Tumor upgrading among very favorable intermediate-risk prostate cancer patients treated with robot-assisted radical prostatectomy: how can it impact the clinical course?

PURPOSE: We sought to investigate predictors of unfavorable tumor upgrading in very favorable intermediate-risk (IR) prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy, in addition to evaluate how it may affect the risk of disease progression. METHODS: A very favorable subset of IR PCa patients presenting with prostate-specific antigen (PSA) < 10 ng/mL, percentage of biopsy positive cores (BPC) < 50%, and either International Society of Urological Pathology (ISUP) grade group 1 and clinical stage T2b or ISUP grade group 2 and clinical stage T1c-2b was identified. Unfavorable pathology at radical prostatectomy was defined as the presence of ISUP grade group > 2 (unfavorable tumor upgrading), extracapsular extension (ECE), and seminal vesicle invasion (SVI). Disease progression was defined as the event of biochemical recurrence and/or local recurrence and/or distant metastases. Associations were evaluated by Cox regression and logistic regression analyses. RESULTS: Overall, 210 patients were identified between January 2013 and October 2020. Unfavorable tumor upgrading was detected in 71 (33.8%) cases, and adverse tumor stage, including ECE or SVI in 18 (8.6%) and 11 (5.2%) patients, respectively. Median (interquartile range) follow-up was 38.5 (16-61) months. PCa progression occurred in 24 (11.4%) patients. Very favorable IR PCa patients with unfavorable tumor upgrading at final pathology showed a persistent risk of disease progression, which hold significance after adjustment for all factors (Hazard Ratio [HR]: 5.95, 95% Confidence Interval [CI]: 1.97-17.92, p = 0.002) of which PSA was an independent predictor (HR: 1.52, 95% CI 1.12-2.08, p = 0.008). Moreover, these subjects were more likely to belong to the biopsy ISUP grade group 2. CONCLUSIONS: Very favorable IR PCa patients hiding unfavorable tumor upgrading were more likely to experience disease progression. Unfavorable tumor upgrading involved about one-third of cases and was less likely to occur in patients presenting with biopsy ISUP grade group 1. Tumor misclassification is an issue to discuss, when counseling this subset of patients for active surveillance because of the risk of delayed active treatment.

Is antibiotic prophylaxis still mandatory for transperineal prostate biopsy? Results of a comparative study.

Introduction and objectives: This study aimed to assess the incidence of urinary tract infections (UTIs) after transperineal prostate biopsy (TP-PB) comparing patients who underwent antibiotic prophylaxis (AP) with patients who had no prophylaxis. Materials and methods: This prospective, double-center trial was conducted between August and December 2020. Patient candidates to PB were included with 1:1 allocation to case (Group A-no AP) and control group (Group B-standard AP). All TP-PBs were performed in an outpatient setting under local anesthesia. Data collected 2 weeks after the procedure included incidence of UTIs or bacteriuria, evaluated with a urine culture (UC), main symptoms, and complications related to TP-PBs. Results: A total of 200 patients were included (100 patients in each group). The mean age was 66.2 ± 7.7 in Group A and 67.4 ± 8 years in Group B (P = 0.134). Mean prostate volume was 65.5 ± 26.7 vs. 51 ± 24.6 cc (P < 0.001), number of biopsy cores was 17.8 ± 2.4 vs. 14.9 ± 0.8 (P < 0.001), and PSA value was 15.9 ± 28.1 vs. 13.3 ± 22.3 ng/ml (P = 0.017). Overall PCa detection rate was 55% vs. 59% (P = 0.567). Postoperative UTI occurred in one patient in Group A vs. zero in Group B. Asymptomatic bacteriuria was present in 3 vs. 5 patients (P = 0.470) and was not treated with antibiotics. Postoperative hematuria was observed in 13 patients vs. 29 (P < 0.05), and acute urinary retention was observed in one patient in each group. Conclusions: The incidence of bacteriuria and UTIs in TP-PBs is not related to AP. Therefore, AP could be discontinued in TP-PB candidates without the risk of increasing UTI-related complications.

Post-void residual urine ratio: A novel clinical approach to the post-void residual urine in the assessment of males with lower urinary tract symptoms.

