Ten-year functional and oncological outcomes of a prospective randomized controlled trial comparing laparoscopic versus robot-assisted radical prostatectomy.

BACKGROUND: Among prostate cancer (PCa) treatment options, mini-invasive surgical approaches have gained a wide diffusion in the last decades. The aim of this study was to present oncological, functional, and quality of life data after 10 years of follow-up of a prospective randomized controlled trial (RCT) (ISRCTN11552140) comparing robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) for the treatment of PCa. METHODS: Patients with localized PCa were randomized to undergo LRP or RARP between January 2010 and January 2011. Functional (continence and potency) and oncological (prostate-specific antigen, biochemical recurrence [BCR] and BCR-free survival [BCRFS]) variables were evaluated. BCRFS curves were estimated by the Kaplan-Meier method and compared using the log-rank test. Machine learning partial least square-discriminant analysis (PLS-DA) was used to identify the variables characterizing more the patients who underwent RARP or LRP. RESULTS: Seventy-five of the originally enrolled 120 patients remained on follow-up for 10 years; 40 (53%) underwent RARP and 35 (47%) LRP. Continence and potency recovery rates did not show significant differences (p = 0.068 and p = 0.56, respectively), despite a Δ12% for continence and Δ8% for potency in favor of the robotic approach. However, the quality of continence (in terms of International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF] score) and erection (in terms of International Index of Erectile Function-5 [IIEF-5] score) was significantly better after 10 years in the robotic group (p = 0.02 and p < 0.001). PLS-DA revealed that LRP was characterized by the worst functional-related outcomes analyzing the entire follow-up period. Four (10%) and six (17%) patients experienced BCR in RARP and LRP groups, respectively (p = 0.36), with an overall 10-year BCR-free survival of 88% and 78% (p = 0.16). CONCLUSIONS: Comparable continence and potency rates were observed between RARP and LRP after a 10-year follow-up. However, the RARP group exhibited superior totally dry rate and erection quality. No difference in terms of oncological outcomes was found.

Visual extended reality tools in image-guided surgery in urology: a systematic review.

PURPOSE: The aim of this systematic review is to assess the clinical implications of employing various Extended Reality (XR) tools for image guidance in urological surgery. METHODS: In June 2023, a systematic electronic literature search was conducted using the Medline database (via PubMed), Embase (via Ovid), Scopus, and Web of Science. The search strategy was designed based on the PICO (Patients, Intervention, Comparison, Outcome) criteria. Study protocol was registered on PROSPERO (registry number CRD42023449025). We incorporated retrospective and prospective comparative studies, along with single-arm studies, which provided information on the use of XR, Mixed Reality (MR), Augmented Reality (AR), and Virtual Reality (VR) in urological surgical procedures. Studies that were not written in English, non-original investigations, and those involving experimental research on animals or cadavers were excluded from our analysis. The quality assessment of comparative and cohort studies was conducted utilizing the Newcastle-Ottawa scale, whilst for randomized controlled trials (RCTs), the Jadad scale was adopted. The level of evidence for each study was determined based on the guidelines provided by the Oxford Centre for Evidence-Based Medicine. RESULTS: The initial electronic search yielded 1,803 papers after removing duplicates. Among these, 58 publications underwent a comprehensive review, leading to the inclusion of 40 studies that met the specified criteria for analysis. 11, 20 and 9 studies tested XR on prostate cancer, kidney cancer and miscellaneous, including bladder cancer and lithiasis surgeries, respectively. Focusing on the different technologies 20, 15 and 5 explored the potential of VR, AR and MR. The majority of the included studies (i.e., 22) were prospective non-randomized, whilst 7 and 11 were RCT and retrospective studies respectively. The included studies that revealed how these new tools can be useful both in preoperative and intraoperative setting for a tailored surgical approach. CONCLUSIONS: AR, VR and MR techniques have emerged as highly effective new tools for image-guided surgery, especially for urologic oncology. Nevertheless, the complete clinical advantages of these innovations are still in the process of evaluation.

