Reporting ChAracteristics of cadaver training and sUrgical studies: The CACTUS guidelines.

INTRODUCTION: Recent systematic reviews highlighted increasing use of cadaveric models in the surgical training, but reports on the characteristics of the models and their impact on training are lacking, as well as standardized recommendations on how to ensure the quality of surgical studies. The aim of our survey was to provide an easy guideline that would improve the quality of the studies involving cadavers for surgical training and research. METHODS: After accurate literature review regarding surgical training on cadaveric models, a draft of the CACTUS guidelines involving 10 different items was drawn. Afterwards, the items were improved by questionnaire uploaded and spread to the experts in the field via Google form. The guideline was then reviewed following participants feedback, ergo, items that scored between 7 and 9 on nine-score Likert scale by 70% of respondents, and between 1 and 3 by fewer than 15% of respondents, were included in the proposed guideline, while items that scored between 1 and 3 by 70% of respondents, and between 7 and 9 by 15% or more of respondents were not. The process proceeded with Delphi rounds until the agreement for all items was unanimous. RESULTS: In total, 42 participants agreed to participate and 30 (71.4%) of them completed the Delphi survey. Unanimous agreement was almost always immediate concerning approval and ethical use of cadaver and providing brief outcome statement in terms of satisfaction in the use of the cadaver model through a short questionnaire. Other items were subjected to the minor adjustments. CONCLUSION: 'CACTUS' is a consensus-based guideline in the area of surgical training, simulation and anatomical studies and we believe that it will provide a useful guide to those writing manuscripts involving human cadavers.

CURRENT ROLE OF MAGNETIC RESONANCE IMAGING IN THE SCREENING, DIAGNOSIS, AND TREATMENT OF PROSTATE CANCER.

Prostate cancer is the most common cancer in men. Diagnosis of prostate cancer poses a significant challenge, due to several different key parameters that need to be evaluated, such as age, history of prostate specific antigen (PSA), clinical examination and more recently magnetic resonance imaging (MRI). The current diagnostic pathway for prostate cancer has resulted in overdiagnosis and overtreatment as well as underdiagnosis and missed diagnoses in many men. Multiparametric MRI (mp-MRI) of the prostate has been identified as a test that could alleviate these diagnostic errors. Before prostate cancer treatment pathological confirmation is mandatory. Prostate biopsy is an invasive procedure with rare but not negligible potential complications. There are several methods of prostate biopsy of which most common are systemic or planar prostate biopsy and cognitive or targeted MRI-guided prostate biopsy. Multiparametric MRI has demonstrated better accuracy and reproducibility in detecting, locating and evaluating prostate cancer and also sparing some men unnecessary biopsies. Recent studies have shown a mpMRI benefit for better procedure planning regarding prostate cancer location, extent of disease and length of the urethra. There are still some challenges ahead, such as ensuring high-quality execution and reporting of mpMRI and ensuring that this diagnostic pathway is cost-effective. According to the latest urological clinical guidelines mpMRI became fundamental tool in management of prostate cancer. The aim of this study is to give a brief insight in use of mpMRI in prostate cancer diagnosis and treatment.

COMPARISON OF GRADING ACCURACY OF PROSTATE CANCER IN SAMPLES ACQUIRED BY A TARGETED AND SYSTEMIC PROSTATE BIOPSY.

