Evolution of anxiety management in prostate biopsy under local anesthesia: a narrative review.

INTRODUCTION AND METHODS: Prostate biopsy (PB) is an essential step in the diagnosis and active surveillance of prostate cancer (PCa). Transperineal PB (TP-PB) is now the recommended approach and is mostly conducted under local anesthesia. However, this procedure can potentially cause anxiety for patients, given the oncological context and the fear of peri-procedural pain and complications. The objective of this narrative review is to summarize the currently available tools for the management of peri-interventional anxiety during TP-PB, with a particular emphasis on the potential role of virtual reality (VR) in this setting. RESULTS: In TP-PB, preoperative anxiety can lead to increased pain perception, longer procedure time, and decreased patient satisfaction. Pharmacological and non-pharmacological approaches have been explored to reduce anxiety, such as premedication, deep sedation, education, relaxation techniques, hypnosis, and music therapy, albeit with mixed results. VR has recently emerged in the technological armamentarium for managing pain and anxiety, and the efficiency of this technology has been evaluated in various medical fields, including pediatrics, gastroenterology, urology, gynecology, and psychiatry. CONCLUSION: Despite the paucity of available data, VR appears to be a safe and effective technique in reducing anxiety in many procedures, even in frail patients. No studies have evaluated the role of VR in TP-PB. Future research should thus explore the optimal way to implement VR technology and any potential benefits for TP-PB patients.

Predicting contralateral extraprostatic extension in unilateral high-risk prostate cancer: a multicentric external validation study.

PURPOSE: Accurate prediction of extraprostatic extension (EPE) is crucial for decision-making in radical prostatectomy (RP), especially in nerve-sparing strategies. Martini et al. introduced a three-tier algorithm for predicting contralateral EPE in unilateral high-risk prostate cancer (PCa). The aim of the study is to externally validate this model in a multicentric European cohort of patients. METHODS: The data from 208 unilateral high-risk PCa patients diagnosed through magnetic resonance imaging (MRI)-targeted and systematic biopsies, treated with RP between January 2016 and November 2021 at eight referral centers were collected. The evaluation of model performance involved measures such as discrimination (AUC), calibration, and decision-curve analysis (DCA) following TRIPOD guidelines. In addition, a comparison was made with two established multivariable logistic regression models predicting the risk of side specific EPE for assessment purposes. RESULTS: Overall, 38%, 48%, and 14% of patients were categorized as low, intermediate, and high-risk groups according to Martini et al.'s model, respectively. At final pathology, EPE on the contralateral prostatic lobe occurred in 6.3%, 12%, and 34% of patients in the respective risk groups. The algorithm demonstrated acceptable discrimination (AUC 0.68), comparable to other multivariable logistic regression models (p = 0.3), adequate calibration and the highest net benefit in DCA. The limitations include the modest sample size, retrospective design, and lack of central revision. CONCLUSION: Our findings endorse the algorithm's commendable performance, supporting its utility in guiding treatment decisions for unilateral high-risk PCa patients.

External validation and comparison of magnetic resonance imaging-based risk prediction models for prostate biopsy stratification.

PURPOSE: Magnetic resonance imaging (MRI) is a promising tool for risk assessment, potentially reducing the burden of unnecessary prostate biopsies. Risk prediction models that incorporate MRI data have gained attention, but their external validation and comparison are essential for guiding clinical practice. The aim is to externally validate and compare risk prediction models for the diagnosis of clinically significant prostate cancer (csPCa). METHODS: A cohort of 4606 patients across fifteen European tertiary referral centers were identified from a prospective maintained database between January 2016 and April 2023. Transrectal or transperineal image-fusion MRI-targeted and systematic biopsies for PI-RADS score of ≥ 3 or ≥ 2 depending on patient characteristics and physician preferences. Probabilities for csPCa, defined as International Society of Urological Pathology (ISUP) grade ≥ 2, were calculated for each patients using eight models. Performance was characterized by area under the receiver operating characteristic curve (AUC), calibration, and net benefit. Subgroup analyses were performed across various clinically relevant subgroups. RESULTS: Overall, csPCa was detected in 2154 (47%) patients. The models exhibited satisfactory performance, demonstrating good discrimination (AUC ranging from 0.75 to 0.78, p < 0.001), adequate calibration, and high net benefit. The model described by Alberts showed the highest clinical utility for threshold probabilities between 10 and 20%. Subgroup analyses highlighted variations in models' performance, particularly when stratified according to PSA level, biopsy technique and PI-RADS version. CONCLUSIONS: We report a comprehensive external validation of risk prediction models for csPCa diagnosis in patients who underwent MRI-targeted and systematic biopsies. The model by Alberts demonstrated superior clinical utility and should be favored when determining the need for a prostate biopsy.

