Comparison of EEP and TURP long-term outcomes: systematic review and meta-analysis.

OBJECTIVE: To compare long-term reoperation rate and functional outcomes between EEP (endoscopic enucleation of the prostate) and TURP (transurethral resection of the prostate). EVIDENCE ACQUISITION: A systematic literature review of Medline, Scopus, and Web of Science was conducted with primary outcome assessed being reoperation rate and secondary outcomes after a long term (> 3 years) being functional outcomes or related values (prostate volume, PSA level, etc.). EVIDENCE SYNTHESIS: Five studies were found with long-term follow-up 4-7 years. EEP reoperation rate ranged from 0 to 1.27%, while from 1.7 to 17.6% for TURP. Meta-analysis showed significantly lower OR for EEP, 0.27 (95% CI 0.24-0.31), with notable homogeneity of the results, I2 = 0%. Long-term Qmax and IPSS were significantly better for EEP. Qmax pooled mean difference was 1.79 (95% CI 1.72-1.86) ml/s with a high concordance among the studies, I2 = 0%. IPSS mean difference -1.24 (95% CI - 1.28 to - 1.2) points, I2 = 57% but QoL did not differ, with mean difference being 0.01 (95% CI - 0.02 to 0.04), I2 = 0%. IIEF-5 score was also significantly better for EEP, mean difference 1.08 (95% CI 1.03-1.13), but heterogeneity was high, I2 = 70%. PSA level and prostate volume were only reported in one study and favored EEP slightly yet statistically significant. CONCLUSION: EEP had a significantly lower reoperation rate and better functional outcomes (Qmax and IPSS) at long term compared with TURP. It may also be beneficial in terms of IIEF-5, PVR, and PSA level.

A systematic review and meta-analysis of artificial intelligence diagnostic accuracy in prostate cancer histology identification and grading.

BACKGROUND: Artificial intelligence (AI) is a promising tool in pathology, including cancer diagnosis, subtyping, grading, and prognostic prediction. METHODS: The aim of the study is to assess AI application in prostate cancer (PCa) histology. We carried out a systematic literature search in 3 databases. Primary outcome was AI accuracy in differentiating between PCa and benign hyperplasia. Secondary outcomes were AI accuracy in determining Gleason grade and agreement among AI and pathologists. RESULTS: Our final sample consists of 24 studies conducted from 2007 to 2021. They aggregate data from roughly 8000 cases of prostate biopsy and 458 cases of radical prostatectomy (RP). Sensitivity for PCa diagnostic exceeded 90% and ranged from 87% to 100%, and specificity varied from 68% to 99%. Overall accuracy ranged from 83.7% to 98.3% with AUC reaching 0.99. The meta-analysis using the Mantel-Haenszel method showed pooled sensitivity of 0.96 with I2 = 80.7% and pooled specificity of 0.95 with I2 = 86.1%. Pooled positive likehood ratio was 15.3 with I2 = 87.3% and negative - was 0.04 with I2 = 78.6%. SROC (symmetric receiver operating characteristics) curve represents AUC = 0.99. For grading the accuracy of AI was lower: sensitivity for Gleason grading ranged from 77% to 87%, and specificity from 82% to 90%. CONCLUSIONS: The accuracy of AI for PCa identification and grading is comparable to expert pathologists. This is a promising approach which has several possible clinical applications resulting in expedite and optimize pathology reports. AI introduction into common practice may be limited by difficult and time-consuming convolutional neural network training and tuning.

Robot-Assisted Magnetic Resonance Imaging-Targeted versus Systematic Prostate Biopsy; Systematic Review and Meta-Analysis.