PURPOSE: To assess the correlation between post-void residual urine ratio (PVR-R) and pathological bladder emptying diagnosed by pressure-flow studies (PFS) in males with lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: PVR-R and PVR urine were evaluated in 410 males underwent PFS for LUTS. PVR-R was the percentage of PVR to bladder volume (voided volume+PVR). Schafer and International Continence Society (ICS) nomograms, Bladder Contractility Index (BCI) were used to diagnose bladder outlet obstruction (BOO) and detrusor underactivity (DUA). We subdivided the cohort in 4 groups: Group I, BOO+/DUA+; Group II, BOO-/DUA+; Group III, BOO+/DUA-; Group IV, BOO-/DUA- (control group). We subdivided the 4 groups according to PVR-R strata: (1) 0%-20%; (2) 21%-40%; (3) 41%-60%; (4) 61%-80%; (5) 81%-100%. RESULTS: Group I had a greater median PVR-R (50%) with a >40% in 61.4% of the cohort. Median PVR-R was 16.6% in Group II, 24% in Group III, and 0% in the control Group. According to ICS nomograms and BCI, median PVR-R and PVR were significantly higher (p<0.001) in obstructed and underactive males. PVR-R threshold of 20% allowed to recognize males with voiding disorders with high sensibility, specificity, PPV, and NPV. A PVR-R cut-off of 40% identified males with associated BOO and DUA and more severe voiding dysfunction. CONCLUSIONS: A higher PVR-R is related to a more severe pathological bladder emptying, and to the association of BOO and DUA. PVR-R may have a clinical role in first assessment of males with LUTS and severe voiding dysfunction.

Omics in urology: An overview on concepts, current status and future perspectives.

Recent technological advances in molecular biology have led to great progress in the knowledge of structure and function of cells and their main constituents. In this setting, 'omics' is standing out in order to significantly improve the understanding of etiopathogenetic mechanisms of disease and contribute to the development of new biochemical diagnostics and therapeutic tools. 'Omics' indicates the scientific branches investigating every aspect of cell's biology, including structures, functions and dynamics pathways. The main 'omics' are genomics, epigenomics, proteomics, transcriptomics, metabolomics and radiomics. Their diffusion, success and proliferation, addressed to many research fields, has led to many important acquisitions, even in Urology. Aim of this narrative review is to define the state of art of 'omics' application in Urology, describing the most recent and relevant findings, in both oncological and non-oncological diseases, focusing the attention on urinary tract infectious, interstitial cystitis, urolithiasis, prostate cancer, bladder cancer and renal cell carcinoma. In Urology the majority of 'omics' applications regard the pathogenesis and diagnosis of the investigated diseases. In future, its role should be implemented in order to develop specific predictors and tailored treatments.

Rotterdam mobile phone app including MRI data for the prediction of prostate cancer: A multicenter external validation.

OBJECTIVES: The Rotterdam Prostate Cancer Risk calculator (RPCRC) has been validated in the past years. Recently a new version including multiparametric magnetic resonance imaging (mpMRI) data has been released. The aim of our study was to analyze the performance of the mpMRI RPCRC app. METHODS: A series of men undergoing prostate biopsies were enrolled in eleven Italian centers. Indications for prostate biopsy included: abnormal Prostate specific antigen levels (PSA>4 ng/ml), abnormal DRE and abnormal mpMRI. Patients' characteristics were recorded. Prostate cancer (PCa) risk and high-grade PCa risk were assessed using the RPCRC app. The performance of the mpMRI RPCRC in the prediction of cancer and high-grade PCa was evaluated using receiver operator characteristics, calibration plots and decision curve analysis. RESULTS: Overall, 580 patients were enrolled: 404/580 (70%) presented PCa and out of them 224/404 (55%) presented high-grade PCa. In the prediction of cancer, the RC presented good discrimination (AUC = 0.74), poor calibration (p = 0.01) and a clinical net benefit in the range of probabilities between 50 and 90% for the prediction of PCa (Fig. 1). In the prediction of high-grade PCa, the RC presented good discrimination (AUC = 0.79), good calibration (p = 0.48) and a clinical net benefit in the range of probabilities between 20 and 80% (Fig. 1). CONCLUSIONS: The Rotterdam prostate cancer risk App accurately predicts the risk of PCa and particularly high-grade cancer. The clinical net benefit is wide for high-grade cancer and therefore its implementation in clinical practice should be encouraged. Further studies should assess its definitive role in clinical practice.

The bladder-flap ureteral augmentation: An original solution in case of complex distal stricture.

An original surgical solution for complex stenosis of the distal ureter is presented. A young, single-kidney male patient developed a stricture of the pelvic ureter after ureteroscopy and laser lithotripsy. Surgical repair was planned after the failure of conservative management. The ureter was sectioned prevesically and spatulated; a bladder flap with the same dimensions of the ureteral plate was taken from the anterior wall, and used to augment the ureter; finally an omental flap was wrapped around the reconstructed tract. Further radiological and ureteroscopic controls showed a largely patent reconstructed ureter, and follow up proved a regularly maintained kidney function.

