Predictors of trainees' proficiency during the learning curve of robot-assisted radical prostatectomy at high- -volume institutions: results from a multicentric series.

Introduction: The aim of this series was to evaluate predictors of Proficiency score (PS) achievement on a multicentric series of robot-assisted radical prostatectomies (RARP) performed by trainee surgeons with two different surgical techniques at four tertiary-care centers. Material and methods: Four institutional datasets were merged and queried for RARPs performed by surgeons during their learning curve (LC) between 2010 and 2020 using two different approaches (Group A, Retzius-sparing RARP, n = 164; Group B, standard anterograde RARP, n = 79). Logistic regression analysis was performed to identify predictors of PS achievement for the overall trainee cohort. For all analyses, a two-sided p <0.05 was considered significant. Results: Group B showed significantly increased median operative time, positive surgical margins (PSM) status, increased number of nerve-sparing procedures, shorter LC time (each p <0.04). PS, continence status, potency, biochemical recurrence and 1-year trifecta rates were comparable between groups (each p >0.3). On multivariable analysis, time from LC starting ≥12 months (OR = 2.79; 95%IC [1.15-6.76]; p = 0.02) and a nerve-sparing intent (OR = 3.18; 95%IC [1.15-8.77]; p = 0.02) were independent predictors of PS score achievement (Table 3). Conclusions: Higher PS rates for RARP trainees may be expected after 12 months from LC beginning. Short-term training courses are unlikely to confer proper surgical training, while long-term structured training programs seem to be beneficial on perioperative outcomes.

A Novel Nomogram Based on Initial Features to Predict BPH Progression.

Objectives: The aim of this study was to establish a tool to identify patients at risk for pharmaceutical and surgical interventions for benign prostatic hyperplasia (BPH)-related lower urinary tract symptoms (LUTS) over a 10 year follow-up. Methods: The data of patients with mild to moderate male LUTS undergoing phytotherapy from January to December 2010 were reviewed. Patients were followed for 10 years through medical visits and telephone consultations. The outcomes were (1) treatment switch from phytotherapy or no therapy to alpha-blockers or 5α-reductase inhibitors (5-ARI), and (2) clinical progression (acute urinary retention or need for surgery). Two calibrated nomograms (one for each outcome) were constructed on significant predictors at multivariate analysis. Results: A total of 107 patients with a median age of 55 years at presentation were included; 47% stopped or continued phytotherapy, while 53% switched to alpha-blockers and/or 5-ARI after a median time of 24 months. One-third in the second group experienced clinical progression after a median time of 54 months. Age, symptom score, peak flow rate (Qmax), prostate-specific antigen (PSA), and post-void residual volume were significantly associated with the outcomes. According to our nomograms, patients switching therapy or progressing clinically had average scores of 75% and 40% in the dedicated nomograms, respectively, as compared to 25% and <5% in patients who did not reach any outcome. Conclusions: We developed a nomogram to predict the risk of pharmaceutical or surgical interventions for BPH-related LUTS at 10 years from presentation. On the basis of our models, thresholds of >75% and >40% for high risk and <25% and <5% for low risk of pharmaceutical or surgical interventions, respectively, can be proposed.

External Validation of a Novel Comprehensive Trifecta System in Predicting Oncologic and Functional Outcomes of Partial Nephrectomy: Results of a Multicentric Series.

BACKGROUND: To validate a novel trifecta for evaluating outcomes of partial nephrectomy (PN) on a multicentric dataset. METHODS: Between 2007 and 2020, three renal cancer databases were queried for patients with solitary renal masses who underwent PN (n = 649). Trifecta was estimated for overall cohort and contributing centers. Overall survival (OS), cancer-specific survival (CSS) and end-stage renal disease (ESRD) probabilities were assessed by Kaplan-Meier. Cox regression was used to identify predictors of OS, CSS, ESRD. For all analyses, a p < 0.05 was considered significant. RESULTS: At a median follow-up of 22.7 months (IQR 12.5-76.5) overall trifecta was 76.7% [Centre A; (n = 230; 68.6%), B (n = 68; 77.3%), C (n = 200; 88.4%); p = 0.001). On Kaplan-Meier, patients achieving trifecta exhibited higher OS (p = 0.024), higher CSS (p = 0.015) and lower ESRD rates (p = 0.024). On multivariable analysis, age (HR 1.04; 95% CI 1.01-1.08) and trifecta (HR 0.34; 95% CI 0.15-0.76) were independent predictors of OS while pT stage (HR 1.95; 95% CI 0.45-8.43) and trifecta (HR 0.33; 95% CI 0.16-0.67) were predictors of CSS (each p < 0.01). Preoperative CKD stage ≥ 3a (HR 13.1; 95% CI 4.07-42.6) and trifecta (HR 0.41; 95% CI 0.19-0.87) were independent predictors of ESRD (each p < 0.05). CONCLUSIONS: On external validation, trifecta was an independent predictor of all PN endpoints, regardless of hilar control and ischemia duration.

