Systematic review comparing uretero-enteric stricture rates between open cystectomy with ileal conduit, robotic cystectomy with extra-corporeal ileal conduit and robotic cystectomy with intra corporeal ileal conduit formation.

Cystectomy is the gold standard treatment for muscle invasive bladder cancer. Robotic cystectomy has become increasingly popular owing to quicker post- operative recovery, less blood loss and less post-operative pain. Urinary diversion is increasingly being performed with an intracorporeal technique. Uretero-enteric strictures (UES) cause significant morbidity for patients. UES for open cystectomy is 3-10%, but the range is much wider (0-25%) for robotic surgery. We aim to perform systematic review for studies comparing all 3 techniques, to assess for ureteric stricture rates. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (Page et al. in BMJ 29, 2021). PubMed, Scopus and Embase databases were searched for the period January 2003 to June 2023 inclusive for relevant publications.The primary outcome was to identify ureteric stricture rates for studies comparing open cystectomy and urinary diversion, robotic cystectomy with extracorporeal urinary diversion (ECUD) and robotic cystectomy with intracorporeal urinary diversion (ICUD). Three studies were identified and included 2185 patients in total. The open operation had the lowest stricture rate (9.6%), compared to ECUD (12.4%) and ICUD (15%). ICUD had the longest time to stricture (7.55 months), ECUD (4.85 months) and the open operation (4.75 months). Open operation had the shortest operating time. The Bricker anastomoses was the most popular technique. Open surgery has the lowest rates of UES compared to both robotic operations. There is a learning curve involved with performing robotic cystectomy and urinary diversion, this may need to be considered to decide whether the technique is comparable with open cystectomy UES rates. Further research, including Randomised Control Trials (RCT), needs to be undertaken to determine the best surgical option for patients to minimise risks of UES.

Management of urolithiasis in pregnancy.

Urolithiasis is the most common cause of nonobstetric abdominal pain, resulting in 1.7 admissions per 1000 deliveries. Urolithiasis most commonly occurs in the second and third trimesters, with an incidence between 1:125 and 1:2000. Acute urinary system obstructions are challenging to manage in obstetric patients because they contribute to physiological and anatomical changes that result in pathological outcomes. The restricted use of computed tomography in diagnosing and managing urolithiasis is particularly challenging. In addition, a prompt diagnosis is required because the presence of renal calculi during pregnancy increases the risk of fulminating sepsis and preterm delivery. Affected pregnancies are conservatively managed; however, 1 in 4 requires surgical intervention. Indications for surgical interventions are complex and range from nephrostomy insertion to empirical stent placement or ureteroscopy. Therefore, a multidisciplinary approach is required to optimize patient care. The diagnosis and management of urolithiasis in pregnancy are complex. We reviewed the role, safety, advantages and disadvantages of diagnostic tests and treatment used to manage acute urinary obstructions in pregnancy.

Modern methods in managing urachal adenocarcinoma.

Objectives: We sought to evaluate modern diagnostic and treatment options for urachal adenocarcinoma (UAC) and to provide clarity regarding the available options and their outcomes for this poorly understood yet damaging disease. Material and methods: We conducted a systematic literature search in PubMed and Medline focusing on updated management of UAC. Results: Surgical intervention continues to be the mainstay of treatment for localized UAC. However, with the increased availability of molecular and genetic profiling, chemotherapy has consistently demonstrated promising response rates and survival outcomes, especially for a disease that commonly presents in a metastatic stage. The role of checkpoint inhibitors remains under investigation. Cross-sectional imaging is vital during postoperative surveillance. However, there may also be a role for the adoption of cystoscopy to detect bladder recurrence. Conclusions: Although the importance of surgical resection remains unchanged, improved survival outcomes with chemotherapy have been found in small retrospective studies. Randomized trial data are required to further assess the influence of systemic treatment as a primary or adjuvant therapy. Moreover, a stringent follow-up regimen incorporating evaluation for distant and local recurrence of UAC must be evaluated and adopted.

