Variant histologies in bladder cancer: Does the centre have an impact in detection accuracy?

OBJECTIVE: To compare the accuracy in detecting variant histologies (VH) at transurethral resection of bladder (TURB) and radical cystectomy (RC) specimen among tertiary referral centres, in order to investigate potential reasons of discrepancies from the pathological point of view. PATIENTS AND METHODS: Clinical and histopathological data of TURB specimen and subsequent cystectomy specimen of 3,445 RC candidate patients have been retrospectively collected from 24 tertiary referral centres between 1980 and 2021. VH considered in the analysis were pure squamous cell carcinoma, urothelial carcinoma with squamous differentiation, pure adenocarcinoma, urothelial carcinoma with glandular differentiation, micropapillary bladder cancer (BCa), neuroendocrine BCa, and other variants. The degree of agreement between TURB and RC concerning the identification of VH was expressed as concordance, classified according to Cohen's kappa coefficient. RESULTS: A VH was reported in 17% of TURB specimens, 45% of which were not confirmed in RC. The lowest concordance rate was reported for micropapillary BCa with 11 out of 18 (61%) centres reporting no agreement, whereas neuroendocrine BCa achieved the highest concordance rate with only 3 centres (17%) reporting no agreement. Our results shows that even among centres with the advantage of a referent uropathologist the micropapillary variant is characterized by scarce accuracy between TURB and RC. Differences in TURB specimen acquisition by the urologist and in sampling methods among different centres are the main limitations of the study. CONCLUSIONS: Accuracy of TURB in detecting VH is poor for certain VH, in particular for micropapillary BCa, with evident variation among centres. Novel diagnostic tools are required to better identify these VH and drive patients toward a personalized treatment.

Radical prostatectomy technique in the robotic evolution: from da Vinci standard to single port-a single surgeon pathway.

To describe perioperative outcomes following robot-assisted prostatectomy performed by a single surgeon during transitions between da Vinci standard/Si/Xi and the single port. Perioperative data were retrospectively evaluated of the first 40 consecutive robot-assisted radical prostatectomies performed by a single surgeon using the da Vinci standard, Si, Xi and single port. A total of 160 patients were included. We matched standard vs Si (Match 1), Si vs Xi (Match 2) and Xi vs single port (Match 3) cohort. Mann-Whitney and Fisher's tests were used to test the difference among the groups. Univariate and multivariate logistic regression analyses were adopted to evaluate the predictors of overall and major complications. Single-port procedures in Match 3 showed significant shorter median operative time than Xi. Both Si and single-port groups showed significantly less median blood loss, a shorter median length of stay, respectively, than standard group in Match 1 and than Xi group in Match 3. 1 standard group patient required conversion to open surgery for an unsolvable conflict of the robotic arms. No other intraoperative complications were noted. On univariate and multivariate analyses, the da Vinci platform model was not a predicting factor of major complications (Clavien-Dindo ≥ 3). We described how technological progress impacted peri and postoperative outcomes during transitions between robotic surgical platforms for radical prostatectomy. In particular, the technological improvements associated to the increased surgeon's expertise made the transition to the single port safe and effective when compared with previous platforms.

Single-Port robot assisted partial nephrectomy: initial experience and technique with the da Vinci Single-Port platform (IDEAL Phase 1).