Simultaneous robotic partial nephrectomy for bilateral renal masses.

PURPOSE: There is currently no consensus regarding the optimal treatment strategy for patients presenting with synchronous bilateral renal masses. The decision to perform bilateral procedures on the same intervention or in staged procedures is debated. The aim of this manuscript is to analyse the outcomes of simultaneous robot-assisted partial nephrectomy (RAPN) in a series of patients with bilateral renal masses treated at five Italian robotic institutions. METHODS: Data from a prospectively maintained multi-institutional database on patients subjected to simultaneous RAPN between November 2011 and July 2019 were reviewed. RAPNs were performed with da Vinci Si or Xi surgical system by expert robotic surgeons. Baseline demographics and clinical features, peri- and post-operative data were collected. RESULTS: Overall, 27 patients underwent simultaneous bilateral RAPN, and 54 RAPNs were performed without need of conversion; median operative time was 250 minutes, median estimated blood loss was 200 mL. Renal artery clamping was needed for 27 (50%) RAPNs with a median warm ischemia time of 15 minutes and no case of acute kidney injury. Complications were reported in 7 (25.9%) patients, mainly represented by Clavien 2 events (6 blood transfusions). Positive surgical margins were assessed in 2 (3.7%) of the renal cell carcinoma. At the median follow-up of 30 months, recurrence-free survival was 100%. CONCLUSION: Our data showed that, in selected patients and expert hands, simultaneous bilateral RAPNs could be a safe and feasible procedure with promising results for the treatment of bilateral synchronous renal masses.

Robotic-assisted radical prostatectomy following colo-rectal surgery: a user's guide.

To assess the feasibility and operative outcomes of RARP following colo-rectal surgery. A prospective database of patients undergoing RARP is maintained at our Institution since January 2015. We reviewed all patients undergoing RARP after previous colo-rectal surgery. Overall, 49 (7.4%) of 658 RARPs were performed after previous pelvic surgery, 14 (2.1%) of which following colo-rectal surgery after an interval of 5 years. (a) Colo-rectal surgery. Previous colo-rectal surgery included resection of the left colon (n = 6), and right colon (n = 4), and rectum (n = 4). Histopathology showed pT0-T2N0 in 5, pT3N0-1 in 3, and benign conditions in 4. Prostate-specific antigen (PSA) was elevated (4 ng/ml or greater) or slightly elevated (3.5-4 ng/ml) in 9 (65%) of 14 cases at the time of colo-rectal surgery. (b) Prostatectomy. Overall prostatectomy and adhesiolysis median operative times were 235 and 42 min, respectively. A robotic approach was accomplished in 11 cases with previous uncomplicated colo-rectal surgery; open conversion occurred in 3 cases. Risk factors for open conversion during RARP were: history of multiple or complicated abdominal surgery, previous open conversion, and hospital stay > 10 days. Postoperative complications included: anemization (n = 2), persistent drain output (n = 1), and urinary tract infection (n = 1). The robotic approach was successful in the case of previous uncomplicated colo-rectal surgery. The risk of intestinal injury during conversion might suggest a direct retropubic approach in case of previous multiple or complicated abdominal surgery. A planned elective colo-rectal surgery should include a thorough urologic evaluation, considering the risk of a subsequent prostate surgery.

Is a Drain Needed After Robotic Radical Prostatectomy With or Without Pelvic Lymph Node Dissection? Results of a Single-Center Randomized Clinical Trial.

