory functional outcomes perform selfcatheterization through a continent cutaneous channel and have either a continent pouch or an augmented bladder.

Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted Biopsies for Prostate Cancer Diagnosis: Final Results of the Randomized PERFECT trial (CCAFU-PR1).

BACKGROUND: Recent guidelines favor transperineal (TP) prostate biopsies over the transrectal (TR) approach due to a reduced sepsis risk. Yet, evidence from controlled trial comparing both approaches within the MRI-targeted pathway for significant prostate cancer (PCa) detection is lacking. OBJECTIVE: To compare the significant PCa detection rate between magnetic resonance imaging (MRI)-targeted TR and TP approaches in biopsy-naïve patients. DESIGN, SETTING, AND PARTICIPANTS: In this noninferiority controlled trial, we randomized (ratio 1:1) 270 MRI-positive biopsy-naïve patients. INTERVENTION: MRI-targeted TP versus TR biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES: The primary outcome was the detection rate of significant PCa (International Society of Urological Pathology [ISUP] ≥2) in MRI-targeted biopsies. Secondary outcomes were any-grade PCa detection, detection on concomitant systematic biopsy, complications, and functional outcomes. RESULTS AND LIMITATIONS: Targeted biopsies identified significant PCa in 47.2% of TP and 54.2% of TR participants (-7%, p = 0.6235). On a per-lesion analysis, posterior lesions yielded higher detection rates via TR (59.0% vs 44.3%, p = 0.0443), while anterior lesions were more frequently detected via TP (40.6% vs 26.5%, p = 0.2228). The overall (any grade) cancer detection rate in targeted biopsies was comparable between groups: 71.3% (TP) versus 64.1% (TR; p = 0.2209) with significantly more ISUP 1 cases detected in the TP arm. Adverse events of grade ≥2 were not different between TP (35.7%) and TR (40.5%, p = 0.4256). One TR patient (0.8%) experienced grade 3 sepsis. Quality of life, and urinary and sexual function, as well as pain scores, were comparable between groups. CONCLUSIONS: Despite a comparable overall detection rate for any-grade PCa, noninferiority of TP over TR for MRI-targeted biopsies for significant PCa detection was not demonstrated. However, MRI lesion location influenced biopsy route performance, suggesting that a pragmatic approach based on lesion location might enhance significant PCa assessment. PATIENT SUMMARY: This trial compared the efficacy and safety of two biopsy approaches for prostate cancer diagnosis. Both approaches seem complementary according to the lesion location.

Management of patients with muscle-invasive bladder cancer with clinical evidence of pelvic lymph node metastases.

Identification of clinically positive pelvic lymph node metastases (cN+) in patients with muscle-invasive bladder cancer is currently challenging, as the diagnostic accuracy of available imaging modalities is limited. Conventional CT is still considered the gold-standard approach to diagnose lymph node metastases in these patients. The development of innovative diagnostic methods including radiomics, artificial intelligence-based models and molecular biomarkers might offer new perspectives for the diagnosis of cN+ disease. With regard to the treatment of these patients, multimodal strategies are likely to provide the best oncological outcomes, especially using induction chemotherapy followed by radical cystectomy and pelvic lymph node dissection in responders to chemotherapy. Additionally, the use of adjuvant nivolumab has been shown to decrease the risk of recurrence in patients who still harbour ypT2-T4a and/or ypN+ disease after surgery. Alternatively, the use of avelumab maintenance therapy can be offered to patients with unresectable cN+ tumours who have at least stable disease after induction chemotherapy alone. Lastly, patients with cN+ tumours who are not responding to induction chemotherapy are potential candidates for receiving second-line treatment with pembrolizumab.

Learning curve for fusion magnetic resonance imaging targeted prostate biopsy and three-dimensional transrectal ultrasonography segmentation.

