AI-powered real-time annotations during urologic surgery: The future of training and quality metrics.

INTRODUCTION AND OBJECTIVE: Real-time artificial intelligence (AI) annotation of the surgical field has the potential to automatically extract information from surgical videos, helping to create a robust surgical atlas. This content can be used for surgical education and qualitative initiatives. We demonstrate the first use of AI in urologic robotic surgery to capture live surgical video and annotate key surgical steps and safety milestones in real-time. SUMMARY BACKGROUND DATA: While AI models possess the capability to generate automated annotations based on a collection of video images, the real-time implementation of such technology in urological robotic surgery to aid surgeon and training staff it is still pending to be studied. METHODS: We conducted an educational symposium, which broadcasted 2 live procedures, a robotic-assisted radical prostatectomy (RARP) and a robotic-assisted partial nephrectomy (RAPN). A surgical AI platform system (Theator, Palo Alto, CA) generated real-time annotations and identified operative safety milestones. This was achieved through trained algorithms, conventional video recognition, and novel Video Transfer Network technology which captures clips in full context, enabling automatic recognition and surgical mapping in real-time. RESULTS: Real-time AI annotations for procedure #1, RARP, are found in Table 1. The safety milestone annotations included the apical safety maneuver and deliberate views of structures such as the external iliac vessels and the obturator nerve. Real-time AI annotations for procedure #2, RAPN, are found in Table 1. Safety milestones included deliberate views of structures such as the gonadal vessels and the ureter. AI annotated surgical events included intraoperative ultrasound, temporary clip application and removal, hemostatic powder application, and notable hemorrhage. CONCLUSIONS: For the first time, surgical intelligence successfully showcased real-time AI annotations of 2 separate urologic robotic procedures during a live telecast. These annotations may provide the technological framework for send automatic notifications to clinical or operational stakeholders. This technology is a first step in real-time intraoperative decision support, leveraging big data to improve the quality of surgical care, potentially improve surgical outcomes, and support training and education.

'Stealth' Prostate Tumors.

BACKGROUND: The aim of this study was to determine the false negative rates of prebiopsy magnetic resonance imaging (MRI) and MRI-ultrasound (US) 12-core systematic prostate biopsy (PBx) by analyzing radical prostatectomy specimens. METHODS: This retrospective study included 3600 prostate cancer (PCa) patients who underwent robot-assisted laparoscopic radical prostatectomy. Based on comparison of lobe-specific data on final pathology with preoperative biopsy and imaging data, the study population was subdivided into group I-contralateral (CL) benign PBx (n = 983), group II-CL and/or bilateral (BL) non-suspicious mpMRI (n = 2223) and group III-CL benign PBx + non-suspicious mpMRI (n = 688). This population was studied for the presence of PCa, clinically significant PCa (csPCa), extracapsular extension (ECE) (pathological stage pT3), positive frozen section and final positive surgical margin (PSM) in the CL lobe. Descriptive statistics were performed. RESULTS: In subgroups I, II and III, PCa was respectively detected in 21.5%, 37.7% and 19.5% of cases, and csPCa in 11.3%, 16.3% and 10.3% of cases. CL pT3 disease was seen in 4.5%, 4% and 5.5%, and CL surgical margins and/or frozen section analysis were positive in 6%, 7% and 5% of cases in subgroups I, II and III, respectively. CONCLUSIONS: There are still significant rates of false negatives in the standard care diagnostics of PCa. Further strategies are required to improve the accuracy of diagnosis and determination of tumor location.

Robot-assisted partial nephrectomy for complex renal tumors: Analysis of a large multi-institutional database.