Is the Voided Volume at Office Uroflowmetry Physiological and Reliable? A Comparison between Voiding Diary and Uroflowmetry.

INTRODUCTION: We compared voided volumes (VV) at voiding diaries (VD) and at uroflowmetry (UF) in men with lower urinary tract symptoms (LUTS). METHODS: This was a prospective, multicenter study. In a cohort of males with LUTS, VV reported in 3-day VD was compared to VV recorded at UF. Demographic data were analyzed. The patients were stratified according to VV. A sub-analysis dividing males by age strata was also performed. RESULTS: We enrolled 169 patients. Mean VV were higher at UF than at VD in the entire population and in each group, stratified by age. VV significantly decreased with aging. Males with the lowest threshold difference (50 mL) were 29%, with a moderate threshold difference (<100 mL) 55.6%, with an intermediate threshold difference 49.1% (51-150 mL), whereas 21.9% of men had a large threshold difference (>150 mL). DISCUSSION/CONCLUSION: VV correlation between VD and UF was poor. A large part of men performed UF with VV which were poorly comparable to the habitual VV assessed by 3-day VD. Therefore, our results indicate the relevance to obtain more than 1 UF in these patients.

Early and Late Efficacy on Wound Healing of Silver Nanoparticle Gel in Males after Circumcision.

We evaluate the early and late safety and efficacy of silver nanoparticle (AgNPs) in wound healing after circumcision. This multicenter prospective comparative non-randomized observational study compares wound dressing with AgNPs (group A) vs. gentamicin cream (group B). Follow-up included objective evaluation at 10 and 30 days by the Southampton Scoring System (SSS) and Stony Brook Scar Evaluation Scale (SBSES). We enrolled 392 males: 194 in group A, and 198 in group B. At 10 days follow-up, in group A, the SSS scale was grade 1 in 49.5% and grade 2 in the remaining; meanwhile, in group B, grade 1 was in 58%, grade 2 in 34.3%, and grade 4 in 7.6%. At 30 days follow-up, grade 1 healing was 97.4% and 98.4% in group A and B, respectively. At 10 days follow-up, the mean SBSES score was 3.58 and 3.69 in group A and B, respectively; while at 30 days follow-up, 4.81 and 4.76 in group A and B, respectively. Only in group B did 7.6% of males have antibiotic therapy due to pus discharge. No patients needed surgical wound revision. AgNPs led to a late but safer healing, they were non-inferior to the antibiotic cream wound dressing efficacy, and they avoided pus discharge and the need for oral antibiotics due to their polymer material.

External validation of Cormio nomogram for predicting all prostate cancers and clinically significant prostate cancers.

PURPOSE: Recently, the Cormio et al. nomogram has been developed to predict prostate cancer (PCa) and clinically significant PCa using benign prostatic obstruction parameters. The aim of the present study was to externally validate the nomogram in a multicentric cohort. METHODS: Between 2013 and 2019, patients scheduled for ultrasound-guided prostate biopsy were prospectively enrolled at 11 Italian institutions. Demographic, clinical and histological data were collected and analysed. Discrimination and calibration of Cormio nomogram were assessed with the receiver operator characteristics (ROC) curve and calibration plots. The clinical net benefit of the nomogram was assessed with decision curve analysis. Clinically significant PCa was defined as ISUP grade group > 1. RESULTS: After accounting for inclusion criteria, 1377 patients were analysed. 816/1377 (59%) had cancer at final pathology (574/816, 70%, clinically significant PCa). Multivariable analysis showed age, prostate volume, DRE and post-voided residual volume as independent predictors of any PCa. Discrimination of the nomogram for cancer was 0.70 on ROC analysis. Calibration of the nomogram was excellent (p = 0.94) and the nomogram presented a net benefit in the 40-80% range of probabilities. Multivariable analysis for predictors of clinically significant PCa found age, PSA, prostate volume and DRE as independent variables. Discrimination of the nomogram was 0.73. Calibration was poor (p = 0.001) and the nomogram presented a net benefit in the 25-75% range of probabilities. CONCLUSION: We confirmed that the Cormio nomogram can be used to predict the risk of PCa in patients at increased risk. Implementation of the nomogram in clinical practice will better define its role in the patient's counselling before prostate biopsy.

A Prospective Comparative Study of the Feasibility and Reliability of Telephone Follow-Up in Female Urology: The Patient Home Office Novel Evaluation (PHONE) Study.

