Neurovascular Structure-Adjacent Frozen-Section Examination (NeuroSAFE) Technique of Nerve-Sparing Robot-Assisted Radical Prostatectomy (RARP) in Indian Scenario: Technique, Feasibility, and Early Outcomes.

Potency and urinary continence are adversely affected post-prostatectomy. The primary objective is oncological safety by ensuring negative surgical margins (NSM) and best functional recovery through nerve preservation in appropriate patients. NeuroSAFE technique of intra-operative frozen-section (IFS) analysis was devised for comprehensive assessment of surgical margins adjacent to the neurovascular tissue surface of the prostate. We analyzed our initial experience with this technique. Five NS-RARPs were performed utilizing the NeuroSAFE technique between October 2021 and February 2022. Patient demographics, disease stage, operative console time, post-operative complications, final histopathology, biochemical recurrence (BCR), erectile function, and urinary continence were recorded. The mean age of patients was 59.2 ± 1.3 years. All had clinically organ-confined disease with ISUP grade ≤ 3. The mean operative time of NS-RARP with NeuroSAFE was 240 ± 21 min and average NeuroSAFE time was 45 ± 3.8 min. All patients had NSM on IFS. No patient had Clavien-Dindo grade > 1 complications. Margins were negative on final histopathology. No patient had BCR at 6 and 12 weeks. Three patients were able to have sexual intercourse and only one patient required single precaution pad at 12 weeks. NeuroSAFE is feasible and can ensure intra-operative oncological safety of the NS procedure. Moreover, it gives the opportunity to convert positive surgical margin to prognostically favorable NSM by secondary resection. Our initial experience which is the first in India is encouraging with favorable functional outcomes. Large prospective studies and longer follow-up are required specially to evaluate the oncological benefit.

Revolutionizing urology: the advancements and applications of robotic platforms.

Robot-assisted surgery is developing as an acme of minimally invasive surgery, given its utmost dominance over laparoscopic surgery. The objective was to review the status of robotic surgery in urological practice with its advantages and disadvantages in current scenario. We conducted a literature search using MEDLINE and identified 72 articles which were relevant to urology. Single-port and various multiport robotic platforms like Da Vinci, Versius, Hugo RAS, Revo-I, Senhance, Mantra, Avatera, Hinotori, and MicroSurge are described with pros and cons. With a surge in different medical surgical robots purging into the market and a race to become the next standard of care in robotic surgery, it is only a matter of time when robotic surgery becomes financially comparable to laparoscopic surgeries.

Exploring the Ethical, Legal, and Social Implications of ChatGPT in Urology.

PURPOSE OF THE REVIEW: ChatGPT is programmed to generate responses based on pattern recognition. With this vast popularity and exponential growth, the question arises of moral issues, security and legitimacy. In this review article, we aim to analyze the ethical and legal implications of using ChatGPT in Urology and explore potential solutions addressing these concerns. RECENT FINDINGS: There are many potential applications of ChatGPT in urology, and the extent to which it might improve healthcare may cause a profound shift in the way we deliver our services to patients and the overall healthcare system. This encompasses diagnosis and treatment planning, clinical workflow, patient education, augmenting consultations, and urological research. The ethical and legal considerations include patient autonomy and informed consent, privacy and confidentiality, bias and fairness, human oversight and accountability, trust and transparency, liability and malpractice, intellectual property rights, and regulatory framework. The application of ChatGPT in urology has shown great potential to improve patient care and assist urologists in various aspects of clinical practice, research, and education. Complying with data security and privacy regulations, and ensuring human oversight and accountability are some potential solutions to these legal and ethical concerns. Overall, the benefits and risks of using ChatGPT in urology must be weighed carefully, and a cautious approach must be taken to ensure that its use aligns with human values and advances patient care ethically and responsibly.

Whole-exome sequencing of Indian prostate cancer reveals a novel therapeutic target: POLQ.