INTRODUCTION: Highly complex renal masses pose a challenge to urologic surgeons' ability to perform robotic partial nephrectomy (RPN). Given the increased utilization of the robotic approach for small renal masses, we sought to characterize the outcomes and determine the safety and feasibility of RPN for complex renal masses from our large multi-institutional cohort. METHODS: We performed a retrospective analysis of patients with R.E.N.A.L. Nephrometry Scores ≥10 who underwent RPN in our multi-institutional cohort (N = 372). Baseline demographic, clinical and tumor related characteristics were evaluated with the primary endpoint of trifecta achievement (defined as negative surgical margin, no major complications, and warm ischemia time ≤25 min). Relationships between variables were assessed using the chi-square test of independence, Fisher exact test, Mann-Whitney U test, and Kruskal Wallis test. Logistic regression was used to evaluate the relationship between baseline characteristics and trifecta achievement. RESULTS: Of 372 patients in the study, mean age was 58 years, and median BMI was 30.49 kg/m2. The median tumor size was 4.3 cm (3.0-5.9 cm). Most of the patients had R.E.N.A.L. scores of 10 (n = 253; 67.01%). Overall, trifecta was achieved in 72.04% of patients. Stratifying intraoperative and postoperative outcomes by R.E.N.A.L. scores, there was no significant difference in trifecta achievement, operative time, warm ischemia time (WIT), open conversion, major complication, or positive margin rates. Length of hospital stay was significantly longer for higher R.E.N.A.L. scores (median days 2 vs. 1, P = 0.012). Multivariate analyses for factors associated with trifecta achievement concluded that age and baseline eGFR were independently associated with trifecta achievement. CONCLUSION: RPN is a safe and reproducible procedure for complex tumors with R.E.N.A.L. Nephrometry scores ≥10. Our results suggest excellent rates of trifecta achievement and short-term functional outcomes when performed by experienced surgeons. Long-term oncological and functional evaluation are needed to further support this conclusion.

Transperitoneal Versus Retroperitoneal Robotic-Assisted Partial Nephrectomy in Patients with Obesity.

Introduction: We aim to compare transperitoneal (TP) and retroperitoneal (RP) robotic partial nephrectomy (RPN) in obese patients. Obesity and RP fat can complicate RPN, especially in the RP approach where working space is limited. Materials and Methods: Using a multi-institutional database, we analyzed 468 obese patients undergoing RPN for a renal mass (86 [18.38%] RP, 382 [81.62%] TP). Obesity was defined as body mass index ≥30 kg/m2*. A 1:1 propensity score matching was performed adjusting for age, previous abdominal surgery, tumor size, R.E.N.A.L nephrometry score, tumor location, surgical date, and participating centers. Baseline characteristics and perioperative and postoperative data were compared. Results: In the propensity score-matched cohort, 79 (50%) TP patients were matched with 79 (50%) RP patients. The RP group had more posterior tumors (67 [84.81%], RP versus 23 [29.11%], TP; P < .001), while the other baseline characteristics were comparable. Warm ischemia time (interquartile range; 15 [10, 12], RP versus 14 [10, 17] minutes, TP; P = .216), operative time (129 [116, 165], RP versus 130 [95, 180] minutes, TP; P = .687), estimated blood loss (50 [50, 100], RP versus 75 [50, 150] mL, TP; P = .129), length of stay (1 [1, 1], RP versus 1 [1, 2] day, TP; P = .319), and major complication rate (1 [1.27%], RP versus 3 [3.80%], TP; P = .620) were similar. No significant difference was observed in positive surgical margin rate and delta estimated glomerular filtration at follow-up. Conclusion: TP and RP RPN yielded similar perioperative and postoperative outcomes in obese patients. Obesity should not be a factor in determining optimal approach for RPN.

Robot-assisted simple prostatectomy for prostates greater than 100 g.

PURPOSE: Efforts are ongoing to treat severe benign prostatic hyperplasia as traditional endoscopic treatment options are often difficult to perform and associated with significant complications. This manuscript highlights our initial experience of robot-assisted simple prostatectomy [RASP] with minimum a year follow-up. We also compared our outcomes with published literature. METHODS: After an Institution Review Board approval, we gathered data of 50 cases of RASP between Jan 2014 and May 2021. Patients with prostate volume > 100 cc [calculated from magnetic resonance imaging (MRI)] and prostate biopsy confirmed benign prostate were candidates for RASP. Patients underwent RASP via transperitoneal route either by suprapubic or trans-vesical approach. Preoperative demographics, peri-operative parameters and post-operative parameters such as hospital stay, catheter removal, urinary continence and uroflow were recorded in standard database and presented as descriptive statistics. RESULTS: Patients presented with a baseline median International Prostate Symptom Score (IPSS) of 23 (inter-quartile range (IQR) 21,25) and a median PSA of 7.7 ng/ml (IQR 6.4,8.7). Median preoperative prostate volume was 167 ml (IQR, 136,198 ml). Median console time was 118 min, and median estimated blood loss was 148 ml (IQR 130, 167 ml). None of our cohort needed intraoperative transfusion, conversion to open surgery or developed any complications. Median time to Foley removal was 10 days (IQR 8,12). Significant drop in the IPSS score and improvement in Qmax was noted over the period of follow-up. CONCLUSION: RASP is associated with considerable improvements in urinary symptoms. However, comparative studies with endoscopic treatment options of large prostatic adenomas are warranted and ideally include cost analysis of different procedures.

