Impact of insufflator/aspirator versus exclusive insufflator during robotic radical prostatectomy: a comparative prospective cohort study.

New generation devices that combine high-flow insufflation with smoke aspiration using continuous gas recirculation ]so-called Insufflator/aspirator systems (IAS)] have recently been developed to generate pneumoperitoneum. The use of an IAS could have an impact on surgical compared to conventional insufflation systems (CIS). The present study aimed to compare the clinical effectiveness/safety, healthorganizational, and pathological/oncological outcomes of the CIS versus IAS during robot-assisted radical prostatectomy (RARP). Methods: Comparative retrospective cohort study including patients with non-metastatic prostate cancer treated with RARP by four expert surgeons at a robotic referral centre between January 2020 and December 2021. A CIS was used until 15 March 2021, and the IAS thereafter. Data were extracted from the Institutional Review Board-approved (#1064) retro and prospective institutional database. Results: The final analysis included 299 patients (143 CIS; 156 IAS). We found no statistically significant differences in demographic data and preoperative results, allowing adequate group comparison. The rate of complications of any degree (9.1% and 1.9%, P<0.05) and major complications (4.2% and 0.6%, P<0.05) were lower in the IAS group. Accordingly, the hospital stay was shorter in the IAS group (P<0.05); however, the small size of this statistically significant difference probably lacks clinical value (1.9±1.6 vs. 1.6±0.8 days). There was no significant difference in surgical time, bleeding, pathological findings, or oncological results. Conclusions: Data from this large group of patients showed that the rate of overall complications, the rate of major complications, and the length of stay were lower in the IAS group. Implementing the IAS in RARP patients increased the occurrence of SCE and affected our daily practice of transversus abdominis plane block. Interpretation of the results should be made with caution since the design of this study did not allow for the identification of a causal relationship.

MRI/TRUS fusion vs. systematic biopsy: intra-patient comparison of diagnostic accuracy for prostate cancer using PI-RADS v2.

OBJECTIVE: To evaluate the efficacy of multiparametric magnetic resonance/transrectal ultrasound fusion (MRI/TRUS fusion) biopsy versus systematic biopsy and its association with PI-RADS v2 categories in patients with suspected prostate cancer. MATERIALS AND METHODS: 122 patients undergoing both MRI/TRUS fusion and systematic biopsy, with suspicion of prostate cancer, with suspicious findings on MRI based on PI-RADS v2, were included between April 2016 and March 2017. Comparison of tumor detection rates using each technique and combined techniques was performed for all lesions as well as those that are traditionally difficult to access (i.e., anterior lesions). RESULTS: Prostate cancer was detected in 83/122 patients (68%) with 74.6% clinically significant lesions (Gleason 3 + 4 or greater). There was a statistically significant difference in presence of clinically significant prostate cancer in PI-RADS v2 categories of 3, 4, and 5 (20%, 52% and 77%, respectively, p < 0.001). Fusion biopsy was positive in a significantly higher percentage of patients versus systematic biopsy (56% versus 48%, respectively, p < 0.05). The fusion biopsy alone was positive in 20%. Of 34 patients with anterior lesions on MRI, 44% were detected only by fusion biopsy, with a joint yield of 71%. In patients with previous negative systematic biopsies, 48.7% lesions were found by fusion biopsy with 20.5% being exclusively positive by this method. The percentage of positive cores for fusion biopsies was significantly higher than for systematic biopsies (26% vs. 12.3%, p < 0.001). CONCLUSION: The incorporation of MRI/TRUS fusion biopsy significantly improves the detection rate of prostate cancer versus systematic biopsy, particularly for anterior lesions.

Densidad de APE en pacientes PI-RADS 3: un parámetro clínico útil para su manejo / PSA density as a new approach for PIRADS 3 patient's management