PURPOSE: Prostate cancer is the second most common cancer diagnosed worldwide and the third most common cancer among men in India. This study's objective was to characterise the mutational landscape of Indian prostate cancer using whole-exome sequencing to identify population-specific polymorphisms. METHODS: Whole-exome sequencing was performed of 58 treatment-naive primary prostate tumors of Indian origin. Multiple computational and statistical analyses were used to profile the known common mutations, other deleterious mutations, driver genes, prognostic biomarkers, and gene signatures unique to each clinical parameter. Cox analysis was performed to validate survival-associated genes. McNemar test identified genes significant to recurrence and receiver-operating characteristic (ROC) analysis was conducted to determine its accuracy. OncodriveCLUSTL algorithm was used to deduce driver genes. The druggable target identified was modeled with its known inhibitor using Autodock. RESULTS: TP53 was the most commonly mutated gene in our cohort. Three novel deleterious variants unique to the Indian prostate cancer subtype were identified: POLQ, FTHL17, and OR8G1. COX regression analysis identified ACSM5, a mitochondrial gene responsible for survival. CYLC1 gene, which encodes for sperm head cytoskeletal protein, was identified as an unfavorable prognostic biomarker indicative of recurrence. The novel POLQ mutant, also identified as a driver gene, was evaluated as the druggable target in this study. POLQ, a DNA repair enzyme implicated in various cancer types, is overexpressed and is associated with a poor prognosis. The mutant POLQ was subjected to structural analysis and modeled with its known inhibitor novobiocin resulting in decreased binding efficiency necessitating the development of a better drug. CONCLUSION: In this pilot study, the molecular profiling using multiple computational and statistical analyses revealed distinct polymorphisms in the Indian prostate cancer cohort. The mutational signatures identified provide a valuable resource for prognostic stratification and targeted treatment strategies for Indian prostate cancer patients. The DNA repair enzyme, POLQ, was identified as the druggable target in this study.

Expert survey on management of prostate cancer in India: Real-world insights into practice patterns.

To gain insights on the diverse practice patterns and treatment pathways for prostate cancer (PC) in India, the Urological Cancer Foundation convened the first Indian survey to discuss all aspects of PC, with the objective of guiding clinicians on optimizing management in PC. A modified Delphi method was used, wherein a multidisciplinary panel of oncologists treating PC across India developed a questionnaire related to screening, diagnosis and management of early, locally advanced and metastatic PC and participated in a web-based survey (WBS) (n = 62). An expert committee meeting (CM) (n = 48, subset from WBS) reviewed the ambiguous questions for better comprehension and reanalyzed the evidence to establish a revote for specific questions. The threshold for strong agreement and agreement was ≥90% and ≥75% agreement, respectively. Sixty-two questions were answered in the WBS; in the CM 31 questions were revoted and 4 questions were added. The panelists selected answers based on their best opinion and closest to their practice strategy, not considering financial constraints and access challenges. Of the 66 questions, strong agreement was reached for 17 questions and agreement was achieved for 22 questions. There were heterogeneous responses for 27 questions indicative of variegated management approaches. This is one of the first Indian survey, documenting the diverse clinical practice patterns in the management of PC in India. It aims to provide guidance in the face of technological advances, resource constraints and sparse high-level evidence.

Outcomes of Minimally Invasive Radical Prostatectomy-a Contemporary Review.

Prostatectomy has been widely accepted as a treatment option for prostate cancer and can be performed via an open, laparoscopic, and robotic approach. The outcomes following prostatectomy are primarily sub-grouped into oncological and functional outcomes. Oncological outcomes have been comparable in the above three surgical modalities. However, the robotic platform seems to have a better functional outcome compared to open prostatectomy. The data on the outcome of the laparoscopic approach is scarce and is not widely performed due to technical difficulty. With experience continence outcomes have reached a plateau in many robotic series, however, the potency outcome is the real Achilles tendon of this procedure. Many factors influence potency outcomes but the amount and quality of nerve-sparing is one factor that is under a surgeon's control and it improves with experience.

Role of RPLND and Metastasectomy in the Management of Oligometastatic Renal Cell Carcinoma.

Although lymphadenectomy is currently accepted as most accurate and reliable staging procedure for lymph node metastases, its therapeutic benefit in renal cell carcinoma (RCC) still remains controversial. Although the new, targeted therapy paradigms have changed the treatment of patients with advanced RCC and offer prolonged survival, cure is extremely uncommon in the absence of surgical resections. In this paper, the current role of metastasectomy is reviewed. Review the available literature concerning the role of retroperitoneal lymph node dissection and metastasectomy in outcome of oligometastatic RCC. A PubMed search was conducted to identify original articles, review articles, and editorials addressing the role of retroperitoneal lymph node dissection and metastasectomy in outcome of oligometastatic RCC. Keywords included renal tumors, renal cell cancer, kidney cancer, lymphadenectomy, metastasectomy, and oligometastases. While there is no randomized study available, recent large observational studies have better defined the prognosis of patients with metastatic RCC with or without metastasectomy and RPLND. To date, the available evidence suggests that RPLND and metastasectomy may be beneficial when technically feasible in patients with locally advanced (unfavorable clinical and pathologic characteristics) and oligometastatic disease. A proportion of patients will achieve long-term survival with aggressive surgical resection.