A comparison of outcomes between transperitoneal and retroperitoneal robotic assisted partial nephrectomy in patients with completely endophytic kidney tumors.

INTRODUCTION: Retroperitoneal robotic partial nephrectomy (RPN) has been shown to have comparable outcomes to the transperitoneal approach for renal tumors. However, this may not be true for completely endophytic tumors as they pose significant challenges in RPN with increased complication rates. Hence, we sought to compare the safety and feasibility of retroperitoneal RPN to transperitoneal RPN for completely endophytic tumors. METHODS: We performed a retrospective analysis of patients who underwent RPN for a completely endophytic renal mass using either transperitoneal or retroperitoneal approach from our multi-institutional database (n = 177). Patients who had a solitary kidney, prior ipsilateral surgery, multiple/bilateral tumors, and horseshoe kidneys were excluded from the analysis. Overall, 156 patients were evaluated (112 [71.8%] transperitoneal, 44 [28.2%] retroperitoneal). Baseline characteristics, perioperative and postoperative data were compared between the surgical transperitoneal and retroperitoneal approach using Chi-square test, Fishers exact test, t test, Mood median test and Mann Whitney U test. RESULTS: Of the 156 patients in this study, 86 (56.9%) were male and the mean (SD) age was 58 (13) years. Baseline characteristics were comparable between the 2 approaches. Compared to transperitoneal approach, retroperitoneal approach had similar ischemia time (19.6 [SD = 7.6] minutes vs. 19.5 [SD = 10.2] minutes, P = 0.952), operative time (157.5 [SD = 44.8] minutes vs. 160.2 [SD = 47.3] minutes, P = 0.746), median estimated blood loss (50 ml [IQR: 50, 150] vs. 100 ml [IQR: 50, 200], P = 0.313), median length of stay (1 [IQR: 1, 2] day vs. 1 [IQR: 1, 2] day, P = 0.126) and major complication rate (2 [4.6%] vs. 3 [2.7%], P = 0.621). No difference was observed in positive surgical margin rate (P = 0.1.00), delta eGFR (P = 0.797) and de novo chronic kidney disease occurrence (P = 1.000). CONCLUSION: Retroperitoneal and transperitoneal RPN yielded similar perioperative and functional outcomes in patients with completely endophytic tumors. In well-selected patients with purely endophytic tumors, either a retroperitoneal or transperitoneal approach could be considered without compromising perioperative and postoperative outcomes.

Technical Tips in Managing Large Median Lobes During Robot-assisted Radical Prostatectomy.

Prostate cancer surgeons are commonly faced by a technically challenging situation dealing with prostate cancer having large median lobes. Patients with large median lobes often have larger prostates, which makes it difficult to visualize anatomical planes during robot-assisted radical prostatectomy (RARP). Herein, we described our experience in dealing with large median lobes during RARP. We have focused on technical tips to avoid complications and facilitate a smooth procedure in patients with large median lobes during RARP. A total of 2671 patients who underwent RARP were divided into two groups based on the presence or absence of a protruded median lobe (PML): group A (2411 patients without a PML) and group B (260 patients with a PML). All patients underwent preoperative magnetic resonance imaging and final intraoperative confirmation for the presence of a PML. Pre-, intra-, and postoperative parameters were compared in two groups using the Student t test and two-proportion t test as appropriate. Patients in group B have statistically significantly higher median prostate-specific antigen (PSA; 7.7 vs 5.8 ng/dl), PSA density (0.17 vs 0.09), and International Prostate Symptom Score (19.5 vs 7.2); longer median console time (114 vs 134 min) and surgery time (145 vs 170 min); and higher blood loss (150 vs 175 ml) than those in group A. There were no statistically significant differences in pathological stages (T2, T3; 87%, 13% vs 88%, 12%) and rates of positive surgical margins (7% vs 8.5%) between groups A and B. Single-center and retrospective design was the major limitation of our study. We conclude that understanding the key steps to facilitate bladder neck dissection is vital to avoid serious intraoperative events and to maximize outcomes. Patient summary: In this report, we looked at our robotic radical prostatectomy cohort with large median lobes. We found that surgery in these patients requires more time and blood loss, but similar cancer control. We conclude that following the key steps are important to avoid complications.

Preoperative cross-sectional imaging allows for avoidance of unnecessary adrenalectomy during RCC surgery.