INTRODUCTION: Robot-assisted devices have been recently developed for use in prostate biopsy. However, it is possible advantages over standard biopsy remain unclear. We aimed to assess the diagnostic performance and safety of robot-assisted targeted (RA-TB) and systematic prostate biopsies (RA-SB). METHODS: A systematic literature search was performed in MEDLINE and Scopus databases. The detailed search strategy is available at Prospero (CRD42021269290). The primary outcome was the clinically significant prostate cancer (PCa) detection rate. The secondary outcomes included the overall detection rate of PCa, cancer detection rate per core, and complications. RESULTS: The clinically significant cancer detection rate, overall cancer detection rate, and "per patient" did not significantly differ between RA-TB and RA-SB [OR = 1.02 (95% CI 0.83; 1.26), p = 0.05, I2 = 62% and OR = 0.95 (95% CI 0.78; 1.17), p = 0.17, I2 = 40%, respectively]. There were no differences in the clinically insignificant cancer detection rate "per patient" between RA-TB and RA-SB [OR = 0.81 (95% CI 0.54; 1.21), p = 0.31, I2 = 0%]. RA-TB had a significantly higher cancer detection rate "per core" [OR = 3.01 (95% CI 2.77; 3.27), p < 0.0001, I2 = 96%]. CONCLUSION: RA-TB and RA-SB are both technically feasible and have comparable clinical significance and overall PCa detection rates.

Nephrometric score based on 3D modeling (3D nephrometry score) for the probability prediction of intra- and postoperative complications for kidney surgery.

AIM: The purpose of the study is the development and evaluation of the informativeness of the author's 3D nephrometric score application to predict the probability of intraoperative and postoperative complications in kidney operations. MATERIAL AND METHODS: The study includes 264 patients who underwent surgical treatment of renal tumors, before that CT and 3D modeling were carried out. All patients underwent an analysis of the surgical intervention complexity on the C-index, PADUA, R.E.N.A.L., and developed 3D nephrometric score. To determine the set of variables that allow to classify patients, the method of discriminant analysis was used to predict the nature, volume of blood loss, duration of ischemia, and the number of complications. The sensitivity and specificity of the predictors were estimated with the help of ROC analysis. RESULTS: Indicators have been established to classify patients according to the probability of complications, the amount of blood loss and the duration of ischemia during surgery for kidney cancer. We have created linear models that predict the development of bleeding during surgery, the volume of blood loss of more than 200 ml and the duration of ischemia more than 20 min, as well as the likelihood of complications using discriminant functions. The proposed author's nephrometric score exceeds the capabilities of C-index, PADUA, R.E.N.A.L in many ways in blood loss and time of ischemia predicting, which allows us to recommend it for the assessment of resectability in kidney operations.

Cardiovascular remodeling as a result of fibroblast growth factor-23 (FGF-23)/Klotho imbalance in patients with CKD.

BACKGROUND: In chronic kidney disease (CKD) cardiovascular remodeling (CVR) is very frequent compared with general population and, as suppose, may be associated with «new¼ renal risk factors. The aim of study was to estimate association of new serum biomarkers (FGF-23, Klotho) and traditional biomarker of cardiac damage-serum Troponin I (sTr-I) with signs of CVR. METHODS: One hundred thirty CKD G1-5D patients without cardiovascular disease (CVD) clinical manifestation were included. We measured serum FGF-23, Klotho and sTr-I. The instrumental methods were: echocardiography, SphygmoCor test [Pulse Wave Velocity (PWV), Central (aortic) Blood Pressure (CBP), Subendocardial Blood Supply (SBS)]. RESULTS: FGF-23 level correlated with: sTr-I (r = 0.512; p < 0.01), eccentric left ventricular hypertrophy, LVH (r = 0.543; p < 0.01), SBS (r = - 0.499; p < 0.05). There were no differences of FGF-23 level in patients with normal and high CBP. Klotho correlated with concentric LVH (r = - 0.451; p < 0.01), PWV (r = - 0.667; p < 0.001), Cardiac Calcification Score, CCS (r = - 0.581; p < 0.01). Multivariate analysis revealed positive independent association of FGF-23 with eccentric LVH (OR = 1.036, 95% CI (1.004-1.068); p = 0.038). Klotho was a negative determinant for concentric LVH (OR = 0.990, 95% CI 0.987-0.994; p < 0.001), increased PWV (OR = 0.984, 95% CI (0.977-0.991); p < 0.001) and CCS (OR = 0.991, 95% CI (0.988-0.995); p < 0.001). In addition, multivariate analysis revealed a relationship between serum Klotho (OR = 0.980, 95% CI (0.964-0.996); p = 0.016), FGF-23 (OR = 3.145, 95% CI (1.020-9.695); p = 0.046) and troponin I level. CONCLUSION: In CKD patients without CVD clinical manifestation increased serum FGF-23 level and decreased Klotho are associated with CVR: FGF-23 with eccentric LVH (independently of CBP), Klotho determinate concentric LVH, PWV and CCS. Moderately elevated sTr-I levels may be a manifestation of FGF-23/Klotho imbalance in CKD.