Resumen: Objetivo: Analizar las biopsias realizadas en paciente categorizados PIRADS 3 en nuestra institución desde el segundo semestre del año 2016 al primer semestre del año 2018 y describir la correlación de la densidad de PSA con la incidencia de cáncer de próstata. Evaluar el rol de la densidad de PSA en la indicación de estudio histológico en pacientes PIRADS 3. Método: Trabajo autorizado por el comité de ética de nuestra institución. Se realizó búsqueda en el PACs, de todos los informes de RM multiparamétricas de próstata que incluyeran la categoría ¨PIRADS 3¨ en el periodo señalado. De ellos se calculó la densidad de PSA, con el último valor de PSA registrado en la ficha clínica previo a RM y volumen prostático en RM. Se procedió a buscar los pacientes con estudio histológico. Se correlacionó los resultados de biopsias con el valor de densidad de PSA. Realizamos análisis uni y multivariados, análisis estadísticos con sensibilidad, especificidad y uso de curva ROC. Resultados: De las 2416 RMmp de próstata realizadas en nuestra institución en las fechas ya descritas, se encontraron 424 informes catalogados con score PIRADS 3, y 267 de esos pacientes tenían estudio y seguimiento institucional, de los cuales 134 contaban con biopsia. La muestra tenía un promedio de edad de 60 años, y una mediana de densidad de PSA de 0,10 (RIC 0,07-0,14). Se encontraron 36 biopsias con cáncer clínicamente significativo (Gleason > 6), lo que corresponde a 26,8% de la muestra, valor similar al encontrado en la literuatua. En estos pacientes se obtuvo un punto de corte óptimo de densidad de PSA de 0,11, con una sensibilidad y especificidad de 67% y un AUC de 0,68. Una densidad de PSA de 0,11 presenta un OR de 4,1, con una probabilidad de 4 veces más de encontrar un cáncer de próstata por sobre este valor (IC 95% 1,3-9,8), lo cuál es estadísticamente significativo con un p igual a 0,01. Conclusión: La DAPE sobre 0,11 ng/ml/cc puede considerarse como una herramienta adicional para indicar biopsia en pacientes con RMmp PI-RADS 3, aumentando la precisión para la detección de cáncer de próstata clínicamente significativos ayudando a disminuir estudios histológicos innecesarios.

Abstract: Objective: To analyze the biopsies performed in patients categorized PIRADS 3 in our institution from the second half of 2016 to the first half of 2018 and describe the correlation of PSA density with the incidence of prostate cancer. To evaluate the role of PSA density in the indication of histological study in PIRADS 3 patients. Method: Work authorized by the ethics committee of our institution. The PACs were searched for all multiparameter prostate MRI reports that included the category "PIRADS 3" in the period indicated. The PSA density was calculated, with the last PSA value recorded in the clinical record before MRI and prostate volume in MRI. We proceeded to look for patients with the histological study. The biopsy results were correlated with the PSA density value. We perform uni and multivariate analyzes, statistical analyzes with sensitivity, specificity and use of the ROC curve. Results: Of the 2416 RMmp of the prostate performed in our institution on the dates already described, 424 reports catalogued with PIRADS 3 score were found, and 267 of those patients had study and institutional follow-up, of which 134 had a biopsy. The sample had an average age of 60 years and a median PSA density of 0.10 (RIC 0.075-0.146). We found 36 biopsies with clinically significant cancer (Gleason> 6), which corresponds to 26.8% of the sample, a value similar to that found in the literature. In these patients, an optimal cut-off point of PSA density of 0.11 was obtained, with a sensitivity and specificity of 67% and an AUC of 0.68. A PSA density of 0.11 has an OR of 4.1, with a 4-fold probability of finding prostate cancer above this value (95% CI 1.3-9.8), which It is statistically significant with a p equal to 0.01. Conclusion: DAPE over 0.11 ng/ml/cc can be considered as an additional tool to indicate biopsy in patients with RMmp PI-RADS 3, increasing the accuracy for the detection of clinically significant prostate cancer helping to reduce unnecessary histological studies.

Comparison of transperineal mapping biopsy results with whole-mount radical prostatectomy pathology in patients with localized prostate cancer.

Objective. We sought to evaluate the accuracy of transperineal mapping biopsy (TMB) by comparing it to the pathology specimen of patients who underwent radical prostatectomy (RP) for localized prostate cancer. Methods. From March 2007 to September 2009, 78 men at a single center underwent TMB; 17 of 78 subsequently underwent RP. TMB cores were grouped into four quadrants and matched to data from RP whole-mount slides. Gleason score, tumor location and volume, cross-sectional area, and maximal diameter were measured; sensitivity and specificity were assessed. Results. For the 17 patients who underwent RP, TMB revealed 12 (71%) had biopsy Gleason grades ≥ 3 + 4 and 13 (76%) had bilateral disease. RP specimens showed 14 (82%) had Gleason scores ≥ 3 + 4 and 13 (76%) had bilateral disease. Sensitivity and specificity of TMB for prostate cancer detection were 86% (95% confidence interval [CI] 72%-94%) and 83% (95% CI 62%-95%), respectively. Four quadrants negative for cancer on TMB were positive on prostatectomy, and six positive on TMB were negative on prostatectomy. Conclusion. TMB is a highly invasive procedure that can accurately detect and localize prostate cancer. These findings help establish baseline performance characteristics for TMB and its utility for organ-sparing strategies.