Treatment preferences of patients with erectile dysfunction: a systematic review of randomized controlled trials.

INTRODUCTION: Patients' treatment preferences (PTP) depend on the complex interaction of numerous patient- and treatment-related factors; their assessment can guide therapy and promote compliance of patients with erectile dysfunction (ED). We aimed to systematically describe the literature evaluating the treatment preferences of patients with ED, published in the last 25 years. EVIDENCE ACQUISITION: A comprehensive bibliographic search of multiple databases was conducted in June, 2023. The literature search was limited to the articles published since 1998. Articles were deemed eligible if they described male patients with ED (P) undergoing treatment for this condition (I) compared with other treatments, placebo or sham therapy (C), and reported PTP (O). Only randomized controlled trials (RCTs) and post-hoc analyses of RCTs were selected (S). The data were presented in a narrative fashion. The risk of bias (RoB) was evaluated using the RoB 2 tool and the Mulhall-Montorsi model. EVIDENCE SYNTHESIS: A total 14 RCTs evaluating 6,841 patients and 4 post-hoc analyses of RCTs were included. All RCTs were considered to be at high RoB. No validated tool was used to investigate PTP. Sildenafil was the most frequently evaluated ED treatment (9 RCTs). Sildenafil was chosen over placebo by 78-100% of subjects and over ICI in 70% of patients due to its easier route of administration. No significant difference in patient preference was recorded between Sildenafil tablets and orodispersible (53% vs. 47%, P>0.05). Tadalafil was preferred over Sildenafil by 66-73% of patients (P<0.05), mainly because it allowed an erection long after taking the drug (55-67%). Tadalafil as-needed was chosen over Tadalafil 3 times/week by 57-59% of the patients (P<0.05). CONCLUSIONS: The available RCTs support the preference of ED patients for Sildenafil over ICI, Tadalafil over Sildenafil, and Tadalafil as-needed over Tadalafil 3 times/week. However, these findings should be considered at high RoB.

Robotic Vena Cava Thrombectomy with Three-dimensional Augmented Reality Guidance.

Robotic surgery has recently been used for treatment of renal cell carcinoma (RCC) and neoplastic thrombus located in the renal vein or inferior vena cava (IVC). Accurate identification of the thrombus location is crucial, and three-dimensional augmented reality (3D AR) may be valuable in achieving this. We enrolled patients with nonmetastatic RCC and level 0-I venous thrombus (Mayo Clinic classification) for robot-assisted radical nephrectomy and thrombectomy with 3D AR guidance. Five patients were prospectively enrolled; three had a level 0 thrombus and two had a level I thrombus. The mean operative time was 123 ± 15 min, mean IVC clamping time was 9.4 ± 6.8 min, and mean estimated blood loss was 750 ± 150 ml. The AR system allowed precise estimation of the thrombus location in all cases. No intraoperative complications or postoperative Clavien-Dindo grade >2 complications occurred. Use of 3D AR guidance allowed correct estimation of the limits of the thrombus and guided the surgeon in selecting an appropriate surgical strategy.

Automatic 3D Augmented-Reality Robot-Assisted Partial Nephrectomy Using Machine Learning: Our Pioneer Experience.

The aim of "Precision Surgery" is to reduce the impact of surgeries on patients' global health. In this context, over the last years, the use of three-dimensional virtual models (3DVMs) of organs has allowed for intraoperative guidance, showing hidden anatomical targets, thus limiting healthy-tissue dissections and subsequent damage during an operation. In order to provide an automatic 3DVM overlapping in the surgical field, we developed and tested a new software, called "ikidney", based on convolutional neural networks (CNNs). From January 2022 to April 2023, patients affected by organ-confined renal masses amenable to RAPN were enrolled. A bioengineer, a software developer, and a surgeon collaborated to create hyper-accurate 3D models for automatic 3D AR-guided RAPN, using CNNs. For each patient, demographic and clinical data were collected. A total of 13 patients were included in the present study. The average anchoring time was 11 (6-13) s. Unintended 3D-model automatic co-registration temporary failures happened in a static setting in one patient, while this happened in one patient in a dynamic setting. There was one failure; in this single case, an ultrasound drop-in probe was used to detect the neoplasm, and the surgery was performed under ultrasound guidance instead of AR guidance. No major intraoperative nor postoperative complications (i.e., Clavien Dindo > 2) were recorded. The employment of AI has unveiled several new scenarios in clinical practice, thanks to its ability to perform specific tasks autonomously. We employed CNNs for an automatic 3DVM overlapping during RAPN, thus improving the accuracy of the superimposition process.