Prospective Single-Center Study of SuperPulsed Thulium Fiber Laser in Retrograde Intrarenal Surgery: Initial Clinical Data.

INTRODUCTION: The objective of this study was to present our clinical experience of using the thulium fiber laser in retrograde intrarenal surgery (RIRS). METHODS: A prospective clinical study performed after the IRB approval (Sechenov University, Russia). Patients with stones <30 mm were treated with SuperPulsed thulium fiber laser (SP TFL) (NTO IRE-Polus, Russia) through a 200-µm-diameter fiber. Stone size, density, the duration of the operation, and laser on time (LOT) were measured. Based on the surgeon's feedback, retropulsion and intraoperative visibility were also assessed (Likert scale). Stone-free rates (SFRs) were assessed with a low-dose CT scan 90 days after the operation. RESULTS: Between January 2018 and December 2019, 153 patients (mean age 54 ± 2.8 years) underwent RIRS with SP TFL (mean stone density 1,020 ± 382 HU). Median stone volume was 279.6 (139.4-615.8) mm3. Median LOT was 2.8 (IQR 1.6-6.6) min with median total energy for stone ablation 4.0 (IQR 2.1-7.17) kJ, median ablation speed was 1.7 (1.0-2.8) mm3/s, median ablation efficacy was 13.3 (7.3-20.9) J/mm3, and energy consumption was 170.3 (59.7-743.3) J/s. Overall, the SFR (at 3 months) was 89%. The overall complication rate was 8.4%. Retropulsion was present in 23 (15.1%) patients. Visibility was estimated as optimal in most patients, with poor visibility reported in only 13 (8.5%) patients. CONCLUSION: The SP TFL is a safe and efficient tool in lithotripsy, irrespective of the stone type and density. Retropulsion is minimal and visibility is maintained with SP TFL. Nonetheless, further clinical studies are needed to ensure optimal comparison with conventional holmium:YAG lithotripsy.

Enucleation vs. vaporization of benign prostatic hyperplasia: a head-to-head comparison of the various outcomes and complications. A systematic review and meta-analysis.

INTRODUCTION: Vaporization of the prostate (VP) and endoscopic enucleation of the prostate (EEP) are reliable and frequently used methods for BPO relief. Both surgeries utilize lasers and EAU recommends them in similar patient cohorts. Our objective was to compare intra- and perioperative results of patients who had undergone VP and EEP. EVIDENCE ACQUISITION: A systematic literature search was performed in three databases (MEDLINE, Web of Science and Scopus). The detailed search strategy is available at Prospero, CRD42020204739. Primary outcomes were functional results (IPSS, QoL, PVR, Qmax), and secondary outcomes were intraoperative results, postoperative PSA and prostate volume, complications, and recurrence rate. EVIDENCE SYNTHESIS: VP required less operative time compared to EEP, mean difference -5.51 (95% CI -7.52; -3.50). IPSS and Qmax for VP were worse after 12-month follow-up, mean difference 0.89 (95% CI 0.52; 1.27) and -3.7 (95% CI -4.56; -2.85), respectively, while QoL did not differ significantly. Postoperative PSA level was higher in the VP group, mean difference 2.28 (95% CI 2.00; 2.55). VP was associated with reduced Clavien-Dindo grade I (OR=4.16; 95% CI 2.96; 5.84) and grade II (OR=3.79; 95% CI 2.25; 6.39) complication rate, especially in terms of the percentage of blood transfusion and transient urinary incontinence. The rate of complications grade IIIa and higher was similar (3-6%). Reoperation rate was only estimated in one study and was significantly higher in the PVP group at 60 months of follow-up, 2.7% vs. 0%, P<0.05. CONCLUSIONS: EEP and VP share the efficacy and safety in BPH management. Our meta-analysis shows comparable complication rate in Clavien-Dindo III, VP superiority in operation time, and EEP superiority in long-term functional outcomes and PSA reduction.