Introduction: All malignancies, including prostate cancer, require accurate diagnosing and staging before making a treatment decision. The introduction of targeted biopsies based on prostate MRI findings has raised prostate biopsy accuracy. Guided biopsies target the tumor itself during the biopsy instead of the most common tumor sites as is the case with a systemic biopsy. Some studies report that targeted biopsies should lower prostate cancer biopsy undergrading and overgrading. Goals: To determine the incidence of prostate cancer biopsy undergrading in patients who underwent a classic systemic biopsy compared to patients who underwent a mpMRI cognitive targeted biopsy. Materials and methods: We identified the patients from our database who underwent a radical prostatectomy at our institution from January 1st, 2021, to June 30th, 2021.There were 112 patients identified. Patients were stratified into two groups based on the type of biopsy that confirmed prostate cancer. The mpMRI (N=50) group had a mpMRI cognitive guided transrectal ultrasound (TRUS) prostate biopsy performed, and the non-mpMRI group (N=62) received a classic, systemic TRUS biopsy. We compared the biopsy results with the final pathological results, and searched for undergrading or overgrading in the biopsies compared to the final histological report. Results: The undergrading was found in 17,7% (N=11) cases in the non-mpMRI group and in 12,0% (N=6) of cases in the mpMRI group (p=0,02, Mann-Whitney U test). No overgrading was found in our cohort. All cases of undergrading had Grade Group 1 in the biopsy report and Grade Group 2 in the final specimen report. The charasteristics of patients are listed in Table 1. Discussion and conclusion: In our cohort, the patients who underwent a mpMRI targeted biopsy had a lower undergrading incidence. During a systemic TRUS biopsy, the urologist targets the areas of the prostate where cancer is most commonly located, which is usually the peripheral zone of the prostate. Since different areas of the tumor have different areas of differentiation, only a low-grade part of the tumor is sometimes biopsied, which results in a sampling error. Once the prostate is removed, the whole tumor is analyzed, so the obtained pathological results related to the removed prostate are far more accurate than the analysis of prostate cores obtained by biopsy.

Annual educational expenses of European urology residents and the role of sponsorship in urology training: a survey-based analysis.

Introduction: The aim of this article was to evaluate the personal monetary costs associated with the urology residency. Material and methods: The European Society of Residents in Urology (ESRU) designed a 35-item survey and distributed it via email and social media to urology residents in Europe.Monthly net salary and educational expenses (general expenses, literature, congresses and courses) and opinions regarding sponsorship and expenditure were evaluated. Comparisons between different countries and salary cut-offs were made. Results: A total of 211 European urology residents completed the survey from 21 European countries. The median interquartile range (IQR) age was 30 (18-42) years and 83.0% were male. A total of 69.6% receive less than €1500 net per month and 34.6% spent ≥€3000 on education in the previous 12 months. Sponsorships came mainly from the pharmaceutical industry (57.8%), but 56.4% of trainees thought that the ideal sponsor should be the hospital/urology department. Only 14.7% of respondents stated that their salary is sufficient to cover training expenses, and 69.2% agreed that training costs have an influence on family dynamics. Conclusions: Personal expenses during training are high, are not sufficiently covered by the salary and impact family dynamics for a majority of residents in Europe. The majority thought that hospitals/national urology associations should contribute to the educational costs. For homogeneous opportunities across Europe, institutions should strive to increase sponsorship.

A systematic review and meta-analysis of prognostic impact of different Gleason patterns in ISUP grade group 4.

INTRODUCTION: This systematic review and meta-analysis was conducted to assess the prognostic differences between different Gleason patterns in patients with prostate cancer (PC) within Internal Society of Urological Pathology (ISUP) grade group 4 (GG 4). EVIDENCE ACQUISITION: PUBMED and Scopus databases were searched for articles published prior to December 2019 according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Studies were deemed eligible if they compared overall survival (OS), cancer-specific survival (CSS), and surgical pathological outcomes in PC patients categorized as ISUP GG 4 (Gleason Score [GS] 4+4 vs. GS 3+5 or GS 5+3). Formal meta-analyses were performed for these outcomes. EVIDENCE SYNTHESIS: Ten studies with 42,041 patients were eligible for the systematic review and eight studies with 36,250 patients for meta-analysis. The treatment type of included study was three surgery and three radiotherapy. The other four studies included many kinds of treatments such as surgery, radiotherapy, androgen deprivation therapy, and chemotherapy. GS 4+4 was significantly associated with better OS (pooled hazard ratio (HR): 0.52, 95% confidential interval (CI): 0.29-0.91) than GS 3+5 or GS 5+3. Positive surgical margin rates were significantly lower with GS 4+4 than GS 3+5 and GS 5+3 (odds ratio [OR] 0.70/95% CI 0.64-0.77 and OR 0.70/95% CI 0.56-0.87, respectively). In contrast, different Gleason patterns in ISUP GG 4 were not significantly associated with CSS (pooled HR: 0.77, 95% CI: 0.56-1.06). CONCLUSIONS: GS 4+4 in patients with PC was associated with better OS and positive surgical margin rates. It seems likely that there is heterogeneity within ISUP GG 4. However, caution should be exercised in interpreting the conclusions drawn from this study, given the limitations of the study, which include the heterogeneity of the population of interest and the retrospective nature of the primary data evaluated.