Overactive bladder negatively affects erectile function and promotes premature ejaculation: findings from large representative population-level study.

PURPOSE: The effect of overactive bladder (OAB) on sexual health has been evaluated extensively for women but much less for men. Therefore, the aim of this study was to evaluate the relationship between OAB and men's sexual activity and the effect of OAB on erectile dysfunction (ED) and premature ejaculation (PE) in a large representative cohort of men at the population level. METHODS: This study was based on computer-assisted web interviews that used validated questionnaires. The most recent census and the sample size estimation calculations were employed to produce a population-representative pool. RESULTS: The study included 3001 men, representative of the population in terms of age and place of residence. The frequency of sexual intercourse was higher for respondents without OAB symptoms compared with persons who had OAB (p = 0.001), but there was no association between OAB symptoms and number of sexual partners (p = 0.754). Regression models did not confirm the effect of OAB on sexual activity (odds ratio 0.993, CI 0.974-1.013, p = 0.511). Both ED and PE were more prevalent in respondents with OAB symptoms compared with persons who lacked those symptoms (p < 0.001). Importantly, the effect of OAB on ED or PE was independent of age, comorbidities, and lifestyle habits (regression coefficients of 0.13 and 0.158 for ED and PE, respectively). CONCLUSION: Overactive bladder did not significantly affect men's sexual activity, but it significantly correlated with ED and PE. Our results suggest a need in daily clinical practice to screen for OAB symptoms for persons who report ED or PE.

Development of Machine Learning Algorithm to Predict the Risk of Incontinence After Robot-Assisted Radical Prostatectomy.

Introduction: Predicting postoperative incontinence beforehand is crucial for intensified and personalized rehabilitation after robot-assisted radical prostatectomy. Although nomograms exist, their retrospective limitations highlight artificial intelligence (AI)'s potential. This study seeks to develop a machine learning algorithm using robot-assisted radical prostatectomy (RARP) data to predict postoperative incontinence, advancing personalized care. Materials and Methods: In this propsective observational study, patients with localized prostate cancer undergoing RARP between April 2022 and January 2023 were assessed. Preoperative variables included age, body mass index, prostate-specific antigen (PSA) levels, digital rectal examination (DRE) results, Gleason score, International Society of Urological Pathology grade, and continence and potency questionnaires responses. Intraoperative factors, postoperative outcomes, and pathological variables were recorded. Urinary continence was evaluated using the Expanded Prostate cancer Index Composite questionnaire, and machine learning models (XGBoost, Random Forest, Logistic Regression) were explored to predict incontinence risk. The chosen model's SHAP values elucidated variables impacting predictions. Results: A dataset of 227 patients undergoing RARP was considered for the study. Post-RARP complications were predominantly low grade, and urinary continence rates were 74.2%, 80.7%, and 91.4% at 7, 13, and 90 days after catheter removal, respectively. Employing machine learning, XGBoost proved the most effective in predicting postoperative incontinence risk. Significant variables identified by the algorithm included nerve-sparing approach, age, DRE, and total PSA. The model's threshold of 0.67 categorized patients into high or low risk, offering personalized predictions about the risk of incontinence after surgery. Conclusions: Predicting postoperative incontinence is crucial for tailoring rehabilitation after RARP. Machine learning algorithm, particularly XGBoost, can effectively identify those variables more heavily, impacting the outcome of postoperative continence, allowing to build an AI-driven model addressing the current challenges in post-RARP rehabilitation.

