Perioperative Rates of Incidental Prostate Cancer after Aquablation and Holmium Laser Enucleation of the Prostate.

INTRODUCTION: Aquablation and holmium laser enucleation of the prostate (HoLEP) have evolved as established therapeutic options for men with benign prostatic obstruction (BPO). We sought to compare the rates of incidental prostate cancer (iPCa) after aquablation and HoLEP. METHODS: At our center, between January 2020 and November 2022, 317 men underwent aquablation, and 979 men underwent HoLEP for BPO. Histopathological assessment of resected tissue was conducted in all cases. If iPCa was detected, the Gleason score and percentage of affected tissue were assessed. Differences in important predictive factors for prostate cancer between study groups were accounted for by additional matched pairs analysis (with matching on age ± 1 year; PSA ± 0.5 ng/mL; and prostate volume ± 5 mL). RESULTS: Histopathology revealed iPCas in 60 patients (4.6%): 59 (6.03%) after HoLEP and 1 (0.3%) after aquablation (p = 0.001). Of 60 of incidental cancers, 11 had a Gleason score ≥7 (aquablation: 1/1 [100%]; HoLEP: 10/59 [16.9%]). The aquablation and HoLEP study groups differed in patient age, preoperative PSA, and prostate volume. Therefore, matched pairs analysis (aquablation: 132 patients; HoLEP: 132 patients) was conducted to improve comparability. Also after the matching procedure, significantly fewer iPCas were diagnosed after aquablation than HoLEP (aquablation: 0 [0%]; HoLEP: 6 [4.5%]; p = 0.015). CONCLUSION: Significantly fewer iPCas were identified after aquablation than HoLEP procedures. Histopathologic assessment of tissue after aquablation is feasible and may lead to the diagnosis of clinically significant iPCa. Therefore, histopathologic examination of the aquablation resective tissue should not be omitted.

Staple Containing Ureteral Stone Formation After Robot-Assisted Radical Cystectomy With Intracorporeal Neobladder Construction in a Female Patient: A Case Report of a Rare Complication.

Radical cystectomy with intracorporeal neobladder formation is a well-established treatment for patients with muscle-invasive urothelial cancer of the bladder. After the wide implementation of robotic systems, numerous centers increasingly offer intracorporeal neobladder construction using robotic staple devices. Stone formation at the area of staple material migration is a long-term complication, as staple material may migrate through the neobladder wall and act as a nidus for urine crystal aggregation. Stone formation in the upper urinary tract and the diversion segment is highly variable and corresponding management protocols are extensively reported in the previous series. However, the presence of staple material within a renal or ureteral stone has been rarely reported before. We present a case of a female patient with a staple-containing ureteral stone four years after radical cystectomy and neobladder formation and the consequent antegrade ureterorenoscopic retrieval. This treatment option is feasible, safe and easily implemented by experienced endourologists.

The Dilemma of Misclassification Rates in Senior Patients With Prostate Cancer, Who Were Treated With Robot-Assisted Radical Prostatectomy: Implications for Patient Counseling and Diagnostics.

OBJECTIVES: There is a recent paradigm shift to extend robot-assisted radical prostatectomy (RARP) to very senior prostate cancer (PCa) patients based on biological fitness, comorbidities, and clinical PCa assessment that approximates the true risk of progression. Thus, we aimed to assess misclassification rates between clinical vs. pathological PCa burden. MATERIALS AND METHODS: We compared senior patients with PCa ≥75 y (n = 847), who were propensity score matched with younger patients <75 y (n = 3,388) in a 1:4 ratio. Matching was based on the number of biopsy cores, prostate volume, and preoperative Cancer of the Prostate Risk Assessment (CAPRA) risk groups score. Multivariable logistic regression models (LRMs) predicted surgical CAPRA (CAPRA-S) upgrade, which was defined as a higher risk of the CAPRA-S in the presence of lower-risk preoperative CAPRA score. LRM incorporated the same variables as propensity score matching. Moreover, patients were categorized as low-, intermediate-, and high-risk, preoperative and according to their CAPRA and CAPRA-S scores. RESULTS: Surgical CAPRA risk strata significantly differed between the groups. Greater proportions of unfavorable intermediate risk (39 vs. 32%) or high risk (30 vs. 28%; p < 0.001) were observed. These proportions are driven by greater proportions of International Society of Urological Pathology (ISUP) Gleason Grade Group 4 or 5 (33 vs. 26%; p = 0.001) and pathological tumor stage (≥T3a 54 vs. 45%; p < 0.001). Increasing age was identified as an independent predictor of CAPRA-S-based upgrade (age odds ratio [OR] 1.028 95% CI 1.02-1.037; p < 0.001). CONCLUSION: Approximately every second senior patient has a misclassification in (i.e., any up or downgrade) and each 4.5th senior patient specifically has an upgrade in his final pathology that directly translates to an unfavorable PCa prognosis. It is imperative to take such substantial misclassification rates into account for this sensitive PCa demographic of senior men. Future prospective studies are warranted to further optimize PCa workflow and diagnostics, such as to incorporate modern imaging, molecular profiling and implement these into biopsy strategies to identify true PCa burden.

