Incidence of complications and urinary incontinence following endoscopic enucleation of the prostate in men with a prostate volume of 80 ml and above: results from a multicenter, real-world experience of 2512 patients.

PURPOSE: To evaluate complications and urinary incontinence (UI) after endoscopic enucleation of the prostate (EEP) stratified by prostate volume (PV). METHODS: We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with different energy sources in 14 centers (January 2019-January 2023). INCLUSION CRITERIA: prostate volume ≥ 80 ml. EXCLUSION CRITERIA: prostate cancer, previous prostate/urethral surgery, pelvic radiotherapy. PRIMARY OUTCOME: complication rate. SECONDARY OUTCOMES: incidence of and factors affecting postoperative UI. Patients were divided into 3 groups. Group 1: PV = 80-100 ml; Group 2 PV = 101-200 ml; Group 3 PV > 200 ml. Multivariable logistic regression analysis was performed to evaluate independent predictors of overall incontinence. RESULTS: There were 486 patients in Group 1, 1830 in Group 2, and 196 in Group 3. The most commonly used energy was high-power Holmium laser followed by Thulium fiber laser in all groups. Enucleation, morcellation, and total surgical time were significantly longer in Group 2. There was no significant difference in overall 30-day complications and readmission rates. Incontinence incidence was similar (12.1% in Group 1 vs. 13.2% in Group 2 vs. 11.7% in Group 3, p = 0.72). The rate of stress and mixed incontinence was higher in Group 1. Multivariable regression analysis showed that age (OR 1.019 95% CI 1.003-1.035) was the only factor significantly associated with higher odds of incontinence. CONCLUSIONS: PV has no influence on complication and UI rates following EEP. Age is risk factor of postoperative UI.

Metabolic disorders affecting the liver and heart: Therapeutic efficacy of miRNA-based therapies?

Liver and heart disease are major causes of death worldwide. It is known that metabolic alteration causing type 2 diabetes (T2D) and Nonalcoholic fatty liver (NAFLD) coupled with a derangement in lipid homeostasis, may exacerbate hepatic and cardiovascular diseases. Some pharmacological treatments can mitigate organ dysfunctions but the important side effects limit their efficacy leading often to deterioration of the tissues. It needs to develop new personalized treatment approaches and recent progresses of engineered RNA molecules are becoming increasingly viable as alternative treatments. This review outlines the current use of antisense oligonucleotides (ASOs), RNA interference (RNAi) and RNA genome editing as treatment for rare metabolic disorders. However, the potential for small non-coding RNAs to serve as therapeutic agents for liver and heart diseases is yet to be fully explored. Although miRNAs are recognized as biomarkers for many diseases, they are also capable of serving as drugs for medical intervention; several clinical trials are testing miRNAs as therapeutics for type 2 diabetes, nonalcoholic fatty liver as well as cardiac diseases. Recent advances in RNA-based therapeutics may potentially facilitate a novel application of miRNAs as agents and as druggable targets. In this work, we sought to summarize the advancement and advantages of miRNA selective therapy when compared to conventional drugs. In particular, we sought to emphasise druggable miRNAs, over ASOs or other RNA therapeutics or conventional drugs. Finally, we sought to address research questions related to efficacy, side-effects, and range of use of RNA therapeutics. Additionally, we covered hurdles and examined recent advances in the use of miRNA-based RNA therapy in metabolic disorders such as diabetes, liver, and heart diseases.

Influence of gestational diabetes mellitus on subclinical myocardial dysfunction during pregnancy: A systematic review and meta-analysis.