Computer Vision and Machine-Learning Techniques for Automatic 3D Virtual Images Overlapping During Augmented Reality Guided Robotic Partial Nephrectomy.

OBJECTIVES: The research's purpose is to develop a software that automatically integrates and overlay 3D virtual models of kidneys harboring renal masses into the Da Vinci robotic console, assisting surgeon during the intervention. INTRODUCTION: Precision medicine, especially in the field of minimally-invasive partial nephrectomy, aims to use 3D virtual models as a guidance for augmented reality robotic procedures. However, the co-registration process of the virtual images over the real operative field is performed manually. METHODS: In this prospective study, two strategies for the automatic overlapping of the model over the real kidney were explored: the computer vision technology, leveraging the super-enhancement of the kidney allowed by the intraoperative injection of Indocyanine green for superimposition and the convolutional neural network technology, based on the processing of live images from the endoscope, after a training of the software on frames from prerecorded videos of the same surgery. The work-team, comprising a bioengineer, a software-developer and a surgeon, collaborated to create hyper-accuracy 3D models for automatic 3D-AR-guided RAPN. For each patient, demographic and clinical data were collected. RESULTS: Two groups (group A for the first technology with 12 patients and group B for the second technology with 8 patients) were defined. They showed comparable preoperative and post-operative characteristics. Concerning the first technology the average co-registration time was 7 (3-11) seconds while in the case of the second technology 11 (6-13) seconds. No major intraoperative or postoperative complications were recorded. There were no differences in terms of functional outcomes between the groups at every time-point considered. CONCLUSION: The first technology allowed a successful anchoring of the 3D model to the kidney, despite minimal manual refinements. The second technology improved kidney automatic detection without relying on indocyanine injection, resulting in better organ boundaries identification during tests. Further studies are needed to confirm this preliminary evidence.

The prognostic role of next-generation imaging-driven upstaging in newly diagnosed prostate cancer patients.

PURPOSE: Phase III evidence showed that next-generation imaging (NGI), such as prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT), provides higher diagnostic accuracy than bone scan and contrast-enhanced computed tomography (conventional imaging, CI) in the primary staging of intermediate-to-high-risk prostate cancer (PCa) patients. However, due to the lack of outcome data, the introduction of NGI in routine clinical practice is still debated. Analysing the oncological outcome of patients upstaged by NGI (though managed according to CI) might shed light on this issue, supporting the design of randomised trials comparing the effects of treatments delivered based on NGI vs. CI. METHODS: We prospectively enrolled a cohort of 100 biopsy-proven intermediate-to-high-risk PCa patients staged with CI and PSMA PET/CT (though managed according to the CI stage), to assess the frequency of the stage migration phenomenon. Stage migration was then assessed as biochemical recurrence-free survival (bRFS) predictor. RESULTS: Three patients were lost at follow-up after imaging. PSMA PET/CT upstaged 26.8% of patients compared to CI, while it downstaged 6.1% of patients. Notably, 50% of patients excluded from surgery due to the presence of bone metastases at CI would have been treated with radical-intent approaches if PSMA PET/CT had guided the treatment choice. After a median follow-up of 6 months of surgically treated patients, 22/83 (26.5%) had biochemical recurrence (BCR). PSMA PET/CT-driven upstaging determined a significant risk increase for BCR (HR:3.41, 95%CI:1.21-9.56, p = 0.019). Including stage migration in a univariable and multivariable model identified PSMA PET/CT-upstaging as an independent predictor of bRFS. CONCLUSIONS: In conclusion, implementing NGI for staging purposes improves the prediction of bRFS. Although phase III evidence is still needed, this advancement suggests that NGI may better identify patients who would benefit from local treatments than those who may achieve better oncological outcomes through systemic treatment.

Current evidence of robotic-assisted surgery use in functional reconstructive and neuro-urology.