OBJECTIVE: To determinate the feasibility, reliability, and patient satisfaction of telephonic follow-up in women treated for stress urinary incontinence (SUI) or pelvic organ prolapse (POP): Patient-Home-Office-Novel-Evaluation (PHONE) study. METHODS: This is a prospective comparative study in women following surgery for SUI underwent middle urethral sling (MUS) (Group A), or symptomatic anterior vaginal wall (AVW) defect underwent AVW repair (fascial/mesh/biomesh) (Group B). The 1-year follow-up included a telephonic interview using a checklist and validated questionnaires followed by a standard outpatient clinic visit 7-12 days later including: an interview, validated questionnaires, objective examination, and score satisfaction with the telephone follow-up. RESULTS: We enrolled 420 pts: 215 for SUI in Group A, and 205 for POP in Group B. SUI recurrence was 19.1% and 11.6% at the telephone and office follow-up, respectively. De-novo urgency urinary incontinence rate was 7.5%. Telephone follow-up was able to detect POP recurrence and related symptoms. Tape and mesh extrusions were detected only at the objective evaluation: 1.9% and 4.4% respectively. No difference was found at the questionnaires. Satisfaction with the telephone follow-up was high. CONCLUSION: Due to the wrongly interpretation of de-novo urge urinary incontinence as a recurrence of SUI, a telephone interview may lose reliability in case of reported incontinence. Thus, telephone follow-up was feasible and reliable in women not reporting incontinence. In patients treated for POP the phone interview was a valid tool only in case of no-prosthetic surgery due to the absence of extrusion in these cases.

Impact of Overactive Bladder-Wet Syndrome on Female Sexual Function: A Systematic Review and Meta-Analysis.

INTRODUCTION: Overactive bladder (OAB) is subtyped into OAB-wet and OAB-dry, based on the presence or absence, respectively, of urgency incontinence. Although women with OAB frequently have a higher risk for sexual dysfunction, a systematic review on the impact of OAB-wet on female sexuality is lacking. This may be evaluated by measuring the effect of the bladder condition on sexuality per se, or by the effect of OAB treatment on female sexual dysfunction. AIM: To assess the role of OAB-wet on female sexual function. METHODS: A systematic review of the literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Research on PubMed, EMBASE, and SCOPUS was performed and concluded on October 15, 2018. A systematic computerized search was conducted on published literature from January 1, 2000-2018. Meta-analysis was performed with a meta-analysis program. MAIN OUTCOMES MEASURES: The following search terms were used: ((("female sexual function") OR ("female sexual dysfunction") OR ("female sexuality") OR ("dyspareunia")) AND (("overactive bladder") OR ("coital incontinence") OR ("detrusor instability") OR ("detrusor overactivity") OR ("urge urinary incontinence") OR (onabotulinumtoxinA) OR ("botulinum") OR ("sacral neuromodulation") OR (SNM) OR (PTNS) OR ("stoller afferent neuro-stimulation") OR ("SANS") OR ("antimuscarinic drugs") OR ("anticholinergic") OR ("peripheral neuromodulation") OR (beta-agonist))). RESULTS: 1,033 references were reviewed for inclusion and exclusion criteria. Final analysis identified 12 articles for systematic review. OAB-wet was reported as the most affecting factor on sexuality. OAB treatments showed improvement of both the OAB-wet and the sexual function. Results of the meta-analysis suggested that OAB therapies improving OAB-wet significantly reduced female sexual dysfunction (odds ratio 0.19; 95% CI 0.26-0.45). CONCLUSION: OAB-wet represents a risk for sexual dysfunction; however, data available show low-quality evidence of the impact of OAB-wet on sexual dysfunction. Balzarro M, Rubilotta E, Mancini V, et al. Impact of Overactive Bladder-Wet Syndrome on Female Sexual Function: A Systematic Review and Meta-Analysis. Sex Med Rev 2019;7:565-574.

Impact of Combination of Local Anesthetic Wounds Infiltration and Ultrasound Transversus Abdominal Plane Block in Patients Undergoing Robot-Assisted Radical Prostatectomy: Perioperative Results of a Double-Blind Randomized Controlled Trial.

