Cytoreductive nephrectomy in metastatic renal cell carcinoma.

BACKGROUND: Nephrectomy is the surgical removal of all or part of a kidney. When the aim of nephrectomy is to reduce tumor burden in people with established metastatic disease, the procedure is called cytoreductive nephrectomy (CN). CN is typically combined with systemic anticancer therapy (SACT). SACT can be initiated before or immediately after the operation or deferred until radiological signs of disease progression. The benefits and harms of CN are controversial. OBJECTIVES: To assess the effects of cytoreductive nephrectomy combined with systemic anticancer therapy versus systemic anticancer therapy alone or watchful waiting in newly diagnosed metastatic renal cell carcinoma. SEARCH METHODS: We performed a comprehensive search in the Cochrane Library, MEDLINE, Embase, Scopus, two trial registries, and other gray literature sources up to 1 March 2024. We applied no restrictions on publication language or status. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that evaluated SACT and CN versus SACT alone or watchful waiting. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies and extracted data. Primary outcomes were time to death from any cause and quality of life. Secondary outcomes were time to disease progression, treatment response, treatment-related mortality, discontinuation due to adverse events, and serious adverse events. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using the GRADE approach. MAIN RESULTS: Our search identified 10 records of four unique RCTs that informed two comparisons. In this abstract, we focus on the results for the two primary outcomes. Cytoreductive nephrectomy plus systemic anticancer therapy versus systemic anticancer therapy alone Three RCTs informed this comparison. Due to the considerable heterogeneity when pooling across these studies, we decided to present the results of the prespecified subgroup analysis by type of systemic agent. Cytoreductive nephrectomy plus interferon immunotherapy versus interferon immunotherapy alone CN plus interferon immunotherapy compared with interferon immunotherapy alone probably increases time to death from any cause (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.51 to 0.89; I²= 0%; 2 studies, 326 participants; moderate-certainty evidence). Assuming 820 all-cause deaths at two years' follow-up per 1000 people who receive interferon immunotherapy alone, the effect estimate corresponds to 132 fewer all-cause deaths (237 fewer to 37 fewer) per 1000 people who receive CN plus interferon immunotherapy. We found no evidence to assess quality of life. Cytoreductive nephrectomy plus tyrosine kinase inhibitor therapy versus tyrosine kinase inhibitor therapy alone We are very uncertain about the effect of CN plus tyrosine kinase inhibitor (TKI) therapy compared with TKI therapy alone on time to death from any cause (HR 1.11, 95% CI 0.90 to 1.37; 1 study, 450 participants; very low-certainty evidence). Assuming 574 all-cause deaths at two years' follow-up per 1000 people who receive TKI therapy alone, the effect estimate corresponds to 38 more all-cause deaths (38 fewer to 115 more) per 1000 people who receive CN plus TKI therapy. We found no evidence to assess quality of life. Immediate cytoreductive nephrectomy versus deferred cytoreductive nephrectomy One study evaluated CN followed by TKI therapy (immediate CN) versus three cycles of TKI therapy followed by CN (deferred CN). Immediate CN compared with deferred CN may decrease time to death from any cause (HR 1.63, 95% CI 1.05 to 2.53; 1 study, 99 participants; low-certainty evidence). Assuming 620 all-cause deaths at two years' follow-up per 1000 people who receive deferred CN, the effect estimate corresponds to 173 more all-cause deaths (18 more to 294 more) per 1000 people who receive immediate CN. We found no evidence to assess quality of life. AUTHORS' CONCLUSIONS: CN plus SACT in the form of interferon immunotherapy versus SACT in the form of interferon immunotherapy alone probably increases time to death from any cause. However, we are very uncertain about the effect of CN plus SACT in the form of TKI therapy versus SACT in the form of TKI therapy alone on time to death from any cause. Immediate CN versus deferred CN may decrease time to death from any cause. We found no quality of life data for any of these three comparisons. We also found no evidence to inform any other comparisons, in particular those involving newer immunotherapy agents (programmed death receptor 1 [PD-1]/programmed death ligand 1 [PD-L1] immune checkpoint inhibitors), which have become the backbone of SACT for metastatic renal cell carcinoma. There is an urgent need for RCTs that explore the role of CN in the context of contemporary forms of systemic immunotherapy.

Prostate Tissue Microbiome in Patients with Prostate Cancer: A Systematic Review.