PROSTATE CANCER DIAGNOSIS IN 2019 - CHANGES IN EUROPEAN GUIDELINES AND IMPACT ON DAILY PRACTICE.

Changes in the diagnostic pathway for prostate cancer advised in the most recent Guidelines of the European Association of Urology bring many endeavors for everyday practice. Availability, costs and radiological expertise are still representing a challenge for the adoption of these guidelines in everyday clinical practice. In this article we discuss the current situation regarding these issues and future options.

History of Urology at the Sestre Milosrdnice University Hospital Center.

The history of Croatian urology clearly shows its affiliation to the medical and civilizational circle of the Western world. The Department of Urology at the Sestre milosrdnice University Hospital Center is the oldest urology institution in the Republic of Croatia. The Department was established in 1894, when the new Sestre milosrdnice Hospital was open in Vinogradska cesta in Zagreb. It was then that doctor Dragutin Masek founded the so-called III Department, which, in addition to treating urology patients, also treated patients with conditions of the ear, nose and throat, eye diseases and dermatologic conditions. Dragutin Masek had already realized that medicine would soon be divided into fields and had assigned younger doctors joining the III Department to specific fields. As a result, urology was given to Aleksandar Blaskovic, who founded the first independent department of urology in Croatia in 1926. In 1927, he was appointed Professor of urology at the Zagreb School of Medicine, where he established the first department of urology and was giving lectures and practicals. Under his leadership, the Department of Urology was given the status of a Clinic, a teach-ing department, the first of its kind in Croatia. Owing to all his activities in the field of urology, the history remembers him as the "father of modern Croatian urology". Over the course of the following years, department chairs had changed, but luckily for the patients, approach to work had not. Conscientiousness, trust, competence and charity. After all, charity is the idea that the hospital carries even in its name, after the Sisters of Charity who had founded it. In all the decades, the Department of Urology has been following global development paths, objectively legging behind top facilities in the world by only a few years. Overall professional and scientific urology activities culminated in 1998, when the Clinic became the Reference Center of the Ministry of Health of the Republic of Croatia for prostate cancer, and in 2011, when it became the European Board of Urology Certified Center. All that has been achieved could not have been done without wholehearted help and cooperation of the nurses, as well as every other department employee from the beginnings of urology until today. Despite its rich history, the Department does not rest on laurels. Today, it is a modern urology department together with its European role models.

20 Years of the Reference Center for Prostate Tumors of the Ministry Of Health at the Department of Urology in Sestre Milosrdnice University Hospital Center.

The Department of Urology at the Sestre milosrdnice University Hospital Center is the oldest urological institution in the Republic of Croatia and this part of Europe. Today, the Department is a modern tertiary healthcare institution, where the most complex methods of urological practice are performed using modern medical devices and highly sophisticated technology. In 2011, our urology specialist education program was certified by the European Board of Urology (EBU) as the only one of its kind in Croatia. The program was recertified in 2017. The Department runs a program for the early detection of prostate cancer and performs more than 240 radical prostatectomies annually, which is the highest number of such interventions in Croatia. The aim of this study is to present the work and the activities of the Reference Center for Prostate Tumors of the Ministry of Health at the Department of Urology in Sestre milosrdnice University Hospital Center over the last 20 years. The database of the Reference Center for Prostate Tumors of the Ministry of Health at the Department of Urology in Sestre milosrdnice University Hospital Center was reviewed. During the twenty-year period, approximately 15,000 prostate interventions were performed due to benign and malignant diseases. Of this, 7,374 transrectal ultrasound guided prostate biopsies, 2,632 radical prostatectomies with open retropubic access, 3,988 transurethral prostate resections and 1,097 open suprapubic adenomectomies were performed. With the achieved scientific and professional results in monitoring, studying and improving the prevention, diagnosis and therapy of prostate tumors, as well as with the professional conditions and personnel, the Department of Urology in Sestre milosrdnice University Hospital Center truly justifies the title of the Reference Center for Prostate Tumors of the Ministry of Health of the Republic of Croatia awarded to it in 1998.

