Oncological and safety profiles in patients undergoing simultaneous transurethral resection (TUR) of bladder tumour and TUR of the prostate.

OBJECTIVES: To determine the oncological impact and adverse events of performing simultaneous transurethral resection of bladder tumour (TURB) and transurethral resection of the prostate (TURP), as evidence on the outcomes of simultaneous TURB for bladder cancer and TURP for obstructive benign prostatic hyperplasia is limited and contradictory. PATIENTS AND METHODS: Patients from 12 European hospitals treated with either TURB alone or simultaneous TURB and TURP (TURB+TURP) were retrospectively analysed. A propensity score matching (PSM) 1:1 was performed with patients from the TURB+TURP group matched to TURB-alone patients. Associations between surgery approach with recurrence-free (RFS) and progression-free (PFS) survivals were assessed in Cox regression models before and after PSM. We performed a subgroup analysis in patients with risk factors for recurrence (multifocality and/or tumour size >3 cm). RESULTS: A total of 762 men were included, among whom, 76% (581) underwent a TURB alone and 24% (181) a TURB+TURP. There was no difference in terms of tumour characteristics between the groups. We observed comparable length of stay as well as complication rates including major complications (Clavien-Dindo Grade ≥III) for the TURB-alone vs TURB+TURP groups, while the latest led to longer operative time (P < 0.001). During a median follow-up of 44 months, there were more recurrences in the TURB-alone (47%) compared to the TURB+TURP group (28%; P < 0.001). Interestingly, there were more recurrences at the bladder neck/prostatic fossa in the TURB-alone group (55% vs 3%, P < 0.001). TURB+TURP procedures were associated with improved RFS (hazard ratio [HR] 0.39, 95% confidence interval [CI] 0.29-0.53; P < 0.001), but not PFS (HR 1.63, 95% CI 0.90-2.98; P = 0.11). Within the PSM cohort of 254 patients, the simultaneous TURB+TURP was still associated with improved RFS (HR 0.33, 95% CI 0.22-0.49; P < 0.001). This was also true in the subgroup of 380 patients with recurrence risk factors (HR 0.41, 95% CI 0.28-0.62; P < 0.001). CONCLUSION: In our contemporary cohort, simultaneous TURB and TURP seems to be an oncologically safe option that may, even, improve RFS by potentially preventing disease recurrence at the bladder neck and in the prostatic fossa.

Ventriculorenal shunts in the treatment of pediatric and adult hydrocephalus-historical perspective and analysis of current practice.

Hydrocephalus is a complex pathology that can have a significant impact on the quality of life in all age groups. Cerebrospinal fluid (CSF) diversions from the lateral ventricle to the peritoneal cavity are regarded as the treatment of first intent, but they have a high revision rate, and there are multiple factors which can impair their proper insertion and function. One of the many alternatives to peritoneal shunting is redirecting the CSF towards the renal system. A literature search was conducted to identify the particularities of these types of shunts and what clinical context rendered them feasible in pediatric and adult patient populations. Twenty-eight studies were found to meet the selection criteria. The shunts were classified into ventriculopyeloureteral, ventriculoureteral, and ventriculovesical. Their main advantage was that they did not depend on absorption properties of the tissues, like in the case of the peritoneum. However, several issues with ascending infections, bladder pressure imbalance, distal shunt migration, and calculus formation were noted. Literature suggests that the urinary tract can have the potential of diverting CSF when the peritoneum or atrium is not available, but further research is required to establish their proper role in current practice.

An Algorithm to Personalize Nerve Sparing in Men with Unilateral High-Risk Prostate Cancer.