OBJECTIVES: To assess the frequency of adrenal involvement and the reliability of preoperative imaging to predict adrenal involvement in patients treated for cortical renal masses at a single institution. METHODS: Using a retrospective pathology database, we identified 117 consecutive patients who underwent radical nephrectomy and concomitant ipsilateral adrenalectomy at our institution over the course of 2 decades. Patient demographics, tumor characteristics, and radiographic results were obtained for analysis. RESULTS: Of 117 patients, only 6 (5.1%) were identified as having adrenal involvement. The average age of the patient was 58.3 years, and the average tumor size was 7.13 cm. The mean tumor size in patients without adrenal involvement was 6.79 cm, whereas in those with adrenal involvement, it was 9.62 cm (P = 0.057). Of 6 patients with adrenal involvement, 5 had imaging studies available for review, and all 5 demonstrated suspicion for adrenal involvement preoperatively. Among 111 patients without adrenal involvement, 53 (47.7%) had imaging available for review, with only 3 (5.7%) demonstrating suspicion for adrenal involvement. The negative predictive value was 100%, whereas the sensitivity and specificity were 100% and 94.3%, respectively. CONCLUSIONS: Ipsilateral adrenal involvement in renal cell carcinoma is uncommon and reliably predicted by preoperative cross-sectional imaging. Among all adrenalectomies in this series, nearly 95% were performed unnecessarily. With careful review, preoperative imaging can help avoid unnecessary adrenalectomy during radical nephrectomy in patients with renal cortical tumors.

Identification of the variables associated with pain during transrectal ultrasonography-guided prostate biopsy in the era of periprostatic nerve block: the role of transrectal probe configuration.

OBJECTIVE: To identify the different factors that are associated with pain perceived during transrectal ultrasonography (TRUS)-guided prostate biopsy (PBx), with special focus on the role of transrectal probe configuration. PATIENTS AND METHODS: We analysed prospective data on 1114 patients undergoing TRUS-guided PBx at our institute from January 2007 to August 2010. Patients completed questionnaires based on a 10-point visual analogue pain scale related to the consecutive steps of PBx: probe insertion, application of periprostatic nerve block (PPNB) and the obtaining of PBx cores. The variables of interest were age, prostate volume, DRE findings, number of previous biopsies, probe type and the number of retrieved cores. All variables were correlated to pain scores using multivariate regression analysis. RESULTS: At the probe insertion step, end-fire probes were more painful than side-fire probes. The Siemens G50 with metal, short plastic and long plastic needle guides (Siemens, Munich, Germany) had higher pain scores than the B&K probe (Bruel & Kjaer Medical, Copenhagen, Denmark; P = 0.09, 0.008 and 0.003, respectively). For pain at the PPNB application step, all G50(TM) guide subtypes and the Sonoline Prima probe (Siemens) had higher pain scores than the B&K probe, but this only reached statistical significance for the G50(TM) probe with short plastic guide (P = 0.03). On obtaining PBx cores, all G50(TM) subtypes had higher pain scores when compared with the B&K probe (P = 0.59, 0.38 and 0.69, respectively). CONCLUSIONS: The probe design and needle guide affect pain during each step of TRUS-guided PBx. Both the B&K and Sonoline Prima probes caused less pain when compared with the G50(TM) probe, regardless of needle guide.

Early infectious complications with transponder placement for external beam radiation therapy for prostate cancer.

UNLABELLED: What's known on the subject? and What does the study add? Little has been published related to transponders per se, but a number of studies relating to prostate biopsy-related infections and the increased incidence of quinolone-resistant Escherichia coli have been published. The study alerts the practising urologist to the risk of quinolone-resistant E. coli in the setting of transrectally placed transponders. Furthermore, it proposes an antibiotic regimen that should reduce this risk. OBJECTIVE: To report our series of early infectious complications after placement of Calypso(®) transponders (Calypso Medical, Seattle, WA, USA) into the prostate. PATIENTS AND METHODS: Between February 2008 and October 2010, 50 consecutive patients underwent placement of Calypso(®) transponders into the prostate. Patients were administered ciprofloxacin 500 mg every 12 h, starting the night before the procedure and for 2 days after the procedure. Data were collected via chart review, and complications were classified according to the Clavien classification system. RESULTS: Of the 50 patients undergoing the procedure, five (10%) developed infectious complications, and three (6%) developed a grade II complication with a UTI requiring antibiotic therapy. One patient (2%) developed a grade IIIb complication with an epidural abscess and osteomyelitis of the lumbar vertebrae requiring open debridement and a lumbar fusion. One patient (2%) developed a prostatic abscess with methicillin-resistant Staphylococcus aureus and subsequently died of an unrelated lower GI bleed. In 4/50 patients (8%), a culture confirmed the responsible bacteria, of which three cases were quinolone-resistant Escherichia coli. CONCLUSION: As with prostate biopsy, the emergence of quinolone-resistant E. coli remains a challenging infectious complication with transrectal prostate procedures. We propose an alternative strategy of double antibiotic coverage with one dose of oral ciprofloxacin 500 mg and gentamicin 80 mg i.m. before this procedure.