Some researchers have speculated that the prostatic microbiome is involved in the development of prostate cancer (PCa) but there is no consensus on certain microbiota in the prostatic tissue of PCa vs. healthy controls. This systematic review aims to investigate and compare the microbiome of PCa and healthy tissue to determine the microbial association with the pathogenesis of PCa. We searched MEDLINE, Embase, and Scopus databases. Articles were screened by two independent and blinded reviewers. Literature that compared the prostatic tissue microbiome of patients with PCa with benign controls was included. We found that PCa may be associated with increased Propionibacterium acnes, the herpesviridae and papillomaviridae families, and Mycoplasma genitalium, but definitive conclusions cannot be drawn from the existing data. Challenges include the difficulty of obtaining uncontaminated tissue samples and securing tissue from healthy controls. As a result, methods are varied with many studies using cancerous and "healthy" tissue from the same prostate. The organisms chosen for each study were also highly variable, making it difficult to compare studies. These issues have led to lower confidence in our results. Overall, further work is warranted to better understand the implications of the prostatic microbiome in the pathogenesis of PCa.

Percutaneous nephrolithotomy vs retrograde intrarenal surgery for renal stones: a Cochrane Review.

OBJECTIVES: To assess the effects of percutaneous nephrolithotomy (PCNL) vs retrograde intrarenal surgery (RIRS) for the treatment of renal stones in adults. METHODS: We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of the grey literature, and conference proceedings up to 23 March 2023. We applied no restrictions on publication language or status. Screening, data extraction, risk-of-bias assessment, and certainty of evidence (CoE) rating using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach were done in duplicate by two independent reviewers. This co-publication focuses on the primary outcomes of this review only. RESULTS: We included 42 trials that met the inclusion criteria. Stone-free rate (SFR): PCNL may improve SFRs (risk ratio [RR] 1.13, 95% confidence interval [CI] 1.08-1.18; I2 = 71%; 39 studies, 4088 participants; low CoE). Major complications: PCNL probably has little to no effect on major complications (RR 0.86, 95% CI 0.59-1.25; I2 = 15%; 34 studies, 3649; participants; moderate CoE) compared to RIRS. Need for secondary interventions: PCNL may reduce the need for secondary interventions (RR 0.31, 95% CI 0.17-0.55; I2 = 61%; 21 studies, 2005 participants; low CoE) compared to RIRS. CONCLUSION: Despite shortcomings in most studies that lowered our certainty in the estimates of effect to mostly very low or low, we found that PCNL may improve SFRs and reduce the need for secondary interventions while not impacting major complications. Ureteric stricture rates may be similar compared to RIRS. We expect the findings of this review to be helpful for shared decision-making about management choices for individuals with renal stones.

Comparison of incidental parathyroid tissue detection rates on pathology after total thyroidectomy performed with or without near-infrared autofluorescence imaging.

BACKGROUND: Near-infrared autofluorescence imaging is an adjunct to parathyroid identification. As it does not show perfusion, it is important to study its impact during thyroidectomy by measuring quantifiable data on parathyroid detection rather than function. The aim of this study was to compare incidental parathyroidectomy rates in patients undergoing total thyroidectomy with or without near-infrared autofluorescence. METHODS: Retrospective study of patients who underwent total thyroidectomy between 2014 and 2022 at one center. Clinical parameters, including rates of incidental parathyroid tissue on pathology reports, were compared between near-infrared autofluorescence and non-near-infrared autofluorescence groups. Near-infrared autofluorescence was used to guide dissection (identification) and/or to confirm tissue as parathyroid (confirmation). Statistical analysis was done with Wilcoxon rank sum test and χ2 analysis. RESULTS: There were 300 patients in the near-infrared autofluorescence and 750 patients in the non-near-infrared autofluorescence group. The rate of incidental parathyroid tissue detection on final pathology was 13.3% (n = 40) in the near-infrared autofluorescence and 23.2% (n = 174) in the non-near-infrared autofluorescence group (P < .001). The rate of incidental parathyroid tissue detected on pathology with near-infrared autofluorescence decreased when used for identification and confirmation of parathyroid tissue (30.0% to 13.4%, P < .001), but not when used for confirmation only (19.6% to 18.5%, P = .89). Impact of near-infra red autofluorescence in decreasing the rate of incidental parathyroid tissue was more profound for early (38.5% to 17.1%) versus mid-late career surgeons (20% to 13%). CONCLUSION: Our results suggest that the use of near-infrared autofluorescence may help decrease the rate of incidental parathyroid tissue detected on final pathology if used for both identification and confirmation of parathyroid glands during thyroidectomy.

Percutaneous nephrolithotomy versus retrograde intrarenal surgery for treatment of renal stones in adults.