The impact of prostate volume estimation on the risk-adapted biopsy decision based on prostate-specific antigen density and magnetic resonance imaging score.

PURPOSE: Utility of prostate-specific antigen density (PSAd) for risk-stratification to avoid unnecessary biopsy remains unclear due to the lack of standardization of prostate volume estimation. We evaluated the impact of ellipsoidal formula using multiparametric magnetic resonance (MRI) and semi-automated segmentation using tridimensional ultrasound (3D-US) on prostate volume and PSAd estimations as well as the distribution of patients in a risk-adapted table of clinically significant prostate cancer (csPCa). METHODS: In a prospectively maintained database of 4841 patients who underwent MRI-targeted and systematic biopsies, 971 met inclusions criteria. Correlation of volume estimation was assessed by Kendall's correlation coefficient and graphically represented by scatter and Bland-Altman plots. Distribution of csPCa was presented using the Schoots risk-adapted table based on PSAd and PI-RADS score. The model was evaluated using discrimination, calibration plots and decision curve analysis (DCA). RESULTS: Median prostate volume estimation using 3D-US was higher compared to MRI (49cc[IQR 37-68] vs 47cc[IQR 35-66], p < 0.001). Significant correlation between imaging modalities was observed (τ = 0.73[CI 0.7-0.75], p < 0.001). Bland-Altman plot emphasizes the differences in prostate volume estimation. Using the Schoots risk-adapted table, a high risk of csPCa was observed in PI-RADS 2 combined with high PSAd, and in all PI-RADS 4-5. The risk of csPCa was proportional to the PSAd for PI-RADS 3 patients. Good accuracy (AUC of 0.69 and 0.68 using 3D-US and MRI, respectively), adequate calibration and a higher net benefit when using 3D-US for probability thresholds above 25% on DCA. CONCLUSIONS: Prostate volume estimation with semi-automated segmentation using 3D-US should be preferred to the ellipsoidal formula (MRI) when evaluating PSAd and the risk of csPCa.

Accuracy of elastic fusion biopsy: Comparing prostate cancer detection between targeted and systematic biopsy.

INTRODUCTION: When performing targeted biopsy (TBx), the need to add systematic biopsies (SBx) is often debated. Aim of the study is to evaluate the added value of SBx in addition to TBx in terms of prostate cancer (PCa) detection rates (CDR), and to test the concordance between multiparametric magnetic resonance imaging (mpMRI) findings and fusion biopsy results in terms of cancer location. METHODS: We performed a retrospective, multicentric study that gathered data on 1992 consecutive patients who underwent elastic fusion biopsy between 2011 and 2020. A standardized approach was used, with TBx (2-4 cores per target) followed by SBx (12-14 cores). We assessed CDR of TBx, of SBx, and TBx+SBx for all cancers and clinically significant PCa (csPCa), defined as ISUP score ≥2. CDR was evaluated according to radiological and clinical parameters, with a particular focus on PI-RADS 3 lesions. In a subgroup of 1254 patients we tested the discordance between mpMRI findings and fusion biopsy results in terms of cancer location. Uni- and multivariable logistic regression analyses were performed to identify predictors of CDR. RESULTS: CDR of TBx+SBx was 63.0% for all cancers and 38.8% of csPCa. Per-patient analysis showed that SBx in addition to TBx improved CDR by 4.5% for all cancers and 3.4% for csPCa. Patients with lesions scored as PI-RADS 3, 4, and 5 were diagnosed with PCa in 27.9%, 72.8%, and 92.3%, and csPCa in 10.7%, 43.6%, and 69.3%, respectively. When positive, PI-RADS 3 lesions were ISUP grade 1 in 61.1% of cases. Per-lesion analysis showed that discordance between mpMRI and biopsy was found in 56.6% of cases, with 710 patients having positive SBx outside mpMRI targets, of which 414 (58.0%) were clinically significant. PSA density ≥0.15 was a strong predictor of CDR. CONCLUSIONS: The addition of systematic mapping to TBx contributes to a minority of per-patient diagnoses but detects a high number of PCa foci outside mpMRI targets, increasing biopsy accuracy for the assessment of cancer burden within the prostate. High PSA-density significantly increases the risk of PCa, both in the whole cohort and in PI-RADS 3 cases.