When serial prostate biopsy is recommended: most cancers detected are clinically insignificant.

UNLABELLED: Study Type - Disagnostic (exploratory cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Many patients undergo serial biopsy with a low rate of detection of prostate cancer, and the rate of detection declines as more biopsies are pursued. Furthermore, the clinical significance of detected cancer appears to decline as well. It is important to follow all possible methods to detect cancer; however, there should be a parallel consideration for the clinical value for detection of these tumours with low malignant potential. The present study investigated in detail the total rate of cancer detection in serial biopsy and how many of these were deemed clinically insignificant. Moreover, it addressed the impact of detecting premalignant lesions on further detection of cancer in serial biopsy. OBJECTIVE: Many patients pursue serial prostate biopsies after two consecutive negative biopsy sessions. The objective of this study is to determine the indications of serial prostate biopsy and to compare outcomes, including the risk of detecting clinically insignificant cancer using different biopsy protocols in this highly selected population. PATIENTS AND METHODS: • Most cases of prostate cancer are detected on initial or one repeat biopsy, but persistent suspicion of prostate cancer occasionally leads to serial biopsy, which we define as more than two biopsy sessions. We recently showed that transrectal saturation biopsy (sPBx) significantly increases cancer detection when compared with extended schemes (ePBx) in the initial repeat biopsy (second overall biopsy) population, and that most cases identified are clinically significant. • In the past decade, 479 men underwent 749 repeat prostate biopsies after two prior negative biopsy sessions. • The ePBx group included 347 biopsies with 10-14 cores. • The sPBx group included 402 biopsies with >20 cores. • We analysed overall cancer detection and risk of detecting clinically significant vs insignificant tumours. RESULTS: Prostate cancer was detected in 15.9% of 749 serial biopsies, representing a cumulative prostate cancer detection rate of 24.8% (119/479 patients). • The sPBx group had a significantly higher detection rate per biopsy session (18.6% vs 12.7%, P= 0.026). • Nevertheless, most positive biopsies 75/119 (63%) revealed clinically insignificant cancer, including 74.6% of cancers detected by sPBx. CONCLUSION: In men with two prior negative prostate biopsies, prostate cancer detection remains low regardless of clinical indication or transrectal biopsy protocol; most cancers identified are clinically insignificant, suggesting the threshold to repeat biopsy after more than one negative session should be very high.

Robotic single port suprapubic transvesical enucleation of the prostate (R-STEP): initial experience.

UNLABELLED: What's known on the subject? and What does the study add? Single port transvesical enucleation of the prostate (STEP) performed through a solitary suprapubic incision using a single access port inserted directly into the bladder has been demonstrated to be technically feasible but still challenging.3. Despite being feasible and providing adequate relief of bladder outlet obstruction, robotic STEP carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. OBJECTIVE: To report our initial experience with a novel robot assisted single port procedure for the management of benign prostatic hyperplasia (BPH). METHODS: Between March 2009 and July 2010, nine patients with symptomatic BPH were scheduled for robotic single port suprapubic transvesical enucleation of the prostate (R-STEP). Prior to intervention, all were submitted to preoperative transrectal ultrasound of the prostate and uroflowmetry. The surgical procedure included an initial transurethral incision of the prostatic apex. With the patient in the supine position, an approximate 3 cm lower midline incision was made. A cystotomy was created and a GelPort(®) laparoscopic system positioned in the bladder. The da Vinci S™ robotic operating system was docked through the GelPort(®) platform and enucleation was performed. Perioperative outcomes and short-term postoperative functional outcomes were assessed. Intra-operative and postoperative complications, graded according to the Dindo-Clavien system, were recorded. RESULTS: One patient was excluded from the analysis as the procedure was aborted and converted to open simple prostatectomy. Median operative time was 3.9 h. Median visual analogue pain scale on discharge was 2. Estimated blood loss was 425 mL. Two patients required intra-operative blood transfusion. Postoperatively, two patients developed clot retention and required evacuation and fulguration (grade IIIb), one of them had a deep vein thrombosis (grade II) and a urinary tract infection (grade II). One patient was admitted to the intensive care unit after a myocardial infarction (grade IVa). All patients were discharged after a median of 4.5 days. There was almost three and four times postoperative improvement in both median maximum flow (Qmax) and average flow (Qave) rates, respectively. CONCLUSION: The first series of R-STEP is reported herein. Despite being feasible and providing adequate relief of bladder outlet obstruction, the procedure carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. Thus, its role in the surgical armamentarium of BPH remains to be determined.