Pelvic lymph node dissection for patients with elevated risk of lymph node invasion during radical prostatectomy: comparison of open, laparoscopic and robot-assisted procedures.

BACKGROUND AND PURPOSE: Published outcomes of pelvic lymph node dissection (PLND) during robot-assisted laparoscopic prostatectomy (RALP) demonstrate significant variability. The purpose of the study was to compare PLND outcomes in patients at risk for lymph node involvement (LNI) who were undergoing radical prostatectomy (RP) by different surgeons and surgical approaches. PATIENTS AND METHODS: Institutional policy initiated on January 1, 2010, mandated that all patients undergoing RP receive a standardized PLND with inclusion of the hypogastric region when predicted risk of LNI was ≥ 2%. We analyzed the outcomes of consecutive patients meeting these criteria from January 1 to September 1, 2010 by surgeons and surgical approach. All patients underwent RP; surgical approach (open radical retropubic [ORP], laparoscopic [LRP], RALP) was selected by the consulting surgeon. Differences in lymph node yield (LNY) between surgeons and surgical approaches were compared using multivariable linear regression with adjustment for clinical stage, biopsy Gleason grade, prostate-specific antigen (PSA) level, and age. RESULTS: Of 330 patients (126 ORP, 78 LRP, 126 RALP), 323 (98%) underwent PLND. There were no significant differences in characteristics between approaches, but the nomogram probability of LNI was slightly greater for ORP than RALP (P=0.04). LNY was high (18 nodes) by all approaches; more nodes were removed by ORP and LRP (median 20, 19, respectively) than RALP (16) after adjusting for stage, grade, PSA level, and age (P=0.015). Rates of LNI were high (14%) with no difference between approaches when adjusted for nomogram probability of LNI (P=0.15). Variation in median LNY among individual surgeons was considerable for all three approaches (11-28) (P=0.005) and was much greater than the variability by approach. CONCLUSIONS: PLND, including hypogastric nodal packet, can be performed by any surgical approach, with slightly different yields but similar pathologic outcomes. Individual surgeon commitment to PLND may be more important than approach.

Obtención de cultivos primarios de estroma prostático benigno y tumoral mediante explantes de tejido desde biopsias por punción / Obtaining primary cultures of bening and tumoral prostatic stromal tissue through explants from needle biopsias

La progresión del cáncer de próstata (CaP) es regulada por el microentorno tumoral,el cual tiene como principal componente el estroma asociado al carcinoma (CAS). Sin embargo, los métodos experimentales usando cultivos primarios para modelar el comportamiento del estroma tumoral han sido insatisfactorios debido a la dificultad de obtener cultivos primarios de células estromales prostáticas humanas (Hpscs) con alta proporción de CAS. Así, el objetivo de este estudio consistió en estandarizar una metodología que permita ta obtención de cultivos primarios de HPSCs con alta proporción de CAS. Métodos: se recolectaron biopsias prostáticas de 10 pacientes,5 de ellos con CaP localmente avanzado y/o metastásico, y 5 sin evidencia de neoplasia. Se evaluó la proporción estromal por estudios histológicos y se estandarizó la obtención de cultivos primarios de HPScs mediante explantes de tejido. Los culilvos se caracterizaron por curvas de crecimiento y proliferación Resultados: El tejido obtenido desde biopsias prostáticas por punción de pacientes con CaP localmente avanzado y/o metastásico presentan alta proporción de CAS. La técnica explantes de tejido permite la obtención de cultivos primarios de HPSC desde biopsias, indicando además que cultivos primarios de CAS presentan un patrón de crecimiento y proliferación, superior a las células obtenidas de tejido benigno (BAS). Discusión: Nuestro estudio demuestra que a través de la técnica explantes de tejido es posible obtener cultivos primarios de HPSCs con CaP invasor, debido a que estos presentan zonas con alta proporción de CAS...