BACKGROUND: Kidney stones (also called renal stones) can be a source of pain, obstruction, and infection. Depending on size, location, composition, and other patient factors, the treatment of kidney stones can involve observation, shock wave lithotripsy, retrograde intrarenal surgery (RIRS; i.e. ureteroscopic approaches), percutaneous nephrolithotomy (PCNL), or a combination of these approaches. OBJECTIVES: To assess the effects of percutaneous nephrolithotomy (PCNL) versus retrograde intrarenal surgery (RIRS) for the treatment of renal stones in adults. SEARCH METHODS: We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, Scopus, and two trials registries up to 23 March 2023. We applied no restrictions on publication language or status. SELECTION CRITERIA: We included randomized controlled trials that evaluated PCNL (grouped by access size in French gauge [Fr] into three groups: ≥ 24 Fr [standard PCNL], 15-23 Fr [mini-PCNL and minimally invasive PCNL], and < 15 Fr [ultra-mini-, mini-micro-, super-mini-, and micro-PCNL]) versus RIRS. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies and extracted data from the included studies. Our primary outcomes were stone-free rate, major complications, and need for secondary interventions. Our main secondary outcomes were unplanned medical visits to emergency/urgent care or outpatient clinic, length of hospital stay, ureteral stricture or injury, and quality of life. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using GRADE criteria. We adopted a minimally contextualized approach with predefined thresholds for minimal clinically important differences (MCIDs). MAIN RESULTS: We included 42 trials assessing the effects of PCNL versus RIRS in 4571 randomized participants. Twenty-two studies were published as full-text articles, and 20 were published as abstract proceedings. The average size of stones ranged from 10.1 mm to 39.1 mm. Most studies did not report sources of funding or conflicts of interest. The main results for the most important outcomes are summarized below. Stone-free rate PCNL compared with RIRS may improve stone-free rates (risk ratio [RR] 1.13, 95% confidence interval [CI] 1.08 to 1.18; I2 = 71%; 39 studies, 4088 participants; low-certainty evidence). Based on 770 participants per 1000 being stone-free with RIRS, this corresponds to 100 more (62 more to 139 more) stone-free participants per 1000 with PCNL (an absolute difference of 10%, where the predefined MCID was 5%). Major complications PCNL compared with RIRS probably has little or no effect on major complications (RR 0.86, 95% CI 0.59 to 1.25; I2 = 15%; 34 studies, 3649 participants; moderate-certainty evidence). Based on 31 complications in the RIRS group, this corresponds to six fewer (13 fewer to six more) major complications per 1000 with PCNL (an absolute difference of 0.6%, where the predefined MCID was 2%). Need for secondary interventions PCNL compared with RIRS may reduce the need for secondary interventions (RR 0.31, 95% CI 0.17 to 0.55; I2 = 61%; 21 studies, 2005 participants; low-certainty evidence). Based on 222 secondary interventions in the RIRS group, this corresponds to 153 fewer (185 fewer to 100 fewer) secondary interventions per 1000 with PCNL (an absolute difference of 15.3%, where the predefined MCID was 5%). Unplanned medical visits No studies reported unplanned medical visits. Length of hospital stay PCNL compared with RIRS may extend length of hospital stay (mean difference 1.04 days more, 95% CI 0.27 more to 1.81 more; I2 = 100%; 26 studies, 2804 participants; low-certainty evidence). This effect size is greater than the predefined MCID of one day. Ureteral stricture or injury PCNL compared with RIRS may have little or no effect on the occurrence of ureteral strictures (RR 0.93, 95% CI 0.39 to 2.21; I2 = 0%; 13 studies, 1574 participants; low-certainty evidence). Based on 14 ureteral strictures in the RIRS group, this corresponds to one fewer (nine fewer to 17 more) ureteral strictures per 1000 with PCNL (an absolute difference of 0.1%, where the predefined MCID was 2%). Quality of life No studies reported quality of life. AUTHORS' CONCLUSIONS: Based on a large body of evidence from 42 trials, we found that PCNL compared with RIRS may improve stone-free rates and may reduce the need for secondary interventions, but probably has little or no effect on major complications. PCNL compared with RIRS may have little or no effect on ureteral stricture rates and may increase length of hospital stay. We found no evidence on unplanned medical visits or participant quality of life. Because of the considerable shortcomings of the included trials, the evidence for most outcomes was of low certainty. Access size for PCNL was less than 24 Fr in most studies that provided this information. We expect the findings of this review to be helpful for shared decision-making about management choices for individuals with renal stones.

AI-generated R.E.N.A.L.+ Score Surpasses Human-generated Score in Predicting Renal Oncologic Outcomes.