Robot-Assisted Nerve-Sparing Excision of a Symptomatic Obturator Nerve Schwannoma: A Case Report.

Reports in the literature have presented the feasibility of a minimally invasive resection of retroperitoneal or pelvic schwannomas. However, there are only a few reports in the literature about a robot-assisted nerve-sparing approach towards obturator schwannomas. We present a case of a concomitant excision of a symptomatic obturator nerve schwannoma in a patient undergoing robot-assisted radical prostatectomy with pelvic lymphadenectomy. The patient complained about an ongoing, low-grade sensory dysfunction in the left proximal thigh area, without loss of muscular function. A preoperative pelvic MRI incidentally showed a thickening of the left obturator nerve of about 1 cm. During pelvic lymphadenectomy, the thickening was identified, an axial incision was made to the nerve sheath, and a small tumor mass (9 mm x 5 mm x 3 mm) was excised, thereby decompressing the nerve fibers and simultaneously preserving the continuity of the obturator nerve. The nerve sheath was closed using a 7-0 monofilament suture. Frozen section biopsy that was undertaken during the surgical procedure excluded the presence of a malignancy. There were no intra- or postoperative complications. Postoperatively, the patient described a temporary sensory dysfunction of the left inner-thigh area, which regressed completely. The histopathological result confirmed a benign schwannoma of the obturator nerve. In experienced hands, the robot-assisted approach appears safe and feasible as a technique to excise a schwannoma of the obturator nerve, without the need to proceed to a full nerve resection.

The EORTC quality of life questionnaire predicts early and long-term incontinence in patients treated with robotic assisted radical prostatectomy: Analysis of a large single center cohort.

OBJECTIVES: The aim of our study is to evaluate the role of preoperative quality of life (QL) as a possible risk factor for post robotic assisted radical prostatectomy (RARP) urinary incontinence. The secondary aim is to evaluate the possible effect of preoperative QL on post RARP lower urinary tract symptoms (LUTS) and erectile dysfunction (ED). METHODS AND MATERIALS: Between 2012 and 2017, all patients undergoing RARP for prostate cancer were enrolled. Patient's demographic, clinical, and histological characteristics were recorded. ED, LUTS, urinary incontinence, and QL were evaluated at baseline and postoperatively at 3, 6, and 12 months. Incontinence was evaluated with the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form questionnaire and QL with the EORTC QLQ-C30 global health score (QLQ-GHS). Multivariate logistic regression analysis was used to evaluate the risk of postoperative incontinence, moderate/severe incontinence, LUTS, and moderate/severe ED. RESULTS: Overall 4,603 patients were enrolled. Incontinence rates at 3, 6, and 12 months were respectively 17%, 10%, and 8%. On multivariate analysis, QL was an independent predictor of early incontinence (QLQ-GHS:0.71, CI:0.59-0.86; P= 0.001), severe incontinence (QLQ-GHS:0.65, CI:0.49-0.97; P= 0.006), and LUTS (QLQ-GHS:0.48, CI:0.41-0.57; P= 0.001). Single center design may be considered a limitation. CONCLUSIONS: In our study a comprehensive evaluation of preoperative patient's QL, assessed by the EORTC QLQ-C30 questionnaire, can predict the early and long-term moderate/severe incontinence risk in RARP treated patients. Further studies should confirm our results.