BACKGROUND: The aim of this paper was to evaluate the safety and feasibility of robotic-assisted laparoscopic partial nephrectomy (RAPN) performed using the da Vinci Single-Port (SP) platform. METHODS: A retrospective review was conducted from December 2018 to December 2019 of 14 consecutive patients with localized renal cancer who underwent SP robot-assisted partial nephrectomy at a single institution. The procedures were performed by 2 experienced robotic surgeons, reproducing the steps of the standard multiport robotic approach to partial nephrectomy. A transperitoneal approach was utilized with a 2.5 cm para-rectus incision with one assistant 12 mm laparoscopic port. RESULTS: No conversions to open or laparoscopic surgery occurred and no additional laparoscopic assistant ports were required. The median total operative time was 202 (162-231) minutes and the median total room time was 258 (215-295) minutes. The warm ischemia time averaged 20±8 minutes. 2 patients required angioembolization due to postoperative acute bleeding (Clavien-Dindo Grade 3a complication). Trifecta outcome (<25 min warm ischemia, no perioperative complications and negative margins) was achieved in 79% of patients. In one case, a positive margin was present. The median length of stay was of 1 day (Interquartile Range 1-2) with a median pain score on post-operative day 1 of 3.5 (Interquartile Range 2.4-5); 1/14 (7%) patient needed narcotic use at one week from discharge. At a median follow up of 5.0 (4.0-8.0) months, no patients have had evidence of disease recurrence. CONCLUSIONS: In this initial cohort, considering the introduction of a new technology, we observed satisfactory outcomes for several key perioperative variables including operative time, warm ischemia time, surgical margins, hospital stay, pain requirements in patients undergoing RAPN with the SP platform. For experienced robotic surgeons, RAPN with the SP platform is a safe and feasible approach for single site partial nephrectomy.

Non-metastatic ductal adenocarcinoma of the prostate: pattern of care from an uro-oncology multidisciplinary group.

PURPOSE: To retrospectively review our 20 year experience of multidisciplinary management of non-metastatic ductal prostate cancer (dPC), a rare but aggressive histological subtype of prostate cancer whose optimal therapeutic approach is still controversial. METHODS: Histologically confirmed dPC patients undergoing primary, curative treatment [radical prostatectomy (RP), external beam radiotherapy (EBRT), and androgen deprivation therapy (ADT)] were included, and percentage of ductal and acinar pattern within prostate samples were derived. Survival outcomes were assessed using the subdistribution hazard ratio (SHR) and Fine-and-Gray model. RESULTS: From January 1997 to December 2016, 81 non-metastatic dPC fitted selection criteria. Compared to surgery alone, SHR for progression-free survival and cancer-specific mortality were 2.8 (95% CI 0.6-13.3) and 1.3 (95% CI 0.1-16.2) for exclusive EBRT, 2.7 (95% CI 0.6-13.0) and 6.5 (95% CI 0.6-69.8) for adjuvant EBRT, 4.9 (95% CI 0.7-35.5) and 5.8 (95% CI 0.5-65.6) for salvage EBRT post-prostatectomy recurrence, and 3.2 (95% CI 0.7-14.0) and 3.9 (95% CI 0.3-44.1) for primary ADT (P = 0.558; P = 0.181), respectively. Comparing multimodal treatment and monotherapy confirmed the above trends. Local recurrence more typically occurred in pure dPC patients, mixed histology more frequently produced metastatic spread (29.6% relapse in total, P = 0.026). CONCLUSION: Albeit some limitations affected the study, our findings support the role of local treatment to achieve better disease control and improve quality of life. Different behavior, with typical local growth in pure dPC, higher distant metastatization in the mixed form, might influence treatment response. Given its poor prognosis, we recommend multidisciplinary management of dPC.

Perioperative and Mid-term Oncological and Functional Outcomes After Partial Nephrectomy for Complex (PADUA Score ≥10) Renal Tumors: A Prospective Multicenter Observational Study (the RECORD2 Project).