Diagnostic and cost-effectiveness of axial skeleton MRI in staging high-risk prostate cancer.

Introduction: Current literature suggests that axial skeleton magnetic resonance imaging (AS-MRI) is more sensitive than Tc 99m bone scintigraphy (BS) for detecting bone metastases (BM) in high-risk prostate cancer (PCa). However, BS is still widely performed. Its diagnostic accuracy has been studied; however, its feasibility and cost implications are yet to be examined. Methods: We reviewed all patients with high risk PCa undergoing AS-MRI over a 5-year period. AS-MRI was performed on patients with histologically confirmed PCa and either PSA > 20 ng/ml, Gleason ≥8, or TNM Stage ≥T3 or N1 disease. All AS-MRI studies were obtained using a 1.5-T AchievaPhilips™MRI scanner. We compared the AS-MRI positivity and equivocal rate with that of BS. Data were analysed according to Gleason score, T-stage and PSA. Multivariate logistic regression analyses were used to quantify the strength of association between positive scans and clinical variables. Feasibility and burden of expenditure was also evaluated. Results: Five hundred three patients with a median age of 72 and a mean PSA of 34.8 ng/ml were analysed. Eighty-eight patients (17.5%) were positive for BM on AS-MRI (mean PSA 99 [95% CI 69.1-129.9]). Comparatively 409 patients (81.3%) were negative for BM on AS-MRI (mean PSA 24.7 (95% CI [21.7-27.7]) (p = 0.007); 1.2% (n = 6) of patients had equivocal results (mean PSA 33.4 [95% CI 10.5-56.3]). There was no significant difference in age (p = 0.122) between this group and patients with a positive scan, but there was a significant difference in PSA (p = 0.028), T stage (p = 0.006) and Gleason score (p = 0.023). In comparison with BS, AS-MRI detection rate was equivalent or higher compared with the literature. Based on NHS tariff calculations, there would be a minimum cost saving of £8406.89. All patients underwent AS-MRI within 14 days. Conclusion: The use of AS-MRI to stage BM in high-risk PCa is both feasible and results in a reduced burden of expenditure.

Lower vs standard pressure pneumoperitoneum in robotic-assisted radical prostatectomy: a systematic review and meta-analysis.

Robotic-assisted laparoscopic radical prostatectomy (RARP) has been traditionally performed at a pneumoperitoneum insufflation pressure of 12-15 mmHg. This meta-analysis and systematic review aims to assess the current evidence comparing lower to standard pressure pneumoperitoneum in RARP. Systematic searches of MEDLINE, COCHRANE, SCOPUS and EMBASE were performed to identify articles published up until November 2021 comparing lower pressure with standard pressure pneumoperitoneum in RARP. Standard pressure was defined as > 12 mmHg and lower pressure ≤ 12 mmHg. Estimated blood loss, length of operation, length of hospital stay, post-operative ileus, 30-day readmissions, Clavien-Dindo complications and rate of positive surgical margins were extracted as endpoints of interest. Our searches identified 165 abstracts of which 4 articles with 1319 patients were eligible. Cumulative analysis demonstrated reduced length of stay when a lower pressure was used: WMD - 0.23 (- 0.45 to - 0.02) days (p = 0.03) as well as a reduced rate of post-operative ileus: OR 0.41 (0.22 to 0.77) (p = 0.006). There was no significant increase in length of operation WMD - 1.79 (- 15.96 to 12.38) (p = 0.8), estimated blood loss WMD - 2.89 (- 29.41 to 23.62) (p = 0.83), 30-day readmissions or positive surgical margins OR 1.04 (0.78 to 1.38) (p = 0.81) and RD - 0.01 (- 0.04 to 0.01) (p = 0.3) when using a lower pressure. We have demonstrated reduced length of stay and rates of post-operative ileus, when performing RARP at a lower pressure without a significant increase in length of operation, estimated blood loss, positive surgical margins or complications. The recommendation to use lower pressure pneumoperitoneum is moderate to weak and more randomised control trials are required to validate these results.