Radical Prostatectomy for Locally Advanced Prostate Cancers-Review of Literature.

Twenty-five to thirty percent of patients with prostate cancer present with locally advanced disease. While risk stratification remains the same with high incidence of upstaging of disease on imaging and histopathological evaluation; there have been progressive refinements in surgical therapy. With availability of reasonably robust data, radical prostatectomy in men with locally advanced prostate cancers seems to effect improvement in both cancer specific and overall survival rates in comparison to the current standard of care of radiation with androgen deprivation therapy. Studies using radical prostatectomy as a part of multimodality approach have also shown promising results. There is an imminent need for well-designed prospective studies of benefits of radical prostatectomy over radiation and androgen deprivation as well as benefits of multimodality therapy over monotherapy. Surgery for patients with locally advanced prostate cancer is technically challenging. Surgical outcomes are comparable to those of organ-confined disease when performed in high-volume centers. Neoadjuvant therapies prior to radical prostatectomy might improve surgical outcomes, but whether they will translate into a better cancer specific and overall survival are yet to be ascertained.

VEIL Surgical Steps.

Inguinal lymphadenectomy remains the standard of care for metastatic nodal disease in cases of penile, urethral, vulval and vaginal cancers. Outcomes, including cure rates and overall and progression-free survivals, have progressively improved in these diseases with extending criteria to offer inguinal lymph node dissection for patients 'at-risk' for metastasis or loco-regional recurrence. Hence, despite declining incidence of advanced stages of these cancers, many patients will still need to undergo lymphadenectomy for optimal oncological outcomes. Inguinal node dissection is a morbid procedure with operative morbidity noted in almost two third of the patients. Video endoscopic inguinal lymphadenectomy (VEIL) was described and currently practiced with proven equivalent oncological outcomes. We describe our technique of VEIL using laparoscopic and robotic access as well as various new surgical strategies.

GnRH Antagonist: a New and an Effective Way of Treatment of Advanced Prostate Cancer.

Castration remains the mainstay of treatment in the management of metastatic prostate cancer. Medical castration plays an important role in a majority of these patients. Gonadotropin releasing hormone (GnRH) agonists have been commonly used hitherto to achieve medical castration. Arrival of GnRH antagonists have opened a new approach in the management of these patients with distinct drug-related and cancer-related benefits including prevention of microsurges and reduction in cardiovascular complications. This article elucidates the mechanism of action of GnRH antagonists along with its clinical advantages and demerits.

Oncology Gold Standard™ practical consensus recommendations 2016 for treatment of advanced clear cell renal cell carcinoma.

The Oncology Gold Standard (OGS) Expert Group on renal cell carcinoma (RCC) developed the consensus statement to provide community oncologists practical guidelines on the management of advanced clear cell (cc) RCC using published evidence, practical experience of experts in real life management, and results of a nationwide survey involving 144 health-care professionals. Six broad question categories containing 33 unique questions cover major situations in the routine management of RCC. This document serves as a ready guide for the standard of care to optimize outcome. The table of "Take Home Messages" at the end is a convenient tool for busy practitioners.

Minilaparotomy radical cystoprostatectomy (Minilap RCP) in the surgical management of urinary bladder carcinoma: early experience.