OBJECTIVE: To determine whether we can surpass the traditional R.E.N.A.L. nephrometry score (H-score) prediction ability of pathologic outcomes by creating artificial intelligence (AI)-generated R.E.N.A.L.+ score (AI+ score) with continuous rather than ordinal components. We also assessed the AI+ score components' relative importance with respect to outcome odds. METHODS: This is a retrospective study of 300 consecutive patients with preoperative computed tomography scans showing suspected renal cancer at a single institution from 2010 to 2018. H-score was tabulated by three trained medical personnel. Deep neural network approach automatically generated kidney segmentation masks of parenchyma and tumor. Geometric algorithms were used to automatically estimate score components as ordinal and continuous variables. Multivariate logistic regression of continuous R.E.N.A.L. components was used to generate AI+ score. Predictive utility was compared between AI+, AI, and H-scores for variables of interest, and AI+ score components' relative importance was assessed. RESULTS: Median age was 60years (interquartile range 51-68), and 40% were female. Median tumor size was 4.2 cm (2.6-6.12), and 92% were malignant, including 27%, 37%, and 23% with high-stage, high-grade, and necrosis, respectively. AI+ score demonstrated superior predictive ability over AI and H-scores for predicting malignancy (area under the curve [AUC] 0.69 vs 0.67 vs 0.64, respectively), high stage (AUC 0.82 vs 0.65 vs 0.71, respectively), high grade (AUC 0.78 vs 0.65 vs 0.65, respectively), pathologic tumor necrosis (AUC 0.81 vs 0.72 vs 0.74, respectively), and partial nephrectomy approach (AUC 0.88 vs 0.74 vs 0.79, respectively). Of AI+ score components, the maximal tumor diameter ("R") was the most important outcomes predictor. CONCLUSION: AI+ score was superior to AI-score and H-score in predicting oncologic outcomes. Time-efficient AI+ score can be used at the point of care, surpassing validated clinical scoring systems.

Non-surgical therapies for Peyronie's disease.

BACKGROUND: Peyronie's disease is a condition that results in the development of penile plaques that can lead to penile curvature, pain, and erectile dysfunction, making sexual activity difficult. A number of non-surgical interventions exist to improve this condition, which include topical and injection agents as well as mechanical methods; however, their effectiveness remains uncertain. We performed this review to determine the effects of these non-surgical treatments. OBJECTIVES: To assess the effects of non-surgical therapies compared to placebo or no treatment in individuals with Peyronie's disease. SEARCH METHODS: We performed a comprehensive search using multiple databases (the Cochrane Library, MEDLINE, Embase, Scopus, Google Scholar, and Web of Science), trials registries, other sources of grey literature, and conference proceedings, up to 23 September 2022. We applied no restrictions on publication language or status. SELECTION CRITERIA: We included trials in which men with Peyronie's disease were randomized to undergo non-surgical therapies versus placebo or no treatment for penile curvature and sexual function. DATA COLLECTION AND ANALYSIS: Two of four review authors, working in pairs, independently classified studies and abstracted data from the included studies. Primary outcomes were: patient-reported ability to have intercourse, quality of life, and treatment-related adverse effects. Secondary outcomes were: degree of penile curvature, discontinuation from treatment (for any reason), subjective patient-reported change in penile curvature, and improvement in penile pain. We performed statistical analyses using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach. MAIN RESULTS: Our search identified 1288 relevant references of which we included 18 records corresponding to 14 unique randomized controlled trials (RCTs) with 1810 men. These informed 10 distinct comparisons with relevant outcome data that were mostly extracted from single trials. In this abstract, we focus only on the most clinically relevant comparisons for the three primary outcomes and also include the outcome of degree penile curvature. Injectional collagenase (short-term): We found no short-term evidence on injectional collagenase for patients' self-reported ability to have intercourse and treatment-related adverse effects compared to placebo injection. Injectional collagenase may result in little to no difference in quality of life (scale 0 to 20 with lower scores indicating better quality of life; mean difference (MD) 1.8 lower, 95% confidence interval (CI) -3.58 to -0.02; 1 study, 134 participants; low CoE) and there may be little to no effect on the degree of penile curvature (MD 10.90 degrees less, 95% CI -16.24 to -5.56; 1 study, 136 participants; low CoE). Injectional collagenase (long-term): We also found no long-term evidence on injectional collagenase for patients' self-reported ability to have intercourse compared to placebo injection. It likely results in little to no effect on quality of life (MD 1.00 lower, 95% CI -1.60 to -0.40; 1 study, 612 participants; moderate CoE). Treatment-related adverse effects are likely increased (risk ratio (RR) 2.32, 95% CI 1.98 to 2.72; 1 study, 832 participants; moderate CoE). Injectional collagenase likely results in little to no change in the degree of penile curvature (MD 6.90 degrees less, 95% CI -9.64 to -4.14; 1 study, 612 participants; moderate CoE). Injectional verapamil (short-term): We are very uncertain how injectional verapamil may affect patients' self-reported ability to have intercourse compared to placebo injection short-term (RR 7.00, 95% CI 0.43 to 114.70; 1 study, 14 participants; very low CoE). We found no evidence for the outcome of quality of life. We are very uncertain how injectional verapamil may affect treatment-related adverse effects (RR not estimable; 1 study, 14 participants; very low CoE). Similarly, we are very uncertain how injectional verapamil may affect degree of penile curvature (MD -1.86, 95% CI -10.39 to 6.67; 1 study, 14 participants; very low CoE). We found no long-term data for any outcome. Extracorporeal shock wave treatment (ESWT) (short-term): We are very uncertain how ESWT affects patients' self-reported ability to have intercourse short-term (RR 1.60, 95% CI 0.71 to 3.60; 1 study, 26 participants; very low CoE). ESWT may result in little to no difference in quality of life (MD 3.10, 95% CI 1.57 to 4.64; 2 studies, 130 participants; low CoE). We are very uncertain if ESWT has an effect on treatment-related adverse effects (RR 2.73, 95% CI 0.74 to 10.14; 3 studies, 166 participants; very low CoE). ESWT may result in little to no difference in the degree of penile curvature compared to placebo (RR -2.84, 95% -7.35 to 1.67; 3 studies, 166 participants; low CoE). We found no long-term data for any outcome. Penile traction therapy (short-term): We found no evidence for whether penile traction compared to no treatment affects patients' self-reported ability to have intercourse. We are very uncertain how traction therapy may affect quality of life (MD 1.50 lower, 95% CI -3.42 to 0.42; 1 study, 90 participants; very low CoE). We are also very uncertain how traction therapy may affect treatment-related adverse effects (RR not estimable; 1 study, 90 participants; very low CoE) and how it affects the degree of curvature (MD 7.40 degrees less, 95% CI -11.18 to -3.62; 1 study, 89 participants; very low CoE). We found no long-term data for any outcome. AUTHORS' CONCLUSIONS: There is little evidence supporting the effectiveness of most non-surgical treatments for Peyronie's disease. Existing trials are mostly of poor methodological quality and/or fail to address patient-centered outcomes. Injectional collagenase appears to have some effectiveness; however, many individuals may not experience the improvement as clinically relevant, and this comes with the risk of increased adverse events. There is a critical need for better non-surgical treatment options for men with Peyronie's disease.