The role of imaging in immunoglobulin G4-related disease of the upper urinary tract.

Background: Immunoglobulin G4-related disease remains a modern, relatively unknown field in the urological world. An increasing number of cases require urological input, often with invasive diagnostics and aggressive medical treatment first-line. Given this, we sought to evaluate modern radiological options of disease affecting the upper urinary tract, to provide clarity and reduce diagnostic burden and delay in this poorly understood yet potentially debilitating disease process. Summary: We conducted a systematic literature search including PubMed and Medline, focusing on immunoglobulin G4-related disease affecting the upper urinary tract, before reviewing articles assessing different radiological modalities in diagnosis. Consistent computed tomography findings have been demonstrated in the literature and contributed to recent breakthroughs in classification criteria, however invasive biopsy remains a mainstay in work-up, given the difficulties in comparing against malignancy. Early work in positron-emission tomography and magnetic resonance imaging has shown promise in radiologically distinguishing from other differentials, especially diffusion-weighted imaging showing high sensitivity levels, but not yet enough to formulate protocols and cause histological investigation to be redundant. Key messages: Our article has highlighted repeated findings in the literature of computed tomography appearances of IgG4-RD in the upper urinary tract, however invasive work-up remains a mainstay given the overlap with malignancy. Prospective, comparative studies into magnetic resonance imaging and positron-emission tomography are now required, given their early results, to improve consistency in reporting and reduce patient burden when investigating this benign, yet debilitating disease process.

Single tertiary cancer center experience on the management of pT3b prostate cancer after robotic-assisted laparoscopic prostatectomy.

Background: Pathological involvement of the seminal vesicle poses a treatment dilemma following robotic prostatectomy. Margin status plays an important role in deciding further management. A wide range of treatment options are available, including active monitoring, adjuvant radiotherapy, salvage radiotherapy, and occasionally androgen deprivation therapy. Patients undergoing postoperative radiotherapy tend to have higher risk of urinary and bowel morbidities. The recent RADICALS-RT concluded that adjuvant radiotherapy did not have any benefit compared with salvage radiotherapy. We aim to audit the incidence, margin status, and management of T3b cancer cases at our center. Materials and methods: A retrospective analysis was conducted of all patients diagnosed with pathological T3b (pT3b) prostate cancer following robotic-assisted laparoscopic prostatectomy from January 2012 to July 2020. Preoperative parameters analyzed included prostate-specific antigen (PSA), T stage, and age. A chi-square test and 2-tailed t test were used to determine the relationship between categorical and continuous variables, respectively. Kaplan-Meier survival curves were generated to assess overall survival in patients with pT3b prostate cancer and used to compare unadjusted progression-free survival among those who underwent adjuvant and salvage radiotherapy. Results: A total of 83 (5%) of 1665 patients who underwent robotic prostatectomy were diagnosed with pT3b prostate cancer between January 2012 and July 2020. Among these, 36 patients (44%) did not receive any radiotherapy during follow-up, compared with 26 patients (31%) who received adjuvant radiotherapy and 21 (25%) who received salvage radiotherapy. The median age of our cohort was 64 (SD, 6.4) years. Mean PSA at presentation was 12.7 µg/L. Positive margins were seen in 36 patients (43%); however, there was no statistically significant difference between treatment groups (p = 0.49). The median overall survival was 96%. There was no significant difference between the adjuvant and salvage groups in terms of biochemical progression-free survival (p = 0.66). Five-year biochemical progression-free survival was 94% for those in the adjuvant radiotherapy group and 97% for those in the salvage radiotherapy group. Conclusions: Our audit corroborates with the recently concluded RADICALS-RT study, although we had fewer patients with positive margins. Radiotherapy can be avoided in patients with T3b prostate cancer, even if margin is positive, until there is definitive evidence of PSA recurrence. In keeping with the conclusion of RADICALS-RT, salvage radiotherapy may be preferable to adjuvant radiotherapy.