Correction: Development and validation of a novel risk score for the detection of insignificant prostate cancer in unscreened patient cohorts.

Since the publication of this paper, the authors noticed that Amar Ahmad was not credited as contributing equally to the paper. He should be considered as a joint first author with Lorenzo Dutto. In addition, the author Ashwin Sridhar was incorrectly listed as Ashwin Shridhar, and the author Gregory L. Shaw was incorrectly listed as Gregory Shaw. The correct names are listed above.

Development and validation of a novel risk score for the detection of insignificant prostate cancer in unscreened patient cohorts.

BACKGROUND: Active surveillance is recommended for insignificant prostate cancer (PCa). Tools exist to identify suitable candidates using clinical variables. We aimed to develop and validate a novel risk score (NRS) predicting which patients are harbouring insignificant PCa. METHODS: We used prospectively collected data from 8040 consecutive unscreened patients who underwent radical prostatectomy between 2006 and 2016. Of these, data from 2799 patients with Gleason 3 + 3 on biopsy were used to develop a multivariate model predicting the presence of insignificant PC at radical prostatectomy (ERSPC updated definition3: Gleason 3 + 3 only, index tumour volume < 1.3 cm3 and total tumour volume < 2.5 cm3). This was used to develop a novel risk score (NRS) which was validated in an equivalent independent cohort (n = 441). We compared the accuracy of existing predictive tools and the NRS in these cohorts. RESULTS: The NRS (incorporating PSA, prostate volume, age, clinical T Stage, percent and number of positive biopsy cores) outperformed pre-existing predictive tools in derivation and validation cohorts (AUC 0.755 and 0.76, respectively). Selection bias due to analysis of a surgical cohort is acknowledged. CONCLUSIONS: The advantage of the NRS is that it can be tailored to patient characteristics and may prove to be valuable tool in clinical decision-making.

The new Epstein gleason score classification significantly reduces upgrading in prostate cancer patients.

PURPOSE: To evaluate the differences between the old and the new Gleason score classification systems in upgrading and downgrading rates. MATERIALS AND METHODS: Between 2012 and 2015, we identified 9703 patients treated with retropubic radical prostatectomy (RP) in four tertiary centers. Biopsy specimens as well as radical prostatectomy specimens were graded according to both 2005 Gleason and 2014 ISUP five-tier Gleason grading system (five-tier GG system). Upgrading and downgrading rates on radical prostatectomy were first recorded for both classifications and then compared. The accuracy of the biopsy for each histological classification was determined by using the kappa coefficient of agreement and by assessing sensitivity, specificity, positive and negative predictive value. RESULTS: The five-tier GG system presented a lower clinically significant upgrading rate (1895/9703: 19,5% vs 2332/9703:24.0%; p = .001) and a similar clinically significant downgrading rate (756/9703: 7,7% vs 779/9703: 8%; p = .267) when compared to the 2005 ISUP classification. When evaluating their accuracy, the new five-tier GG system presented a better specificity (91% vs 83%) and a better negative predictive value (78% vs 60%). The kappa-statistics measures of agreement between needle biopsy and radical prostatectomy specimens were poor and good respectively for the five-tier GG system and for the 2005 Gleason score (k = 0.360 ± 0.007 vs k = 0.426 ± 0.007). CONCLUSIONS: The new Epstein classification significantly reduces upgrading events. The implementation of this new classification could better define prostate cancer aggressiveness with important clinical implications, particularly in prostate cancer management.

Autobiographic memory impairment following acute cortisol administration.

Previous experimental studies in humans have reported that the administration of cortisol impairs retrieval of hippocampal dependent, episodic memory. In particular, cortisol impaired recall of previously learnt words. In the present study, we investigated if cortisol also affects autobiographical memory, which reflects a subcategory of hippocampal dependent, episodic memory. Twenty two male students participated in this placebo-controlled, double-blind crossover study. One hour after the administration of 10 mg hydrocortisone, subjects generated significantly fewer specific memories in the Autobiographical Memory Test (AMT) when compared to placebo. In contrast, cortisol did not affect mood and attention. The present findings extend the current knowledge about cortisol effects on memory retrieval and raise the possibility that impaired autobiographical memory in depression may be at least partly due to elevated cortisol levels which often accompany this disorder.