Robot assisted radical cystectomy with Florence robotic intracorporeal neobladder (FloRIN): Analysis of survival and functional outcomes after first 100 consecutive patients upon accomplishment of phase 3 IDEAL framework.

INTRODUCTION: Aim of the study was to evaluate the Florence intracorporeal neobladder (FloRIN) oncological and functional outcomes at the end of assessment phase (phase 3) IDEAL-Guidelines. MATERIALS AND METHODS: This single-institution prospective series included consecutive patients treated with robot-assisted radical cystectomy (RARC) and FloRIN reconfiguration technique from February 2016 to June 2020. Functional features were evaluated six months after surgery. Patients were grouped into four quartiles according to time of radical cystectomy and impact of learning curve improvement was evaluated. RESULTS: One-hundred FloRIN were completed with a median console time of 373 (IQR: 312-415) minutes. Two cases were converted to open surgery. No intraoperative complications occurred. At pathological examination, 30% of patients were staged as pT ≤ 1 and 47% as pT ≥ 3. Transitional cell carcinoma was present in 87% of cases. Carcinoma in situ (CIS) and nodal involvement were observed in 38% and 29% of patients, respectively. At a median follow-up time of 17 (IQR: 7-28) months, 20 clinically relevant events (Clavien-Dindo≥3) occurred. Operative time significantly decreased throughout the series (median minutes 435; 395; 365 and 330 in the four quartiles, respectively; p < 0.001). Similarly, early Clavien-Dindo≥3 postoperative complications rate significantly decreased across the series (number of events: 1; 4; 0; 0; p = 0.03). Overall, 75% and 65% of patients achieved day-time and nigh-time continence, respectively. Twenty-seven patients experienced disease recurrence. Cancer-specific and overall survival were equal to 80%. CONCLUSIONS: RARC with FloRIN reconfiguration showed worthy functional and survival outcomes, with learning curve improvement significantly influencing operative time and early complications rate across series.

Role of prostate specific antigen and prostate specific antigen density as biomarkers for medical and surgical treatment response in men with lower urinary tract symptoms.

INTRODUCTION: Prostate specific antigen and Prostate specific antigen-density are used for the initial evaluation of patient with LUTS due to benign prostatic enlargement in order to discriminate between benign conditions and prostate cancer. Conversely, the role of these markers during the follow up of benign prostatic enlargement patients is still unclear. The aim of our study is to evaluate the role of prostate specific antigen and prostate specific antigen density as outcome parameter for both medical and surgical treatment in patients with male LUTS. EVIDENCE ACQUISITION: We performed a systematic review and meta-analysis based on data from clinical trials evaluating the clinical effect of medical or surgical therapy on LUTS/benign prostatic enlargement. Meta-regression analyses were done to evaluate the effects of several factors on IPSS score improvement. EVIDENCE SYNTHESIS: We selected 12 studies out of 433, including data on 1959 patients. Both medical and surgical treatment lead to a significant reduction of PSA levels as compared to baseline (P<0.001). However, after medical treatment, lower PSA values are associated with more significant improvements in lower urinary tract symptoms as measured with the IPSS, while after surgery (P<0.05), the recovery of urinary function does not correlate with the decline in PSA values (P=0.59). After medical treatment, the improvement in LUTS correlate with a decline of PSAD, while the opposite holds true in men treated with surgery (both: P<0.001). CONCLUSIONS: PSAD may represent an objective treatment outcome parameter and should be evaluated during the follow up of men treated for LUTS due to BPE as marker of treatment response.

Oncological impact of inflammatory biomarkers in elderly patients treated with radical cystectomy for urothelial bladder cancer.

OBJECTIVE: To evaluate the impact of preoperative markers of systemic inflammation on complications and oncological outcomes in patients aged ≥75 years treated with radical cystectomy (RC) for urothelial bladder cancer (UBC). PATIENTS AND METHODS: The clinical data of 694 patients treated with open RC for UBC at our institution between January 2008 and December 2015 were retrospectively reviewed. Patients aged <75 years, with distant metastases, other-than-urothelial histological type, comorbidities that could affect the systemic inflammatory markers, and patients who received neoadjuvant chemotherapy were excluded. Multivariable regression models were built for the prediction of major postoperative surgical complications, disease recurrence, cancer-specific mortality (CSM), and overall mortality (OM). RESULTS: The median (interquartile range [IQR]) age at surgery was 79 (75-83) years. Major postoperative surgical complications were registered in 41.9% of the patients. The 5-year overall survival, cancer-specific survival and recurrence-free survival rates were 42.4% (95% confidence interval [CI] 34.7-49.9%), 70.3% (95% CI 62.3-76.9%), and 59.8% (95% CI 52.4-66.5), respectively. At multivariable analysis, higher levels of fibrinogen and a modified Glasgow Prognostic Score (mGPS) of 1 and 2 at baseline were independently associated with higher risk of major postoperative complications and of CSM. The inclusion of mGPS and fibrinogen to a standard multivariable model for recurrence and for CSM increased discrimination from 69.4% to 73.0% and from 71.3% to 73.9%, respectively. Preoperative neutrophil-to-lymphocyte ratio of >3 was independently associated with OM (hazard ratio 1.38, 95% CI 1.01-1.77; P = 0.01). CONCLUSIONS: In a cohort of elderly patients with UBC treated with RC, fibrinogen and mGPS appeared to be the most relevant prognostic measurements and increased the accuracy of clinicopathological preoperative models to predict major postoperative complications, disease recurrence and mortality. ABBREVIATIONS: ASA: American Society of Anesthesiologists; CCI: Charlson Comorbidity Index; CIS: carcinoma in situ; CRP: C-reactive protein; CSM: cancer-specific mortality; CSS: cancer-specific survival; ECOG PS: Eastern Cooperative Oncology Group Performance Status; HDL: high-density lipoprotein; (S)HR: (subdistribution) hazard ratio; LND: lymphadenectomy; LVI: lymphovascular invasion; mGPS: modified Glasgow Prognostic Score; NLR: neutrophil-to-lymphocyte ratio; NOC: non-organ-confined; OM: overall mortality; OR: odds ratio; OS: overall survival; RC: radical cystectomy; RNU: radical nephroureterectomy; UBC: urothelial bladder cancer; UTUC: upper urinary tract urothelial carcinoma.