A systematic review and meta-analysis of Histoscanning™ in prostate cancer diagnostics.

CONTEXT: The value of Histoscanning™ (HS) in prostate cancer (PCa) imaging is much debated, although it has been used in clinical practice for more than 10 years now. OBJECTIVE: To summarize the data on HS from various PCa diagnostic perspectives to determine its potential. MATERIALS AND METHODS: We performed a systematic search using 2 databases (Medline and Scopus) on the query "Histoscan*". The primary endpoint was HS accuracy. The secondary endpoints were: correlation of lesion volume by HS and histology, ability of HS to predict extracapsular extension or seminal vesicle invasion. RESULTS: HS improved cancer detection rate "per core", OR = 16.37 (95% CI 13.2; 20.3), p < 0.0001, I2 = 98% and "per patient", OR = 1.83 (95% CI 1.51; 2.21), p < 0.0001, I2 = 95%. The pooled accuracy was markedly low: sensitivity - 0.2 (95% CI 0.19-0.21), specificity - 0.12 (0.11-0.13), AUC 0.12. 8 of 10 studiers showed no additional value for HS. The pooled accuracy with histology after RP was relatively better, yet still very low: sensitivity - 0.56 (95% CI 0.5-0.63), specificity - 0.23 (0.18-0.28), AUC 0.4. 9 of 12 studies did not show any benefit of HS. CONCLUSION: This meta-analysis does not see the incremental value in comparing prostate Histoscanning with conventional TRUS in prostate cancer screening and targeted biopsy. HS proved to be slightly more accurate in predicting extracapsular extension on RP, but the available data does not allow us to draw any conclusions on its effectiveness in practice. Histoscanning is a modification of ultrasound for prostate cancer visualization. The available data suggest its low accuracy in screening and detecting of prostate cancer.

Endoscopic lithotripsy with a SuperPulsed thulium-fiber laser for ureteral stones: A single-center experience.

OBJECTIVES: To estimate the efficacy and safety of SuperPulsed thulium-fiber laser ureteral lithotripsy and to identify optimal laser settings. METHODS: Patients with solitary stones were prospectively included. Lithotripsy was performed with a SuperPulsed thulium-fiber laser (NTO IRE-Polus, Fryazino, Russia) using a rigid ureteroscope 7.5 Ch (Richard Wolf, Knittlingen, Germany). We analyzed the efficacy of lithotripsy by measuring total energy required for stone disintegration, "laser-on" time, ablation speed, ablation efficacy, and energy consumption. Stone retropulsion and visibility were assessed using a three-point Likert scale. Complications were assessed using the Clavien-Dindo classification system. RESULTS: A total of 149 patients were included. The mean stone density was 985 ± 360 Hounsfield units, the median (interquartile range) stone volume was 179 (94-357) mm3 . The median (interquartile range) total energy was 1 (0.4-2) kJ, and laser-on time 1.2 (0.5-2.7) min. The median (interquartile range) stone ablation speed was 140 (80-279) mm3 /min, energy for ablation of 1 mm3 was 5.6 (3-9.9) J/mm3 and energy consumption was 0.9 (0.6-1) J/min. A correlation was found between retropulsion and the energy used (r = 0.5, P < 0.001). Multivariable analysis showed energy to be a predictor of increased retropulsion (odds ratio 65.7, 95% confidence interval 1.6-2774.1; P = 0.028). No predictors for worse visibility were identified. CONCLUSION: The SuperPulsed thulium-fiber laser provides effective and safe lithotripsy during ureteroscopy regardless of stone density. Fiber diameter and laser frequency do not influence visibility or safety. Optimal laser settings are 0.5 J × 30 Hz for fragmentation and 0.15 J × 100 Hz for dusting.