OBJECTIVE: To report the learning curve of multiple operators for fusion magnetic resonance imaging (MRI) targeted biopsy and to determine the number of cases needed to achieve proficiency. MATERIALS AND METHODS: All adult males who underwent fusion MRI targeted biopsy between February 2012 and July 2021 for clinically suspected prostate cancer (PCa) in a single centre were included. Fusion transrectal MRI targeted biopsy was performed under local anaesthesia using the Koelis platform. Learning curves for segmentation of transrectal ultrasonography (TRUS) images and the overall MRI targeted biopsy procedure were estimated with locally weighted scatterplot smoothing by computing each operator's timestamps for consecutive procedures. Non-risk-adjusted cumulative sum (CUSUM) methods were used to create learning curves for clinically significant (i.e., International Society of Urological Pathology grade ≥ 2) PCa detection. RESULTS: Overall, 1721 patients underwent MRI targeted biopsy in our centre during the study period. The median (interquartile range) times for TRUS segmentation and for the MRI targeted biopsy procedure were 4.5 (3.5, 6.0) min and 13.2 (10.6, 16.9) min, respectively. Among the 14 operators with experience of more than 50 cases, a plateau was reached after 40 cases for TRUS segmentation time and 50 cases for overall MRI targeted biopsy procedure time. CUSUM analysis showed that the learning curve for clinically significant PCa detection required 25 to 45 procedures to achieve clinical proficiency. Pain scores ranged between 0 and 1 for 84% of patients, and a plateau phase was reached after 20 to 100 cases. CONCLUSIONS: A minimum of 50 cases of MRI targeted biopsy are necessary to achieve clinical and technical proficiency and to reach reproducibility in terms of timing, clinically significant PCa detection, and pain.

Robot-assisted Periprostatic Artificial Urinary Sphincter Implantation in Men with Neurogenic Stress Urinary Incontinence: Description of the Surgical Technique and Comparison of Long-term Functional Outcomes with the Open Approach.

BACKGROUND: Periprostatic artificial urinary sphincter implantation (pAUSi) is a rare yet relevant indication for male neurogenic stress urinary incontinence (SUI). OBJECTIVE: To describe the surgical technique of robot-assisted pAUSi (RApAUSi) and compare the long-term functional results with the open pAUSi (OpAUSi). DESIGN, SETTING, AND PARTICIPANTS: Data of 65 consecutive men with neurogenic SUI undergoing pAUSi between 2000 and 2022 in a tertiary centre were collected retrospectively. SURGICAL PROCEDURE: Thirty-three patients underwent OpAUSi and 32 underwent RApAUSi. OpAUSi cases were performed by a single surgeon, experienced in functional urology and prosthetic surgery. RApAUSi cases were performed by the same surgeon together with a second surgeon, experienced in robotic surgery. MEASUREMENTS: Outcome measures were achievement of complete urinary continence, intra- and postoperative complications, and surgical revision-free survival (SRFS). RESULTS AND LIMITATIONS: RApAUSi showed superior results to OpAUSi in terms of median (interquartile range) operative time (RApAUSi: 170 [150-210] min vs OpAUSi: 245 [228-300] min; p < 0.001), estimated blood loss (RApAUSi: 20 [0-50] ml vs OpAUSi: 500 [350-700] ml; p < 0.001), and median length of hospital stay (LOS; RApAUSi: 5 [4-6] d vs OpAUSi: 11 [10-14] d; p < 0.001). Clavien-Dindo grade ≥3a complications occurred more frequently after OpAUSi (RApAUSi: 1/32 [3%] vs OpAUSi: 10/33 [30%]; p = 0.014). Achievement of complete urinary continence (zero pads) was comparable between the groups (RApAUSi: 24/32 [75%] vs OpAUSi: 24/33 [73%]; p = 0.500). The median follow-up periods were 118 (50-183) and 56 (25-84) mo for OpAUSi and RApAUSi, respectively (p < 0.001). A tendency towards longer SRFS was observed in the RApAUSi group (p = 0.076). The main study limitation was its retrospective nature. CONCLUSIONS: RApAUSi is an efficient alternative to OpAUSi, resulting in shorter operative times, less blood loss, fewer severe complications, and a shorter LOS with similar functional results and need for revision surgery. PATIENT SUMMARY: Compared with open periprostatic artificial urinary sphincter implantation (pAUSi), robot-assisted pAUSi leads to faster recovery and similar functional results, with fewer postoperative complications.

Robotic-assisted benign hysterectomy compared with laparoscopic, vaginal, and open surgery: a systematic review and meta-analysis.