OBJECTIVE: The correlation between gestational diabetes mellitus (GDM) and subclinical myocardial dysfunction has been poorly investigated. Accordingly, we performed a meta-analysis to examine the influence of GDM on left ventricular (LV) global longitudinal strain (GLS), assessed by speckle tracking echocardiography (STE), during pregnancy. STUDY DESIGN: All echocardiographic studies assessing conventional echoDoppler parameters and LV-GLS in GDM women vs. healthy controls, selected from PubMed and EMBASE databases, were included. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment of Case-Control Studies. The subtotal and overall standardized mean differences (SMDs) of LV-GLS were calculated using the random-effect model. RESULTS: The full-texts of 10 studies with 1147 women with GDM and 7706 pregnant women without diabetes were analyzed. GDM women enrolled in the included studies were diagnosed with a small reduction in LV-GLS in comparison to controls (average value -19.4 ± 2.5 vs -21.8 ± 2.5 %, P < 0.001) and to the accepted reference values (more negative than -20 %). Substantial heterogeneity was detected for the included studies, with an overall statistic value I2 of 94.4 % (P < 0.001). Large SMDs were obtained for the included studies, with an overall SMD of -0.97 (95 %CI -1.32, -0.63, P < 0.001). Egger's test for a regression intercept gave a P-value of 0.99, indicating no publication bias. On meta-regression analysis, all moderators and/or potential confounders (age at pregnancy, BMI, systolic blood pressure and ethnicity) were not significantly associated with effect modification (all P < 0.05). CONCLUSIONS: GDM is independently associated with subclinical myocardial dysfunction in pregnancy. STE analysis allows to identify, among GDM women, those who might benefit of targeted non-pharmacological and/or pharmacological interventions, aimed at reducing the risk of developing type 2 diabetes and cardiovascular complications later in life.

The effect of gestational diabetes mellitus on carotid artery intima-media thickness in and after pregnancy: a systematic review and meta-analysis.

AIMS: The association between gestational diabetes mellitus (GDM) and common carotid artery (CCA) intima-media thickness (IMT) is still controversial. This systematic review and meta-analysis was performed to assess the correlation between GDM and CCA-IMT in and after pregnancy. METHODS: PubMed and EMBASE databases were systematically reviewed on April 2023. Studies measuring CCA-IMT in both pregnant women with GDM and women with previous history of GDM (pGDM) vs. healthy controls were included. The subtotal and overall standardized mean differences (SMDs) of CCA-IMT were calculated using the random-effect model. RESULTS: Nineteen studies with a total of 302 GDM and 861 pGDM women were analyzed. The average value of CCA-IMT measured in GDM/pGDM (0.59 ± 0.12 mm) was slightly increased in comparison to the accepted reference limits of IMT according to age classes. Substantial heterogeneity was detected for the studies involving both GDM and pGDM women, with an overall statistic I2 of 86.0% (p < 0.001). Large SMDs were obtained for the studies conducted on both GDM and pGDM women, with an overall SMD of 0.89 (95%CI 0.63-1.15, p < 0.001). Egger's test for a regression intercept gave a p-value of 0.37, indicating no publication bias. On meta-regression analysis, all potential confounders (number of patients, age at pregnancy, body mass index, measuring time, follow-up duration and GDM criteria) were not significantly associated with effect modification. CONCLUSIONS: GDM in and after pregnancy is independently associated with subclinical atherosclerosis. The association between GDM and carotid remodeling is potentially mediated by the longstanding underlying risk.

Transperineal US-MRI Fusion-Guided Biopsy for the Detection of Clinical Significant Prostate Cancer: A Systematic Review and Meta-Analysis Comparing Cognitive and Software-Assisted Technique.