Risk stratification for early biochemical recurrence of prostate cancer in the era of multiparametric magnetic resonance imagining-targeted biopsy.

BACKGROUND: Multiparametric magnetic resonance imaging (MRI) and MRI-targeted biopsy are nowadays recommended in the prostate cancer (PCa) diagnostic pathway. Ploussard and Mazzone have integrated these tools into novel risk classification systems predicting the risk of early biochemical recurrence (eBCR) in PCa patients who underwent radical prostatectomy (RP). We aimed to assess available risk classification systems and to define the best-performing. METHODS: Data on 1371 patients diagnosed by MRI-targeted biopsy and treated by RP between 2014 and 2022 at eight European tertiary referral centers were analyzed. Risk classifications systems included were the European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN) risk groups, the Cancer of the Prostate Risk Assessment (CAPRA) score, the International Staging Collaboration for Cancer of the Prostate (STAR-CAP) classification, the Ploussard and Mazzone models, and ISUP grade group. Kaplan-Meier analyses were used to compare eBCR among risk classification systems. Performance was assessed in terms of discrimination quantified using Harrell's c-index, calibration, and decision curve analysis (DCA). RESULTS: Overall, 152 (11%) patients had eBCR at a median follow-up of 31 months (interquartile range: 19-45). The 3-year eBCR-free survival rate was 91% (95% confidence interval [CI]: 89-93). For each risk classification system, a significant difference among survival probabilities was observed (log-rank test p < 0.05) except for NCCN classification (p = 0.06). The highest discrimination was obtained with the STAR-CAP classification (c-index 66%) compared to CAPRA score (63% vs. 66%, p = 0.2), ISUP grade group (62% vs. 66, p = 0.07), Ploussard (61% vs. 66%, p = 0.003) and Mazzone models (59% vs. 66%, p = 0.02), and EAU (57% vs. 66%, p < 0.001) and NCCN (57% vs. 66%, p < 0.001) risk groups. Risk classification systems demonstrated good calibration characteristics. At DCA, the CAPRA score showed the highest net benefit at a probability threshold of 9%-15%. CONCLUSIONS: The performance of risk classification systems using MRI and MRI-targeted information was less optimistic when tested in a contemporary set of patients. CAPRA score and STAR-CAP classification were the best-performing and should be preferred for treatment decision-making.

Long term efficacy of prosthetic inguinal herniorrhaphy concomitant with robot-assisted laparoscopic radical prostatectomy.

PURPOSE: Patients who undergo robot-assisted laparoscopic radical prostatectomy (RARP) may present concurrent or secondary inguinal hernia (IH). Surgical repair of IH simultaneously with RARP has been reported. We aimed to assess the long-term efficacy of concurrent prosthetic IH repair with RARP. METHODS: Data for consecutive patients undergoing concurrent IH repair with RARP for localized prostate cancer at our institution between 2006 and 2017 were retrospectively analysed. Patients were matched based on age, BMI, and year of surgery, with patients undergoing RARP alone. IH repair was performed with a polyester mesh. Efficacy of IH repair was the primary outcome. Patient characteristics, perioperative data, recurrence and treatment were recorded. RESULTS: A total of 136 men were included, 50% treated by RARP and concurrent IH, 50% by RARP alone. Mean age was 65 years (SD 6) and mean BMI 26.8 (SD 2.5). IH was diagnosed preoperatively in 42 patients (62%) or intraoperatively in 26 patients (38%). A total 18 patients (26%) had bilateral hernias and 50 patients had unilateral hernias (right 31%, left 43%). There was no significant difference between the two groups regarding perioperative data. The herniorrhaphy added 34 min to the operative time (p < 0.001). After a mean follow-up of 106 months [SD 38], 9 patients (13%) presented recurrence of IH, with a mean time to recurrence of 43 months [SD 35]. Age was significantly associated with IH recurrence (p = 0.0007). CONCLUSION: Concomitant IH repair and RARP appear to be a safe procedure with good long-term safety and efficacy, without significantly increasing morbidity.