Type of transrectal ultrasonography probe influences prostate cancer detection rates on repeat prostate biopsy.

UNLABELLED: It is known that the end-fire probe detects more prostate cancer on initial prostate biopsy, but there is no literature looking at the influence of type of probe on repeat biopsy. Given that the literature on the influence of ultrasonography probe on repeat prostate biopsy is non-existent, the present study adds information which may help urologists improve their chances of detecting prostate cancer on prostate biopsy. Determining which type of probe to use on a prostate biopsy is a simple external factor that may help improve patient management. OBJECTIVE: To determine if the type of transrectal ultrasonography (TRUS) probe used during repeat prostate biopsy influences prostate cancer detection rates. PATIENTS AND METHODS: We conducted a retrospective chart review of 680 men undergoing repeat prostate biopsy at our institution between 2000 and 2010. Patient mean (range) age was 64.2 (39-95) years. The median (range) prostate-specific antigen (PSA) level was 5.5 (0.37-33.8) ng/mL and median (range) free PSA was 17 (5-45) %. Patient age, PSA, prostate volume, number of biopsy cores, time interval between initial and repeat biopsy, digital rectal examination and pathological findings were all included in a multivariate logistic regression analysis. RESULTS: The use of an end-fire probe on repeat biopsy significantly increased prostate cancer detection (odds ratio [OR] 1.59, 95% confidence interval [CI]: 1.03-2.46). The time interval between 1(st) and 2(nd) biopsy was also significant (OR 1.46, 95% CI: 1.11-1.09). On univariate analysis, white race (OR 0.66, 95% CI: 0.44-0.99), increasing prostate volume (OR 0.70, 95% CI: 0.55-0.89), and higher free PSA (OR 0.54, 95% CI: 0.34-0.84) were associated with a decreased risk of cancer. When evaluating the different permutations of using an end-fire or side-fire probe on initial or repeat biopsy, there was no difference in prostate cancer detection regardless of order of use of an end-fire or side-fire probe. CONCLUSIONS: An end-fire probe is associated with improved prostate cancer detection rates on both initial and repeat biopsy. The order of probe use does not appear to matter.

Tamsulosin and doxazosin as adjunctive therapy following shock-wave lithotripsy of renal calculi: randomized controlled trial.

Alpha-blockers have been established as medical expulsive therapy for urolithiasis. We aimed to assess the effect of tamsulosin and doxazosin as adjunctive therapy following SWL for renal calculi. We prospectively included 150 patients who underwent up to four SWL sessions for renal stones from June 2008 to 2009. Patients were randomized into three groups of 50 patients each, group A (phloroglucinol 240 mg daily), group B (tamsulosin 0.4 mg once daily plus phloroglucinol), and group C (doxazosin 4 mg plus phloroglucinol). The treatment continued up to maximum 12 weeks. Patients were evaluated for stone expulsion, colic attacks, amount of analgesics and side-effects of alpha-blockers. There were no significant differences between the groups regarding stone expulsion rates (84; 92 and 90%, respectively). The mean expulsion time of tamsulosin was significantly shorter than both control group (p = 0.002) and doxazosin (p = 0.026). Both number of colic episodes and analgesic dosage were significantly lower with tamsulosin as compared to control and doxazosin. Steinstrasse was encountered in 10 (6.7%) patients with no significant difference between the groups. 16 patients on tamsulosin and 21 on doxazosin experienced adverse effects related to postural hypotension. Moreover, 2 (4%) patients in the tamsulosin group reported ejaculatory complaints. In conclusion, adjunction of tamsulosin or doxazosin after SWL for renal calculi decreases the time for stone expulsion, amount of the analgesics and number colic episodes. There was no benefit regarding the overall stone expulsion rate. The side-effects of these agents are common and should be weighted against the benefits of their usage.

Laparoendoscopic single-site surgery in urology: Evaluation of complications.