OBJECTIVE: To assess the feasibility of minilaparotomy for radical cystoprostatectomy (RCP) and urinary diversion in the management of urinary bladder carcinoma. METHODS: A total of 45 consecutive patients with muscle invasive urinary bladder cancer underwent RCP and urinary diversion [32, 12 and 1 patients with pitchers pot orthotopic neobladder (NB), ileal conduit (IC) and sigma rectal pouch respectively], between May 2006 and June 2007, using 8-12 cm infraumbilical midline vertical incision from pubic symphysis, were prospectively analyzed for technical feasibility, operative time, blood loss, intraoperative and postoperative complications and return of bowel function. RESULTS: All the patients were males with average age of 59.65 years (44-79 years) and average body mass index of 23.97(17.7-29.5). The length of the incision was 8, 10 and 12 cm in 4, 39 and 2 patients, respectively. The average number of lymph nodes removed on the right and left side was 14 and 16, respectively. The average blood loss was 1046 ml (595-2100 ml). Return of bowel sounds was observed on an average by second postoperative day (1-5 days). Average postoperative stay was 14 days (range 10-24 days) for NB and 7 days (6-8 days) for IC patients. One (2.22%) patient died on the 18th postoperative day due to septicemia and acute renal failure. CONCLUSION: Minilaparotomy RCP is technically feasible without compromising the oncological principles. Complete removal of urachus and adequate clearance of pelvic lymph nodes is not difficult with the small incision. Early restoration of bowel function, early postoperative recovery and good cosmesis seem to be the main advantages.

Urinary diversion after cystectomy: An Indian perspective.

Radical cystectomy remains the standard treatment for muscle-invasive carcinoma bladder. Various methods have been described for the urinary diversion. In the last 150 years urinary diversion has evolved from cutaneous ureterostomy to the orthotopic neobladder. Especially during the last 20 years, much advancement has been made. We hereby have reviewed the current approaches being used at different centers in India. We have also analyzed the evolution of diversion from conduit to the orthotopic substitution at our center.

The 'pitcher pot' ileal neobladder: early experiences.

OBJECTIVE: To analyse initial results of newly designed ileal neobladder-a modification of Studer neobladder METHODS: Twenty-four patients with urinary bladder cancer underwent radical cystoprostatectomy from February 2005 to March 2006. Twenty-one of them had urinary diversion using ileal neobladder in spherical configuration with ileal neourethra (giving the shape of an inverted Indian earthenware container called a 'pitcher pot') to circumvent the problem of short mesentery and construct a low-pressure spherical ileal neobladder. RESULTS: Early post-operative complications occurred in 42% of patients. Late complications occurred in 23% of patients. Most of these complications were minor, mainly as a result of wound infection, urine leak or urinary tract infections and were managed conservatively. No early post-operative mortality was observed. Daytime continence was achieved in 100% of patients who completed the 1 year follow-up. Night-time continence was variable as it depended on timed voiding--75% of patients achieved nocturnal continence by 1 year. The functional neobladder capacity was 426 ml. The mean post-operative residual volume was 36 ml. Three patients required cystoscopic mucus evacuation and catheterization. None of them required clean intermittent catheterization. No significant metabolic disturbance occurred in any patient. CONCLUSIONS: Length of mesentery remains one of the factors in deciding the segment of intestine to be taken for neobladder. Ileal neourethra gives about 2-3 cm extra length to perform tensionless anastomosis, which is a key factor in the smooth recovery after such major surgery and also maintains optimum urodynamic features of neobladder.

Lower-caliceal stone clearance index to predict clearance of stone after SWL.

BACKGROUND AND PURPOSE: There is no uniform consensus regarding the anatomic factors that influence the clearance rate of caliceal stones after SWL, as different authors have studied various independent factors separately. We correlated both favorable and unfavorable factors into a formula to predict the clearance rate. PATIENTS AND METHODS: A series of 56 consecutive patients (37 male, 19 female) with isolated lower-caliceal single stones (right 29, left 27) treated with SWL using the Dornier Compact Delta lithotripter were analyzed retrospectively. Of these, 40 patients had soft stones, and 16 patients had hard stones. The first stone-free rate (SFR) according to plain films and ultrasonography was analyzed by stone size, and a stone clearance index (SCI) formula was applied to see if there was any change in the SFR, especially for stones >2 cm. RESULTS: The formula, which correlated well with the clearance, is SCI = [(IVA x IW x stone type)/IH] - (stone size in mm(2)/10). Nearly all (90%) of the patients with an SCI of >0 cleared their stones within 3 months, and 87% of the patients with an SCI <0 cleared their stones after 3 months. Positive and negative predictive values were 93.33% and 76.9%, respectively. The accuracy of the correlation is 85.71%. CONCLUSIONS: The success of SWL for lower-caliceal stones can be predicted easily using the SCI. Stones of >200 mm(2) (>2 cm) surface area may still be suitable for SWL if the SCI is positive, whereas alternative treatment modalities should be considered if the SCI is a low negative value (<-7).