Intraoperative complication of radical cystectomy for muscle-invasive bladder cancer: does the surgical approach matter? A retrospective multicenter study using the EAUiaiC classification.

PURPOSE: Despite surgical and anesthetic progress, radical cystectomy for bladder cancer remains one of the most morbid surgeries in urology. The objective of our study was to describe intraoperative complications and to assess the impact of surgical approach on morbidity. METHODS: We retrospectively reviewed medical records of patients treated by radical cystectomy for localized muscle invasive bladder cancer between 2015 and 2020, following the Martin et al. criteria for complications reports. All intraoperative adverse events were graded according to the EAUiaiC scores. Multivariate regression models were used to determine predicting factors of complications. RESULTS: A total of 318 patients were included for analysis. Among them, 17 patients (5.4%) presented an intraoperative complication. No preoperative oncological or clinical factor was associated with the occurrence of an intraoperative complication. Surgical approach had no impact on morbidity. Both overall survival (HR 2.02; CI95% 0.87-4.68; p = 0.101) and recurrence-free survival (HR 1.856; CI95% 0.804-4.284; p = 0.147) were not associated with intraoperative complication. CONCLUSION: Radical cystectomy remains a highly morbid surgery and surgical approach did not improve the complication rate. Perioperative morbidity has a significant impact on patient survival. The association between intraoperative and postoperative complications illustrates the cumulative effect of perioperative events that are associated with survival.

The role of perioperative chemotherapy for upper tract urothelial carcinoma patients treated with radical nephroureterectomy.

PURPOSE: To summarize evidence regarding the use of neoadjuvant (NAC) and adjuvant chemotherapy (AC) among patients treated with radical nephroureterectomy (RNU). METHODS: A comprehensive literature search of PubMed (MEDLINE), EMBASE and the Cochrane library was performed to identify any original or review article on the role of perioperative chemotherapy for UTUC patients treated with RNU. RESULTS: With regards to NAC, retrospective studies consistently suggested that it may be associated with better pathological downstaging (pDS) ranging from 10.8 to 80% and complete response (pCR) ranging from 4.3 to 15%, while decreasing the risk of recurrence and death as compared to RNU alone. Even higher pDS ranging from 58 to 75% and pCR ranging from 14 to 38% were observed in single-arm phase II trials. With regards to AC, retrospective studies provided conflicting results although the largest report from the National Cancer Database suggested an overall survival benefit in pT3-T4 and/or pN + patients. In addition, a phase III randomized controlled trial showed that the use of AC was associated with a disease-free survival benefit (HR = 0.45; 95% CI = [0.30-0.68]; p = 0.0001) in pT2-T4 and/or pN + patients with acceptable toxicity profile. This benefit was consistent in all subgroups analyzed. CONCLUSIONS: Perioperative chemotherapy improves oncological outcomes associated with RNU. Given the impact of RNU on renal function, the rational is stronger for the use of NAC which impacts final pathology and potentially prolongs survival. However, the level of evidence is stronger for the use of AC that has been proven to decrease the risk of recurrence after RNU with a potential survival benefit.

Optimizing multiparametric magnetic resonance imaging-targeted biopsy and prostate cancer grading accuracy.

PURPOSE: To assess the most efficient biopsy method to improve International Society of Urological Pathology (ISUP) grade group accuracy with final pathology of the radical prostatectomy (RP) specimen in the era of magnetic resonance imaging (MRI)-driven pathway. METHODS: A total of 753 patients diagnosed by transrectal MRI-targeted and systematic biopsies (namely "standard method"), treated by RP, between 2016 and 2021 were evaluated. Biopsy methods included MRI-targeted biopsy, side-specific systematic biopsies relative to index MRI lesion and combination of both. Number of MRI-targeted biopsy cores and positive cores needed per index MRI lesion were assessed. Multivariable analysis was performed to analyze predictive factors of upgrading using MRI targeted and ipsilateral systematic biopsies method. RESULTS: Overall, ISUP grade group accuracy varied among biopsy methods with upgrading rate of 35%, 49%, 27%, and 24% for MRI targeted, systematic, MRI targeted and ipsilateral systematic biopsies and standard methods, respectively (p < 0.001). A minimum of two positive MRI-targeted biopsies cores per index MRI lesion were required when testing MRI targeted and ipsilateral systematic biopsies method to reach equivalent accuracy compared to standard method. Omitting contralateral systematic biopsies spared an average of 5.9 cores per patient. At multivariable analysis, only the number of positive MRI-targeted biopsy cores per index MRI lesion was predictive of upgrading. CONCLUSION: MRI targeted and ipsilateral systematic biopsies allowed an accurate definition of ISUP grade group and appears to be an interesting alternative when compared with standard method, reducing total number of biopsy cores needed.