OBJECTIVE: To comprehensively review current reports on the complications of laparoendoscopic single-site surgery (LESS), introduced recently into urology as an option for treating various urological pathologies. METHODS: We reviewed previous reports to August 2011 using Medline, focusing on LESS in urology, with special interest in the complications, evaluating those during and after surgery, as well as conversions to reduced-port laparoscopy, conventional laparoscopy and open surgery. RESULTS: There are increasing reports of LESS in urology, with expanding indications. Complication rates both during and after surgery are low and related mostly to the technical difficulty and dexterity with the currently available instruments. Overall, intraoperative complications were reported by 11 published studies, while postoperative complications were reported by 15. Although the overall conversion rates to open surgery and conventional laparoscopy were low, the incidence of reduced-port laparoscopy was significantly higher. CONCLUSIONS: Although there are expanding indications for LESS in urology, the risk of complications is low. This might be related to the fact that LESS is still restricted to experienced laparoscopic surgeons, and to the criteria for selecting patients.

Using a saturation biopsy scheme increases cancer detection during repeat biopsy in men with high-grade prostatic intra-epithelial neoplasia.

OBJECTIVE: To determine the role of transrectal saturation biopsy for cancer detection in men with high-grade prostatic intra-epithelial neoplasia (HGPIN) diagnosed by extended biopsy. HGPIN was clearly associated with cancer risk in the sextant biopsy era, but this has not been clearly demonstrated in the extended biopsy era. MATERIALS AND METHODS: From 1999 to 2009, 314 men had at least 1 or more repeat biopsy due to the presence of exclusive HGPIN (without any other pathologic finding) in a previous extended biopsy. They were divided into 2 groups according to the initial follow-up biopsy scheme, 178 men were followed up using a second standard extended biopsy scheme and 136 were followed up using the saturation biopsy scheme. RESULTS: In the standard repeat biopsy group, 35 of 178 (19.7%) men had cancer on initial repeat biopsy. In the saturation biopsy group, 42 of 136 (30.9%) had cancer on initial repeat biopsy (overall, P = .04). Multivariate analysis demonstrates that the biopsy scheme on repeat biopsy is an independent predictor of prostate cancer detection (OR 1.85, (95% CI; 1.03, 3.29), exclusive of age, PSA, days from initial biopsy, DRE status and multifocal PIN. Furthermore, there appears to be no further increase in Gleason 6 disease with usage of saturation biopsy in this unique population. CONCLUSION: Cancer detection in men with HGPIN in the contemporary extended biopsy era is substantially improved using saturation technique.

Office based transrectal saturation biopsy improves prostate cancer detection compared to extended biopsy in the repeat biopsy population.

PURPOSE: Multiple studies have shown significant prostate cancer detection for repeat biopsy. However, the best approach regarding core number and location remains controversial. Transrectal saturation biopsy is believed to increase cancer detection but to our knowledge no studies comparing it to 12 to 14-core extended biopsy have been published. We compared saturation and extended repeat biopsy protocols after initially negative biopsy. MATERIALS AND METHODS: A total of 1,056 men underwent prostate biopsy after initially negative biopsy. The extended biopsy group included 393 men with 12 to 14-core repeat biopsy. The saturation biopsy group included 663 men with 20 to 24-core repeat biopsy. We analyzed demographics and prostate cancer between the 2 groups. We compared prostate cancer detection in patients with previous atypical small acinar proliferation and/or high grade prostatic intraepithelial neoplasia as well as the risk of detecting clinically insignificant tumors. RESULTS: Prostate cancer was detected in 315 of the 1,056 patients (29.8%). Saturation biopsy detected almost a third more cancers (32.7% vs 24.9%, p=0.0075). In patients with a benign initial biopsy saturation biopsy achieved significantly greater prostate cancer detection (33.3% vs 25.6%, p=0.027). For previous atypical small acinar proliferation and/or high grade prostatic intraepithelial neoplasia there was a trend toward higher prostate cancer detection rate in the saturation group but it did not attain statistical significance (31.2% vs 23.3%, p=0.13). Of 315 positive biopsies 119 (37.8%) revealed clinically insignificant cancer (40.1% vs 32.6%, p=0.2). CONCLUSIONS: Compared to extended biopsy, office based saturation biopsy significantly increases cancer detection on repeat biopsy. The potential for increased detection of clinically insignificant cancer should be weighed against missing significant cases.

Utility of percent free prostate-specific antigen in repeat prostate biopsy.