PURPOSE: Current guidelines do not provide strong recommendations on preservation of the neurovascular bundles during radical prostatectomy in case of high-risk (HR) prostate cancer and/or suspicious extraprostatic extension (EPE). We aimed to evaluate when, in case of unilateral HR disease, contralateral nerve sparing (NS) should be considered or not. MATERIALS AND METHODS: Within a multi-institutional data set we selected patients with unilateral HR prostate cancer, defined as unilateral EPE and/or seminal vesicle invasion (SVI) on multiparametric (mp) magnetic resonance imaging (MRI), or unilateral International Society of Urologic Pathologists (ISUP) 4-5 or prostate specific antigen ≥20 ng/ml. To evaluate when to perform NS based on the risk of contralateral EPE, we relied on chi-square automated interaction detection, a recursive machine-learning partitioning algorithm developed to identify risk groups, which was fit to predict the presence of EPE on final pathology, contralaterally to the prostate lobe with HR disease. RESULTS: A total of 705 patients were identified. Contralateral EPE was documented in 87 patients (12%). Chi-square automated interaction detection identified 3 groups, consisting of 1) absence of SVI on mpMRI and index lesion diameter ≤15 mm, 2) index lesion diameter ≤15 mm and contralateral ISUP 2-3 or index lesion diameter >15 mm and negative contralateral biopsy or ISUP 1, and 3) SVI on mpMRI or index lesion diameter >15 mm and contralateral biopsy ISUP 2-3. We named those groups as low, intermediate and high-risk, respectively, for contralateral EPE. The rate of EPE and positive surgical margins across the groups were 4.8%, 14% and 26%, and 5.6%, 13% and 18%, respectively. CONCLUSIONS: Our study challenges current guidelines by proving that wide bilateral excision in men with unilateral HR disease is not justified. Pending external validation, we propose performing NS and incremental NS in case of contralateral low and intermediate EPE risk, respectively.

A prehabilitation programme implemented before robot-assisted radical prostatectomy improves peri-operative outcomes and continence recovery.

OBJECTIVES: To assess the impact of a routine, on-site, 1-day prehabilitation (PreHab) programme on peri-operative and continence recovery after robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: All 303 consecutive RARPs performed between March 2018 and February 2020 since the routine implementation of PreHab were included in our study. PreHab was carried out according to the availability of the 1-day programme before the planned date of surgery (two sessions per month including four patients per session). The PreHab programme was implemented in 165 patients (54.5%). The primary endpoint was continence recovery, strictly defined as no safety pad use at 1 and 6 months. Secondary endpoints were peri-operative variables (blood loss, operating time, length of stay, transfusion, complications, and readmission rates). Comparisons were made according to whether the PreHab pathway was applied or not (PreHab+ vs PreHab-) in univariable and multivariable models. RESULTS: The PreHab pathway was implemented for a stable proportion of patients over time (54.5%). The two cohorts were comparable in terms of preoperative and pathological features (P > 0.05). Length of stay was significantly shorter in the PreHab+ group (1.3 vs 1.9 days; P = 0.001). There was a trend towards fewer complications in the PreHab+ group (P = 0.061). Use of the PreHab pathway was independently correlated with higher continence rates at 1 month (37% vs 60%; P < 0.001) and 6 months (67.4% vs 87.3%; P < 0.001), even after controlling for age, body mass index, prostate volume, type of apical reconstruction, nerve-sparing surgery and lymph node dissection. The main limitation of the study was the absence of randomization. CONCLUSIONS: Our experience demonstrates that the PreHab programme is the major predictor of improved peri-operative outcomes and continence recovery after RARP, with sustainable benefits 6 months after surgery.

Pathological features of Prostate Imaging Reporting and Data System (PI-RADS) 3 MRI lesions in biopsy and radical prostatectomy specimens.

OBJECTIVE: To assess the whole pathology spectrum of Prostate Imaging Reporting and Data System (PI-RADS) 3 lesions, identified on magnetic resonance imaging, using systematic (SB), targeted biopsy (TB) and radical prostatectomy (RP) specimen analysis. METHODS: From a prospective database of patients undergoing RP after a combination of SB (median 12 cores) and fusion TB (median 3 cores), we included 150 PI-RADS 3 cases. Clinically significant prostate cancer (csPCa) was defined by a Grade Group 2 or more. The primary endpoints were unfavourable features in RP specimens. RESULTS: Targeted biopsy was negative in 20.7% of patients. Final Grade Group 3 or more and a pT3 stage was reported in 36.7% and 38.7% of RP specimens. The upgrading rate was 38.2% between biopsy and RP specimens. The concordance rate between Grade Group on TB and RP was only 38.0%. The two independent predictive factors for unfavourable disease (pT3-4 and/or final Grade Group 3-5) were prostate-specific antigen density (PSAD; P = 0.001) and presence of csPCa on TB (odds ratio 3.7; P = 0.001). The risk of unfavourable disease was increased 2.3-fold and 5.8-fold, respectively, for patients with a PSAD between 0.15 and 0.20, and a PSAD >0.20 ng/mL/g. The 5-year biochemical recurrence-free survival rate was 93.2%. CONCLUSIONS: PI-RADS 3 lesions exhibited aggressive features in almost 40% of cases. PSAD and presence of csPCa on TB are independent predictive factors for high-grade and/or extraprostatic disease. A combination of SB and TB improve grade prediction compared to use of TB alone.