BACKGROUND: Partial nephrectomy (PN) for complex renal masses has a non-negligible risk of perioperative complications. Furthermore, late functional and oncological outcomes of patients submitted to these challenging surgeries still remain to be determined. OBJECTIVES: To report the perioperative and mid-term oncological and functional outcomes of PN for complex masses (Preoperative Aspects and Dimensions Used for an Anatomical [PADUA] score≥10) in a large multicenter prospective observational study. DESIGN, SETTING, AND PARTICIPANTS: We prospectively evaluated patients treated with PN for complex renal tumors at 26 urological centers (Registry of Conservative and Radical Surgery for Cortical Renal Tumor Disease [RECORD2] project). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariate logistic regression analyses explored the predictors of surgical complications. Multivariable Cox regression analyses estimated the hazard of renal function loss and disease recurrence. Kaplan-Meier estimates assessed the probability of survival. RESULTS AND LIMITATIONS: In total, 410 patients who underwent PN for complex masses were evaluated. Clinical T1b and T2 tumors accounted for 43.2% and 9.8% of the cases. Overall, 45.9%, 18.8%, and 35.4% of patients underwent open, laparoscopic, and robotic PN, respectively. Intraoperative complications occurred in 15 (3.6%) patients, while postoperative surgical complications were recorded in 76 (18.5%) patients. At multivariable analysis, preoperative hemoglobin (odds ratio [OR]: 0.67; p<0.001) and open (OR: 3.91; p<0.001) versus robotic surgical approach were found to be the only predictors of surgical complications. An estimated glomerular filtration rate drop of >25% from baseline was observed in 30.2% and 17.6% of patients at 1st month and 2 yr after surgery, respectively. Two-year recurrence-free survival was 97.1%; positive surgical margins (hazard ratio [HR]: 3.35; p=0.009), nucleolar grading (HR: 5.61; p<0.001), and tumor stage (HR: 2.62; p=0.05) were associated with recurrence. CONCLUSIONS: In a large series, PN for complex renal masses was a safe technique with an acceptable rate of perioperative complications and excellent mid-term oncological and functional results. PATIENT SUMMARY: In this study, we evaluated peri- and postoperative outcomes of patients treated with partial nephrectomy for complex renal masses. Open surgery was associated with higher complications than the robotic approach. Some histological features were found to be associated with disease recurrence.

Factors contributing to healthcare professional burnout during the COVID-19 pandemic: A rapid turnaround global survey.

BACKGROUND: Healthcare professionals (HCPs) on the front lines against COVID-19 may face increased workload and stress. Understanding HCPs' risk for burnout is critical to supporting HCPs and maintaining the quality of healthcare during the pandemic. METHODS: To assess exposure, perceptions, workload, and possible burnout of HCPs during the COVID-19 pandemic we conducted a cross-sectional survey. The main outcomes and measures were HCPs' self-assessment of burnout, indicated by a single item measure of emotional exhaustion, and other experiences and attitudes associated with working during the COVID-19 pandemic. FINDINGS: A total of 2,707 HCPs from 60 countries participated in this study. Fifty-one percent of HCPs reported burnout. Burnout was associated with work impacting household activities (RR = 1·57, 95% CI = 1·39-1·78, P<0·001), feeling pushed beyond training (RR = 1·32, 95% CI = 1·20-1·47, P<0·001), exposure to COVID-19 patients (RR = 1·18, 95% CI = 1·05-1·32, P = 0·005), and making life prioritizing decisions (RR = 1·16, 95% CI = 1·02-1·31, P = 0·03). Adequate personal protective equipment (PPE) was protective against burnout (RR = 0·88, 95% CI = 0·79-0·97, P = 0·01). Burnout was higher in high-income countries (HICs) compared to low- and middle-income countries (LMICs) (RR = 1·18; 95% CI = 1·02-1·36, P = 0·018). INTERPRETATION: Burnout is present at higher than previously reported rates among HCPs working during the COVID-19 pandemic and is related to high workload, job stress, and time pressure, and limited organizational support. Current and future burnout among HCPs could be mitigated by actions from healthcare institutions and other governmental and non-governmental stakeholders aimed at potentially modifiable factors, including providing additional training, organizational support, and support for family, PPE, and mental health resources.

Factors Contributing to Healthcare Professional Burnout During the COVID-19 Pandemic: A Rapid Turnaround Global Survey.