The use of robot-assisted technology has been widely adopted in urological oncological surgery and its benefits have been well established. In recent years, robotic technology has also been used in several functional reconstructive and neuro-urology (FRNU) procedures. The aim of this review was to evaluate the current evidence in the use of robotic technology in the field of FRNU. We performed a PubMed-based literature search between July and August 2022. The keywords we included were 'robotic assisted', 'ureteric reimplantation', 'cystoplasty', 'ileal conduit', 'neobladder', 'sacrocolpopexy', 'colposuspension', 'artificial urinary sphincter', 'genitourinary fistula' and 'posterior urethral stenoses'. We identified the latest available evidence in the use of robotic technology in specific FRNU procedures such as the reconstruction of the ureters, bladder and urinary sphincter, urinary diversion, and repair of genitourinary prolapse and fistula. We found that there is a lack of prospective studies to assess the robotic-assisted approach in the field of FRNU. Despite this, the advantages that robotic technology can bring to the field of FRNU are evident, including better ergonomics and visual field, less blood loss and shorter hospital stays. There is therefore a need for further prospective studies with larger patient numbers and longer follow-up periods to establish the reproducibility of these results and the long-term efficacy of the procedures, as well as the impact on patient outcomes. Common index procedures and a standardized approach to these procedures should be identified to enhance training.

Development of Bleeding Artificial Intelligence Detector (BLAIR) System for Robotic Radical Prostatectomy.

BACKGROUND: Addressing intraoperative bleeding remains a significant challenge in the field of robotic surgery. This research endeavors to pioneer a groundbreaking solution utilizing convolutional neural networks (CNNs). The objective is to establish a system capable of forecasting instances of intraoperative bleeding during robot-assisted radical prostatectomy (RARP) and promptly notify the surgeon about bleeding risks. METHODS: To achieve this, a multi-task learning (MTL) CNN was introduced, leveraging a modified version of the U-Net architecture. The aim was to categorize video input as either "absence of blood accumulation" (0) or "presence of blood accumulation" (1). To facilitate seamless interaction with the neural networks, the Bleeding Artificial Intelligence-based Detector (BLAIR) software was created using the Python Keras API and built upon the PyQT framework. A subsequent clinical assessment of BLAIR's efficacy was performed, comparing its bleeding identification performance against that of a urologist. Various perioperative variables were also gathered. For optimal MTL-CNN training parameterization, a multi-task loss function was adopted to enhance the accuracy of event detection by taking advantage of surgical tools' semantic segmentation. Additionally, the Multiple Correspondence Analysis (MCA) approach was employed to assess software performance. RESULTS: The MTL-CNN demonstrated a remarkable event recognition accuracy of 90.63%. When evaluating BLAIR's predictive ability and its capacity to pre-warn surgeons of potential bleeding incidents, the density plot highlighted a striking similarity between BLAIR and human assessments. In fact, BLAIR exhibited a faster response. Notably, the MCA analysis revealed no discernible distinction between the software and human performance in accurately identifying instances of bleeding. CONCLUSION: The BLAIR software proved its competence by achieving over 90% accuracy in predicting bleeding events during RARP. This accomplishment underscores the potential of AI to assist surgeons during interventions. This study exemplifies the positive impact AI applications can have on surgical procedures.

3D Model Artificial Intelligence-Guided Automatic Augmented Reality Images during Robotic Partial Nephrectomy.

More than ever, precision surgery is making its way into modern surgery for functional organ preservation. This is possible mainly due to the increasing number of technologies available, including 3D models, virtual reality, augmented reality, and artificial intelligence. Intraoperative surgical navigation represents an interesting application of these technologies, allowing to understand in detail the surgical anatomy, planning a patient-tailored approach. Automatic superimposition comes into this context to optimally perform surgery as accurately as possible. Through a dedicated software (the first version) called iKidney, it is possible to superimpose the images using 3D models and live endoscopic images during partial nephrectomy, targeting the renal mass only. The patient is 31 years old with a 28 mm totally endophytic right-sided renal mass, with a PADUA score of 9. Thanks to the automatic superimposition and selective clamping, an enucleoresection of the renal mass alone was performed with no major postoperative complication (i.e., Clavien-Dindo < 2). iKidney-guided partial nephrectomy is safe, feasible, and yields excellent results in terms of organ preservation and functional outcomes. Further validation studies are needed to improve the prototype software, particularly to improve the rotational axes and avoid human help. Furthermore, it is important to reduce the costs associated with these technologies to increase its use in smaller hospitals.

