Long-term outcomes of Holmium laser enucleation of prostate and predictive model for symptom recurrence.

INTRODUCTION AND OBJECTIVES: Holmium laser enucleation of prostate (HoLEP) represents one of the most studied surgical techniques for benign prostatic hyperplasia (BPH). Its efficacy in symptom relief has been widely depicted. However, few evidence is available regarding the possible predictors of symptom recurrence. We aimed to evaluate long-term outcomes, symptom recurrence rate, and predictors in patients that underwent HoLEP. MATERIALS AND METHODS: We retrospectively analyzed data from patients that consecutively underwent HoLEP for BPH from 2012 to 2015 at two tertiary referral centers. Functional outcomes were evaluated by uroflowmetry parameters and International Prostate Symptom Score (IPSS) questionnaire administration at follow-up visits at 12, 24, and 60 months. The primary outcome was the symptomatic patients' rate presenting lower urinary tract symptoms (LUTS) after 60 months from surgery, defined as in case of one or more of the following: IPSS more than 7, post voidal residue (PVR) more than 20 ml, need for medical therapy for LUTS or redo surgery for bladder outlet obstruction. Multivariable logistic regression analyses evaluated predictors for being symptomatic at follow-up. Covariates consisted of: preoperative peak flow rate (PFR), PVR, and IPSS, prostate volume, age (all as continuous), and surgical technique. RESULTS: A total of 567 patients were available for our analyses. Median prostate volume was 80cc, with a median PFR of 8 ml/s and median PVR of 100cc. One hundred and twenty-five (22%) patients were found to be symptomatic at follow-up. Redo surgery was needed for 25 (4.4%) patients. After adjusting for possible confounders, an increase in preoperative PVR (odds ratio [OR] 1.005) and IPSS (OR 1.12) resulted as independent predictors for symptom recurrence (all p < 0.001). CONCLUSIONS: HoLEP can provide durable symptom relief regardless of the chosen technique. Patients with an important preoperative symptom burden or a high PVR should be carefully counseled on the risk of symptom recurrence.

Short Time Delay Between Previous Prostate Biopsy for Prostate Cancer Assessment and Holmium Laser Enucleation of the Prostate Correlates with Worse Perioperative Outcomes.

BACKGROUND: No data are available regarding the impact of time between a previous transrectal prostate biopsy (PB) and holmium laser enucleation of the prostate (HoLEP) on perioperative outcomes. OBJECTIVE: To evaluate the impact of time from PB to HoLEP on perioperative outcomes. DESIGN, SETTING, AND PARTICIPANTS: A total of 172 consecutive patients treated with HoLEP within 12 mo of a single previous transrectal PB at two tertiary centers were included. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patients were stratified into two groups according to the median time from PB to HoLEP (namely, ≤6 and >6 mo). The primary outcome was intraoperative complications. Multivariate logistic regressions were used to identify the predictors of intraoperative complications. Linear regressions were used to test the association between the time from PB to HoLEP and intraoperative complications, enucleation efficiency, and enucleation time. RESULTS AND LIMITATIONS: In total, 93 (54%) and 79 (46%) patients had PB ≤ 6 and >6 mo before HoLEP, respectively. Patients in PB ≤ 6 mo group experienced higher rates of intraoperative complications than those in PB > 6 mo group (14% vs 2.6%, p = 0.04). At multivariable analysis, time between PB and HoLEP was an independent predictor of intraoperative complications (odds ratio: 0.74; 95% confidence interval: 0.6-0.9; p = 0.006). Finally, the risk of intraoperative complications reduced by 1.5%, efficiency of enucleation increased by 4.1%, and enucleation time reduced by 1.7 min for each month passed from PB to HoLEP (all p ≤ 0.006). Selection of patients with only one previous PB represents the main limitation. CONCLUSIONS: The time from PB to HoLEP of ≤6 mo is associated with a higher risk of intraoperative complications, lower enucleation efficacy, and longer enucleation time. PATIENT SUMMARY: Patients with a prostate biopsy (PB) ≤6 mo before holmium laser enucleation of the prostate (HoLEP) had significantly worse outcomes than those with a PB > 6 mo before HoLEP.