BACKGROUND: Healthcare professionals (HCPs) on the front lines against COVID-19 may face increased workload, and stress. Understanding HCPs risk for burnout is critical to supporting HCPs and maintaining the quality of healthcare during the pandemic. METHODS: To assess exposure, perceptions, workload, and possible burnout of HCPs during the COVID-19 pandemic we conducted a cross-sectional survey. The main outcomes and measures were HCPs self-assessment of burnout and other experiences and attitudes associated with working during the COVID-19 pandemic. FINDINGS: A total of 2,707 HCPs from 60 countries participated in this study. Fifty-one percent of HCPs reported burnout. Burnout was associated with work impacting household activities (RR=1.57, 95% CI=1.39-1.78, P<0.001), feeling pushed beyond training (RR=1.32, 95% CI=1.20-1.47, P<0.001), exposure to COVID-19 patients (RR=1.18, 95% CI=1.05-1.32, P=0.005), making life prioritizing decisions (RR=1.16, 95% CI=1.02-1.31, P=0.03). Adequate personal protective equipment (PPE) was protective against burnout (RR=0.88, 95% CI=0.79-0.97, P=0.01). Burnout was higher in high-income countries (HICs) compared to low- and middle-income countries (LMICs) (RR=1.18; 95% CI=1.02-1.36, P=0.018). INTERPRETATION: Burnout is prevalent at higher than previously reported rates among HCPs working during the COVID-19 pandemic and is related to high workload, job stress, and time pressure, and limited organizational support. Current and future burnout among HCPs could be mitigated by actions from healthcare institutions and other governmental and non-governmental stakeholders aimed at potentially modifiable factors, including providing additional training, organizational support, support for family, PPE, and mental health resources. FUNDING: N/A.

Arterial Mesenteric Thrombosis as a Complication of SARS-CoV-2 Infection.

A 52-year-old patient with SARS-CoV-2 was diagnosed with interstitial pneumonia and treated with darunavir/ritonavir, hydroxychloroquine, azithromycin and low molecular weight heparin (LMWH). After LMWH cessation, he developed superior mesenteric arterial thrombosis. An abdominal CT scan showed arterial thrombosis of vessels efferent of the superior mesenteric artery with bowel distension. COVID-19 may predispose to venous and arterial thromboembolism. Anticoagulation prophylaxis should be considered in hospitalized patients with COVID-19, and potential thromboembolism investigated in each symptomatic patient affected by SARS-CoV-2. LEARNING POINTS: Potential thromboembolism must be investigated in each symptomatic patient with SARS-CoV-2 infection.The preventive and therapeutic use of antithrombotic agents should be strongly considered in order to mitigate thrombotic and haemorrhagic events in patients with SARS-CoV-2 infection.

A Comparison of Perioperative Outcomes Between Single-port and Multiport Robot-assisted Laparoscopic Prostatectomy.

Single-port (SP) robot-assisted laparoscopic prostatectomy (RALP) appears to be a safe and feasible approach for radical prostatectomy, but no prior studies have compared SP-RALP to a multiport (MP) platform. Using retrospective data from a single-center tertiary institution we compare 50 consecutive SP-RALP patients (da Vinci SP) to a contemporary cohort of 113 patients who underwent MP-RALP (da Vinci Xi). We found no significant differences in surgical or total operating room time. Pain scores were measured on a scale from 0 to 10. There were more pain-free patients on postoperative day 1 (18% difference, 95% confidence interval [CI] 9.9-27%) and there were shorter hospital stays (-1 d, 95% CI -1.0 to 0) in favor of SP. There were no significant differences in inpatient total morphine equivalents used, complication rates, or stress incontinence determined at a minimum of 90 d. These findings show that the learning curve for SP-RALP is relatively short for an experienced robotic surgeon and may favor better pain control and shorter hospitalization. PATIENT SUMMARY: We analyzed the differences in robotic surgery for localized prostate cancer using a single-port robotic platform compared to the traditional multiport robotic platform. We did not find significant differences in operative times, but significantly more patients were pain-free on the first postoperative day and had shorter hospital stays.