Secondary neoplasms of the urinary bladder-clinical management and oncological outcomes.

BACKGROUND: Secondary neoplasms of the bladder account for 4.5% of all bladder neoplasms however there is limited literature reporting management and survival. This is the largest single centre series presented in current literature with long term oncological follow up. METHODS: This is a single institutional, retrospective cohort study of patients with a histological diagnosis of a secondary bladder neoplasm from January 2007 to December 2017 (n=40). Prognostic variables examined included age at diagnosis, histology, disease free survival and treatment. Kaplan-Meier analysis was used to calculate survival. We used multiple regression analysis to identify the most significant treatments for each population group in terms of their survival. RESULTS: Twenty-one patients were male (53%) with a median age of 68 and 19 were female (47%) with a median age of 64. The most common secondary neoplasms and their median survival were prostate [12 patients (30%), 446 days], colorectal [9 patients (23%), 403 days], ovarian [5 patients (13%), 369 days], cervical [4 patients (10%), 148 days], breast [3 patients (8%), 241 days], lymphoma [3 patients (8%), 145 days], gastric [2 patients (5%), 66 days], and renal [2 patients (5%), 854 days]. Those receiving treatment following a secondary diagnosis demonstrated statistical significance in survival for colorectal (surgery P=0.013), prostate (radiotherapy P=0.0012 and hormonal therapy P=0.004) and ovarian cancer (chemotherapy P=0.00002). CONCLUSIONS: Prognosis and treatment depends upon the primary neoplasm. There is some survival benefit in well selected patients receiving treatment following a diagnosis of a bladder secondary.

Selective transperineal prostate biopsy for fluoroquinolone-resistance patients reduces sepsis and cost.

BACKGROUND: Urosepsis is a recognized complication of transrectal ultrasound-guided prostate biopsy (TRUS-Bx). Pre-biopsy rectal swabs have been used to identify patients with microorganisms in the rectal flora resistant to the conventionally used empirical prophylaxis. The transperineal route of biopsy (TP-Bx) has a lower complication risk but comes at an increased cost. MATERIALS AND METHODS: Retrospective cohort study including patients undergoing prostate biopsies between October/2015 and April/2018. The intervention cohort, a rectal swab was performed, the result of which dictated the biopsy route; TRUS-Bx against TP-Bx. TP-Bx for patients with fluoroquinolone resistance or extended-spectrum ß-lactamase. The control cohort underwent TRUS without a rectal swab receiving empirical antibiotics-oral ciprofloxacin and intravenous gentamicin. RESULTS: Total 1000 patients were included in which 500 underwent a swab, 14 (2.8%) developed post-TRUS biopsy infective complications with 3 having positive bacteremia (0.6%); 500 had no swab, 47 (9.4%) developed post-TRUS biopsy infective complications with 22 (4.4%, p < 0.05) having positive bacteremia. Three patients (0.6%) of patients who underwent swab developed urinary tract infection symptoms whilst 12 (2.4%) had urinary tract infection in the control group. In those patients that underwent a swab, 14 required hospitalization with mean length of stay of 2.5 days versus 43 patients of the control with 3.6 days. Cost analysis concluded savings of this strategy was £18,711. CONCLUSIONS: We have demonstrated a protocol that reserves template biopsies for higher risk patients and can significantly reduce sepsis and other infectious complication rates whilst also proving to be a cost-efficient strategy. We recommend that units not utilizing rectal swabs to uncover the fluoroquinolone resistance rate by introducing them. We advocate units that already utilize rectal swabs, to introduce transperineal biopsy for their higher risk patients.