INTRODUCTION: We aimed to find potential differences in clinically significant prostate cancer (csPCa) detection rates between transperineal software-assisted fusion biopsy (saFB) and cognitive fusion biopsies (cFB). METHODS: A systematic review of the literature was performed to identify comparative studies using PubMed, EMBASE, and Scopus according to the PICOS criteria. Cancer detection and complication rates were pooled using the Cochran-Mantel-Haenszel method with the random effect model and reported as odds ratios (ORs), 95% confidence intervals (CI), and p-values. A meta-analysis was performed using Review Manager (RevMan) 5.4 software by Cochrane Collaboration. The quality assessment of the included studies was performed using the Cochrane Risk of Bias tool, using RoB 2 for randomized studies and ROBINS-I for retrospective and nonrandomized ones. RESULTS: Eight studies were included for the meta-analysis, including 1149 cases in software-based and 963 cases in cognitive fusion biopsy. The detection rates of csPCa were similar between the two groups (OR 1.01, 95% CI 0.74-1.37, p = 0.95). Study heterogeneity was low (I2 55%). CONCLUSION: There is no actual evidence of the superiority of saFB over cFB in terms of the csPCa detection rate. Operator experience and software availability can drive the choice of one fusion technique over the other.

Improving Outcomes of Same-sitting Bilateral Flexible Ureteroscopy for Renal Stones in Real-world Practice-Lessons Learnt from Global Multicenter Experience of 1250 Patients.

Background: Bilateral kidney stones are commonly treated in staged procedures. Objective: To evaluate outcomes after same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS) for renal stones. Design setting and participants: Data from adults who underwent bilateral RIRS in 21 centers were retrospectively reviewed (from January 2015 to June 2022). The inclusion criteria were unilateral/bilateral symptomatic bilateral stone(s) of any size/location in both kidneys and bilateral stones on follow-up with symptom/stone progression. Stone-free rate (SFR) was defined as absence of any fragment >3 mm at 3 mo. Outcome measurements and statistical analysis: Continuous variables are presented as medians and 25-75th percentiles. A multivariable logistic regression analysis was performed to evaluate independent predictors of sepsis and bilateral SFR. Results and limitations: A total of 1250 patients were included. The median age was 48.0 (36-61) yr. Of the patients, 58.2% were prestented. The median stone diameter was 10 mm on both sides. Multiple stones were present in 45.3% and 47.9% of the left and right kidneys, respectively. Surgery was stopped in 6.8% of cases. The median surgical time was 75.0 (55-90) min. Complications were transient fever (10.7%), fever/infection needing prolonged stay (5.5%), sepsis (2%), and blood transfusion (1.3%). Bilateral and unilateral SFRs were 73.0% and 17.4%, respectively. Female (odds ratio [OR] 2.97, 95% confidence interval [CI] 1.18-7.49, p = 0.02), no antibiotic prophylaxis (OR 5.99, 95% CI 2.28-15.73, p < 0.001), kidney anomalies (OR 5.91, 95% CI 1.96-17.94, p < 0.001), surgical time ≥100 min (OR 2.86, 95% CI 1.12-7.31, p = 0.03) were factors associated with sepsis. Female (OR 1.88, 95% CI 1.35-2.62, p < 0.001), bilateral prestenting (OR 2.16, 95% CI 1.16-7.66, p = 0.04), and the use of high-power holmium:YAG laser (OR 1.63, 95% CI 1.14-2.34, p < 0.01) and thulium fiber laser (OR 2.50, 95% CI 1.32-4.74, p < 0.01) were predictors of bilateral SFR. Limitations were retrospective study and no cost analysis. Conclusions: SSB-RIRS is an effective treatment with an acceptable complication rate in selected patients with kidney stones. Patient summary: In this large multicenter study, we looked at outcomes after same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS) for renal stones in a large cohort. We found that SSB-RIRS was associated with acceptable morbidity and good stone clearance after a single session.

Vacuum erection device for erectile function rehabilitation after radical prostatectomy: which is the correct schedule? Results from a systematic, scoping review.