ANTECEDENTES: La enfermedad de Peyronie es una afección que da lugar al desarrollo de placas en el pene que pueden provocar curvatura peneana, dolor y disfunción eréctil, dificultando la actividad sexual. Existen varias intervenciones no quirúrgicas para mejorar esta afección, que incluyen agentes tópicos e inyectables, así como métodos mecánicos; sin embargo, su eficacia aún es incierta. Esta revisión se realizó para determinar los efectos de estos tratamientos no quirúrgicos. OBJETIVOS: Evaluar los efectos de los tratamientos no quirúrgicos en comparación con placebo o ningún tratamiento en individuos con enfermedad de Peyronie. MÉTODOS DE BÚSQUEDA: Se realizó una búsqueda exhaustiva en múltiples bases de datos (la Biblioteca Cochrane, MEDLINE, Embase, Scopus, Google Scholar y Web of Science), en registros de ensayos, otras fuentes de literatura gris y resúmenes de congresos, hasta el 23 de septiembre de 2022. No se impusieron restricciones respecto al idioma ni el estado de publicación. CRITERIOS DE SELECCIÓN: Se incluyeron ensayos en los que se asignó al azar a hombres con enfermedad de Peyronie a someterse a tratamientos no quirúrgicos versus placebo o ningún tratamiento para la curvatura del pene y la función sexual. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Dos de los cuatro autores de la revisión, trabajando en pareja, clasificaron de forma independiente los estudios y resumieron los datos de los estudios incluidos. Los desenlaces principales fueron: capacidad para mantener relaciones sexuales autoinformada por el paciente, calidad de vida y efectos adversos relacionados con el tratamiento. Los desenlaces secundarios fueron: grado de curvatura del pene, interrupción del tratamiento (por cualquier motivo), cambio subjetivo de la curvatura del pene autoinformado por el paciente y mejoría del dolor del pene. Se realizaron análisis estadísticos con un modelo de efectos aleatorios. La certeza de la evidencia se calificó según el método GRADE. RESULTADOS PRINCIPALES: La búsqueda identificó 1288 referencias pertinentes, de las cuales se incluyeron 18 registros correspondientes a 14 ensayos controlados aleatorizados (ECA) individuales con 1810 hombres. Éstos informaron 10 comparaciones distintas con datos de desenlaces relevantes que se extrajeron en su mayoría de ensayos individuales. Este resumen se centra solo en las comparaciones clínicamente más relevantes para los tres desenlaces principales y también se incluye el desenlace de grado de curvatura peneana. Colagenasa inyectable (a corto plazo): No se encontró evidencia a corto plazo de la colagenasa inyectable, en comparación con la inyección placebo, en la capacidad autoinformada por los pacientes de tener relaciones sexuales ni en los efectos adversos relacionados con el tratamiento. La colagenasa inyectable podría dar lugar a poca o ninguna diferencia en la calidad de vida (escala de 0 a 20 con puntuaciones más bajas que indican mejor calidad de vida; diferencia de medias [DM] 1,8 menor; intervalo de confianza [IC] del 95%: ­3,58 a ­0,02; un estudio, 134 participantes; evidencia de certeza baja) y podría haber poco o ningún efecto en el grado de curvatura del pene (DM 10,90 grados menos; IC del 95%: ­16,24 a ­5,56; un estudio, 136 participantes; evidencia de certeza baja). Colagenasa inyectable (a largo plazo): Tampoco se encontró evidencia a largo plazo sobre la colagenasa inyectable en la capacidad autoinformada por los pacientes de tener relaciones sexuales en comparación con la inyección placebo. Es probable que tenga un efecto escaso o nulo sobre la calidad de vida (DM 1,00 inferior; IC del 95%: ­1,60 a ­0,40; un estudio, 612 participantes; evidencia de certeza