Renal Function Impairment Below Safety Limits Correlates With Cancer-specific Mortality in Localized Renal Cell Carcinoma: Results From a Single-center Study.

BACKGROUND: A recent multi-center study showed how estimated glomerular filtration rate (eGFR) and cancer-specific mortality (CSM) are linearly and inversely related in organ-confined renal cell carcinoma (RCC) whenever the eGFR decreases below specific thresholds. We addressed our previous work limitations related to heterogeneity and missing data, and explored the relationship between eGFR and CSM also in locally advanced RCC. MATERIALS AND METHODS: All patients with RCC treated with either partial or radical nephrectomy from 1990 to 2018 at a single institution and with complete data on renal function were included. eGFR was managed as a time-dependent variable. The relationship between eGFR and CSM was analyzed using a Fine and Gray multivariable competing risks framework. Subdistribution hazard ratios (SHRs) were calculated accounting for deaths from other causes. RESULTS: Multivariable competing risks analysis showed a "piecewise" relationship between eGFR and CSM, with an inverse linear correlation for eGFR values below 85 mL/min. Below this breakpoint, a significant relationship existed between eGFR and CSM in both clinical (SHR, 1.27; P < .001) and pathologic (SHR, 1.27; P = .001) models in stage I to II RCC subgroup. Conversely, no significance was recorded in this subgroup when considering eGFR values above 85 mL/min. In the stage III to IV subgroup, no significant relationships were recorded, regardless of eGFR values. The retrospective design with inherent biases in data collection represents a limitation. CONCLUSIONS: In patients undergoing surgery for stage I to II RCC, preservation of renal function over "safety limits" is protective from CSM.

Extraperitoneal versus Transperitoneal Single Port Robotic Radical Prostatectomy: A Comparative Analysis of Perioperative Outcomes.

PURPOSE: We compared intraoperative and perioperative outcomes between extraperitoneal and transperitoneal radical prostatectomy performed using a "purpose-designed" single port robotic platform. MATERIALS AND METHODS: A total of 98 patients underwent single port robotic prostatectomy using the da Vinci SP® robotic system with extraperitoneal (group I, 52) vs transperitoneal (group II, 46) approach. Demographics and perioperative data including postoperative recovery outcomes were recorded and compared between the 2 groups. RESULTS: Groups were similar in terms of demographics and prostate cancer risk category. Mean operative time (201±37.5 vs 248.2±42.3 minutes, p <0.00001) as well as median postoperative hospital stay (4.3 vs 25.7 hours p <0.0001) was significantly shorter with the extraperitoneal approach. Overall need for pain medications or narcotics as well as the required amount of narcotics per patient (if administered) were significantly lower with the extraperitoneal approach. Extraprostatic extension was detected in 48.1% vs 41.3% of patients in groups I and II, respectively. Surgical margins were positive in 26.9% in group I vs 41.3% in group II (p=0.13). More than 80% of patients with positive surgical margins had high risk features on final surgical pathology. The 90-day continence rate was similar between the 2 groups (60% vs 62.5%, p=0.82). CONCLUSIONS: Extraperitoneal and transperitoneal single port robotic radical prostatectomy are safe and feasible approaches. The extraperitoneal approach is associated with a significantly shorter postoperative hospital stay and decreased need for postoperative narcotics. Randomized trials with adequate sample size and postoperative followup are advisable for further evaluation of the outcomes to clarify patient selection criteria for each approach.

Robotic versus other nephroureterectomy techniques: a systematic review and meta-analysis of over 87,000 cases.