Active Surveillance for Intermediate-Risk Prostate Cancer: Systematic Review and Meta-analysis of Current Protocols and Outcomes.

INTRODUCTION: Current guidelines allow active surveillance for intermediate-risk prostate cancer patients but do not provide comprehensive recommendations for selection. We performed a systematic review and meta-analysis of outcomes for active surveillance in intermediate- and low-risk groups. METHODS: We performed a systematic literature search of intermediate-risk localized prostate cancer patients undergoing active surveillance using 3 literature search engines (Medline, Web of Science, and Scopus) over the past 10 years. The primary outcome was the percentage of patients who remain under surveillance. Secondary outcomes included cancer-specific survival, overall survival, and metastasis-free survival. For articles including both low- and intermediate-risk patients undergoing active surveillance, comparisons between the two groups were made. RESULTS: The proportion of patients who remained on active surveillance was comparable between the low- and intermediate-risk groups after 10 and 15 years' follow-up (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.83-1.14; and OR, 0.86; 95% CI, 0.65-1.13). Cancer-specific survival was worse in the intermediate-risk group after 10 years (OR, 0.47; 95% CI, 0.31-0.69) and 15 years (OR, 0.34; 95% CI, 0.2-0.58). The overall survival rate showed no statistical difference at 5 years' follow-up (OR, 0.84; 95% CI, 0.45-1.57) but was worse in the intermediate-risk group after 10 years (OR, 0.43; 95% CI, 0.35-0.53). Metastases-free survival did not significantly differ after 5 years (OR, 0.55; 95% CI, 0.2-1.53) and was worse in the intermediate-risk group after 10 years (OR, 0.46; 95% CI, 0.28-0.77). CONCLUSION: Active surveillance could be offered to patients with intermediate-risk prostate cancer. However, they should be informed of the need for regular monitoring and the possibility of discontinuation as a result of a higher rate of progression. Available data indicate that 5-year survival rates between intermediate- and low-risk patients do not differ; 10-year survival rates are worse. To assess the long-term effectiveness and safety of active surveillance, it is necessary to develop unified algorithms for patient selection and management, and to prospectively conduct studies with long-term surveillance.

Dual-Energy Computed Tomography for Stone Type Assessment: A Pilot Study of Dual-Energy Computed Tomography with Five Indices.

Purpose: To assess the efficacy of dual-energy CT (DECT) in predicting the composition of urinary stones with a single index (dual energy ratio [DER]) and five indices. Methods: Patients undergoing DECT before active urolithiasis treatment were prospectively enrolled in the study. Predictions of stone composition were made based on discriminant analysis with a single index (DER) and five indices (stone density at 80 and 135 kV, Zeff [the effective atomic number of the absorbent material] of the stone, DER, dual-energy index [DEI] and dual-energy difference [DED]). After extraction, stone composition was evaluated by means of physicochemical analyses (X-ray phase analysis, electron microscopy, wet chemistry techniques, and infrared spectroscopy). Results: A total of 91 patients were included. For calcium oxalate monohydrate (COM) stones, the sensitivity, specificity, and overall accuracy of DECT with one index (DER) were 83.3%, 89.8%, and 86.8%, respectively; for calcium oxalate dihydrate (COD) and calcium phosphate stones-88.2%, 92.9%, and 91.2%, respectively; for uric acid stones-0%, 98.8% and 97.8%, respectively; for struvite stones-60%, 95.3%, and 93.4%, respectively. Discriminant analysis with five indices yielded the following sensitivity, specificity, and overall accuracy: 95.2%, 89.8%, and 92.3% for COM stones, 85.3%, 96.4%, and 92.3% for COD stones, and 100% in all three categories for both uric acid and struvite stones. Conclusions: DECT is a promising tool for stone composition assessment. It allowed for evaluation of chemical composition of all stone types with specificity and accuracy ranging from 85% to 100%. Five DECT indices have shown much better diagnostic accuracy compared to a single DECT index.