Vacuum erection device (VED), for its capacity to improve the peak flow and elasticity of cavernous arteries, is a well-known tool to improve recovery of erectile function (EF) after radical prostatectomy. Aim of this study is to compare the different therapeutic schemes proposed in literature to find the most effective timing for VED treatment and to evaluate its efficacy alone or associated with phosphodiesterase 5 inhibitors (PDE5i). We performed a systematic review of Literature in October 2022 using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials to retrieve all articles dealing with EF rehabilitation after radical prostatectomy (excluding non-English papers, reviews, or meeting abstracts). Patients were divided among those receiving VED alone or combined with other treatments. Study outcomes were compared dividing them between those with follow-up shorter or longer than 12 months. Sixteen papers were included according to selection criteria. Among them, seven were randomized-controlled trials, five were prospective observational studies and four were retrospective. VED alone was evaluated in eight articles, while the remaining papers evaluated the combination of VED with PDE5i. Regarding VED therapeutic protocol, 7/16 studies used it daily. Rehabilitation protocol lasted less than 1 year in 4 studies, up to 12 months in 6 studies and more than 1 year in 6 studies. All the studies show improvement in International Index of Erectile Function Questionnaire (IIEF-5), conservation of penile length and satisfactory intercourses when compared to controls. VED results appear to increase when patients were addressed to VED-dedicated programs to enhance their compliance with the device.

Does power setting impact surgical outcomes of holmium laser enucleation of the prostate? A systematic review and meta-analysis.

Introduction: The aim of this article was to enumerate the differences in immediate and postoperative outcomes for holmium laser enucleation of the prostate (HoLEP) performed with low-power (LP) or high-power (HP) laser settings through a systematic review of comparative studies. Material and methods: We performed a systematic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. Potential clinical differences among LP and HP HoLEP were determined using the PICOS (Patient Intervention Comparison Outcome Study type) model, where outcomes were surgical time, operative efficiency, postoperative catheterization time, length of hospital stay, blood transfusion, incontinence rate, maximum urinary flow rate (QMax) and International Prostatic Symptom score (IPSS). Retrospective, prospective nonrandomized, randomized studies, and meeting abstracts were considered. Results: A total of five studies were included for meta-analysis. No significant differences between LP and HP HoLEP were evidenced in terms of intraoperative variables (surgical time, surgical efficiency); postoperative outcomes (length of stay, length of catheterization); postoperative complications; functional results (IPSS; Qmax). Urinary incontinence rate did not differ between the two groups (OR 0.95, 95% CI 0.362.47, p = 0.91). Conclusions: The study shows equal outcomes in outcomes from HoLEP performed with LP or HP energy settings. Even if further comparative studies are still needed to increase the level of evidence, those results encourage a further clinical adoption of LP HoLEP.

Validation of the effectiveness of a modified Studer orthotopic neobladder in a single center after 3 years of its application.

INTRODUCTION AND OBJECTIVE: In this study, we reported the 2 years outcomes of orthotopic neobladder diversion according to the Studer modified technique described by Bianchi G. et al. This technique improves the stability of the reservoir and the urine-storage capacity. After radical cystectomy, urinary diversion is created with a spheroidal-shaped reservoir with a conic distal-part, obtained with 40 cm detubulized ileal segment, and a 15 cm of tubular afferent limb, where a Wallace ureteral anastomoses is made. The conic distal part of the neobladder that is anastomized to the urethral stump. After the reconstructive part, the neobladder and the afferent limb are attached to the elevator ani and psoas muscles, respectively. MATERIALS AND METHODS: In all, 18 patients underwent radical cystectomy with the reconstruction of urinary diversion with the Modified-Studer Orthotopic technique, at S. Giuseppe Hospital. We studied the post-operative years of follow-up, especially with anamnesis of lower urinary tract, axial computerized tomography, and blood tests, according to the EAU guidelines. RESULTS: We discover with TC 2 cases of low-grade bilateral hydronephrosis, associated with a slight increase in creatinine levels (1.4-1.8 mg/dL). No stricture at the neobladder-urethral anastomosis was detected. Three patients complain daytime urinary incontinence; only two patients report nocturnal urinary incontinence. One patient underwent ureteroscopy for lithiasis and 1 patient died for non-onco-urological disease. CONCLUSION: The modifications we applied to the Studer-Neobladder seems to improve urinary tract restoration, potentially decreasing long-term complications like hydronephrosis connected to ureteral anastomotic stenosis (11.1% vs 16.9% reported in literature) and urinary retention (0% vs 12% reported in literature). However, we discovered the same risk of diurnal and nocturnal incontinence reported in literature for the classic Studer Neobladder.