Safety and feasibility of same-day discharge laparoscopic radical prostatectomy: a systematic review.

PURPOSE: Day case or same-day discharge (SDD) pure laparoscopic or robot-assisted radical prostatectomy (RP) has risen over the last few years with the aim of discharging patients within 24 h, reducing costs and length of stay, and facilitating return to active life. We perform a systematic review of literature to evaluate the feasibility of SDD RP. METHODS: A systematic review search was performed and the following bibliographic databases were accessed: PubMed, Science Direct, Scopus, and Embase. This was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. RESULTS: Based on the literature search of 509 articles, 12 (1378 patients) met the inclusion criteria (mean age: 63 years). All studies were unicentric except one. The mean SDD surgeries experience per centre was 66 cases .The means operative time and blood loss were 154 min and 126.5 ml, respectively. Mean SDD failure was 7.4%. Concomitant lymph node dissection was performed in 56.2%. The overall complication rate was 10.2% of cases; with a majority of Clavien grade I or II. Mean readmission rate after discharge was 5%. SDD generated cost reductions compared to inpatient surgery with variable differences according to the considered healthcare system. CONCLUSIONS: Day-case RP is a safe and feasible strategy in selected cases with multicentre proofs of concept. Its widespread use in routine practice needs further research due to biases in patient selection. Implementation of peri-operative pathways such as ERAS and prehabilitation improves patient adherence to SDD.

Impact of outcomes and costs for implementation of robotic radical cystectomy with full intracorporeal urinary diversion.

Introduction: Radical cystectomy (RC) remains a surgery with important morbidity despite technical advances. Our aim was to determine the impact on outcomes and costs of robot-assisted radical cystectomy (RARC) with full intracorporeal diversion. Material and methods: We retrospectively included 196 consecutive patients undergone RC for bladder cancer between 2017 and 2022. Comparisons were done between the open radical cystectomy (ORC; n = 166) and RARC with full intracorporeal diversion (n = 30) in the overall cohort and after matched pair analysis. Results: More neobladders were performed in the RARC group (40% vs 18.7%, p = 0.011). Peri-operative parameters continuously improved over time in the RARC cohort despite an increased proportion of elderly patients with higher comorbidity index. RARC patients had lower prolonged stay (33.3% vs 68.3%, p = 0.002), lower grade 1 complication rates (26.7% vs 53.3%, p = 0.016) and blood loss (185 vs 611 ml, p <0.001) than ORC patients. RARC was an independent favorable predictor for prolonged stay (OR 0.199) and complication (OR 0.334). Cost balance favored ORC, with an increase of hospitalization cost at 816 euros for RARC. Conclusions: After matching, RARC with full intracorporeal diversion was associated with improved outcomes and a moderated increase of post-operative costs mainly due to the use of robotic devices.

Risk Stratification of Patients Candidate to Radical Prostatectomy Based on Clinical and Multiparametric Magnetic Resonance Imaging Parameters: Development and External Validation of Novel Risk Groups.