moderada). Es probable que aumenten los efectos adversos relacionados con el tratamiento (razón de riesgos [RR] 2,32; IC del 95%: 1,98 a 2,72; un estudio, 832 participantes; evidencia de certeza moderada). La colagenasa inyectable probablemente provoca poco o ningún cambio en el grado de curvatura del pene (DM 6,90 grados menos; IC del 95%: ­9,64 a ­4,14; un estudio, 612 participantes; evidencia de certeza moderada). Verapamilo inyectable (a corto plazo): No está muy claro cómo el verapamilo inyectable podría afectar la capacidad autoinformada por los pacientes de tener relaciones sexuales en comparación con la inyección placebo a corto plazo (RR 7,00; IC del 95%: 0,43 a 114,70; un estudio, 14 participantes; evidencia de certeza muy baja). No se encontró evidencia del desenlace de calidad de vida. No se sabe con certeza cómo podría afectar el verapamilo inyectable los efectos adversos relacionados con el tratamiento (RR no estimable; un estudio, 14 participantes; evidencia de certeza muy baja). Del mismo modo, es muy incierto cómo el verapamilo inyectable podría afectar el grado de curvatura peneana (DM ­1,86; IC del 95%: ­10,39 a 6,67; un estudio, 14 participantes; evidencia de certeza muy baja). No se encontraron datos a largo plazo para ningún desenlace. Tratamiento con ondas de choque extracorpóreas (OCE) (a corto plazo): No está muy claro cómo el tratamiento con OCE afecta la capacidad autoinformada por los pacientes de mantener relaciones sexuales a corto plazo (RR 1,60; IC del 95%: 0,71 a 3,60; un estudio, 26 participantes; evidencia de certeza muy baja). El tratamiento con OCE podría dar lugar a poca o ninguna diferencia en la calidad de vida (DM 3,10; IC del 95%: 1,57 a 4,64; dos estudios, 130 participantes; evidencia de certeza baja). No está muy claro si el tratamiento con OCE influye en los efectos adversos relacionados con el tratamiento (RR 2,73; IC del 95%: 0,74 a 10,14; tres estudios, 166 participantes; evidencia de certeza muy baja). El tratamiento con OCE podría dar lugar a poca o ninguna diferencia en el grado de curvatura peneana en comparación con el placebo (RR ­2,84; 95%: ­7,35 a 1,67; tres estudios, 166 participantes; evidencia de certeza baja). No se encontraron datos a largo plazo para ningún desenlace. Terapia de tracción peneana (a corto plazo): No se encontró evidencia de si la tracción peneana comparada con ningún tratamiento afecta la capacidad autoinformada por los pacientes de tener relaciones sexuales. No se sabe con certeza cómo podría afectar la terapia de tracción la calidad de vida (DM 1,50 inferior; IC del 95%: ­3,42 a 0,42; un estudio, 90 participantes; evidencia de certeza muy baja). Tampoco se sabe con certeza cómo podría afectar la terapia de tracción los efectos adversos relacionados con el tratamiento (RR no estimable; un estudio, 90 participantes; evidencia de certeza muy baja) ni cómo afecta el grado de curvatura (DM 7,40 grados menos; IC del 95%: ­11,18 a ­3,62; un estudio, 89 participantes; evidencia de certeza muy baja). No se encontraron datos a largo plazo para ningún desenlace. CONCLUSIONES DE LOS AUTORES: Existe poca evidencia que respalde la eficacia de la mayoría de los tratamientos no quirúrgicos para la enfermedad de Peyronie. Los ensayos existentes son en su mayoría de baja calidad metodológica y no abordan los desenlaces centrados en el paciente. La colagenasa inyectable parece tener cierta eficacia; sin embargo, es posible que muchas personas no experimenten una mejoría clínicamente relevante, lo que conlleva el riesgo de un aumento de los eventos adversos. Existe una necesidad imperiosa de mejores opciones terapéuticas no quirúrgicas para los hombres con enfermedad de Peyronie.