Role of Multiparametric Magnetic Resonance Imaging in Prostate Cancer Assessment.

Multiparametric magnetic resonance is assuming an increasingly important role in the diagnosis, initial assessment and monitoring of patients with prostate cancer. This paper offers a more complex insight into the application of magnetic resonance imaging with prostate cancer, with a current literature overview. The focus is on the problem of initial prostate cancer evaluation which strongly affects further decision-making and therapeutic interventions. Clinical suggestions based on the current guidelines are also offered.

Diagnostic Value of Cognitive-Registration Multiparametric Magnetic Resonance Guided Biopsy for the Detection of Prostate Cancer after Initial Negative Biopsy.

The aim of this prospective clinical study was to determine the detection rate of prostate cancers by multiparametric magnetic resonance and transrectal ultrasound (mpMRI-TRUS) cognitive fusion biopsies in patients with a previously negative TRUS-guided biopsy. Between 1 October 2016 and 1 July 2017, in 101 consecutive patients with elevated antigen (PSA) and/or positive digital rectal examination and after a negative first TRUS biopsy, a second, repeated prostate biopsy was performed. In 24 patients, cognitive fusion mpMRI-TRUS biopsy of the prostate with 8-10 system cores and 1-3 target biopsies was performed, in line with the European Association of Urology guidelines. In 77 patients, only a classic, repeated TRUS guided biopsy was performed. In patients with mpMRI, the detection rate according to PIRADS-v2 reporting system was: PIRADS 1, n = 0; PIRADS 2, n = 0; PIRADS 3, n = 0; PIRADS 4, n = 6/8 (75%); and PIRADS 5, n = 2/3 (67%). In the group of patients with MR-TRUS cognitive fusion biopsy, the prostate cancer detection rate was 8/24 (33%), while in the control group the detection rate was 12/77 (16%), which was statistically significant (t test, p = 0.037, CI 95% is 0.01 to 0.37). Patients with PIRADS ≤ 3 (54%) could have avoided the biopsy.

Cost-Benefit Analysis of the Introduction of Mp-Mri Guided Biopsies in Croatia.

The objective of this study was to determine differential expression of TFF1, TFF2 and TFF3 genes and proteins in breast tumor subtypes. In addition, we investigated the correlation between TFF genes within tumor subgroups, and TFF genes with clinical and pathologic characteristics of the tumor. Study group included 122 patients with surgically removed breast tumors. Samples were investigated using qRT-PCR and immunohistochemistry. TFF1 and TFF3 genes and proteins were expressed in breast tumors, while the levels of TFF2 gene and protein expression were very low or undetectable. TFF1 was significantly more expressed in benign tumors, while TFF3 was more expressed in malignant tumors. Gene and protein expression of both TFF1 and TFF3 was greater in lymph node-negative tumors, hormone positive tumors, tumors with moderate levels of Ki67 expression, and in grade II tumors. A strong positive correlation was found between TFF1 and TFF3 genes, and the expression of both negatively correlated with Ki67 and the level of tumor histologic differentiation. Our results suggest that TFF1 and TFF3, but not TFF2, may have a role in breast tumor pathogenesis and could be used in the assessment of tumor differentiation and malignancy.

Histopathological Outcomes after Radical Prostatectomy for Prostate Cancer Based On a New Grading System.