Three-dimensional automatic artificial intelligence driven augmented-reality selective biopsy during nerve-sparing robot-assisted radical prostatectomy: A feasibility and accuracy study.

Objective: To evaluate the accuracy of our new three-dimensional (3D) automatic augmented reality (AAR) system guided by artificial intelligence in the identification of tumour's location at the level of the preserved neurovascular bundle (NVB) at the end of the extirpative phase of nerve-sparing robot-assisted radical prostatectomy. Methods: In this prospective study, we enrolled patients with prostate cancer (clinical stages cT1c-3, cN0, and cM0) with a positive index lesion at target biopsy, suspicious for capsular contact or extracapsular extension at preoperative multiparametric magnetic resonance imaging. Patients underwent robot-assisted radical prostatectomy at San Luigi Gonzaga Hospital (Orbassano, Turin, Italy), from December 2020 to December 2021. At the end of extirpative phase, thanks to our new AAR artificial intelligence driven system, the virtual prostate 3D model allowed to identify the tumour's location at the level of the preserved NVB and to perform a selective excisional biopsy, sparing the remaining portion of the bundle. Perioperative and postoperative data were evaluated, especially focusing on the positive surgical margin (PSM) rates, potency, continence recovery, and biochemical recurrence. Results: Thirty-four patients were enrolled. In 15 (44.1%) cases, the target lesion was in contact with the prostatic capsule at multiparametric magnetic resonance imaging (Wheeler grade L2) while in 19 (55.9%) cases extracapsular extension was detected (Wheeler grade L3). 3D AAR guided biopsies were negative in all pathological tumour stage 2 (pT2) patients while they revealed the presence of cancer in 14 cases in the pT3 cohort (14/16; 87.5%). PSM rates were 0% and 7.1% in the pathological stages pT2 and pT3 (<3 mm, Gleason score 3), respectively. Conclusion: With the proposed 3D AAR system, it is possible to correctly identify the lesion's location on the NVB in 87.5% of pT3 patients and perform a 3D-guided tailored nerve-sparing even in locally advanced diseases, without compromising the oncological safety in terms of PSM rates.

Comparison of perioperative and short-terms outcomes of en-bloc Holmium laser enucleation of the prostate (HoLEP) and robot-assisted simple prostatectomy: a propensity-score matching analysis.

BACKGROUND: Surgical treatment of symptomatic benign prostatic hyperplasia (BPH) has seen an evolution during the last decades. On one hand, en-bloc HoLEP emerged as a valid endoscopic treatment regardless prostate size. On the other hand, robot-assisted simple prostatectomy (RASP) has gained attention in larger prostates showing encouraging results. Herein, for the first time in the scientific scenario, we sought to compare the outcomes of RASP and en-bloc HoLEP cases after propensity-score matching (PSM) analysis. METHODS: We retrospectively queried our prospectively database of patients treated with HoLEP or RASP between 2017 and 2022 among two high-volume centers. PSM was applied based on the International Prostate Symptom Score (IPSS) questionnaire, prostate volume and max-flow rate. All procedures were performed by a single surgeon per center. Outcomes were assessed at 1, 3, and 6-month postoperatively and therefore annually. Trifecta definition was used to assess "success" in surgical procedures and was defined as the contemporary presence of: a) no postoperative complications within the first postoperative month; b) 1-month postoperative Qmax >15 ml/s and c) no urinary incontinence at 3-month evaluation. RESULTS: Overall, 48 HoLEP and 47 RASPs were matched. Operative time, hospitalization time (median 4 vs 5 days) and catheterization time (median 3 vs 2 day) were found to be shorter in the HoLEP group as compared to the counterpart (p < 0.05). Early postoperative complication rate was also lower in the HoLEP cohort (6.2% vs 12.6%; p = 0.03) as well as postoperative haemoglobine blood level drop (1.4 vs 2.4 g/dL; p = 0.03). On the other hand, postoperative antegrade ejaculation (55.3% vs 6.8%) 1-month max flow (median 28 vs 24 ml/sec) and continence rates (0% vs 20.8%) favored RASP (p < 0.05). Overall, Trifecta rate was similar in the two groups (76.1% vs 82.6%). CONCLUSION: Both HoLEP and RASP are safe and effective treatments for symptomatic BPH. HoLEP demonstrated to have lower perioperative risks while is affecting by a higher probability of transient early UI. On the other hand, RASP is more effective in reducing postoperative ejaculatory dysfunction.