The Use of Multiparametric Magnetic Resonance Imaging for Follow-up of Patients Included in Active Surveillance Protocol. Can PSA Density Discriminate Patients at Different Risk of Reclassification?

INTRODUCTION: The objective of this study was to test Prostate Imaging Reporting and Data System (PI-RADS) classification on multiparametric magnetic resonance imaging (mpMRI) and MRI-derived prostate-specific antigen density (PSAD) in predicting the risk of reclassification in men in active surveillance (AS), who underwent confirmatory or per-protocol follow-up biopsy. MATERIALS AND METHODS: Three hundred eighty-nine patients in AS underwent mpMRI before confirmatory or follow-up biopsy. Patients with negative (-) mpMRI underwent systematic random biopsy. Patients with positive (+) mpMRI underwent targeted fusion prostate biopsies + systematic random biopsies. Different PSAD cutoff values were tested (< 0.10, 0.10-0.20, ≥ 0.20). Multivariable analyses assessed the risk of reclassification, defined as clinically significant prostate cancer of grade group 2 or more, during follow-up according to PSAD, after adjusting for covariates. RESULTS: One hundred twenty-seven (32.6%) patients had mpMRI(-); 72 (18.5%) had PI-RADS 3, 150 (38.6%) PI-RADS 4, and 40 (10.3%) PI-RADS 5 lesions. The rate of reclassification to grade group 2 PCa was 16%, 22%, 31%, and 39% for mpMRI(-) and PI-RADS 3, 4, and 5, respectively, in case of PSAD < 0.10 ng/mL2; 16%, 25%, 36%, and 44%, in case of PSAD 0.10 to 0.19 ng/mL2; and 25%, 42%, 55%, and 67% in case of PSAD ≥ 0.20 ng/mL2. PSAD ≥ 0.20 ng/mL2 (odds ratio [OR], 2.45; P = .007), PI-RADS 3 (OR, 2.47; P = .013), PI-RADS 4 (OR, 2.94; P < .001), and PI-RADS 5 (OR, 3.41; P = .004) were associated with a higher risk of reclassification. CONCLUSION: PSAD ≥ 0.20 ng/mL2 may improve predictive accuracy of mpMRI results for reclassification of patients in AS, whereas PSAD < 0.10 ng/mL2 may help selection of patients at lower risk of harboring clinically significant prostate cancer. However, the risk of reclassification is not negligible at any PSAD cutoff value, also in the case of mpMRI(-).

Prostate Cancer Peripheral Blood NK Cells Show Enhanced CD9, CD49a, CXCR4, CXCL8, MMP-9 Production and Secrete Monocyte-Recruiting and Polarizing Factors.