Objective: To investigate by means of a randomized clinical trial the safety of no drain in the pelvic cavity after robot-assisted radical prostatectomy (RARP) with or without extended pelvic lymph node dissection (ePLND). Materials and Methods: From May to December 2016, 112 consecutive patients who underwent RARP with or without ePLND were prospectively randomized into a control group (CG) and study group (SG). In the CG, a drain was placed in the pelvic cavity at the end of surgery and removed after 24 hours. The trial was designed to assess noninferiority. The primary endpoint was evaluated as complication rates graded by the Clavien-Dindo score (CDS). Secondary endpoints included length of hospital stay (LOHS) and hospital readmission (RAD). Results and Limitations: At final analysis, 56 patients were in the CG and 54 belonged to the SG. The groups were homogenous for all preoperative and perioperative variables and did not show any difference in CDS complication rates (28.9% in the CG and 20.4% in the SG; p = 0.254), LOHS (on average 4 days in each group; p = 0.689), and RAD rates (3.6% in the CG and 3.7% in the SG; p = 0.970). Conclusions: In a modern cohort of patients who underwent RARP with or without ePLND, a single-center randomized controlled trial showed that no-drain policy is equivalent to drain after RARP in terms of CDS complication rate, LOHS, and RAD rate. The option of placing a postoperative drain for the first 24 hours could be considered in cases of difficult urethrovesical anastomosis with uncertain watertightness.

Posterior reconstruction during robotic-assisted radical cystectomy with intracorporeal orthotopic ileal neobladder: description and outcomes of a simple step.

A posterior reconstruction (PR) might improve the fluidity and delicacy of the maneuvers related to the neovesico-urethral anastomosis during robotic-assisted radical cystectomy (RARC). Our objective is to describe in detail the surgical steps of PR and to assess its feasibility and functional outcomes. The data regarding patients undergoing a totally intracorporeal RARC with neobladder and PR for high-grade and/or muscle-invasive urothelial cancer of the bladder at Karolinska University Hospital between October 2015 and November 2016 by a single surgeon (PW) were reviewed. Prior to the anastomosis, a modified posterior Rocco's repair involving the Denonvillier's fascia, the rhabdosphincter, and the posterior side of the ileal neobladder neck was performed. The steps are shown in a video at https://doi.org/10.1089/vid.2019.0029 . The primary outcome was urinary continence; the secondary outcomes were urinary leakage, intermittent catheterization, and complications related to the reconstructive steps. Eleven male patients with a median age and BMI of 67 years and 24, respectively, underwent RARC with PR associated to the neovesico-urethral anastomosis. Overall and posterior reconstruction time were 300' (195-320) and 6' (4-7), respectively. The daytime and nighttime continence rates were 100% and 44% at 12 months, respectively; the median pad weight was 3.5 g and 108 g at daytime and nighttime, respectively. One urinary leakage from the urethrovesical anastomosis was treated conservatively. Two patients perform intermittent catheterization. The posterior reconstruction during RARC is safe and feasible, providing good continence rates. It supported a careful suturing of the anastomosis as well as an uncomplicated catheter placement.

Comparison of GreenLight 180-W XPS laser vaporization versus transurethral resection of the prostate: Outcomes of a single regional center.

BACKGROUND: To evaluate the intermediate perioperative outcomes, rate of complications and functional data after XPS 180-W Greenlight photoselective laser vaporization (PVP) compared with transurethral resection of the prostate (TURP) in a prospective non-randomized single centre study. METHODS: We analyzed a prospectively-maintained database collecting data on 100 patients undergoing surgical treatment of BPH (50 consecutive PVP and 50 consecutive TURP). All complications, recorded and graduated according to the Clavien Dindo system and the clinical, operative, perioperative variables were compared. The functional outcomes, International Prostate Symptom Score (IPSS), max flow rate (Qmax) and Prostate Specific Antigen (PSA), were recorded preoperatively and at 1 year of follow up. RESULTS: Age, prostate volume, use of anticoagulants or antiplatelets, ASA score and operative time were comparable in the two groups. The reduction in the hemoglobin levels (0.46 vs 1.8 g/dL), the catheterization time (1.2 vs 3.2 days), the hospital stay (1.7 vs 3.8 days) and rate of transfused patients (0 vs 8%), were significantly lower for PVP. Transient re-catherization (6 vs 26%) was significantly lower for PVP. The IPSS and Qmax at 1 year showed no significant difference. The rate of repeat TURP/PVP was higher in the TURP group (0 vs 10%). Reduction of PSA, that reflects the major reduction of prostate volume, was statistically greater in PVP group respect TURP group (p = 0.001). CONCLUSIONS: PVP has advantages in terms of perioperative safety and major complications than TURP. Functional outcomes at 1 year of follow-up were comparable.