Metaverse Surgical Planning with Three-dimensional Virtual Models for Minimally Invasive Partial Nephrectomy.

The recent integration of new virtual visualization modalities with artificial intelligence and high-speed internet connection has opened the door to the advent of the metaverse in medicine. In this totally virtual environment, three-dimensional virtual models (3DVMs) of the patient's anatomy can be visualized and discussed via digital avatars. Here we present for the first time a metaverse preoperative clinical case discussion before minimally invasive partial nephrectomy. The surgeons' digital avatars met in a virtual room and participated in a virtual consultation on the surgical strategy and clamping approach before the procedure. Robotic or laparoscopic procedures are then carried out according to the simulated surgical strategy. We demonstrate how this immersive virtual reality experience overcomes the barriers of distance and how the quality of surgical planning is enriched by a great sense of "being there", even if virtually. Further investigation will improve the quality of interaction with the models and among the avatars.

The impact of a second MRI and re-biopsy in patients with initial negative mpMRI-targeted and systematic biopsy for PIRADS ≥ 3 lesions.

OBJECTIVE: To evaluate the proportions of detected prostate cancer (PCa) and clinically significant PCa (csPCa), as well as identify clinical predictors of PCa, in patients with PI-RADS > = 3 lesion at mpMRI and initial negative targeted and systematic biopsy (initial biopsy) who underwent a second MRI and a re-biopsy. METHODS: A total of 290 patients from 10 tertiary referral centers were included. The primary outcome measures were the presence of PCa and csPCa at re-biopsy. Logistic regression analyses were performed to evaluate predictors of PCa and csPCa, adjusting for relevant covariates. RESULTS: Forty-two percentage of patients exhibited the presence of a new lesion. Furthermore, at the second MRI, patients showed stable, upgrading, and downgrading PI-RADS lesions in 42%, 39%, and 19%, respectively. The interval from the initial to repeated mpMRI and from the initial to repeated biopsy was 16 mo (IQR 12-20) and 18 mo (IQR 12-21), respectively. One hundred and eight patients (37.2%) were diagnosed with PCa and 74 (25.5%) with csPCa at re-biopsy. The presence of ASAP on the initial biopsy strongly predicted the presence of PCa and csPCa at re-biopsy. Furthermore, PI-RADS scores at the first and second MRI and a higher number of systematic biopsy cores at first and second biopsy were independent predictors of the presence of PCa and csPCa. Selection bias cannot be ruled out. CONCLUSIONS: Persistent PI-RADS ≥ 3 at the second MRI is suggestive of the presence of a not negligible proportion of csPca. These findings contribute to the refinement of risk stratification for men with initial negative MRI-TBx.

Predictors of mid-term functional outcomes for robot-assisted Madigan simple prostatectomy: results of a multicentric series according to the BPH-6 achievement.

