Minimally invasive surgical therapies (MISTs) for lower urinary tract symptoms (LUTS): promise or panacea?

ABSTRACT: The increasing importance of treatment of lower urinary tract symptoms (LUTS), while avoiding side effects and maintaining sexual function, has allowed for the development of minimally invasive surgical therapies (MISTs). Recently, the European Association of Urology guidelines reported a paradigm shift from the management of benign prostatic hyperplasia (BPH) to the management of nonneurogenic male LUTS. The aim of the present review was to evaluate the efficacy and safety of the most commonly used MISTs: ablative techniques such as aquablation, prostatic artery embolization, water vapor energy, and transperineal prostate laser ablation, and nonablative techniques such as prostatic urethral lift and temporarily implanted nitinol device (iTIND). MISTs are becoming a new promise, even if clinical trials with longer follow-up are still lacking. Most of them are still under investigation and, to date, only a few options have been given as a recommendation for use. They cannot be considered as standard of care and are not suitable for all patients. Advantages and disadvantages should be underlined, without forgetting our objective: treatment of LUTS and re-treatment avoidance.

Which factors can influence post-operative renal function preservation after nephron-sparing surgery for kidney cancer: a critical review.

Introduction: The aim of this article was to compare different surgical approaches to perform nephron-sparing surgery (NSS) in terms of preservation of renal function. Material and methods: We critically reviewed the literature from January 2000 to December 2020 including studies comparing different surgical techniques. Results: A total of 51 studies met the inclusion criteria. Functional outcomes were evalutated in terms of percentual change of estimated glomerular filtration rate (eGFR) and impaired renal function (IRF) on scintigraphy. In cases with a mean age <60 years, the mean decrease in eGFR after NSS was 11.7% and that of IRF 10.0%, whereas higher changes were found in cases with a mean age ≥60 years. For open NSS, the mean eGFR and IRF changes were 15.3% and 21.1%, respectively; using the laparoscopic approach, the mean percentual eGFR and IRF changes were 13.9% and 11.1%, respectively; in robotic cases, the mean eGFR and IRF changes were 10.8% and 13.1%, respectively. In cases performed with global ischemia, the mean eGFR and IRF changes were 12.7% and 15.1%, respectively. Similar results were found distinguishing ischemia time ≤20 and >20 minutes, whereas using the off-clamp technique the mean decreases in eGFR and IRF were only 4.2% and 6%, respectively. Conclusions: Patients' age, tumor size, off-clamp technique, and robot-assisted approach were significant independent predictive factors able to influence renal function changes after NSS. A lower reduction of eGFR and IRF after NSS was reported in patients aged <60 years, submitted to a robot-assisted procedure, and using selective and cold ischemia <20 minutes or an off-clamp technique.

A prospective observational study on oral administration of Ellagic Acid and Annona Muricata in patients affected by non-muscle invasive bladder cancer not undergoing maintenance after 6-week intravesical prophylaxis.

INTRODUCTION: BCG and MMC shortage and Covid-19 pandemic, more recently, limit accessibility to maintenance regimen in intravesical prophylaxis against recurrence of non-muscle invasive bladder cancer (NMIBC). Ellagic acid (EA) and Annona muricata (AM) exert antitumor activity against different human tumours. An observational prospective study on the prophylactic effect of oral administration of EA+AM in patients avoiding maintenance regimen is presented. MATERIALS AND METHODS: Patients affected by NMIBC and not undergoing maintenance after a 6-week course of intravesical prophylaxis with MMC or BCG were entered. Tis and very high-risk tumours were excluded. After informed consent, the patients were subdivided in relation to the oral assumption or not of EA (100 mg) plus AM (100 mg), daily for 6 months. All patients were submitted to 3-month cytology and cystoscopy. RESULTS: 162 (90%) of 180 entered patients are evaluable, 90 and 72 receiving or not EA+AM. No difference emerged in patients' characteristics between the two groups. BCG was given in 86 (54%) and chemotherapy in 74 (46%) patients. The recurrence free rate at 3, 6 and 12 months in patients assuming or not EA was 96.5% versus 84.6% (p = 0.003), 85.4% versus 64.8% (p = 0.005) and 74.2% versus 60.6% (p = 0.246), respectively. The recurrence free survival at 12 months in patients assuming or not EA was 63.0% versus 34.5% (p < 0.0001). DISCUSSION AND CONCLUSIONS: Our study suffers several limits: not randomized trial although prospective, limited number of patients and short follow-up, nevertheless it shows the prophylactic effect of oral EA+AM in absence of maintenance after intravesical chemotherapy or immunotherapy induction.

Prospective comparative trial on nerve-sparing radical prostatectomy using a robot-assisted versus laparoscopic technique: expectation versus satisfaction and impact on surgical margins.

INTRODUCTION: The aim of this study was to analyze whether differences exist in a population selected for a nerve-sparing (NS) procedure between robot-assisted (RARP) and laparoscopic radical prostatectomy (LRP), and whether they can have an impact on surgical margins (SM) status. MATERIAL AND METHODS: This is a single center prospective comparative trial on prostate cancer patients submitted to a RARP-NS or LRP-NS. A self-administered questionnaire on expectations before surgery, and level of satisfaction after surgery was used. RESULTS: A total of 134 cases were included in our analysis. A higher percentage of capsular bulging was found in the RARP group, compared to the LRP group (p = 0.077). At biopsy, the percentage of positive cores and multifocality were higher in the RARP group (p = 0.005). Positive SM (SM+) rate was higher in the RARP, than in LRP group (p = 0.046). On univariable analysis, the risk of SM+ increased 1.95 times using RARP when compared with LRP. On multivariable analysis, the surgical approach did not maintain a significant predictive role in terms of risk for SM+. Expectations before surgery were mainly focused on oncological radicality, however in the RARP group a higher percentage of cases focused on sexual function recovery. Satisfaction after surgery was lower in the RARP than in the LRP group. CONCLUSIONS: Comparing LRP-NS with RARP-NS in a high-volume single center, the expectation/satisfaction ratio is in favor of LRP. Worse oncologic preoperative characteristics in the RARP group may influence the higher incidence of SM+. However, the surgical approach does not result as a significant and independent factor able to influence SM positivity.