The potential benefits and limitations of benign hysterectomy surgical approaches are still debated. We aimed at evaluating any differences with a systematic review and meta-analysis. PubMed, MEDLINE, and EMBASE databases were last searched on 6/2/2021 to identify English randomized controlled trials (RCTs), prospective cohort and retrospective independent database studies published between Jan 1, 2010 and Dec 31, 2020 reporting perioperative outcomes following robotic hysterectomy versus laparoscopic, open, or vaginal approach (PROSPERO #CRD42022352718). Twenty-four articles were included that reported on 110,306 robotic, 262,715 laparoscopic, 189,237 vaginal, and 554,407 open patients. The robotic approach was associated with a shorter hospital stay (p < 0.00001), less blood loss (p = 0.009), and fewer complications (OR: 0.42 [0.27, 0.66], p = 0.0001) when compared to the open approach. The main benefit compared to the laparoscopic and vaginal approaches was a shorter hospital (R/L WMD: - 0.144 [- 0.21, - 0.08], p < 0.0001; R/V WMD: - 0.39 [- 0.70, - 0.08], p = 0.01). Other benefits seen were sensitive to the inclusion of database studies. Study type differences in outcomes, a lack of RCTs for robotic vs. open comparisons, learning curve issues, and limited robotic vs. vaginal publications are limitations. While the robotic approach was mainly comparable to the laparoscopic approach, this meta-analysis confirms the classic benefits of minimally invasive surgery when comparing robotic hysterectomy to open surgery. We also reported the advantages of robotic surgery over vaginal surgery in a patient population with a higher incidence of large uterus and prior surgery.

Perioperative, renal function and oncological outcomes of robot-assisted radical nephroureterectomy for patients with upper tract urothelial carcinoma.

PURPOSE: To report perioperative, renal function and oncological outcomes of robot-assisted radical nephroureterectomy (RNU) for patients with upper tract urothelial carcinoma (UTUC). METHODS: This was a retrospective single-arm monocentric study including all consecutive UTUC patients treated with robot-assisted RNU at our institution between 2014 and 2022. Descriptive statistics with median and interquartile range (IQR) for continuous variables and numbers with frequencies for categorical variables were used to report perioperative and renal function outcomes while Kaplan-Meier curves were computed to present extravesical and intravesical recurrence-free survival(RFS) as well as cancer-specific (CSS) and overall survival (OS) with the corresponding 95% confidence intervals(CIs). RESULTS: Overall, 70 patients with a median age of 69.6 [63.3-74.9] years were included in our study. With regards to perioperative outcomes, the median operative time was 157 [130-182] min with a median blood loss of 200 [100-300] cc. Intraoperative complications occurred in 4 (5.7%) patients but no conversion to open or laparoscopic surgery was required. Postoperative complications occurred in 9 (12.9%) patients, including 5 (7.1%) with grade ≥ 3 complications according to the Clavien-Dindo classification. The median length of stay was 4 [3-6] days. With regards to renal function outcomes, the median postoperative loss in estimated glomerular filtration rate at discharge was 16 [10.25-26] mL/min/1.73 m2. With regards to oncological outcomes, the 3-year extravesical and intravesical RFS, CSS and OS rates were 73.6 [62.8-86.2]%, 68.1 [54.6-85]%, 82.5 [72-94.4]% and 75.3 [63.4-89.5]%, respectively. CONCLUSION: We report favorable perioperative and oncological outcomes with expected decrease in renal function after robot-assisted RNU for patients with UTUC.

Unleashing the Power of Artificial Intelligence and Fusion Magnetic Resonance Imaging-Targeted Biopsy: Transforming Prostate Cancer Diagnosis.

Advances in artificial intelligence (AI) and medical imaging have opened new avenues for the diagnosis and management of prostate cancer. In particular, AI technology can enhance the performance of fusion magnetic resonance imaging-targeted biopsy of the prostate, and has the potential to enhance the usability and precision of this biopsy technique, guide treatment decisions, and further advance prostate cancer care.

Impact of Relative Volume Difference Between Magnetic Resonance Imaging and Three-dimensional Transrectal Ultrasound Segmentation on Clinically Significant Prostate Cancer Detection in Fusion Magnetic Resonance Imaging-targeted Biopsy.