Expanding inclusion criteria for active surveillance in intermediate-risk prostate cancer: a machine learning approach.

PURPOSE: To develop new selection criteria for active surveillance (AS) in intermediate-risk (IR) prostate cancer (PCa) patients. METHODS: Retrospective study including patients from 14 referral centers who underwent pre-biopsy mpMRI, image-guided biopsies and radical prostatectomy. The cohort included biopsy-naive IR PCa patients who met the following inclusion criteria: Gleason Grade Group (GGG) 1-2, PSA < 20 ng/mL, and cT1-cT2 tumors. We relied on a recursive machine learning partitioning algorithm developed to predict adverse pathological features (i.e., ≥ pT3a and/or pN + and/or GGG ≥ 3). RESULTS: A total of 594 patients with IR PCa were included, of whom 220 (37%) had adverse features. PI-RADS score (weight:0.726), PSA density (weight:0.158), and clinical T stage (weight:0.116) were selected as the most informative risk factors to classify patients according to their risk of adverse features, leading to the creation of five risk clusters. The adverse feature rates for cluster #1 (PI-RADS ≤ 3 and PSA density < 0.15), cluster #2 (PI-RADS 4 and PSA density < 0.15), cluster #3 (PI-RADS 1-4 and PSA density ≥ 0.15), cluster #4 (normal DRE and PI-RADS 5), and cluster #5 (abnormal DRE and PI-RADS 5) were 11.8, 27.9, 37.3, 42.7, and 65.1%, respectively. Compared with the current inclusion criteria, extending the AS criteria to clusters #1 + #2 or #1 + #2 + #3 would increase the number of eligible patients (+ 60 and + 253%, respectively) without increasing the risk of adverse pathological features. CONCLUSIONS: The newly developed model has the potential to expand the number of patients eligible for AS without compromising oncologic outcomes. Prospective validation is warranted.

[Urology: what's new in 2022]. / Urologie : ce qui a changé en 2022.

Over the last year, urologic progress remains driven by evolutions in oncological and functionnal urology. Prostate cancer imaging modalities are improving, as well as treatment options for advanced stages. Kidney and bladder cancer are benefiting from new treatment modalities including immunotherapy, whose role in the peri-operative setting is still unclear. Surveillance startegies for testicular cancer has been greatly simplified, for the benefit of the patients. In functional urology, a new therapeutic class in now available for the treatment of overactive bladder. Mutliples alternatives to transurethral resection are emerging in the surgical treatment of benign prostatic hypertrophy, whose expected benefits will need to be validated by long-term studies.

Les progrès de cette année sont marqués par des avancées en uro-oncologie et urologie fonctionnelle. La prise en charge du cancer de la prostate s'améliore tant dans la qualité de son diagnostic que dans le traitement des stades avancés. Les cancers du rein et de la vessie bénéficient de nouvelles options de traitement incluant l'immunothérapie, qui cherche encore sa place en périopératoire. Quant au cancer des testicules, il a vu sa surveillance grandement simplifiée au bénéfice des patients. En urologie fonctionnelle, une nouvelle classe thérapeutique est désormais disponible pour le traitement de l'hyperactivité vésicale et de multiples alternatives à la résection endoscopique de la prostate émergent dans le traitement chirurgical de l'hypertrophie bénigne de la prostate. Il faudra toutefois valider les avantages espérés par des études à long terme.

[Urology in the era of immersive technologies]. / L'urologie à l'ère des technologies immersives.