Tumor microenvironment plays a critical role in the progression of prostate cancer (CaP), which main component ¡s the ®carcinoma associated stroma¼ (CAS).However, the in vitro models utilizing human prostate stroma cells (HPSCs) as primary cultures have failed in recapitulate the human prostate microenvironment due to the unfeasibility to obtain primary cultures of HPSCs with a pure population of CAS. The aim of this study was to standardize a new methodology that allow to obtain primary cultures of HPSCs with high proportion of CAS. Methods: Primary cultures of HPSCs were obtained from explants of human needle biopsies from 5 benign and 5 locally advances and/or metastatic human prostate tissues. The primary cell cultures were characterized by proliferation rates and growth curves. Locally advanced and/or metastatic prostate needle biopsies exhibit a high presence of CAS. The analysis of human primary cultures isolated from benign and malignant prostate tissue explants revealed distinctive populations of HPSCs that can be distinguishable by proliferation rates and growth curves. Discussion: our studies demonstrated for the first time that prostate explants from needle biopsy, represents a feasible technique to obtain primary cultures of stromal cells from benign and malignant tissues, and represents in more accurate way the complexity of the tumor microenvironment...

Role of short-term antibiotic therapy at the moment of catheter removal after laparoscopic radical prostatectomy.

OBJECTIVE: To assess the role of short-term antibiotic therapy (ABT) in preventing urinary tract infection (UTI) after catheter removal following laparoscopic radical prostatectomy (LRP). METHODS: 729 consecutive patients underwent LRP by one of two surgeons. One surgeon systematically prescribed a 3-day course of ABT (ciprofloxacin) starting the day before catheter removal; the other surgeon did not. The groups were compared for the incidence of symptomatic UTI occurring within 6 weeks after catheter removal. RESULTS: ABT was given to 261 of 713 patients (37%), while the remaining 452 patients (63%) did not receive ABT. After catheter removal, UTI was observed less frequently among patients receiving ABT: 3.1 vs. 7.3% in those not receiving ABT (p = 0.019). A number needed to treat to prevent 1 UTI is 24. Hospital readmission for febrile UTI was observed only in patients who did not receive ABT (n = 5, 1.1 vs. 0%, p = 0.16). One would need to prescribe ABT for 91 LRP patients to prevent 1 case of febrile UTI. CONCLUSIONS: ABT at the time of catheter removal reduced the risk of postoperative UTI after LRP. One would need to prescribe ABT to 24 patients to prevent 1 case of UTI.

Comprehensive standardized report of complications of retropubic and laparoscopic radical prostatectomy.

BACKGROUND: The lack of standardized reporting of the complications of radical prostatectomy in the literature has made it difficult to compare incidences across institutions and across different surgical approaches. OBJECTIVE: To define comprehensively the incidence, severity, and timing of onset of medical and surgical complications of open retropubic prostatectomy (RP) and laparoscopic radical prostatectomy (LP) using a standardized reporting methodology to facilitate comparison. DESIGN, SETTING, AND PARTICIPANTS: Between January 1999 and June 2007, 4592 consecutive patients underwent RP or LP without prior radiation or hormonal therapy. Median follow-up was 36.9 mo (interquartile range: 20.3-60.6). INTERVENTION: Open or laparoscopic radical prostatectomy. MEASUREMENTS: All medical and surgical complications of radical prostatectomy were captured and graded according to the modified Clavien classification and classified by timing of onset. RESULTS AND LIMITATIONS: There were 612 medical complications in 467 patients (10.2%) and 1426 surgical complications in 925 patients (20.1%). The overall incidences of early minor and major medical and surgical complications for RP were 8.5% and 1.5% for medical and 11.4% and 4.9% for surgical complications, respectively. The overall incidences of early minor and major medical and surgical complications for LP were 14.2% and 2.3% for medical and 23.1% and 6.6% for surgical complications, respectively. On multivariate analysis, LP approach was associated with a higher incidence of any grade medical and surgical complications but a lower incidence of major surgical complications than RP. Six hundred fifty-two men (14.2%) visited the emergency department, and 240 men (5.2%) required readmission. The main limitation is the retrospective nature. CONCLUSIONS: With standardized reporting, the incidence of some complications is higher than recognized in the literature. Although most complications are minor in severity, medical and surgical complications are observed in approximately 10% and 20% of patients, respectively. Accurate reporting of complications through a standardized methodology is essential for counseling patients regarding risk of complications, for identifying modifiable risk factors, and for facilitating comparison across institutions and approaches.

Focal treatment or observation of prostate cancer: pretreatment accuracy of transrectal ultrasound biopsy and T2-weighted MRI.

