Thulium Fiber Versus Holmium:Yttrium-aluminum-garnet Laser for Endoscopic Enucleation of the Prostate: A Systematic Review and Meta-analysis.

BACKGROUND AND OBJECTIVE: Thulium fiber laser (TFL) emerged as a competitor of holmium:yttrium-aluminum-garnet (Ho:YAG) laser for anatomic enucleation of the prostate (AEEP) in men with lower urinary tract symptoms (LUTS) related to benign prostatic obstruction (BPO). The aim was to compare the surgical outcomes of Ho:YAG and TFL for AEEP. METHODS: A literature search was conducted to identify reports published from inception until January 2024. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The coprimary outcomes were the postoperative International Prostate Symptom Score (IPSS), IPSS-Quality of Life (IPSS-QoL), and peak urinary flow (Qmax). KEY FINDINGS AND LIMITATIONS: Five studies met our inclusion criteria, and data from 1287 and 1555 patients who underwent AEEP with Ho:YAG (holmium laser enucleation of the prostate [HoLEP]) and TFL (thulium fiber laser enucleation of the prostate [ThuFLEP]), respectively, were reviewed. ThuFLEP was associated with a better IPSS at 3 mo even if the difference was not clinically significant (mean difference [MD] 0.59, 95% confidence interval [CI]: 0.29-0.88; p < 0.001). No difference was found for IPSS at 6-12 mo (p = 0.9), and IPSS-QoL at 3 mo (p = 0.9) and 6-12 mo (p = 0.2). HoLEP was associated with a better Qmax at 3 mo (MD 1.41 ml/s, 95% CI: 0.51-2.30; p = 0.002) and ThuFLEP at 6-12 mo (MD -2.61 ml/s, 95% CI: -4.68 to 0.59; p = 0.01), but the differences were not clinically significant. No difference was found in the major (p = 0.3) and overall (p = 0.3) complication rates. HoLEP was associated with shorter enucleation (MD -11.86, 95% CI: -22.36 to 1.36; p = 0.03) but not total operative time (p = 0.5). CONCLUSIONS AND CLINICAL IMPLICATIONS: The present review provides the most updated evidence on the impact of Ho:YAG and TFL in AEEP, demonstrating that these two energy sources are effective in relieving bothersome LUTS in men with BPO. PATIENT SUMMARY: Thulium fiber laser is a new energy source that can be used safely for performing endoscopic enucleation of the prostate in men with bothersome symptoms associated with benign prostatic enlargement.

Natural history of renal angiomyolipoma in a high-volume center: our experience during more than 15 years of follow up.

OBJECTIVES: To describe the natural history of AML, the clinical results and the need for treatment during long-term follow-up of renal AML. METHODS: Retrospective study of patients diagnosed with AML by computed tomography or nuclear magnetic resonance between 2001 and 2019, with at least two follow-up images. Clinical and imaging variables, need for intervention, complications and follow-up time were recorded. Statistical analysis was performed using SPSS 22.0. RESULTS: 111 patients and 145 AML were included. The median follow-up was 6.17 years (range 0.7-18.1, IQR 11.8-12.2). The median tumor size at diagnosis was 13 mm (IQR 7.5-30), with 24 (16.4%) being ≥ 4 cm. Most presented as an incidental finding (85.5%); in 3 (2.1%) cases, the presentation was as a spontaneous retroperitoneal hematoma. The main indication for intervention was size ≥ 4 cm in 50%. Eighteen (12%) patients received a first intervention, being urgent in 3. Embolization was performed in 15 cases and partial nephrectomy in 3. The need for reintervention was recorded in five: two underwent partial nephrectomy and two total nephrectomy; one patient required a new urgent embolization. Of the non-operated patients, 43% decreased in size or did not change, while 57% increased, with the median annual growth being 0.13 mm (IQR - 0.11 to 0.73). There were no differences in the median growth in tumors measuring ≥ 4 cm (0.16 mm) at diagnosis vs. < 4 cm (0.13 mm) (p = 0.9). CONCLUSIONS: The findings of this study suggest that AML typically demonstrate a slow-progressing clinical course during long-term follow-up. Moreover, our observations, which cast doubt on tumor size as a reliable predictor of adverse clinical outcomes, advocate for a less intensive monitoring strategy in both monitoring frequency and choice of imaging modality.