PURPOSE: To perform a systematic review and meta-analysis of the literature inherent robotic nephroureterectomy (RNU) and to compare its outcomes with those of other nephroureterectomy (NU) techniques. METHODS: A systematic literature search was performed up to April 2019 using PubMed, Embase®, and Web of Science. The Preferred Reporting Items for Systematic Review and Meta-analysis Statement was followed for study selection. The following data were extracted for each study: baseline features, surgical outcomes, oncological outcomes, and survival outcomes. Stata® 15.0 was used for statistical analysis. RESULTS: Literature search identified 80 studies eligible for the meta-analysis and overall 87,291 patients were included in the analysis: open NU (ONU; n = 45,601), hand-assisted laparoscopic NU (HALNU; n = 442), laparoscopic NU (LNU n = 31,093), and RNU (n = 10,155). RNU was more likely to be performed in those patients with multifocal tumor location (proportion: 0.19; 95% CI 0.14, 0.24) and high-grade disease (proportion: 0.70; 95% CI 0.53, 0.68). The lowest EBL was recorded in the RNU group (weighted mean (WM) 163.31 mL; 95% CI 88.94, 237.68), whereas the highest was in the ONU group (414.99 mL; 95% CI 378.52, 451.46). Operative time was shorter for ONU (224.98 mL; 95% CI 212.26, 237.69). RNU had lower rate of intraoperative complications (0.02; 95% CI 0.01, 0.05). ONU showed higher odds of transfusions (0.20; 95% CI 0.15, 0.25). LOS was statistically significantly shorter for the RNU group (5.35 days; 95% CI 4.97, 5.82). HALNU seemed to present lower risk of PSM (0.02; 95% CI - 0.01, 0.05), and lower risk of recurrence (0.22; 95% CI 0.15, 0.30), metastasis (0.07; 95% CI 0.05, 0.10), and cancer-related death (0.03; 95% CI 0.01, 0.06). ONU showed the lowest 5 years cancer specific survival (proportion: 0.77; 95% CI 0.74, 0.80). No correlation was found between the surgical technique and recurrence-free and cancer-specific survival. CONCLUSIONS: Evidence regarding RNU for the treatment of UTUC is increasing but it remains quite sparse and of low quality. Despite this, RNU seems to be safe, and to offer the advantages of a minimally invasive approach without impairing the oncological outcomes. Nevertheless, ONU, HALNU, and LNU still represent a valid, and commonly used surgical treatment option. As RNU becomes more popular, and concerns related to its use remain, the best surgical technique for NU remains to be determined.

On-clamp versus off-clamp robotic partial nephrectomy: A systematic review and meta-analysis.

BACKGROUND: The debate on the pros and cons of robot-assisted partial nephrectomy performed with (on-clamp) or without (off-clamp) renal artery clamping is ongoing. The aim of this meta-analysis is to summarize the available evidence on the comparative studies assessing the outcomes of these two approaches. MATERIAL AND METHODS: A systematic review of the literature on PubMed, ScienceDirect®, and Embase® was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA). Only comparative and case-control studies were submitted to full-text assessment and meta-analysis. RevMan 5.3 software was used. RESULTS: From the initial retrieval of 1937 studies, 15 fulfilling inclusion criteria were selected and provided 2075 patients for analysis (702 off-clamp, 1373 on-clamp). Baseline tumor's features showed a significant difference in size (weighted mean difference: -0.58 cm; 95% confidence interval: [-1.06, -0.10]; p = 0.02) and R.E.N.A.L. score (weighted mean difference: -0.53; 95% confidence interval: [-0.81, -0.25]; p = 0.0002), but not in the exophytic property, the location, and the PADUA score. Pooled analysis revealed shorter operative time (p = 0.02) and higher estimated blood loss (p = 0.0002) for the off-clamp group. Overall complication and transfusion rates were similar, while higher major complication rate was observed in the on-clamp approach (5.6% vs 1.9%, p = 0.03). No differences in oncological outcomes were found. Finally, functional outcomes (assessed by estimated glomerular filtration rate at early postoperative, 3 month, 6 month, and last available follow-up) were not statistically different. CONCLUSION: This meta-analysis shows that off-clamp robot-assisted partial nephrectomy is reserved to smaller renal masses. Under such conditions, no differences with the on-clamp approach emerged.