OBJECTIVES: To assess the utility of the percent free prostate-specific antigen (%fPSA) for the prediction of prostate cancer in men undergoing repeat biopsy. METHODS: A retrospective review was performed of 1037 patients in an institutional review board-approved repeat prostate biopsy database. A total of 617 patients who underwent 683 biopsies had all their data available for analysis. The patients were categorized as having undergone 1 repeat biopsy or >1 repeat biopsy. RESULTS: The overall cancer detection rate was 27% and 22% in men who underwent 1 and >1 repeat biopsy, respectively. The area under the receiver operating characteristic curve for the %fPSA was 0.65 for men who underwent 1 repeat biopsy. Multivariate analysis demonstrated that a positive family history, decreasing %fPSA, and presence of high-grade intraepithelial neoplasia and/or atypical small acinar proliferation predicted for cancer. The univariate odds ratio for every 5% decrease in the %fPSA was 1.5 (95% confidence interval 1.2-1.7). The performance of %fPSA was further improved in men who underwent >1 repeat biopsy, with an area under the curve of 0.72. In men who underwent >1 repeat biopsy, multivariate analysis showed that a decreasing %fPSA, >20 cores removed, and high-grade intraepithelial neoplasia predicted for cancer. The univariate odds ratio for every 5% decrease in the %fPSA was 1.8 (95% confidence interval 1.4-2.3). A %fPSA cutoff of 10% achieved 90% and 91% specificity in the 1 repeat biopsy and >1 repeat biopsy groups, respectively. CONCLUSIONS: %fPSA is useful in predicting for prostate cancer in the repeat biopsy population, particularly for those who have undergone multiple repeat biopsies. A persistently low %fPSA should prompt additional investigation in these men.

Prostate cancer detection after a negative prostate biopsy: lessons learnt in the Cleveland Clinic experience.

Urologists are often faced with the dilemma of managing patients with a negative initial prostate biopsy in whom clinical or pathological risk for prostate cancer still exists. Such real-life challenging scenarios might raise questions such as: Who should undergo further biopsies? What are the optimal predictors for prostate cancer on subsequent biopsies? What is the optimal biopsy protocol that should be used? When to stop the biopsy cascade? The last decade has witnessed numerous studies that have analyzed factors conferring a significant risk for cancer discovered on repeat biopsies. We and others have developed predictive models to aid decision-making regarding pursuing further biopsies. For decades, high-grade prostatic intraepithelial neoplasia has been considered a strong risk indicator for subsequent cancer. However, it has been recently shown that only through segmentation of this heterogeneous population does the real risk profile emerge. Biopsy templates underwent modification regarding the number and location of cores with emergence of the transrectal or brachytherapy grid transperineal saturation biopsy. However, the best biopsy protocol remains controversial. We have refined the initial biopsy template to a 14 core initial biopsy template that optimizes cancer detection, and have shown that transrectal saturation biopsy significantly improves cancer detection for repeat biopsy. Another concern is the overdiagnosis of clinically insignificant cancer on repeat biopsies, so we explored ways to limit this, and to deal with its ramifications. Through carrying out a Medline literature search, we critically evaluated pertinent articles together with emphasis of our own journey in this arena to assist in the decision-making process for repeat biopsy population.

Development of improved nomogram for prediction of outcome of initial prostate biopsy using readily available clinical information.

OBJECTIVES: To construct a nomogram that can be used to estimate the risk of prostate cancer (PCa) and high-grade PCa using readily available clinical information for men undergoing initial extended prostate biopsy (PBx). Many nomograms have been developed to predict the outcome of initial PBx. However, most require information not available at the decision to biopsy. METHODS: From March 2000 to April 2010, 1551 men with a prostate-specific antigen (PSA) of ≤10 ng/mL who underwent initial extended PBx were included in the present study. The nomogram predictor variables were patient age, race, prostate-specific antigen (PSA) level, percent free PSA, family history of PCa, and the digital rectal examination findings. The area under the receiver operating characteristic curve was calculated as a measure of discrimination. The calibration was assessed graphically. RESULTS: Of the 1551 men, 606 (39.1%) had PCa on biopsy. The mean value for age, PSA, and percent free PSA was 63.4 years, 5.1 ng/mL, and 21.4%, respectively. Also, 25.1% and 7.8% of patients with positive PBx findings had digital rectal examination abnormalities and a positive family history, respectively. The univariate and multivariate analyses suggested that all 6 risk factors were predictors of PCa in the study cohort (P < .05). The area under the curve for all factors in a model predicting PCa was 0.73 (95% confidence interval 0.71-0.76). The area under the curve for predicting high-grade PCa was 0.71 (95% confidence interval 0.69-0.74). CONCLUSIONS: The present predictive model allows an assessment of the risk of PCa and high-grade PCa for men undergoing initial extended PBx using readily available, noninvasively obtained clinical data.