Laparoscopic versus robotic adrenalectomy in severely obese patients.

BACKGROUND: Over the last 20 years, the prevalence of severe obesity (body mass index ≥ 35 kg/m2) has almost doubled. This condition increases the challenge of laparoscopic adrenalectomy (LA) by creating problems with instrument reach, adequate exposure, and visualization. The aim was to compare perioperative outcomes of laparoscopic versus robotic adrenalectomy (RA) in severely obese patients. METHODS: This was an institutional review board-approved retrospective study. Prospectively collected clinical parameters of patients who underwent LA versus RA between 2000 and 2021 at a single center were compared using Mann-Whitney U, ANOVA, Chi-square, and multivariate regression analysis. Continuous data are expressed as median (interquartile range). RESULTS: For lateral transabdominal (LT) adrenalectomies, skin-to-skin operative time (OT) [164.5 (71.0) vs 198.8 (117.0) minutes, p = 0.006] and estimated blood loss [26.2 (15.0) vs 72.6 (50.0) ml, p = 0.010] were less in RA versus LA group, respectively. Positive margin rate, hospital stay and 90-day morbidity were similar between the groups (p = NS). For posterior retroperitoneal (PR) approach, operative time and perioperative outcomes were similar between LA and RA groups. Multivariate analysis demonstrated robotic versus laparoscopic technique (p = 0.006) to be an independent predictor of a shorter OT. CONCLUSION: There was a benefit of robotic over the laparoscopic LT adrenalectomy regarding OT and estimated blood loss. Although limited by the small sample size, there was no difference regarding perioperative outcomes between RA and LA performed through a PR approach.

Robotic Surgery for Male Infertility and Chronic Scrotal Content Pain.

Robot-assisted microsurgery is a trending approach for the treatment of male infertility and chronic scrotal pain. The advantages seem to include increased optical magnification, improved surgical efficiency, absent tremor, and similar outcomes with standard methods. This chapter covers robotic microsurgical application and techniques for: robot-assisted vasectomy reversal with vasovasostomy and vasoepididymostomy, varicocelectomy, microsurgical testicular sperm extraction, and targeted denervation of the spermatic cord.

The utility of near infrared autofluorescence imaging for detecting small bowel carcinoid tumors in comparison to DOTATATE PET: A pilot study.

BACKGROUND: Small bowel carcinoid (SBC) primary tumors can be multifocal in 40%-55% of patients and challenging to detect. Near infrared autofluorescence (NIRAF) is used for detection of parathyroid glands. It is unknown if this technology can be used to identify SBCs and how it would compare with current imaging modalities. METHODS: This was a prospective institutional review board-approved pilot study of three patients undergoing resection of SBCs. NIRAF was used to image SBCs and mesenteric lymph nodes intraoperatively and at back table. Findings were compared with preoperative imaging, surgical exploration and pathology. Statistics were performed using Mann-Whitney U test. RESULTS: Eleven SBCs and 12 mesenteric lymph nodes were analyzed. All SBCs had a brighter focal autofluorescence (AF) signal compared to background. Normalized pixel intensity of SBCs was 2.2 (0.7) and normal small bowel 1.4 (0.6) (p < 0.0001). NIRAF was less accurate in detecting occult lymph node metastasis, but was superior to DOTATATE PET for detecting SBCs in two of three patients. CONCLUSIONS: This preliminary report suggests that SBCs exhibit distinctly bright AF signals on NIRAF to create a contrast distinction from normal small bowel. This technology may have a utility as an adjunctive tool for intraoperative detection of occult SBCs.

Ablation technologies.

Ablative therapies have recently emerged as an alternate to the gold-standard liver resection in treatment of malignant liver tumors. These modalities include radiofrequency ablation and microwave ablation which utilize thermocoagulative energy and microwave energy, respectively, to create a complete necrosis zone encircling the lesion. In this review, we aimed to show different perspectives of these treatment methods including indications, outcomes, surgical techniques, and perioperative management.

Laparoscopic versus robotic adrenalectomy in pheochromocytoma patients.