Long-term Prognostic Impact of Chromosome Abnormalities in Clear Cell Renal Cell Carcinoma.

BACKGROUND/AIM: Clear cell renal cell carcinoma (ccRCC) shows variable chromosomal abnormalities. The aim of this study was to assess the prognostic role of ccRCC chromosomal abnormalities in a single-center cohort with an extended follow-up. MATERIALS AND METHODS: A systematic cytogenetic analysis was performed in 283 consecutive surgically-treated patients for renal masses between 1997 and 2002. Kaplan-Meier and multivariable Cox regression (MCR) models were used to calculate cancer specific survival (CSS). RESULTS: Among 174 ccRCC patients, the most common abnormality was deletion in chromosome 3 (54.6%). At a median follow-up of 119 months, 38 patients (21.8%) died from RCC. At MCR models, worse CSS was independently predicted by deletions in chromosomes 2, 19, 20 or 22 and insertions in chromosome 18. CONCLUSION: Specific ccRCC chromosomal abnormalities are independently associated with worse CSS. Cytogenetic evaluation may direct further genetic analysis for personalized prognostic stratification.

Minimally Invasive Radical Prostatectomy after Previous Bladder Outlet Surgery: A Systematic Review and Pooled Analysis of Comparative Studies.

PURPOSE: Prostate cancer surgery after previous bladder outlet surgery of benign prostatic hyperplasia is an uncommon yet challenging scenario. We performed a systematic review and pooled analysis of comparative studies on laparoscopic and robotic minimally invasive radical prostatectomy after bladder outlet surgery. MATERIALS AND METHODS: We searched the literature on PubMed®, Embase® and Web of Science™ up to February 2019 according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to identify eligible studies. Surgical, oncologic and functional outcomes in patients who underwent minimally invasive radical prostatectomy after bladder outlet surgery were compared to those without a history of bladder outlet surgery. Sensitivity analysis was done according to surgical technique (laparoscopic or robotic). RevMan 5.3 was used for statistical analysis. RESULTS: A total of 12 comparative studies were included in analysis. Patients who underwent minimally invasive radical prostatectomy after bladder outlet surgery were older (p ≤0.00001) and had a smaller prostate (p = 0.04) and lower prostate specific antigen (p = 0.003). The previous bladder outlet surgery group had lower odds of nerve sparing procedures, longer operative time, a higher rate of bladder neck reconstruction (each p <0.0001) and longer catheter time (p = 0.03). They were at higher risk for intraoperative (p = 0.001), overall (p <0.00001) and major complications (p = 0.0008), a higher positive surgical margin rate (p = 0.0005) and biochemical recurrence (p = 0.05). Moreover, potency (p = 0.03) and continence recovery (p = 0.007) at 12 months were lower in men with previous bladder outlet surgery. Robotic surgery seemed to offer better outcomes than laparoscopy. CONCLUSIONS: Minimally invasive radical prostatectomy after previous bladder outlet surgery represents a challenging surgical task with a higher risk of complications, and higher odds of worse functional and oncologic outcomes. Patients should be aware of these drawbacks and these factors should be considered during patient counseling. When surgery is pursued, robot-assisted radical prostatectomy should be preferred over laparoscopic radical prostatectomy since it can offer superior outcomes. The overall literature on this topic is of low quality and further efforts should be made to obtain higher levels of evidence.

Current evidence and future perspectives about the role of iXip® in the diagnosis of prostate cancer.