Radical Cystectomy in England from 2013 to 2019 on 12,644 patients: An analysis of national trends and comparison of surgical approaches using Hospital Episode Statistics data.

Introduction: We evaluate the data of 12,644 Radical Cystectomies in England (Open, Robotic and Laparoscopic) with trends in the adaption of techniques and post-operative complications. Methods: This analysis utilised national Hospital Episode Statistics (HES) from NHS England. Results: There was a statistically significant increase (P < .001) in the number of Robotic assisted radical cystectomies from 10.8% in 2013-2014 and 39.5% in 2018-2019.The average LOS reduced from 12.3 to 10.8 days for RARC from 2013 to 2019 similarly the LOS reduced from 16.2 to 14.3 for ORC. The rate of sepsis (0-90 days) did rise from 5% to 14.5% between 2013-2014 and 2017-2018 for the entire cohort (P < .001). Acute renal failure (ARF) increased over the years from 9.5% to 17% (P < .001). The rate for fever, UTI, critical care activity and ARF were higher for ORC than RARC (P < .001).The comparison of all episodes within 90 days for conduit versus non-conduit diversions showed significantly higher rates of sepsis, infections, UTI and fever in non-conduit group .Overall complications were significantly higher in non-conduit group throughout the duration except was year 2016-17(P < .001).The robotic approach has increased in last 5 years with nearly 40% of the cystectomies now being robotically in 2018-19 from the initial percentage of 10.8% in 2013-14. Conclusion: This evaluation of the HES data from NHS England for 12,644 RC confirms an increase in the adoption of Robotic Cystectomy. Our data confirms the need to develop strategies with enhanced recovery protocols and post-operative close monitoring following Radical Cystectomy in order to reduce post-operative complications.

A Retrospective Study of Immunotherapy Treatment with Uro-Vaxom (OM-89®) for Prophylaxis of Recurrent Urinary Tract Infections.

OBJECTIVES: To present our experience with the long-term preventive effect of immunotherapy with Uro-Vaxom® on recurrent urinary tract infections (UTI) in adult patients. MATERIALS AND METHODS: Retrospective analysis of 79 patients with recurrent UTI treated with Uro-Vaxom. Recurrent UTIs were defined as ≥ 2 infections in 6 months or ≥ 3 in 12 months. Patients received a 6 mg Uro-Vaxom capsule daily for 90 days followed by discontinuation for 3 months and then administration for the first 10 days of subsequent months 7, 8 and 9 as a 'booster' regime. The primary outcome measure was the number of UTIs encountered in the 12 months pre-treatment compared to 12 months post-treatment. RESULTS: There was a significant decrease in the mean number of UTIs in the year following initiation of Uro-Vaxom® compared to the year preceding administration 3.14 versus 1.53 (p < 0.05) respectively. CONCLUSION: Uro-Vaxom represents a safe and effective treatment option for prophylaxis of recurrent UTIs. In the UK, Uro-Vaxom is currently unlicensed. This study adds to a growing body of evidence in favor of non-antibiotic immune-prophylaxis for recurrent UTI.

The clinical and financial implications of a decade of prostate biopsies in the NHS: analysis of Hospital Episode Statistics data 2008-2019.