OBJECTIVE: To determinate benefits of the combination of local anesthetic wounds infiltration and ultrasound transversus abdominal plane (US-TAP) block with ropivacaine on postoperative pain, early recovery, and hospital stay in patients undergoing robot-assisted radical prostatectomy (RARP). METHODS: The study is double-blinded randomized controlled trial. Our hypothesis was that the combination of wound infiltration and US-TAP block with ropivacaine would decrease immediate postoperative pain and opioids use. Primary outcomes included postoperative pain and opioids demand during the hospital stay. Secondary outcomes were nausea/vomiting rate, stool passing time, use of prokinetics, length of hospital stay (LOS), and 30-days readmission to the hospital for pain or other US-TAP block-related complications. RESULTS: A total of 100 patients who underwent RARP were eligible for the analysis; 57 received the US-TAP block with 20 mL of 0.35% ropivacaine (US-TAP block group) and 43 did not receive US-TAP block (no-US-TAP group). All the patients received the local wound anesthetic infiltration with 20 mL of 0.35% ropivacaine. US-TAP block group showed a decreased mean Numerical Rating Scale (NRS) within 12 hours after surgery (1.6 vs 2.6; p = 0.02) and mean NRS (1.8 vs 2.7; p = 0.04) with lesser number of patients who used opioid (3.5% vs 18.6%; p = 0.01) during the first 24 hours. Moreover, we found a shorter mean LOS (4.27 vs 4.72, days; p = 0.04) with a lower requirement of prokinetics administration during the hospital stay (21% vs 72%; p < 0.001). No US-TAP block-related complications were reported. CONCLUSION: Combination of anesthetic wound infiltration and US-TAP block with ropivacaine as part of a multimodal analgesic regimen can be safely offered to patients undergoing RARP and extended pelvic lymph node dissection. It improves the immediate postoperative pain control, reducing opioids administration and is associated to a decreased use of prokinetics and shorter hospital stay.

Long-term follow-up of anterior vaginal repair: A comparison among colporrhaphy, colporrhaphy with reinforcement by xenograft, and mesh.

AIMS: To assess the long-term complications and outcomes in patients treated for pelvic organ prolapse (POP) with transvaginal anterior colporrhaphy (AC) alone, transvaginal naterior AC with reinforcement by using porcine Xenograft (AC-P) (Pelvisoft® Biomesh), and transvaginal anterior repair with polypropylene mesh (AC-M). METHODS: This was a retrospective analysis of 109/123 consecutive patients, who underwent cystocele repair: 42 AC, 19 AC-P, and 48 AC-M. Subjective outcomes included validated questionnaires as well as questions that had not been previously validated. Objective outcomes have been evaluated considering failure the anterior vaginal wall recurrence >2 stage POP-Quantification. Statistical analysis included the chi-square or Fisher exact test. RESULTS: The mean follow-up was 94.80 ± 51.72 months (19-192 months). In all groups, the patient's personal satisfaction was high. There was no evidence of difference in outcome based on whether a biological graft was or was not performed, or whether synthetic mesh was used to reinforce the repair. Data showed a higher rate of complications in the AC-M group (P < 0.05) that could explain the lower subjective satisfaction of these patients. CONCLUSIONS: This study evaluated long-term outcomes to anterior vaginal repair over a period of more than 5 years in all the groups. Our data show that anterior vaginal repair with mesh and xenograft did not improve significantly objective and subjective outcomes. Rather, prosthetic device use leads to higher rate of complications.

Original flow chart for the management of hydroureteronephrosis caused by pessary placement.

INTRODUCTION: The use of a pessary to treat a pelvic organ prolapse (POP) is a valid non-invasive option. Severe complications are usually associated with neglected, oversized, or misplaced pessaries. Major complications include fistulas, bowel or bladder erosion, and hydroureteronephrosis (HUN). MATERIALS AND METHODS: We reviewed the literature and our experience in the management of HUN in the last decade, as a consequence of pessary placement. RESULTS: We used flow charts to take an accurate medical history of each patient. Blood and urine analyses were taken at admission to assess the potential presence of sepsis, renal failure, and urinary tract infection. Physical examination included vaginal examination. In cases of pessary presence with a concomitant increase of serum creatinine value, a possible ureteral obstruction is suspected. In order to assess the presence of HUN and its underlying causes, a computed tomography (CT) scan should be performed to assess the mechanism of urinary tract obstruction. However, in case of renal insufficiency, abdominal ultrasonography (US) could be sufficient. If HUN is detected in a patient with no signs of urosepsis, we suggest a conservative management by the removal of the pessary and catheter placement. When urosepsis is suspected, it is mandatory to administer antibiotic therapy and evaluate the HUN drainage by nephrostomy. CONCLUSIONS: There is no uniform management of women with HUN and a concomitant pessary. For this reason, and based on the literature and our experience, we propose an original management flowchart.