The Use of Augmented Reality to Guide the Intraoperative Frozen Section During Robot-assisted Radical Prostatectomy.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) can guide the surgical plan during robot-assisted radical prostatectomy (RARP), and intraoperative frozen section (IFS) can facilitate real-time surgical margin assessment. OBJECTIVE: To assess a novel technique of IFS targeted to the index lesion by using augmented reality three-dimensional (AR-3D) models in patients scheduled for nerve-sparing RARP (NS-RARP). DESIGN, SETTING, AND PARTICIPANTS: Between March 2019 and July 2019, 20 consecutive prostate cancer patients underwent NS-RARP with IFS directed to the index lesion with the help of AR-3D models (study group). Control group consists of 20 patients matched with 1:1 propensity score for age, clinical stage, Prostate Imaging Reporting and Data System score v2, International Society of Urological Pathology grade, prostate volume, NS approach, and prostate-specific antigen in which RARP was performed by cognitive assessment of mpMRI. SURGICAL PROCEDURE: In the study group, an AR-3D model was superimposed to the surgical field to guide the surgical dissection. Tissue sampling for IFS was taken in the area in which the index lesion was projected by AR-3D guidance. MEASUREMENTS: Chi-square test, Student t test, and Mann-Whitney U test were used to compare, respectively, proportions, means, and medians between the two groups. RESULTS AND LIMITATIONS: Patients in the AR-3D group had comparable preoperative characteristics and those undergoing the NS approach were referred to as the control group (all p ≥ 0.06). Overall, positive surgical margin (PSM) rates were comparable between the two groups; PSMs at the level of the index lesion were significantly lower in patients referred to AR-3D guided IFS to the index lesion (5%) than those in the control group (20%; p = 0.01). CONCLUSIONS: The novel technique of AR-3D guidance for IFS analysis may allow for reducing PSMs at the level of the index lesion. PATIENT SUMMARY: Augmented reality three-dimensional guidance for intraoperative frozen section analysis during robot-assisted radical prostatectomy facilitates the real-time assessment of surgical margins and may reduce positive surgical margins at the index lesion.

The robotic approach improves the outcomes of ERAS protocol after radical cystectomy: A prospective case-control analysis.

BACKGROUND: Minimally-invasive approach is one of the mainstays of Enhanced Recovery After Surgery (ERAS) pathways. Robot-assisted radical cystectomy (RARC) introduction has reduced the surgical burden on patient's recovery. Accordingly, ERAS protocol benefits may be more striking in RARC patients. We evaluated the impact of surgical approach on perioperative outcomes, Fast Track (FT) recovery steps and Trifecta success rates in patients undergoing RC followed by FT protocol. MATERIALS AND METHODS: We considered 147 patients who underwent RC, with open (Open radical cystectomy [ORC]; 47.6%) or robotic (RARC; 52.4%) approach at 2 tertiary centers. Urinary diversions were ileal conduit or orthotopic neobladder. All patients underwent FT protocol. We analyzed perioperative surgical and functional outcomes and Trifecta success rates (namely, defecation <5 days, in-hospital stay <10 days and no major complications). Uni and multivariable logistic regression explored the predictors for Trifecta success and the impact of surgical approach on recovery steps. RESULTS: Patients undergoing RARC had higher FT adherence (95% vs. 61%) compared to ORCs (P < 0.01). Trifecta success rates were higher for RARC (79.2% vs 28.6%; P < 0.001). At multivariable analyses, RARC was an independent predictor for Trifecta success (OR 9.1), early mobilization (OR 5.9) and FT adherence (OR 3.33; all P < 0.001). Surgical technique was not associated with major complications or readmission within 90 days (all P > 0.05). CONCLUSION: RARC has more favorable perioperative outcomes compared to ORC, with higher Trifecta success rates. Accordingly, robotic approach should be ideally included in every center where ERAS protocol is applied to RC for maximizing patient's recovery.