BACKGROUND: BPH-6 achievement remains an objective far to be evaluated for every technique currently available for the surgical management of bladder outlet obstruction (BOO) with the goal of preserving ejaculatory function. The aim of this study was to evaluate predictors of BPH-6 achievement of urethral-sparing robot assisted simple prostatectomy (us-RASP) on a large series performed at two tertiary-care centers. METHODS: Two institutional us-RASP datasets were merged, considering eligible all patients with a follow-up >12 months. Baseline, perioperative and functional data according to BPH-6 endpoint were assessed. Descriptive analysis was used. Frequencies and proportions were reported for categorical variables while medians and interquartile ranges (IQRs) were reported for continuously coded variables. A logistic regression model was built to identify predictors of BPH-6 achievement. For all statistical analyses, a two-sided P<0.05 was considered significant. RESULTS: Study cohort consisted of 94 eligible patients. The median follow-up was 40.7 months (IQR 31.3-54.2). Overall BPH-6 achievement was 54.7%. Compared to baseline, reduction of ≥30% in IPSS was observed in 93.6% of patients, reduction of <6 points for SHIM in 95.7% and response to MSHQ-EjD question 3 indicating emission of semen in 72.6%, respectively. On multivariable analysis, prostate volume between 110-180 mL (OR 0.09; 95% CI 0.01-0.92; P=0.043) and higher preoperative SHIM score (OR 1.18; 95% CI 1.05-1.32; P<0.01) were independent predictors of BPH-6 metric achievement. CONCLUSIONS: us-RASP may provide a complete resolution of BOO and preservation of ejaculatory function in sexually active men with a prostate volume ranging 110-180 mL.

Urinary outcomes of new ultra-minimally invasive treatments for prostate cancers.

PURPOSE OF REVIEW: The aim of this narrative review is to evaluate the current available literature on urinary outcomes following cryotherapy and high-intensity focused ultrasound (HIFU) for localized prostate cancer (PCa). RECENT FINDINGS: The available literature is heterogeneous in terms of intervention modalities and assessment of urinary outcome measures. Nevertheless, ultra-minimally invasive treatments seem to provide good urinary outcomes. Technological advancement and the adoption of more conservative ablation templates allow for a further reduction of toxicity and better preservation of urinary function. Urinary incontinence occurs in 0-10% of the patients and, is mostly transient. Voiding and storage lower urinary tract symptoms (LUTS) mostly occur in the early postoperative period and rarely require surgical treatment. Focal therapies performed with a salvage intent after external beam radiotherapy have a significantly higher impact on patient's urinary function. SUMMARY: Ultra-minimally invasive treatment for PCa show a good safety profile concerning urinary function, but consensus on when and how best to assess this is still lacking. Efforts should be made to standardize the report of preoperative and postoperative urinary function to provide higher level of evidence.

Machine-Learning-Based Tool to Predict Target Prostate Biopsy Outcomes: An Internal Validation Study.

The aim of this study is to present a personalized predictive model (PPM) with a machine learning (ML) system that is able to identify and classify patients with suspected prostate cancer (PCa) following mpMRI. We extracted all the patients who underwent fusion biopsy (FB) from March 2014 to December 2019, while patients from August 2020 to April 2021 were included as a validation set. The proposed system was based on the following four ML methods: a fuzzy inference system (FIS), the support vector machine (SVM), k-nearest neighbors (KNN), and self-organizing maps (SOMs). Then, a system based on fuzzy logic (FL) + SVM was compared with logistic regression (LR) and standard diagnostic tools. A total of 1448 patients were included in the training set, while 181 patients were included in the validation set. The area under the curve (AUC) of the proposed FIS + SVM model was comparable with the LR model but outperformed the other diagnostic tools. The FIS + SVM model demonstrated the best performance, in terms of negative predictive value (NPV), on the training set (78.5%); moreover, it outperformed the LR in terms of specificity (92.1% vs. 83%). Considering the validation set, our model outperformed the other methods in terms of NPV (60.7%), sensitivity (90.8%), and accuracy (69.1%). In conclusion, we successfully developed and validated a PPM tool using the FIS + SVM model to calculate the probability of PCa prior to a prostate FB, avoiding useless ones in 15% of the cases.