BACKGROUND AND OBJECTIVES: Pheochromocytoma is a challenging tumor type requiring resection with a clear margin and an intact capsule to prevent recurrences. Our aim was to compare perioperative outcomes of laparoscopic adrenalectomy (LA) versus robotic adrenalectomy (RA) for pheochromocytoma. METHODS: In an institutional review board-approved retrospective study, clinical parameters of patients who underwent LA versus RA at a single center were compared using Mann-Whitney U, χ2 , and survival analyses. Continuous data are expressed as median (interquartile range). RESULTS: There was a total of 157 patients (RA: n = 87, LA: n = 70) analyzed. Estimated blood loss (36.3 [35.0] vs. 99.9 [65.0] cc, p = 0.020) and hospital stay (1.3 [0.0] vs. 2.2 [1.0] days, p = 0.010) were lower in robotic versus laparoscopic group, respectively. Disease-free and overall survival was similar between groups. The rate of conversion to open for tumors ≥5 cm was less in the robotic group (0% vs. 14%, respectively, p = 0.048). CONCLUSION: In this study, long-term outcomes of LA and RA were similar, although adrenalectomies performed robotically were associated with less blood loss, shorter hospital stay, and a lower chance of conversion to open in the case of large tumors.

A visual deep learning model to predict abnormal versus normal parathyroid glands using intraoperative autofluorescence signals.

BACKGROUND: Previous work demonstrated that abnormal versus normal parathyroid glands (PGs) exhibit different patterns of autofluorescence, with former appearing darker and more heterogenous. Our objective was to develop a visual artificial intelligence model using intraoperative autofluorescence signals to predict whether a PG is abnormal (hypersecreting and/or hypercellular) or normal before excision during surgical exploration for primary hyperparathyroidism. METHODS: A total of 906 intraoperative parathyroid autofluorescence images of 303 patients undergoing parathyroidectomy/thyroidectomy were used to develop model. Autofluorescence image of each PG was uploaded into the visual artificial intelligence platform as abnormal or normal. For deep learning, randomly chosen 80% of data was used for training, 10% for testing, 10% for validation. The area under the receiver operating characteristic (AUROC), area under the precision-recall curve (AUPRC), recall (sensitivity), and precision (positive predictive value) of the model were calculated. RESULTS: AUROC and AUPRC of the model to predict normal and abnormal PGs were 0.90 and 0.93, respectively. Recall and precision of the model were 89% each. CONCLUSION: Visual artificial intelligence platforms may be used to compare the autofluorescence signal of a given parathyroid gland against a large database. This may be a new adjunctive tool for intraoperative assessment of parathyroid glands during surgical exploration for primary hyperparathyroidism.

Detection of near-infrared autofluorescence from adrenal neoplasms: An initial experience.

BACKGROUND AND OBJECTIVES: Fluorescence from adrenal tumors can be detected with near-infrared imaging after injection with indocyanine green. However, it is unknown if adrenal tumors exhibit autofluorescence. The aim of this study was to determine whether adrenal tumors emit near-infrared autofluorescence (NIRAF). METHODS: This was a prospective study of patients who underwent minimally invasive adrenalectomy at a tertiary center. Intraoperative images were analyzed to detect NIRAF with a 750 nm camera. Descriptive and comparative statistical analyses were performed. RESULTS: Twenty-five adrenalectomies were examined. Only 11 tumors (44%), that originated from the cortex exhibited autofluorescence. A contrast distinction between the tumor and retroperitoneum was observed in 23 patients, whereas a contrast distinction between the tumor and normal adrenocortical tissue was seen in 12 patients. The overall fluorescence intensity of adrenal tumors was found to be variable and ranging between 0.3 and 5.6 times that of the background tissue. Pheochromocytoma, malignancy and adrenal cyst did not demonstrate NIRAF. CONCLUSION: This is the first study to show that adrenocortical tissue can demonstrate NIRAF. The pattern of fluorescence was similar to that observed after indocyanine green injection in our historical experience. NIRAF has a potential to be used as an intraoperative optical adjunct during adrenalectomy.

Management of Chronic Orchialgia: Challenges and Solutions - The Current Standard of Care.

INTRODUCTION: Chronic scrotal content pain (CSP) or chronic orchialgia can be debilitating for patients and difficult to treat. There is a paucity of structured treatment algorithms to approach this difficult condition. METHODS: A review of the literature was performed. Conservative treatment options are presented and then targeted surgical interventions that the urologist may perform are then presented in a structured algorithm format. Many of these patients may obtain a significant reduction in pain with some of these treatments. RESULTS: This review presents the pathophysiology, a new assessment tool, and various treatment options available for CSP patients, such as targeted spermatic cord blocks, targeted and standard microsurgical denervation of the spermatic cord (77-100% success rates), ultrasound-guided peri-spermatic cord and ilioinguinal cryoablation (59-75% success rates), scrotox (botox) (56-72% success rates), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation (72% success rate), radical orchiectomy (20-75% success rate), targeted robotic-assisted intra-abdominal denervation (71% success rate) and vasectomy reversal (69-100% success rates). CONCLUSION: A structured and evidence-based approach to help urologists manage patients with chronic orchialgia or scrotal content pain is presented.