Diagnostic performance of MRI/TRUS fusion-guided biopsies vs. systematic prostate biopsies in biopsy-naïve, previous negative biopsy patients and men undergoing active surveillance.

BACKGROUND: We aimed to assess the detection rate of overall PCa and csPCa, and the clinical impact of MRI/TRUS fusion targeted biopsy (FUSION-TB) compared to TRUS guided systematic biopsy (SB) in patients with different biopsy settings. METHODS: Three hundred and five patients were submitted to FUSION-TB, divided into three groups: biopsy naïve patients, previous negative biopsies and patients under active surveillance (AS). All patients had a single suspicious index lesion at mpMRI. Within these groups, we enrolled men underwent both to FUSION-TB and SB in the same session. Overall detection rate of PCa and csPCa for the two biopsy methods were compared separately between the three groups of patients. RESULTS: No differences were observed between the three groups concerning clinical and radiological characteristics. We found no differences in terms of overall PCa detection (66% vs. 63.8%, P=0.617) and csPCa detection (56.4% vs. 51.1%; P=0.225) concerning biopsy naïve patients. In patients previously submitted to a negative biopsy, FUSION-TB showed higher detection rate of csPCa compared to SB alone (41,3% vs. 27% respectively, P=0.038). In patients under AS, no differences were observed between FUSION-TB and SB in terms of overall PCa (50% vs. 73.1%) and csPCa (30.8% vs. 26.9%, respectively; P=0.705) detection. CONCLUSIONS: Our results suggest that in men with previously negative biopsy, FUSION-TB showed significantly higher diagnostic performance for clinically significant PCa as compared to SB. Combination of FUSION-TB and SB should be recommended in AS population to offer higher chance of csPCa diagnosis.

Real-time Augmented Reality Three-dimensional Guided Robotic Radical Prostatectomy: Preliminary Experience and Evaluation of the Impact on Surgical Planning.

BACKGROUND: Augmented reality (AR) is a novel technology adopted in prostatic surgery. OBJECTIVE: To evaluate the impact of a 3D model with AR (AR-3D model), to guide nerve sparing (NS) during robot-assisted radical prostatectomy (RARP), on surgical planning. DESIGN, SETTING, AND PARTICIPANTS: Twenty-six consecutive patients with diagnosis of prostate cancer (PCa) and multiparametric magnetic resonance imaging (mpMRI) results available were scheduled for AR-3D NS RARP. INTERVENTION: Segmentation of mpMRI and creation of 3D virtual models were achieved. To develop AR guidance, the surgical DaVinci video stream was sent to an AR-dedicated personal computer, and the 3D virtual model was superimposed and manipulated in real time on the robotic console. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The concordance of localisation of the index lesion between the 3D model and the pathological specimen was evaluated using a prostate map of 32 specific areas. A preliminary surgical plan to determinate the extent of the NS approach was recorded based on mpMRI. The final surgical plan was reassessed during surgery by implementation of the AR-3D model guidance. RESULTS AND LIMITATIONS: The positive surgical margin (PSM) rate was 15.4% in the overall patient population; three patients (11.5%) had PSMs at the level of the index lesion. AR-3D technology changed the NS surgical plan in 38.5% of men on patient-based and in 34.6% of sides on side-based analysis, resulting in overall appropriateness of 94.4%. The 3D model revealed 70%, 100%, and 92% of sensitivity, specificity, and accuracy, respectively, at the 32-area map analysis. CONCLUSIONS: AR-3D guided surgery is useful for improving the real-time identification of the index lesion and allows changing of the NS approach in approximately one out of three cases, with overall appropriateness of 94.4%. PATIENT SUMMARY: Augmented reality three-dimensional guided robot-assisted radical prostatectomy allows identification of the index prostate cancer during surgery, to tailor the surgical dissection to the index lesion and to change the extent of nerve-sparing dissection.

The role of magnetic resonance imaging-guided biopsy for diagnosis of prostate cancer; comparison between FUSION and "IN-BORE" approaches.