Same-day discharge for endoscopic enucleation of the prostate: a systematic review and meta-analysis.

PURPOSE: To systematically review studies focused on the feasibility and outcomes of outpatient endoscopic enucleation of the prostate for benign prostatic obstruction. METHODS: A literature search was conducted through December 2022 using PubMed/Medline, Web of Science, and Embase databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. Risk of bias assessment was performed according to the Newcastle-Ottawa Scale for case control studies. RESULTS: Of 773 studies, ten were included in the systematic review (n = 1942 patients) and four in the meta-analysis (n = 1228 patients). The pooled incidence of successful same-day discharge was 84% (95% CI 0.72-0.91). Unplanned readmission was recorded in 3% (95% CI 0.02-0.06) of ambulatory cases. In the reported criteria-selected patients submitted to SDD surgery, the forest plot suggested a lower rate of postoperative readmission (OR 0.56, 95% CI 0.34-0.91, p = 0.02) and complications (OR 0.69, 95% CI 0.48-1, p < 0.05) rates compared to standard protocols. CONCLUSION: We provide the first systematic review and meta-analysis on SDD for endoscopic prostate enucleation. Despite the lack of randomized controlled trials, we confirm the feasibility and safety of the protocol with no increase in complications or readmission rate in well-selected patients.

Robotic retroperitoneal lymphadenectomy in paratesticular rhabdomyosarcoma.

INTRODUCTION: Paratesticular sarcoma is an aggressive malignant tumor of mesenchymal origin. The rhabdomyosarcoma is the most common among children. Rhabdomyosarcoma treatment consists of surgery, chemotherapy and radiotherapy. Prognosic depends on local recurrence and distant metastasis. MATERIAL AND METHODS: We present the case of a 16-year-old male, who in April 2016 underwent right radical orchiectomy surgery by testicular mass rapidly evolving, with pathological results indicating a paratesticular rhabdomyosarcoma. The extension study showed a precaval adenopathy suggestive of lymph node metastasis, therefore it was a high-grade rhabdomyosarcoma. There was an appropriate response after chemotherapy (Protocol EpSSG RMS2005) and we decided to perform a robotic lymphadenectomy. RESULTS: We performed a transperitoneal approach with 8 mm trocar and 12 mm optica trocar. We accessed the retroperitoneal space through a latero-colic incision. Then we performed a craniocaudal lymph node dissection until the aortic bifurcation. The surgical time was 240 min with a blood loss of 200 ml. There were no complications. The patient was discharged on the fourth day after surgery. Pathology showed metastasis of rhabdomyosarcoma without capsular rupture. After two months, we placed the left testicle into inguinal canal prior to radiotherapy. CONCLUSIONS: Robotic lymph node metastasis lymphadenectomy from paratesticular sarcomas is a feasible treatment with the advantage of minimally invasive surgery and acceptable morbidity.

The current recommendation for the management of isolated high-grade prostatic intraepithelial neoplasia.

OBJECTIVE: To analyse the current predictive value of isolated high-grade prostatic intraepithelial neoplasia (HGPIN) for clinically significant prostate cancer (csPCa) detection in repeat biopsies. PATIENTS AND METHODS: A cohort of 293 men with isolated HGPIN detected in previous biopsies performed without multiparametric magnetic resonance imaging (mpMRI), and who underwent repeat biopsy within 1 to 3 years, was analysed. Pre-repeat biopsy mpMRI and guided biopsies to suspicious lesions (Prostate Imaging - Reporting and Data System [PI-RADS] ≥3) and/or and systematic biopsies were performed. Persistent prostate cancer (PCa) suspicion, defined as sustained serum prostate-specific antigen level >4 ng/mL and/or abnormal digital rectal examination, was present in 248 men (84.6%), and was absent in 45 men (15.4%). A control group of 190 men who had no previous HGPIN, atypical small acinar proliferation or HGPIN with atypia who were scheduled to undergo repeat biopsy due to persistent PCa suspicion were also analysed. csPCa was defined as tumours of Grade Group ≥2. RESULTS: In the subset of 45 men with isolated HGPIN, in whom PCa suspicion disappeared, only one csPCa (2.2%) and one insignificant PCa (iPCa) were detected. csPCa was detected in 34.7% of men with persistent PCa suspicion and previous HGPIN, and in 28.4% of those without previous HGPIN (P =0.180). iPCa was detected in 12.1% and 6.3%, respectively (P =0.039). Logistic regression analysis showed that the risk of csPCa detection was not predicted by previous HGPIN: odds ratio (OR) 1.369 (95% confidence interval [CI] 0.894-2.095; P =0.149); however, previous HGPIN increased the risk of iPCa detection: OR 2.043 (95% CI 1.016-4.109; P =0.006). CONCLUSION: The risk of csPCa in men with isolated HGPIN, in whom PCa suspicion disappears, is extremely low. Moreover, in those men in whom PCa suspicion persists, the risk of csPCa is not influenced by the previous finding of HGPIN. However, previous HGPIN increases the risk of iPCa detection. Therefore, repeat prostate biopsy should not be recommended solely because of a previous HGPIN.