BACKGROUND: Despite the key importance of magnetic resonance imaging (MRI) parameters, risk classification systems for biochemical recurrence (BCR) in prostate cancer (PCa) patients treated with radical prostatectomy (RP) are still based on clinical variables alone. OBJECTIVE: We aimed at developing and validating a novel classification integrating clinical and radiological parameters. DESIGN, SETTING, AND PARTICIPANTS: A retrospective multicenter cohort study was conducted between 2014 and 2020 across seven academic international referral centers. A total of 2565 patients treated with RP for PCa were identified. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Early BCR was defined as two prostate-specific antigen (PSA) values of ≥0.2 ng/ml within 3 yr after RP. Kaplan-Meier and Cox regressions tested time and predictors of BCR. Development and validation cohorts were generated from the overall patient sample. A model predicting early BCR based on Cox-derived coefficients represented the basis for a nomogram that was validated externally. Predictors consisted of PSA, biopsy grade group, MRI stage, and the maximum diameter of lesion at MRI. Novel risk categories were then identified. The Harrel's concordance index (c-index) compared the accuracy of our risk stratification with the European Association of Urology (EAU), Cancer of the Prostate Risk Assessment (CAPRA), and International Staging Collaboration for Cancer of the Prostate (STAR-CAP) risk groups in predicting early BCR. RESULTS AND LIMITATIONS: Overall, 200 (8%), 1834 (71%), and 531 (21%) had low-, intermediate-, and high-risk disease according to the EAU risk groups. The 3-yr overall BCR-free survival rate was 84%. No differences were observed in the 3-yr BCR-free survival between EAU low- and intermediate-risk groups (88% vs 87%; p = 0.1). The novel nomogram depicted optimal discrimination at external validation (c-index 78%). Four new risk categories were identified based on the predictors included in the Cox-based nomogram. This new risk classification had higher accuracy in predicting early BCR (c-index 70%) than the EAU, CAPRA, and STAR-CAP risk classifications (c-index 64%, 63%, and 67%, respectively). CONCLUSIONS: We developed and externally validated four novel categories based on clinical and radiological parameters to predict early BCR. This novel classification exhibited higher accuracy than the available tools. PATIENT SUMMARY: Our novel and straightforward risk classification outperformed currently available preoperative risk tools and should, therefore, assist physicians in preoperative counseling of men candidate to radical treatment for prostate cancer.

Same Day Discharge versus Inpatient Surgery for Robot-Assisted Radical Prostatectomy: A Comparative Study.

(1) Background: no study has compared outcomes of same day discharge (SDD) versus inpatient robot-assisted radical prostatectomy (RARP) in homogenous cohorts. Our aim was to compare perioperative outcomes and urinary continence recovery between SDD and inpatient RARP in contemporary, comparable patients. (2) Methods: we included consecutive patients undergoing RARP between 2018 and 2020 (n = 376). Only patients eligible for SDD (no oral anticoagulant, distance home-hospital <150 km) and having >6-month follow-up were included (n = 180). All patients underwent RARP with or without lymph node dissection. Comparisons were performed between SDD (n = 42) and inpatient RARP (n = 138). Primary outcomes were 90-day complication and readmission rates and continence rates at 1 and 6 months. (3) Results: median patient age was 66.7 years. Median duration of surgery and blood loss was 134 min and 200 mL, respectively. Lymph node dissection and nerve-sparing procedures were performed in 76.7% and 82.2% of cases, respectively. Median follow-up was 19.5 months. No difference was seen regarding patient features, peri-operative outcomes, and pathology parameters between both groups. The proportion of SDD RARP was stable over time (23.5%). The 90-day unplanned visits, readmission and complication rates were 9.5%, 7.1%, and 19.0% in SDD patients versus 14.5% (p = 0.407), 10.1% (p = 0.560), 28.3% (p = 0.234) for inpatient RARP, respectively. Trends favoring SDD were not statistically significant. Continence rates at 1-(p = 0.589) and 6-months (p = 0.674) were comparable between SDD and inpatient RARP. The main limitation was the lack of randomization. (4) Conclusions: this multi-surgeon comparative study confirms the safety of routine SDD RARP in terms of perioperative and functional outcomes. Trends favoring SDD in terms of complications, emergency visits and readmission have to be confirmed.

First report of testis-sparing surgery for sertoliform cystadenoma: case presentation and review of literature.

INTRODUCTION: Sertoliform cystadenoma is a very rare, benign lesion of the rete-testis difficult to distinguish from other malignancies of the testicle. CASE PRESENTATION: We present the case of a 42-year-old male who presented with a right testicular mass, asymptomatic for 1 year. Clinical examination revealed a palpable, painless, and well-delimited right testicular superior pole nodule. Testicular ultrasound confirmed the nodule, whereas serum tumoral markers were normal. The patient underwent inguinal partial orchiectomy. Intraoperative excisional biopsy and frozen section pathology were performed, reporting undetermined tumoral origin with negative surgical margins. Ischemia time was 12 minutes. The final pathology report showed a Sertoliform cystadenoma of rete testis, with immunomorphology positive for AE1, CK7, and negative surgical margins. CONCLUSION: To our knowledge, this is the first report of testicular sparing surgery for Sertoliform cystadenoma, a very rare benign tumor of rete testis. All previously reported cases were managed by radical inguinal orchidectomy.