Natural killer (NK) cells, effector lymphocytes of the innate immunity, have been shown to be altered in several cancers, both at tissue and peripheral levels. We have shown that in Non-Small Cell Lung Cancer (NSCLC) and colon cancer, tumour associated circulating NK (TA-NK) and tumour infiltrating NK (TI-NK) exhibit pro-angiogenic phenotype/functions. However, there is still a lack of knowledge concerning the phenotype of peripheral blood (PB) NK (pNK) cells in prostate cancer (PCa). Here, we phenotypically and functionally characterized pNK from PCa patients (PCa TA-NKs) and investigated their interactions with endothelial cells and monocytes/macrophages. NK cell subset distribution in PB of PCa patients was investigated, by multicolor flow cytometry, for surface antigens expression. Protein arrays were performed to characterize the secretome on FACS-sorted pNK cells. Conditioned media (CM) from FACS-sorted PCa pTA-NKs were used to determine their ability to induce pro-inflammatory/pro-angiogenic phenotype/functions in endothelial cells, monocytes, and macrophages. CM from three different PCa (PC-3, DU-145, LNCaP) cell lines, were used to assess their effects on human NK cell polarization in vitro, by multicolor flow cytometry. We found that PCa pTA-NKs acquire the CD56brightCD9+CD49a+CXCR4+ phenotype, increased the expression of markers of exhaustion (PD-1, TIM-3) and are impaired in their degranulation capabilities. Similar effects were observed on healthy donor-derived pNK cells, exposed to conditioned media of three different PCa cell lines, together with increased production of pro-inflammatory chemokines/chemokine receptors CXCR4, CXCL8, CXCL12, reduced production of TNFα, IFNγ and Granzyme-B. PCa TA-NKs released factors able to support inflammatory angiogenesis in an in vitro model and increased the expression of CXCL8, ICAM-1, and VCAM-1 mRNA in endothelial cells. Secretome analysis revealed the ability of PCa TA-NKs to release pro-inflammatory cytokines/chemokines involved in monocyte recruitment and M2-like polarization. Finally, CMs from PCa pTA-NKs recruit THP-1 and peripheral blood CD14+ monocyte and polarize THP-1 and peripheral blood CD14+ monocyte-derived macrophage towards M2-like/TAM macrophages. Our results show that PCa pTA-NKs acquire properties related to the pro-inflammatory angiogenesis in endothelial cells, recruit monocytes and polarize macrophage to an M2-like type phenotype. Our data provides a rationale for a potential use of pNK profiling in PCa patients.

Multiparametric magnetic resonance imaging and clinical variables: Which is the best combination to predict reclassification in active surveillance patients?

INTRODUCTION & OBJECTIVES: We tested the role of multiparametric magnetic resonance imaging (mpMRI) in disease reclassification and whether the combination of mpMRI and clinicopathological variables could represent the most accurate approach to predict the risk of reclassification during active surveillance. MATERIALS & METHODS: Three-hundred eighty-nine patients (pts) underwent mpMRI and subsequent confirmatory or follow-up biopsy according to the Prostate Cancer Research International Active Surveillance (PRIAS) protocol. Pts with negative (-) mpMRI underwent systematic random biopsy. Pts with positive (+) mpMRI [Prostate Imaging Reporting and Data System, version 2 (PI-RADS-V2) score ≥3] underwent targeted + systematic random biopsies. Multivariate analyses were used to create three models predicting the probability of reclassification [International Society of Urological Pathology ≥ Grade Group 2 (GG2)]: a basic model including only clinical variables (age, prostate-specific antigen density, and number of positive cores at baseline), an Magnetic resonance imaging (MRI) model including only the PI-RADS score, and a full model including both the previous ones. The predictive accuracy (PA) of each model was quantified using the area under the curve. RESULTS: mpMRI negative (-) was recorded in 127 (32.6%) pts; mpMRI positive (+) was recorded in 262 pts: 72 (18.5%) had PI-RADS 3, 150 (38.6%) PI-RADS 4, and 40 (10.3%) PI-RADS 5 lesions. At a median follow-up of 12 months, 125 pts (32%) were reclassified to GG2 prostate cancer. The rate of reclassification to GG2 prostate cancer was 17%, 35%, 38%, and 52% for mpMRI (-), PI-RADS 3, 4, and 5, respectively (P < 0.001). The PA was 69% and 64% in the basic and MRI models, respectively. The full model had the best PA of 74%: older age (P = 0.023; Odds ratio (OR) = 1.040), prostate-specific antigen density (P = 0.037; OR = 1.324), number of positive cores at baseline (P = 0.001; OR = 1.441), and PI-RADS 3, 4, and 5 (overall P = 0.001; OR = 2.458, 3.007, and 3.898, respectively) were independent predictors of reclassification. CONCLUSIONS: Disease reclassification increased according to the PI-RADS score increase, at confirmatory or follow-up biopsy. However, a no-negligible rate of reclassification was found also in cases of mpMRI (-). The combination of mpMRI and clinicopathological variables still represents the most accurate approach to pts on active surveillance.