One of the main reasons for the introduction of a new grading system was Gleason sum 7, which differed significantly in the prognosis of the disease depending on the primary Gleason. The aim of this study was to compare grade group 2 and grade group 3, and the impact of cancer percentages in final pathology reports after radical prostatectomy on the occurrence of T3 stage of the disease after radical prostatectomy of clinically localized prostate cancer. The study covered 365 patients with clinically localized prostate cancer who underwent radical retropubic prostatectomy (RRP) over the period of two years. The average percentage of carcinomas found in pathology reports after RRP was 20.1%. With the increase in the grade group, the average percentage of carcinomas in pathology reports increased significantly, p <0.001. With regard to grade groups 2 and 3, irrespective of cancer percentages in pathology reports, more cases of T3 stage were found in grade group 3 when compared to grade group 2, which was statistically significant (p <0.001). However, grade group 2 and grade group 3 patients with ≤10% cancer occurrences in final pathology reports after RRP did not show any statistical significance in the occurrence of T3 stage, p=0.96. Prognostic differences in grade group 2 and grade group 3 patients after RRP are significant, but not in all cases, because of their dependence on the percentage of cancer in the final pathology report after RRP of clinically localized prostate cancer.

Unfavorable Clinicopathological Features in Radical Prostatectomy Patients Who Were Spared Pelvic Lymphadenectomy.

Pelvic lymph node dissection (PLND) during radical prostatectomy (RP) is the most accurate staging modality for lymph node assessment in patients with prostate cancer. It is recommended in all patients with intermediate or high-risk disease undergoing radical prostatectomy. The goal of our study was to assess unfavorable clinicopathological characteristics in patients with omitted lymphadenectomy (PLND) during radical prostatectomy based on the nomogram proposed by Briganti and colleagues. In 2011, 200 patients undertook radical prostatectomy in our institution. Among them 53 patients who fulfilled Briganti criteria and in whom we omitted lymphadenectomy based on current guidelines. Unfavorable clinicopathological features considered were: stage T3, positive surgical margins or biochemical relapse (BCR). We registered biopsy Gleason score 6 in 34 patients, and 19 patients had Gleason score 7. Stage pT2 was seen in 49 patients, and pT3 in 4. Glea-son score after radical prostatectomy was upgraded from GS 6 to GS 7 in 20 patients (37%) and reduced in 1 patient (2%). After a median follow-up of 49 (44-56) months, there were 12 (22.6%) patients with BCR. Patients with biopsy Gleason score 6 (n=34) compared to biopsy Gleason 7 (n=19) patients showed no difference regarding positive margins (p=0.0738) and BCR (p=0,736) at 49 months follow-up. Thus, PLND according to current guidelines can be safely omitted in low-risk patients using Brigantinomogram.

CROATIAN UROLOGISTS' CLINICAL PRACTICE AND COMPLIANCE WITH GUIDELINES IN THE MANAGEMENT OF NON-NEUROGENIC MALE LOWER URINARY TRACT SYMPTOMS.

The aim of this study was to assess the Croatian urologists' management of non-neurogenic male lower urinary tract symptoms (LUTS) and their compliance with the European Association of Urology (EAU) guidelines. A cross-sectional survey included 51/179 Croatian urologists. We developed a questionnaire with questions addressing compliance with EAU guidelines. The rate of performing recommended evaluations on the initial assessment of patients with benign prostate hyperplasia (BPH)/LUTS varied from 8.0% (serum creatinine and voiding diary) to 100.0% (physical examination, prostate specific antigen and ultrasound). The international prostate symptom score was performed by 31%, analysis of urine sediment by 83%, urine culture by 53%, and serum creatinine by 8% of surveyed urologists. Only 8% of urologists regularly used bladder diary in patients with symptoms of nocturia. Our results indicated that 97% of urologists preferred alpha blockers as the first choice of treatment; 5-alpha reductase inhibitors (5ARI) were mostly prescribed (84%) in combination with an alpha-blocker, preferably as a continuous treatment, whilst 29% of urologists used to discontinue 5ARI after 1-2 years. Half of the Croatian urologists used antimuscarinics in the treatment of BPH/LUTS and recommended phytotherapeutic drugs in their practice. In conclusion, Croatian urologists do not completely comply with the guidelines available.