Retrospective Assessment of Endoscopic Enucleation of Prostate Complications: A Single-Center Experience of More Than 1400 Patients.

Introduction: Endoscopic enucleation of the prostate (EEP) is a safe method of treating benign prostatic hyperplasia, regardless of prostate volume and type of applied energy. To date, however, there has been no study that examines complication rates with respect to the type of applied energy. This study aims to address this problem by providing a retrospective analysis of >1400 patients who have undergone prostate enucleation. Materials and Methods: We performed a retrospective analysis of all patients undergoing EEP between 2013 and 2018 at a single tertiary institution. This analysis included patients who had undergone one of three forms of EEP: holmium laser enucleation of the prostate (HoLEP), thulium fiber laser enucleation of the prostate (ThuFLEP), or monopolar enucleation of the prostate (MEP). We compared intraoperative and early postoperative complications, as well as complications at 3 and 6 months follow-up. Results: A total of 1413 patients were included in this study; 36% patients underwent HoLEP, 57.5% had ThuFLEP, and 6.5% MEP. The most frequent complication in the early postoperative period was a mild fever (2.76% of the cases). The morcellation was delayed to a separate stage because of intensive hemorrhaging in 1.4% of the cases. Bladder tamponade was found in 1.1% of the cases. We found no correlation between complication rate and either prostate volume or energy source. Stress urinary incontinence was found in 3.9% of patients at 3 months and in only 1.4% of patients at 6 months after the operation. Urethral stricture at 6 months after the surgery was found in 1.4% of patients, whereas bladder neck sclerosis was found in only 0.9% of these cases. No significant difference was observed between these complication frequencies and any preoperative factors or energy source. Conclusions: All EEP types are safe with equal rates of complications intraoperatively, postoperatively, and at 6 months follow-up.

Effect of essential amino acid кetoanalogues and protein restriction diet on morphogenetic proteins (FGF-23 and Кlotho) in 3b-4 stages chronic кidney disease patients: a randomized pilot study.

BACKGROUND: A low protein diet (LPD) with essential amino acid ketoanalogue supplementation (KA) may contribute in improving of chronic kidney disease (CKD), while the exact mechanisms of KA's effect are not established yet. We have conducted a prospective, randomized, controlled comparative study of LPD + KA and LPD alone in relation to serum Klotho, FGF-23 levels in CKD patients. METHODS: 79 non-diabetic CKD 3b-4 stage patients, compliant with LPD diet (0.6 g/kg of body weight/day), had been selected. The patients were randomized into two groups. The first group (42 patients) received LPD + КA. The second group (37 patients) continued the LРD alone. In addition to routine tests, serum Klotho, FGF-23 levels, as well as bioimpedance analysis, sphygmography (stiffness (augmentation) indices (AI), central (aortal) blood pressure) with a «SphygmaCor¼ device; echocardiography (valvular calcification score (VCS) and LVMMI), were performed. RESULTS: There were body mass indices' decrease (p = 0.046), including muscle body mass in men (p = 0.027) and woman (p = 0.044) in the LPD group to the end of study (14th month). In addition, lower FGF-23 (p = 0.029), and higher sKlotho (p = 0.037) were detected in the LPD + KA group compared to the LPD one. The increase in AI (p = 0.034), VCS (p = 0.048), and LVMMI (p = 0.023) was detected more often in the LPD group at the end of study. CONCLUSION: LPD + KA provides support for nutrition status and contributes to more efficient correction of FGF-23 and Klotho abnormalities that may result in cardiovascular calcification and cardiac remodeling decreasing in CKD. At the same time, a prolonged LPD alone may lead to malnutrition.