BACKGROUND: The aim of the present study is to evaluate the difference in terms of feasibility and detection rate of two magnetic resonance imaging (MRI) guided biopsy approaches (MRI fusion versus "in-bore" MRI) in a single tertiary center. METHODS: We retrospectively identified 297 patients with suspected prostate cancer who underwent MRI based target prostate biopsy (FUSION or "in-bore" approaches) between January 2016 and January 2018 in a single tertiary center. RESULTS: Lesion site (peripheral vs. central) and localization (anterior vs. posterior) were equally comparable among two groups, but maximum diameter of multiparametric-MRI Index lesion was slightly superior in the in-bore MRI-GB group (14 vs. 12 mm, P=0.002). Mean random biopsy cores taken were 11.2±2.1, with 1.3±2 positive cores in FUSION-GB group. Mean number of targeted biopsy cores taken was significantly superior in the FUSION-GB group as compared to the in-bore MRI-GB group (2.6±0.7 vs.1.7±1, P<0.001), whereas mean number of positive targeted biopsy cores was comparable between two groups (1±1.3 vs.1±0.9, P=0.1). 70 (45.5%) and 75 (52.8%) patients had positive targeted bioptic cores at pathologic examination among FUSION-GB and in-bore MRI-GB groups, respectively (P=0.2). Bioptical ISUP grade was also comparable among two groups (P=0.2) in multivariate analysis PI-RADS Score (OR=3.04 and OR=8.32 for PI-RADS 4 and 5, respectively) and PSA density (OR=2.69) were identified as independent predictors of positive targeted cores at histological examination (P<0.001 and P=0.01, respectively). CONCLUSIONS: In-bore MRI-GB approaches represent a promising technique that may offer some advantages compared to standard systematic FUSION-GB despite higher costs of in bore-procedure. Our experience, although not showing a clear advantage between the FUSION technique and the "in-bore" technique, resulted safe and feasible and represents a viable procedure for the diagnosis and characterization of prostate especially in a subgroup of patient with clinically significant disease. Further investigations are needed in order to identify the best approach for MRI-GB.

Percutaneous tumor ablation versus partial nephrectomy for small renal mass: the impact of histologic variant and tumor size.

BACKGROUND: The aim, of this study was to investigate recurrence rates in patients with T1 renal cell carcinoma (RCC) undergone partial nephrectomy (PN), radiofrequency ablation (RFA) or cryoablation (Cryo). METHODS: We retrospectively evaluated data from 665 (81.4%), 68 (8.3%) and 83 (10.3%) patients who underwent PN, RFA and Cryo, respectively. Kaplan-Meier curves depict recurrence-free survival (RFS) rates in the overall population and after stratifying according to tumor's histology (namely, clear cell RCC and non-clear RCC) and size (namely <2 cm and 2-4 cm). Multivariable Cox regression model was used to identify predictors of recurrence. Cumulative-incidence plots evaluated disease recurrence and other causes of mortality (OCM). RESULTS: Patients referred to PN experienced higher RFS rate compared to those treated with RFA and Cryo at 60-month in the overall population (96.4% vs. 79.4% vs. 87.8%), in patients with clear cell RCC (93.3% vs. 75% vs. 80.4%) and in those with tumor of 2-4 cm (97.3% vs. 78% and 84.4%; all P≤0.01). In patients with non-clear cell RCC and with tumor <2cm, PN showed higher RFS rate at 60-month as compared to RFA (97.9% vs. 84.4% and 95.1% vs. 78.1%, respectively: all P≤0.02). At multi-variate analysis, ablative techniques (RFA [HR=4.03] and Cryo [HR=3.86]) were independent predictors of recurrence (all P<0.03). At competing risks analysis, recurrence rate and OCM were 7.3% and 1.3% vs. 25% and 7.2% vs. 19.9% and 19.9% for PN, RFA and Cryo, respectively. CONCLUSIONS: PN and Cryo showed similar RFS rates in patients with non-clear cell RCC and with renal mass <2cm.

Postoperative outcomes of Fast-Track-enhanced recovery protocol in open radical cystectomy: comparison with standard management in a high-volume center and Trifecta proposal.