BACKGROUND: Segmentation of three-dimensional (3D) transrectal ultrasound (TRUS) images is known to be challenging, and the clinician often lacks a reliable and easy-to-use indicator to assess its accuracy during the fusion magnetic resonance imaging (MRI)-targeted prostate biopsy procedure. OBJECTIVE: To assess the effect of the relative volume difference between 3D-TRUS and MRI segmentation on the outcome of a targeted biopsy. DESIGN, SETTING, AND PARTICIPANTS: All adult males who underwent an MRI-targeted prostate biopsy for clinically suspected prostate cancer between February 2012 and July 2021 were consecutively included. INTERVENTION: All patients underwent a fusion MRI-targeted prostate biopsy with a Koelis device. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Three-dimensional TRUS and MRI prostate volumes were calculated using 3D prostate models issued from the segmentations. The primary outcome was the relative segmentation volume difference (SVD) between transrectal ultrasound and MRI divided by the MRI volume (SVD = MRI volume - TRUS volume/MRI volume) and its correlation with clinically significant prostate cancer (eg, International Society of Urological Pathology [ISUP] ≥2) positiveness on targeted biopsy cores. RESULTS AND LIMITATIONS: Overall, 1721 patients underwent a targeted biopsy resulting in a total of 5593 targeted cores. The median relative SVD was significantly lower in patients diagnosed with clinically significant prostate cancer than in those with ISUP 0-1: (6.7% [interquartile range {IQR} -2.7, 13.6] vs 8.0% [IQR 3.3, 16.4], p < 0.01). A multivariate regression analysis showed that a relative SVD of >10% of the MRI volume was associated with a lower detection rate of clinically significant prostate cancer (odds ratio = 0.74 [95% confidence interval: 0.55-0.98]; p = 0.038). CONCLUSIONS: A relative SVD of >10% of the MRI segmented volume was associated with a lower detection rate of clinically significant prostate cancer on targeted biopsy cores. The relative SVD can be used as a per-procedure quality indicator of 3D-TRUS segmentation. PATIENT SUMMARY: A discrepancy of ≥10% between segmented magnetic resonance imaging and transrectal ultrasound volume is associated with a reduced ability to detect significant prostate cancer on targeted biopsy cores.

A Systematic Review of Oncological Outcomes Associated with Bladder-sparing Strategies in Patients Achieving Complete Clinical Response to Initial Systemic Treatment for Localized Muscle-invasive Bladder Cancer.

CONTEXT: Bladder-sparing strategies (BSSs) have been proposed for the treatment of muscle-invasive bladder cancer (MIBC) patients achieving clinical complete response (cCR) to initial systemic treatment to avoid toxicity related to radical cystectomy. OBJECTIVE: To systematically review the current literature evaluating oncological outcomes of BSSs in patients achieving cCR to initial systemic treatment for localized MIBC. EVIDENCE ACQUISITION: A computerized bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting oncological outcomes of MIBC patients undergoing either surveillance or radiation therapy after achieving cCR to initial systemic treatment. Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we identified 23 noncomparative prospective or retrospective studies published between 1990 and 2021. The mean bladder and metastatic recurrence rates (range) as well as the mean bladder preservation rate (BPR; range) were calculated, and overall survival (OS) was extracted from included reports. EVIDENCE SYNTHESIS: Overall, 16 and seven studies evaluated surveillance (n = 610) and radiation therapy (n = 175) in MIBC patients achieving cCR to initial systemic treatment, respectively. With regard to surveillance, the median follow-up ranged from 10 to 120 mo, with a mean bladder recurrence rate of 43% (0-71%), including 65% of non-muscle-invasive bladder cancer (NMIBC) and 35% of MIBC recurrences. The mean BPR was 73% (49-100%). The mean metastatic recurrence rate was 9% (0-27%), while 5-yr OS rates ranged from 64% to 89%. With regard to radiation therapy, the median follow-up ranged from 12 to 60 mo, with a mean bladder recurrence rate of 15% (0-29%), including 24% of NMIBC, 43% of MIBC, and 33% of unspecified recurrences. The mean BPR was 74% (71-100%). The mean metastatic recurrence rate was 17% (0-22%), while the 4-yr OS rate was 79%. CONCLUSIONS: Our systematic review showed that only low-level evidence supports the effectiveness of BSSs in selected patients achieving cCR to initial systemic treatment for localized MIBC. These preliminary findings highlight the need for further prospective comparative research to demonstrate its efficacy. PATIENT SUMMARY: We reviewed studies evaluating bladder-sparing strategies in patients achieving complete clinical response to initial systemic treatment for localized muscle-invasive bladder cancer. Based on low-level evidence, we observed that selected patients could benefit from surveillance or radiation therapy in this setting, but prospective comparative research is requested to confirm their efficacy.