iXip® (Immune CompleX Predictive Index, Xeptagen, Venice, Italy) is a diagnostic tool which biological bases ground on PSA-IgM complexes. An algorithm merges the data of PSA-IgM and serum total PSA dosage, prostate volume and patient's age, providing as output a numerical value that correlates with the risk of finding prostate cancer (PCa) at biopsy. The present paper reviews the available evidence and explores future perspective on iXip. A few studies consistently showed that iXip offers better diagnostic accuracy in the diagnosis of PCa than every single parameter composing the index. In detail, for values of iXip below 20% prostatic biopsies were invariably negative, between 20% and 30% only one out of 10 patients had cancer, generally Gleason Score 6, whereas for iXiP>30% the detection rate raised up to 35% and comprised the majority of Gleason score >6 cancers. The PROXIMA study is an ongoing prospective trial that should assess the predictive ability of iXip towards the presence of a clinically significant PCa defined at radical prostatectomy, accounting for clinical, multiparametric magnetic resonance and bioptic data. Preliminary data showed that for iXip values <20% prostatic biopsy could be safely omitted and that the diagnosis of Gleason Score >6 PCa is unlikely for values below 30%.

Standard vs delayed ligature of the dorsal vascular complex during robot-assisted radical prostatectomy: results from a randomized controlled trial.

PURPOSE: Prospective randomized trial to compare standard vs delayed approach to dorsal vascular complex (s-DVC vs d-DVC) in robot-assisted radical prostatectomy (RARP). METHODS: Patients scheduled for RARP were randomized into a 1:1 ratio to receive either s-DVC or d-DVC by two experienced surgeons. In s-DVC arm an eight-shaped single stitch was given at the beginning of the procedure and the DVC was subsequently cut at time of apical dissection; in d-DVC arm the plexus was transected at the end of prostatectomy, prior to apex dissection and then sutured. Primary endpoint was difference in estimated blood loss (EBL) and a sample size of 226 cases was calculated; ad interim analysis was planned after 2/3 of recruitment. RESULTS: Endpoint was reached at ad interim analysis after 162 cases (81 s-DVC, 81 d-DVC) and recruitment was, therefore, interrupted. Baseline and tumor characteristics were overlapping. EBL was significantly higher in d-DVC arm (mean EBL 107 vs 65 ml, p = 0.003), but without differences in post-operative hemoglobin, transfusions and complications. Overall PSM rate was higher in d-DVC arm (21.0 vs 14.8%, p = 0.323), with statistical significance relatively to organ-confined disease (15.5 vs 3.6%, p = 0.031). Apical involvement was instead significantly higher in s-DVC arm (prevalence in PSM patients 66.7 vs 23.5%, p = 0.020). Post-operative PSA, continence and potency rates were similar between groups. CONCLUSIONS: Standard and delayed approaches to DVC are safe and lead to similar functional outcomes. A delayed approach exposes to a higher risk of PSM in organ-confined disease but with a lower risk of apical involvement.

Clinical evaluation of the iXip index to reduce prostate re-biopsies.

BACKGROUND: Prostate biopsy is the gold standard for prostate cancer (PCa) diagnosis, but it's invasive and associated with adverse events. Novel reliable tumor biomarkers and accurate non-invasive tests are required to avoid biopsies. The immune complex PSA-IgM is a new marker for PCa, and it has been included in an algorithm to generate the diagnostic index iXip, which determines the probability of having PCa. In this study we evaluated the ability of iXip to reduce the number of repeat biopsies in patients with a previous negative biopsy and suspicious for PCa. PATIENTS AND METHODS: 219 patients referred for prostate rebiopsy were included in the study. Each patient underwent a trans-rectal ultrasound-guided prostate biopsy and prostate volume examination. Blood samples were collected before any prostatic manipulation to determine the serological levels of PSA-IgM and PSA. The iXip index was calculated as previously reported using an online calculator. RESULTS: iXip values in patients with a positive biopsy were significantly higher than the ones observed in negative patients (p-value = 0.001). Based on iXip values, patients were divided in five risk groups: those with iXip < 0.2 had 0% probability of having PCa. High values of the Gleason score (≥7) were observed mostly in patients with iXip 0.3-0.8. CONCLUSION: Our preliminary results show that iXip identifies a sub-group of patients who can safely avoid rebiopsy because they do not have PCa. The index is a promising tool that could reduce the number of unnecessary prostate biopsies and the relative clinical complications and expenses.