BACKGROUND: We aimed at comparing perioperative outcomes in patients submitted to radical cystectomy followed by Fast Track (FT) protocol or standard management, and propose a definition of Trifecta, to improve standardized quality assessment for RC. METHODS: We considered 191 patients submitted to RC between January 2017 and January 2019. Patients followed FT or standard management according to surgeon's preference. Preoperative and intraoperative characteristics, alongside with postoperative outcomes were compared between the two groups. Trifecta was defined as follows: in-hospital stay (HS) ≤ 10 days, time to defecation (TtD) below the overall mean and no major (≥ Clavien-Dindo grade III) complications. Finally, Trifecta achievement rates were assessed in both groups. RESULTS: Seventy-five patients (39%) followed the FT protocol and 116 (61%) standard management. The two groups were homogeneous for preoperative, intraoperative and pathological characteristics. Patients in the FT group had shorter TtD (5 vs. 6 days P=0.006), HS (12 vs. 14 days P=0.008) and lower readmission rate (8% vs. 19% P=0.04). Early complication rates and grades were similar, while less late complications were found in FT group (6.7% vs. 21.6% P=0.006). Trifecta achievement rate was higher for FT group (31% vs. 8% P<0.001). Single-item failure percentages for HS, TtD and major grade complications were respectively 90%, 60% and 19%, with no difference between the two groups. CONCLUSIONS: FT protocol can safely consent faster bowel recovery and earlier discharge after RC, plus reducing readmission rates. Using a Trifecta incorporating essential perioperative outcomes, could improve standardized quality assessment for RC.

Secondary bladder amyloidosis due to Crohn's disease: a case report and literature review.

The presence of amyloid deposits in bladder walls is a rare histological finding. It can be linked to primary (limited to bladder) or secondary (systemic, associated with chronic inflammatory disorders) amyloidosis. Secondary bladder involvement is very uncommon; it usually presents with gross hematuria, which is challenging to manage, due to frail bladder mucosa and/or necrosis. We present a case of 54-year old man with secondary bladder amyloidosis due to Crohn's disease, that caused gross hematuria and severe anemia, which was managed conservatively by endoscopic transurethral resection, diatermocoagulation, clot evacuation and urinary drainage by bilateral percutaneous nephrostomy, with spontaneous resolution. Secondary bladder amyloidosis is a rare condition that presents with severe hematuria, difficult to control with standard management. Owing to chronic nature of the disease, treatment should be aimed to a conservative approach whenever possible. In case of failure, invasive procedures should be considered as salvage therapies.

The Impact of 3D Digital Reconstruction on the Surgical Planning of Partial Nephrectomy: A Case-control Study. Still Time for a Novel Surgical Trend?

INTRODUCTION: The purpose of this study was to evaluate the impact of 3-dimensional (3D) digital reconstructions of renal models on the arterial clamping approach during partial nephrectomy (PN). PATIENTS AND METHODS: Fifty-seven patients with T1 renal mass, referred for PN, were prospectively enrolled in 2 groups: Group 1 (n = 32) with revision of both 2-dimensional (2D) computed tomography (CT) imaging and 3D virtual model before surgery; Group 2 (n = 25) with revision of 2D CT imaging. Segmentation of the 3D models from preoperative high-quality CT scan was achieved using D2P software. In a sub-analysis of patients treated with PN with the on-clamp approach (n = 36), the effective intraoperative level of arterial clamping was compared with the preoperative planning. RESULTS: In the sub-group of patients referred to PN with the on-clamp approach, the intraoperative selective clamping was performed in 12 (57.1%) patients of Group 1 and in 2 (13.3%) cases of Group 2 (P = .01). The intraoperative management of the renal pedicle was done as preoperatively planned in 61.9% of patients in Group 1 and in 86.6% of cases in Group 2 (P = .1). CONCLUSION: The 3D-guided plan of PN allows to perform selective clamping in higher proportion of patients compared with the standard 2D-guided approach without increasing intraoperative and postoperative complications.

Is Fast Track protocol a safe tool to reduce hospitalization time after radical cystectomy with ileal urinary diversion? Initial results from a single high-volume centre.