Predictive factors for progression of patients with carcinoma in situ of the bladder at long-term follow-up: pure versus non-pure CIS.

BACKGROUND: The aim of this study was to identify the predictive factors for progression defined as any event that shifted the management of the disease from a bladder sparing approach, by comparing patients with pure versus non-pure carcinoma in situ (CIS) of the bladder. METHODS: A retrospective analysis was carried out in consecutive patients affected by newly-diagnosed pure CIS and non-pure CIS (excluding cases with concomitant muscle invasive cancer). All patients were enrolled a in our institution from 1998 to 2010. Data was prospectively collected. Main end point was progression-free survival. RESULTS: Overall, 149 patients with CIS were identified for the analysis. A total of 98 patients had pure CIS (66%). Median follow-up was 103 months (range: 40-206 months). Progression occurred in 29 patients (19%). A total of 30 patients died during the follow-up (20%). In 13 cases (9%), the death was cancer specific. Progression-free survival estimate was 181 months (95% CI: 169-193 months) and 154 months (95% CI: 133-176 months) respectively for pure and non-pure CIS population (P=0.03). Among examined variables (age, gender, symptoms, smoking habit, ASA score, number of bacillus Calmette-Guérin [BCG] instillations), multivariate analysis disclosed that only CIS type was an independent predictor of progression (P=0.03) with a relative risk of 0.37 in favor of pure CIS. CONCLUSIONS: Pure and non-pure CIS are efficiently treated by BCG therapy combined with trans-urethral resection and/or radical cystectomy, with relatively low rate of progression. CIS type was the only significant predictor of progression.

Role of Restaging Transurethral Resection for T1 Non-muscle invasive Bladder Cancer: A Systematic Review and Meta-analysis.

CONTEXT: Repeat transurethral resection (reTUR) is advocated as a fundamental step towards complete clearance and appropriate staging of T1 bladder cancer tumors. OBJECTIVE: To assess the impact of reTUR in T1 bladder cancer via a systematic review of the literature and meta-analysis of available data sets. EVIDENCE ACQUISITION: After definition of the population and of the outcome, a systematic search of English language articles in the literature from 1980 to 2016 was performed. The pooled prevalence of residual tumor and of upstaging at reTUR were assessed and computed using a random effects model to take into account heterogeneity showed by I2 and Cochran's Q values. A sensitivity analysis was conducted to exclude excessive influence by a single study. EVIDENCE SYNTHESIS: Among the papers identified, 29 were selected. A total of 3566 and 2556 cases formed the study population for assessment of the prevalence of residual tumor and upstaging, respectively. The corresponding numbers for the subgroup with detrusor muscle involvement at the initial TUR were 1565 and 1187. The pooled prevalence was 0.56 (95% confidence interval [CI] 0.48-0.63) for residual tumor and 0.1 (95% CI 0.06-0.14) for upstaging to T2 at reTUR. The corresponding rates for the detrusor muscle subgroup were 0.47 (95% CI 0.33-0.62) and 0.1 (95% CI 0.06-0.14). The sensitivity analysis excluded an excessive influence of each of the studies examined. CONCLUSIONS: Pooled prevalence rates for residual tumor (∼50%) and upstaging to invasive disease (10%) at reTUR in T1 cases were high, and were stable among studies in different decades and for cases with detrusor muscle involvement at the initial TUR. Therefore, reTUR remains a fundamental procedure. PATIENT SUMMARY: Repeat transurethral resection after a diagnosis of stage T1 bladder cancer is recommended given the high risk of misallocation to the proper treatment.