Immersive technologies (IT) are undergoing significant expansion in medicine. Among them, virtual augmented or mixed reality offers an interactive or immersive virtual environments to its users, opening a wide array of applications in modern medicine. IT seem particularly interesting in urology, offering a real-time overlay of diagnostic information onto the surgical field and helping visualizing complex anatomical structures, potentially enhancing intraoperative decision-making. Training through realistic simulations with IT represent an excellent and secure tool for trainees and urologists. Finally, patient's comfort during procedures under local anesthesia could be optimized with the use of IT. Further studies are awaited to validate their effectiveness and evaluate their costs to permit their integration into routine medical practice.

Les technologies immersives (TI) connaissent une expansion significative dans le domaine médical. Parmi elles, la réalité virtuelle, augmentée ou mixte offre un environnement virtuel interactif ou immersif à ses utilisateurs, avec une vaste palette d'applications dans la médecine moderne. En urologie, elles sont particulièrement intéressantes, notamment dans la superposition d'informations diagnostiques en temps réel sur le champ opératoire ou la visualisation de structures anatomiques complexes, ce qui peut améliorer la prise de décision peropératoire. La formation à l'aide de simulations réalistes représente un excellent outil pour l'urologue. Enfin, le confort du patient lors des gestes techniques sous anesthésie locale peut être optimisé à l'aide des TI. Des études ultérieures sont nécessaires pour valider leur efficacité et évaluer leur coût avant une intégration dans la pratique médicale courante.

Urodynamic assessment and quality of life outcomes of robot-assisted totally intracorporeal radical cystectomy and orthotopic neobladder for bladder cancer: a preliminary study.

PURPOSE: Few data exist regarding the functional outcomes of robot-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder. The aim of this study was to evaluate the urodynamic and functional outcomes in patients undergoing RARC and totally intracorporeal orthotopic neobladder for bladder cancer. METHODS: In this monocentric, observational study carried out between 2016 and 2020, consecutive patients undergoing RARC and intracorporeal orthotopic neobladder in the Department of Urology, Pitié-Salpêtrière Hospital, were included. Reconstruction was totally intracorporeal Y-shaped neobladder. Main outcomes were urodynamic findings 6 months post-surgery, continence and quality of life (QoL). Continence was defined by no pad or one safety pad. International Consultation on Incontinence Questionnaire (ICIQ), International Index of Erectile Function questionnaire (IIEF-5) and Bladder Cancer Index (BCI) scores were recorded. RESULTS: Fourteen male patients were included (median age: 64 years [IQR 54-67]. Median maximal neobladder cystometric capacity was 495 ml [IQR 410-606] and median compliance was 35.5 ml/cm H2O [IQR 28-62]. All patients had post-void residual volume < 30 ml, except for three (22%) who required clean intermittent-self catheterisation. Daytime continence was achieved in 10 patients (71%) and night-time continence in two (14.3%). Median ICIQ score was 7 [IQR 5-11]. Postoperative erectile function was present in 7% of patients (mean IIEF-5 = 5 [IQR 2-7]). Thirteen patients (93%) were satisfied with their choice of neobladder. CONCLUSION: RARC with totally intracorporeal orthotopic neobladder for bladder cancer provides satisfactory urodynamic results and good QoL. These findings should be confirmed long-term.

Neoadjuvant chemotherapy does not increase peri-operative morbidity following radical cystectomy.

OBJECTIVE: To determine whether use of neoadjuvant chemotherapy (NAC) is associated with a higher risk of post-operative complications following radical cystectomy (RC) for bladder cancer (BCa). MATERIALS AND METHODS: We retrospectively reviewed records of patients undergoing RC for non-metastatic urothelial BCa at 13 tertiary care centres from 2007-2019. Patients who received NAC ('NAC + RC' group) were compared with those who underwent upfront RC ('RC alone' group) for intra-operative variables, incidence of post-operative complications as per the Clavien-Dindo classification (CDC) and rates of re-admission and re-intervention. Multivariable logistic regression analysis was performed to determine predictors of CDC overall and CDC major (grade III-V) complications. We also analysed the trend of NAC utilization over the study period. RESULTS: Of the 3113 patients included, 968 (31.1%) received NAC while the remaining 2145 (68.9%) underwent upfront RC for BCa. There was no significant difference between the NAC + RC and RC alone groups with regards to 30-day CDC overall (53.2% vs 54.6%, p = 0.4) and CDC major (15.5% vs 16.5%, p = 0.6) complications. The two groups were comparable for the rate of surgical re-intervention (14.6% in each group) and re-hospitalization (19.6% in NAC + RC vs 17.9% in RC alone, p = 0.2%) at 90 days. On multivariable regression analysis, NAC use was not found to be a significant predictor of 90-day CDC overall (OR 1.02, CI 0.87-1.19, p = 0.7) and CDC major (OR 1.05, CI 0.87-1.26, p = 0.6) complications. We also observed that the rate of NAC utilization increased significantly (p < 0.001) from 11.1% in 2007 to 41.2% in 2019, reaching a maximum of 48.3% in 2018. CONCLUSION: This large multicentre analysis with a substantial rate of NAC utilization showed that NAC use does not lead to an increased risk of post-operative complications following RC for BCa. This calls for increasing NAC use to allow patients to avail of its proven oncologic benefit.

