Flexible fibre optic vs digital ureteroscopy and enhanced vs unenhanced imaging for diagnosis and treatment of upper tract urothelial carcinoma (UTUC): results from the Clinical Research Office of the Endourology Society (CROES)-UTUC registry.

OBJECTIVES: To compare the oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) undergoing kidney-sparing surgery (KSS) with fibre-optic (FO) vs digital (D) ureteroscopy (URS). To evaluate the oncological impact of image-enhancement technologies such as narrow-band imaging (NBI) and Image1-S in patients with UTUC. PATIENTS AND METHODS: The Clinical Research Office of the Endourology Society (CROES)-UTUC registry is an international, multicentre, cohort study prospectively collecting data on patients with UTUC. Patients undergoing flexible FO- or D-URS for diagnostic or diagnostic and treatment purposes were included. Differences between groups in terms of overall survival (OS) and disease-free survival (DFS) were evaluated. RESULTS: The CROES registry included 2380 patients from 101 centres and 37 countries, of whom 401 patients underwent URS (FO-URS 186 and D-URS 215). FO-URS were performed more frequently for diagnostic purposes, while D-URS was peformed when a combined diagnostic and treatment strategy was planned. Intra- and postoperative complications did not differ between the groups. The 5-year OS and DFS rates were 91.5% and 66.4%, respectively. The mean OS was 42 months for patients receiving FO-URS and 39 months for those undergoing D-URS (P = 0.9); the mean DFS was 28 months in the FO-URS group and 21 months in the D-URS group (P < 0.001). In patients who received URS with treatment purposes, there were no differences in OS (P = 0.9) and DFS (P = 0.7). NBI and Image1-S technologies did not improve OS or DFS over D-URS. CONCLUSIONS: D-URS did not provide any oncological advantage over FO-URS. Similarly, no differences in terms of OS and DFS were found when image-enhancement technologies were compared to D-URS. These findings underline the importance of surgeon skills and experience, and reinforce the need for the centralisation of UTUC care.

Preservation of antegrade ejaculation after surgical relief of benign prostatic obstruction is a valid endpoint.

PURPOSE: To review the current data on retrograde ejaculation (RE) and ejaculatory dysfunction (EjD) after endoscopic and minimally invasive surgical treatment of benign prostatic obstruction (BPO) and, their perceived impact in the quality of life (QoL) and sexual life of patients and their partners. METHODS: Narrative review of systematic reviews (SR) assessing comparative rates of RE, EjD or erectile dysfunction (EF) was carried out. Relevant articles on the prevalence of RE, EjD or EF and on their impact in the QoL or sexual life of patients and partners were manually selected based on relevance. RESULTS: Twelve SRs reporting on comparisons of different endoscopic/minimally invasive treatments of BPO were found. Data on outcomes varied widely. Overall, after conventional TURP or laser techniques 42-75% of patients present RE. Prostatic incision and ablative procedures present lowest rates of de novo RE or EjD whereas laser adenomectomy and ejaculation preservation procedures preserve antegrade ejaculation in 46-68% of patients. EjDs is associated to LUTS and present in 10% of sexualy active men before intervention. It modulates the QoL and sexual life of the couple. In spite of the scarce literature assessing patient's and partner's perception of postoperative EjD, it strongly suggests that both parties value the maintenance of the ejaculatory function. CONCLUSION: Ejaculation-preserving techniques and minimally invasive techniques successfully prevent BPO treatment-induced RE or EjD in 70-100% of the cases. While this is appealing to patients and spouses, technique selection and treatment durability are issues to be discussed with the couple.

Systematic review and cumulative analysis of the managements for proximal impacted ureteral stones.

PURPOSE: To compare the efficacy and safety of different treatment options for the management of proximal impacted ureteral stones (PIUS). METHODS: A systematic literature search using Pubmed, Medline, Embase and Cochrane Library was conducted to obtain studies concerning different managements for PIUS up to Jan 2018. Summary odds ratios (ORs), standard mean differences (SMDs) or weighted mean differences with their 95% confidence intervals (CIs) were calculated to compare the efficacy and safety of all included treatment methods, registered in PROSPERO under number CRD42018092745. RESULTS: A total of 15 comparative studies with 1780 patients were included. Meta-analyses of final stone-free rate (SFR) favored percutaneous nephrolithotomy (PCNL) over ureteroscopic lithotripsy (URL) (OR 10.35; 95% CI 5.26-20.35; P < 0.00001), laparoscopic ureterolithotomy over URL (OR 0.11; 95% CI 0.05-0.25; P < 0.00001) and URL over extracorporeal shockwave lithotripsy (OR 0.47; 95% CI 0.28-0.77; P = 0.003). As to complications, PCNL had a significantly higher blood transfusion rate (OR 7.47; 95% CI 1.3-42.85; P = 0.02) and a lower ureteral injury rate (OR 0.15; 95% CI 0.04-0.52; P = 0.003) compared with URL. It also shared a significantly lower stone-retropulsion rate (OR 0.03; 95% CI 0.01-0.15; P < 0.0001) and higher treatment costs (SMD = 2.71; 95% CI 0.71-4.70; P = 0.008) than URL. CONCLUSIONS: Our meta-analysis suggested that PCNL might be the best option for PIUS owing to its higher successful rate. Complications such as hemorrhage could be decreased by the application on mini-PCNL.

Comparison of retropubic, laparoscopic and robotic radical prostatectomy: who is the winner?

PURPOSE: This study is a systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes and the cost of open retropubic radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALP). METHODS: Summary data was abstracted from 104 original research articles representing 227,400 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE and the Cochrane Library were reviewed in December 2016. A total of 104 publications were selected for inclusion. The primary outcomes were positive surgical margin (PSM) and major complication rate according to Clavien classifications. Secondary outcomes were operative time, length of hospital stay, estimated blood loss, transfusions, conversions, rate of post-operative erectile dysfunction and incontinence and total cost of procedure. RESULTS: ORP had a significantly higher rate than RALP for PSM (OR: 1.18; 95% CI 1.05-1.32; p = 0.004), but the rate of PSM was not significantly different between ORP versus LRP (OR: 1.37; 95% CI 0.88-2.14; p = 0.17) and RALP versus LRP (OR: 0.83; 95% CI 0.40-1.72; p = 0.62). The major Clavien complication rate was significantly different between ORP and RALP (OR: 2.14; 95% CI 1.24-3.68; p = 0.006). Estimated blood loss, transfusions and length of hospital stay were low for RALP, moderate for LRP and high for ORP. The rate of erectile dysfunction (OR: 2.58; 95% CI 1.77-3.75; p < 0.001) and incontinence (OR: 3.57; 95% CI 2.28-5.58; p < 0.001) were significantly lower after RALP than LRP and equivalent for other comparisons. Total cost was highest for RALP, followed by LRP and ORP. CONCLUSIONS: For PSM and peri- and post-operative complications, RALP showed better results than ORP and LRP. In the context of the biases between the studies, one should interpret the results with caution.