Upper Urinary Tract Urothelial Carcinoma Tumor Seeding along Percutaneous Nephrostomy Track: Case Report and Review of the Literature.

Upper urinary tract urothelial carcinomas (UTUC) account for 5-10% of all transitional cells neoplasms. Kidney-sparing treatment should be considered for low grade (LG) UTUC and for imperative conditions. Percutaneous approach may have a role in LG tumors not manageable endoscopically. Tumor seeding along nephrostomy track is a rare report. We describe the case of a 73-year-old male, with a history of high-grade UC of the left renal pelvis. A CT scan showed the thickening of left renal pelvic wall, and percutaneous biopsy was performed. The patient underwent laparoscopic left nephroureterectomy. Seven months later, he was admitted for left flank pain due to a mass along the percutaneous track site. Mass en-bloc resection was performed, and histopathology finding demonstrated undifferentiated carcinoma, compatible with UTUC metastasis. The percutaneous approach should be considered to be the possible cause of tumor seeding. Multimodal therapy seems mandatory, as highlighted in our outcomes, with 5 years of recurrence free survival.

Cateterización tras ureteroscopia, ¿siempre, nunca, cuándo? / Catheterization after ureteroscopy. Always? never? when?

OBJETIVO: El desarrollo de ureteroscopios de menor diámetro junto al avance de las técnicas quirúrgicas, han hecho que la ureteroscopia sea cada vez menos traumática. La no despreciable morbilidad producida por un catéter ureteral hace que merezca la pena cuestionar la colocación rutinaria de este. MÉTODO: Realizamos un amplia revisión de la literatura en busca de revisiones sistemáticas, metaanálisis y ensayos clínicos prospectivos randomizados y controlados sobre el cateterismo después de ureteroscopia. RESULTADOS: Se revisaron 3 revisiones sistemáticas y metaanálisis, y 14 ensayos clínicos. La mayoría de artículos consultados muestran mayor incidencia de clínica irritativa miccional y dolor hipogástrico y en flanco en pacientes portadores de catéter JJ. No se observan diferencias en cuanto a complicaciones postoperatorias. DISCUSIÓN: Aparentemente existen pocos beneficios derivados de la colocación de un catéter ureteral en cuanto a complicaciones postoperatorias en procedimientos no complicados, con algunas excepciones puntuales. El reto en cuanto a la colocación de catéter ureteral tras ureteroscopia es identificar los casos que se beneficiarán de la misma. Una alternativa interesante, que requiere mayores estudios, es la colocación de un catéter ureteral interno externo durante las primeras 24 horas tras el procedimiento. CONCLUSIONES: Parece recomendable colocar un catéter en casos complicados o en los que se considera que presentan un mayor riesgo de complicaciones postoperatorias. En el resto de casos parecería que el cateterismo tras ureteroscopia presenta más problemas que beneficios