Substaging of pT1 Urothelial Bladder Carcinoma Predicts Tumor Progression and Overall Survival.

INTRODUCTION: Limitations in tumor staging and the heterogeneous natural evolution of pT1 urothelial bladder carcinoma (UBC) make the choice of treatment challenging. We evaluated if histopathological substaging (pT1a, pT1b, and pT1c) helps predict disease recurrence, progression, and overall survival following transurethral resection of the bladder (TURB). METHODS: We included 239 consecutive patients diagnosed with pT1 UBC at TURB in a single institution since 2001. Each sample was interpreted by our specialized uropathologists trained to subclassify pT1 stage. Three groups were distinguished according to the degree of invasion: T1a (up to the muscularis mucosae [MM]), T1b (into the MM), and T1c (beyond the MM). RESULTS: T1 substaging was possible in 217/239 (90%) patients. pT1a, b, and c occurred in 124 (57), 59 (27), and 34 (16%), respectively. The median follow-up was 3.1 years, with a cumulative recurrence rate of 52%, progression rate of 20%, and survival rate of 54%. Recurrence was not significantly associated with tumor substage (p = 0.61). However, the Kaplan-Meier survival analysis showed a significantly higher progression rate among T1b (31) and T1c (26%) tumors than T1a (13%) (log-rank test: p = 0.001) stages. In a multivariable model including gender, age, ASA score, smoking, tumor grade, and presence of carcinoma in situ, T1 substage was the single variable significantly associated with progression-free survival (HR 1.7, p = 0.005). Nineteen patients (9%) needed radical cystectomy; among them, 12/19 (63%) had an invasive tumor. Overall survival was significantly associated with tumor substaging (p = 0.001). CONCLUSION: Histopathological substaging of pT1 UBC is significantly associated with tumor progression and overall survival and therefore appears to be a useful prognostic tool to counsel patients about treatment options.

[Male contraception: what are the currently available options?] / Contraception masculine : quelles options actuellement disponibles ?

Male contraception plays a small role in global contraception. However, safe and effective means exist and are available with a low failure rate, such as vasectomy or to a lesser extent, condoms. Other so-called natural methods are used despite being less effective, such as periodic abstinence or withdrawal. Finally, new methods are currently being evaluated or developed, such as thermal contraception, hormonal and non-hormonal contraception. Although preliminary results are encouraging, the effectiveness of these methods remains variable and sometimes difficult to reproduce, and still requires controls and validation regarding their safety over long-term use.

La contraception masculine ne représente qu'une faible proportion de la contraception mondiale. Pourtant, des moyens sûrs et efficaces existent et sont disponibles avec un taux d'échec faible, comme la vasectomie ou, dans une moindre mesure, le préservatif. D'autres méthodes dites naturelles telles que l'abstinence périodique ou le retrait sont utilisées malgré leur efficacité moindre. Enfin, certaines méthodes sont en cours d'évaluation ou de développement comme les contraceptions thermique, hormonale et non hormonale. Bien que certains résultats préliminaires soient encourageants, l'efficacité de ces méthodes reste variable et parfois difficilement reproductible. Elle nécessite encore des contrôles et validations concernant leur sûreté pour une utilisation à long terme.

[Hyperbaric oxygen therapy for the treatment of radiation-induced cystitis]. / Oxygénothérapie hyperbare dans le traitement de la cystite radio-induite.