OBJECTIVES: To test the hypothesis that men with prostate cancer (PCA) and preoperative disease features considered favorable for focal treatment would be accurately characterized with transrectal biopsy and prostate magnetic resonance imaging (MRI) by performing a retrospective analysis of a selected cohort of such patients treated with radical prostatectomy (RP). METHODS: A total of 202 patients with PCA who had preoperative MRI and low-risk biopsy criteria (no Gleason grade 4/5, 1 involved core, < 2 mm, PSA density < or = 0.10, clinical stage < or = T2a) were included in the study. Indolent RP pathology was defined as no Gleason 4/5, organ confined, tumor volume < 0.5 mL, and negative surgical margins. MRI ability to locate and determine the tumor extent was assessed. RESULTS: After RP, 101 men (50%) had nonindolent cancer. Multifocal and bilateral tumors were present in 81% and 68% of patients, respectively. MRI indicated extensive disease in 16 (8%). MRI sensitivity to locate PCA ranged from 2% to 20%, and specificity from 91% to 95%. On univariate analysis, MRI evidence of extracapsular extension (P = .027) and extensive disease (P = .001) were associated with nonindolent cancer. On multivariate analysis, only the latter remained as significant predictor (P = .0018). CONCLUSIONS: Transrectal biopsy identified men with indolent tumors favorable for focal treatment in 50% of cases. MRI findings of extracapsular extension and extensive tumor involving more than half of the gland are associated with unfavorable features, and may be useful in excluding patients from focal treatment. According to these data, endorectal MRI is not sufficient to localize small tumors for focal treatment.

Critical evaluation of perioperative complications in laparoscopic partial nephrectomy.

OBJECTIVES: To analyze our experience with laparoscopic partial nephrectomy (LPN) to detail postoperative adverse events and identify factors that may contribute to adverse surgical outcomes. Complications from LPN result from a variety of factors, both technical and inherent. METHODS: Single-center review of 144 consecutive LPN (4 surgeons) performed between November 2002 and January 2008 was conducted. Identified complications were graded using standard reporting criteria. Univariate and multivariate statistical analysis of variables and their association with complication event and blood loss was performed. RESULTS: A total of 39 complications occurred in 29 (20%) cases. Of these, 20 (51%) were urologic and 19 (49%) were nonurologic. Individual adverse events by grade were as follows: grade I, 6 (15.4%); grade II, 19 (48.7%), grade III, 11 (28.2%), and grade IV, 3 (7.7%). No grade V complications occurred. The median tumor size and ischemia time were 2.7 cm and 35 minutes, respectively. Univariate analysis identified increased American Society of Anesthesiologists risk score (odds ratio 2.99, 95% confidence interval [CI] 1.28, 6.94) and ischemia time (odds ratio 1.31; 95% CI 1.00, 1.71) as associated with complication risk. On multivariate analysis, longer ischemia time was associated with increased estimated blood loss (95% CI 3, 57; P = .03). Hospital readmission and reintervention was required in 15 (10.4%) and 9 (6.2%) patients, respectively. CONCLUSIONS: Complications from LPN occur in a meaningful proportion of procedures although the majority does not require reintervention and half are not urologic. Increasing ischemia time and American Society of Anesthesiologists score are associated with risk for unfavorable surgical outcomes.

Comparison of gelatine matrix-thrombin sealants used during laparoscopic partial nephrectomy.

OBJECTIVE: To compare haemostasis and other outcomes after the use of bovine-derived or porcine-derived gelatine matrix-thrombin sealants (GMTS) in a continuous series of patients during and for 6 months after laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Between October 2006 and September 2007, a consecutive sample of 35 patients with renal tumours underwent LPN by a single surgeon at a referral centre. Group 1 (25 patients) received a bovine-derived GMTS and Group 2 (10 patients) a porcine-derived GMTS. All patients underwent LPN and received one of the two GMTS, applied to the resected bed before sutured renorrhaphy over oxidized nitrocellulose bolsters. Surgical and pathology variables, including ischaemia time, blood loss, tumour size, and serum creatinine values before and after LPN, were measured. Glomerular filtration rates were calculated before and after LPN. Haemostasis was ascertained by visual examination. RESULTS: Intraoperative haemostasis was achieved in all cases. No associated complications occurred within 3 weeks of LPN. The two groups were comparable in age (median, 65 vs 69 years, P = 0.62), gender, tumour number and location, median ischaemia time (34 vs 28 min, P = 0.148), and blood loss (200 vs 150 mL, P = 0.518). One patient in Group 1 developed a urinary fistula. One patient in Group 2 experienced self-limited gross haematuria. CONCLUSIONS: Both the porcine- and bovine-derived agents provided acceptable haemostasis without adverse events during LPN and in the early postoperative period. Occurrences of delayed haemorrhage and urinary fistula were not likely to be related to the choice of prothrombotic agent.