OBJECTIVE: To evaluate the clinical and financial implications of a decade of prostate biopsies performed in the UK National Health Service (NHS) through the transrectal (TR) vs the transperineal (TP) route. METHODS: We conducted an evaluation of the TR vs the TP biopsy approach in the context of 28 days post-procedure complications and readmissions. A secondary evaluation of burden of expenditure in NHS hospitals over the entire decade (2008-2019) was conducted through examination of national Hospital Episode Statistics (HES) data. RESULTS: In this dataset of 486 467 prostate biopsies (387 879 TR and 98 588 TP biopsies), rates of infection and sepsis were higher for the TR compared to the TP cohort (0.53% vs 0.31%; P < 0.001, confidence interval 99% ). Rates of sepsis have more than doubled for TR biopsies in the last 2 years compared to the previous decade (1.12% vs 0.53%). Infective complications were the main reasons for readmissions in the TR cohort, whereas urinary retention was the predominant reason for readmission in the TP cohort. Over the last decade, non-elective (NEL) readmissions seem higher for the TP group; however, in the last 2 years these have reduced compared to the TR group (3.54% vs 3.74%). The cost estimates for NEL readmissions for the entire decade were £33,589,527.00 and £7,179,926.00 respectively, for TR and TP cohorts (P < 0.001). Estimated costs per patient readmission were £2,225.00 and £1,758.00 in the TR and TP groups (P < 0.001). CONCLUSIONS: Evaluation of nearly half a million prostate biopsies in the NHS over the entire decade gives sufficient evidence for the distinct advantages of the TP route over the TR route in terms of reduced infections and burden of expenditure. In addition, there is a potential for savings both in upstream and downstream costs if biopsy is performed under a local anaesthetic.

Incidental Lymphoplasmacytic Lymphoma Diagnosed Following Robotic-Assisted Laparoscopic Prostatectomy for Prostate Cancer.

We report a case of prostatic lymphoma of the Walden-ström's macroglobulinemia subtype in a 64-year-old gentleman who underwent a robotic-assisted laparoscopic prostatectomy following lower urinary tract symptoms and high grade adenocarcinoma on transperineal prostate biopsy's. Histopathological and immunohistochemistry analysis at the time of surgery was consistent with a CD5-negative small B-cell lymphoma. To our knowledge this is the first reported prostatic lymphoma identified following robotic-assisted laparoscopic prostatectomy and the first documented case of lymphoplasmacytic lymphoma involving prostate. Lymphoma of the prostate is an uncommon entity in surgical practice and their diagnosis often poses considerable difficulty as they often mimic carcinoma. We discuss this rare diagnosis and review the literature for current considerations and prognosis.

Bladder Sparing Approaches for Muscle-Invasive Bladder Cancers.

OPINION STATEMENT: Organ preservation has been increasingly utilised in the management of muscle-invasive bladder cancer. Multiple bladder preservation options exist, although the approach of maximal TURBT performed along with chemoradiation is the most favoured. Phase III trials have shown superiority of chemoradiotherapy compared to radiotherapy alone. Concurrent chemoradiotherapy gives local control outcomes comparable to those of radical surgery, but seemingly more superior when considering quality of life. Bladder-preserving techniques represent an alternative for patients who are unfit for cystectomy or decline major surgical intervention; however, these patients will need lifelong rigorous surveillance. It is important to emphasise to the patients opting for organ preservation the need for lifelong bladder surveillance as risk of recurrence remains even years after radical chemoradiotherapy treatment. No randomised control trials have yet directly compared radical cystectomy with bladder-preserving chemoradiation, leaving the age-old question of superiority of one modality over another unanswered. Radical cystectomy and chemoradiation, however, must be seen as complimentary treatments rather than competing treatments. Meticulous patient selection is vital in treatment modality selection with the success of recent trials within the field of bladder preservation only being possible through this application of meticulous selection criteria compared to previous decades. A multidisciplinary approach with radiation oncologists, medical oncologists, and urologists is needed to closely monitor patients who undergo bladder preservation in order to optimise outcomes.

Bladder reconstruction: The past, present and future.

Ileal conduit urinary diversion is the gold standard treatment for urinary tract reconstruction following cystectomy. This procedure uses gastrointestinal segments for bladder augmentation, a technique that is often associated with significant complications. The substantial progression in the fields of tissue engineering and regenerative medicine over the previous two decades has resulted in the development of techniques that may lead to the construction of functional de novo urinary bladder substitutes. The present review identifies and discusses the complications associated with current treatment options post-cystectomy. The current techniques, achievements and perspectives of the use of biomaterials and stem cells in the field of urinary bladder reconstruction are also reviewed.