OBJECTIVE: The development of smaller diameter ureteroscopes, along with the advance in surgical techniques has allowed ureteroscopy to be progressively less traumatic. The considerable morbidity produced by a ureteral stent makes it advisable to question routine placement. METHODS: We performed a review of the literature searching for systematic reviews, meta-analysis and prospective randomized clinical trials. RESULTS: Three systematic reviews and meta-analysis along with 14 clinical trials were included in our review. Most of the consulted articles show a higher incidence of irritative urinary symptoms, and hypogastric and flank pain in patients carrying a JJ stent. No differences were observed in postoperative complication rates. DISCUSSION: Apparently, there is little benefit in ureteral stenting regarding postoperative complications after uncomplicated ureteroscopy, with a few exceptions. The challenge regarding ureteral stenting after ureteroscopy is to identify the cases that will benefit from it. An interesting alternative, that requires further study, is the placement of a ureteral catheter (internal-external) during the first 24 hours after procedure. CONCLUSIONS: It seems advisable to place a JJ stent in complicated cases or in those considered to have a higher risk of postoperative complications. In the rest of cases it seems that stenting after ureteroscopy involves more problems tan benefits

Renal and Adrenal Minilaparoscopy: A Prospective Multicentric Study.

OBJECTIVE: To investigate the role of contemporary minilaparoscopy (ML; 3 mm instruments and laparoscope) and to identify predictive factors for complications in a prospective multicenter series for renal and adrenal surgeries. MATERIALS AND METHODS: From July 2013 to December 2014, 110 patients from 6 laparoscopic Spanish centers were enrolled. A common database was used and data were collected in a prospective manner. Standard approach was defined as 3 to 4 3-mm trocars with a 3-mm laparoscope and 3-mm instruments (Karl Storz, Tuttlingen, Germany). Descriptive variables were analyzed and statistical analysis was performed for predictive factors for complications. RESULTS: Patient mean age was 57.8 ± 14.6 years, with an average body mass index of 25.3 ± 3.6 kg/m(2). Median American Society of Anesthesiologists score was II and 32% (n = 35) of the patients had a previous surgery. A total of 59 nephrectomies, 20 partial nephrectomies, 9 nephroureterectomies, 13 pyeloplasties, 3 pyelolithotomies, and 6 adrenalectomies were performed. Overall operative time was 180 ± 64 minutes. There were 12 clampless partials and 8 with a mean warm ischemia time of 14 ± 7 min. There were 5% of intraoperative and 8% of postoperative complications (Clavien II-IV). Mean hospital stay was 5 ± 2.3 days, with optimal pain and cosmetic control. CONCLUSION: To our knowledge, this is one of the largest prospective series of ML for renal and adrenal surgeries. Despite a mean operative time possibly longer than in standard laparoscopy, clinical and safety outcomes are not compromised. Furthermore, ML results in excellent pain control and cosmetic outcomes.

Mini-laparoscopic live donor nephrectomy with the use of 3-mm instruments and laparoscope.

PURPOSE: To analyze our preliminary outcomes on the use of 3 mm instruments for laparoscopic live donor nephrectomy (LLDN). METHODS: Our series includes thirteen patients, who underwent LLDN using 3-mm instruments and laparoscope and 5-mm transumbilical trocar. The patients were followed at 7 and 14 days from discharge and were specifically asked about their cosmetic satisfaction. At follow-up, the recipient graft function was controlled, as well as the donor's cosmetic results. Eight months after surgery, all thirteen patients were asked to fill out the Patient Scar Assessment Questionnaire and Scoring System (PSAQ). RESULTS: All patients presented good recovery after surgery. Regarding cosmetic outcomes, the donors expressed their satisfaction toward the minimal incision size and optimal esthetic results at 7 and 14 days from discharge home. The low scores on each section of the PSAQ confirmed the favorable outcomes. Early graft function was satisfactory at 1 and 3 months after the kidney transplantation. Furthermore, there were no major complications in the recipients. CONCLUSIONS: Our persistent positive results with the use of 3-mm instruments during LLDN support this technique as a good alternative to the standard laparoscopic approach for minimizing the incision site, while maintaining safety and excellent clinical outcomes. The fact that the general laparoscopic standards are maintained could make this approach a very attractive alternative to the other minimally invasive approaches for live donor nephrectomy. The hope is in that the higher degree of satisfaction in the donor population demonstrated in this study may likely enhance living kidney donation.