INTRODUCTION AND AIM: Radical Cystectomy (RC) with ileal urinary diversion is one of the most complex urological surgical procedure, and many Fast Track (FT) protocols have been described to reduce hospitalization, without increasing postoperatory complications. We present the one-year results of a dedicated protocol developed at a high volume centre. MATERIALS AND METHODS: The FT protocol was designed after a review of the literature and a multidisciplinary collegiate discussion, and it was applied to patients scheduled to open RC with intestinal urinary diversion. To validate its feasibility, we compared its results with data collected from a 1:1 matched population of patients who had undergone the same surgical procedure, without the implementation of the FT protocol. RESULTS: We enrolled in the FT group 11 (55%) patients scheduled to RC with ileal conduit diversion, and 9 patients (45%) scheduled to orthotopic neobladder (Studer) substitution, while a numerically equivalent population was enrolled in the control group, matched according to age at surgery, BMI, gender, ASA score, CCI, preoperative stage and type of urinary diversion. No statistically significant difference was found in terms of pre-operatory and intra-operatory domains. Median overall age was 71 years (Inter Quartile Range - IQR: 63-76) and mean operatory time was 276 ± 57 minutes. Hospitalization time was significantly reduced in the FT group, considering oralization and canalization items we found a significant advantage in the FT group. No statistically significant difference was found in the control of the post-operatory pain. We found no difference, in terms of both early and late complications ratio, among the two populations. Complications graded Clavien ≥ 3 were found in 4 patients of the control group (20%), while in only one patient (5%) in the Fast Track group, though this difference was not statistically significant. CONCLUSIONS: The Fast Track protocol developed in this study has proven to be effective in significantly reducing hospitalization time in patients submitted to RC with intestinal urinary diversion, without increasing post-operatory complications ratio.

Patterns of positive surgical margins after open radical prostatectomy and their association with clinical recurrence.

BACKGROUND: We report long-term oncologic outcomes in patients with positive surgical margins (PSMs) at radical prostatectomy (RP) and the oncologic impact of different scenarios of PSMs presentation. METHODS: We selected 494 men with at least 3 years follow-up after surgery. PSMs patterns were recorded as: burden (focal vs. multifocal), site (apical-anterior vs. posterolateral vs. base-bladder neck vs. multiple) and side (unilateral vs. bilateral). Kaplan-Meier curves depicted the clinical recurrence-free survival (CR-FS) rates at 10-year in the overall population, after biochemical recurrence and according to different PSMs patterns. Multivariate Cox-regression analysis was performed to predict CR. RESULTS: Overall, PSMs sites were apical-anterior, postero-lateral, base-bladder neck and multiple in 19.8%, 23.7%, 3.4% and 43.8%, respectively. Out of 494 patients, 278 (56.3%) had a focal margin, while 216 (43.7%) had a multifocal margin. In 268 (54.3%) and 87 (17.6%) men, PSMs were unilateral and bilateral, respectively. Median follow-up was 93 months. No significant differences were found in CR-FS rates after stratifying according to burden and site of PSMs. Men with unilateral PSMs experienced significant higher CR-FS rates compared to those with bilateral PSMs (87.1% vs. 71.3% at 10 years, P<0.001). At multivariate Cox regression Gleason score 8-10 (HR: 2.53, Confidence Interval [CI]: 1.01-6.33; P=0.04), pathologic stage pT3b-pT4 (HR 3.02, CI: 1.60-7.85; P=0.02) and adjuvant radiotherapy (HR: 0.30, CI: 0.11-0-86; P=0.02) were independent predictors of CR. CONCLUSIONS: Men with bilateral PSMs had higher risk to experience CR, suggesting that the different patterns of PSMs, should be considered during patients counseling to guide postoperative treatments. Retrospective nature of the study and restricted number of patients included consist of main limitations.

Which patients with clinical localized renal mass would achieve the trifecta after partial nephrectomy? The impact of surgical technique.

BACKGROUND: To develop a clinical nomogram aimed to predict the achievement of trifecta in patients treated with open, laparoscopic and robotic partial nephrectomy (PN) for localized renal masses (