Radiation-induced cystitis (RIHC) is a late complication of pelvic radiation therapy defined by irritative lower urinary tract symptoms with recurrent and sometimes refractory hematuria. Conservative or endoscopic treatments are the first lines, but cystectomy in required in refractory cases. Hyperbaric oxygen therapy (HOT) has recently emerged in the management charts for recurrent and refractory hematuria. Thanks to its neoangiogenic and stem-cell stimulation properties, HOT achieves a complete resolution of hematuria in almost two third of patients and appears to be a good therapeutic alternative for this fragile population. However, its geographical availability is currently limited in Switzerland and its implementation can sometimes require long hospital stays.

La cystite radio-induite (CR) est une complication tardive de la radiothérapie pelvienne se présentant notamment sous forme de troubles mictionnels irritatifs ou de macrohématurie récidivante. Le traitement est initialement conservateur ou endoscopique mais peut, dans des cas réfractaires, aboutir à une cystectomie à visée hémostatique ou fonctionnelle. L'oxygénothérapie hyperbare (OHB) a récemment fait son apparition dans les diagrammes de prise en charge de la CR réfractaire. Grâce à ses propriétés néoangiogéniques et à la stimulation des cellules souches, elle permet une résolution complète de l'hématurie chez près de deux tiers des patients et semble être une alternative thérapeutique pour cette population fragile. Actuellement, sa disponibilité géographique reste toutefois limitée en Suisse et sa réalisation implique parfois de longues hospitalisations.

Timing and delay of radical prostatectomy do not lead to adverse oncologic outcomes: results from a large European cohort at the times of COVID-19 pandemic.

PURPOSE: The current COVID-19 pandemic is transforming our urologic practice and most urologic societies recommend to defer any surgical treatment for prostate cancer (PCa) patients. It is unclear whether a delay between diagnosis and surgical management (i.e., surgical delay) may have a detrimental effect on oncologic outcomes of PCa patients. The aim of the study was to assess the impact of surgical delay on oncologic outcomes. METHODS: Data of 926 men undergoing radical prostatectomy across Europe for intermediate and high-risk PCa according to EAU classification were identified. Multivariable analysis using binary logistic regression and Cox proportional hazard model tested association between surgical delay and upgrading on final pathology, lymph-node invasion (LNI), pathological locally advanced disease (pT3-4 and/or pN1), need for adjuvant therapy, and biochemical recurrence. Kaplan-Meier analysis was used to estimate BCR-free survival after surgery as a function of surgical delay using a 3 month cut-off. RESULTS: Median follow-up and surgical delay were 26 months (IQR 10-40) and 3 months (IQR 2-5), respectively. We did not find any significant association between surgical delay and oncologic outcomes when adjusted to pre- and post-operative variables. The lack of such association was observed across EAU risk categories. CONCLUSION: Delay of several months did not appear to adversely impact oncologic results for intermediate and high-risk PCa, and support an attitude of deferring surgery in line with the current recommendation of urologic societies.

[Urology]. / Urologie.

Over the last year, urologic progress remains driven by the quick technologic evolution, with a focus on Laser and robotics. The latter appears to potentially contribute to the drift towards ambulatory surgery, in particular for distinct sub-populations harbouring kidney or prostate cancer. The Da Vinci robot appears also to increase the drive towards minimally invasiveness with respect to female incontinence and the laparoscopic placement of an artificial urethral sphincter. Last, a new Laser is in the midst to offer its polyvalence in terms of endoscopic stone surgery, so as that of benign prostatic hyperplasia. Facing this technologic pressure, it remains of utmost importance to scrupulously validate on a short so as longer-term basis the true hoped advantages.

Les progrès urologiques de cette dernière année restent, comme l'année précédente, sous le sceau des rapides avancées technologiques, notamment celles du laser et de la robotique. Cette dernière va contribuer à faire évoluer la chirurgie ambulatoire, notamment pour certaines interventions et sous-populations de malades porteurs d'un cancer du rein ou de la prostate. Elle est également en train d'exercer une nouvelle percée dans le domaine de l'incontinence féminine, en ce qui concerne la mise en place du sphincter urétral artificiel. Enfin, un nouveau laser est sur le point d'offrir sa polyvalence en termes de chirurgie endoscopique lithiasique ainsi que celle de l'hypertrophie bénigne de la prostate. Face à cette pression technologique, il faut rigoureusement valider à court et moyen termes les véritables avantages espérés.