Guess Who's Coming to Dinner: COVID-19 in a COVID-free Unit.

OBJECTIVE: To assess the impact of the pandemic on surgical activity and the occurrence and features of Covid-19 in a Covid-free urologic unit in a regional hospital in Northern Italy. MATERIALS AND METHODS: Our Department is the only urologic service in the Trento Province, near Lombardy, the epicenter of Covid-19 in our Country. We reviewed the surgical and ward activities during the 4 weeks following the national lockdown (March 9 to April 5, 2020). The following outcomes were investigated: surgical load, rate of admissions and bed occupation, and the rate and characteristics of unrecognized Covid-positive patients. Data were compared with that of the same period of 2019 (March 11 to April 7). RESULTS AND CONCLUSION: About 63%, 70%, 64%, and 71%, decline in surgery, endoscopy, bed occupation, and admission, respectively, occurred during the 4 weeks after the lockdown, as compared to 2019. Urgent procedures also declined by 32%. Three (8%) of 39 admissions regarded unrecognized Covid-19 overlapping or misinterpreted with urgent urologic conditions such as fever-associated urinary stones or hematuria. In spite of a significant reduction of activity, a non-negligible portion of admissions to our Covid-free unit regarded unrecognized Covid-19. In order to preserve its integrity, we propose an enhanced triage prior to the admission to a Covid-free unit including not only routine questions on fever and respiratory symptoms but also nonrespiratory symptoms, history of exposure, and a survey about the social and geographic origin of the patient.

Teleurology in the Time of Covid-19 Pandemic: Here to Stay?

OBJECTIVE: To assess the implementation and outcomes of telemedicine in a Department of Urology in Northern Italy during the outbreak of the Covid-19 pandemic. METHODS: All the outpatient clinical activities during the 4 weeks following the national lockdown (March 9-April 3, 2020) in the Department of Urology of the Trento Province, Italy, were reviewed and categorized. Expert staff members examined the electronic records, selecting whether the clinic appointments should be canceled or confirmed (via telephone consultation or face-to-face visit). The rate, indication, and modality of visits were investigated. RESULTS: Overall, 415 of 928 (45%) scheduled patients canceled their clinic appointment themselves or were canceled by staff members without rescheduling. The remaining 523 (55%) cases were screened undergoing telephone consultation in 295 (56%) and face-to-face visit in 228 (44%). The rate of face-to-face visit decreased from 63% to 9% during week 1 and 4, respectively. Seventy-four percent of face-to-face visits regarded suspected recurrent or new onset malignancy or potentially dangerous clinical conditions (severe urinary symptoms or complicated urinary stones or infection). The median age of patients in the face-to-face and telephone groups was 59 (range 20-69) and 65 years old (range 37-88), respectively. CONCLUSION: A pandemic is a dynamic scenario, requiring reorganization and flexibility of the healthcare delivery. Forty-five percent visits were canceled without rescheduling. Although a minimum portion of face-to-face visit (<10% 1 month after the lockdown) was preserved mostly for suspected malignancy or potentially life-threatening conditions, telemedicine proved a pragmatic approach allowing efficient screening of cases and adequate protection for patients and clinicians.

Fosfomycin trometamol and N-acetyl-L-cysteine as combined oral therapy of difficult-to-treat chronic bacterial prostatitis: Results of a pilot study.

This paper presents the results of a pilot study of difficult-to-treat patients (exhibiting several previous treatment failures or detection of extended-spectrum beta-lactamase [ESBL] strains) with chronic bacterial prostatitis (CBP) who underwent treatment with fosfomycin trometamol (FT) and N-acetyl-L-cysteine (NAC). Twenty-eight patients with clinically- and microbiologically-confirmed CBP who attended a single urological institution between January 2018 and March 2019 were treated with oral administration of 3 g FT once a day for 2 days, followed by a dose of 3 g every 48 h for 2 weeks, in combination with oral administration of NAC 600 mg once a day for 2 weeks. Clinical and microbiological analyses were carried out at the time of admission (T0) and during follow-up at 1 month (T1) and 6 months (T2) after the end of treatment. Symptoms were assessed by the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and International Prostatic Symptom Score (IPSS), and quality of life was assessed by Quality of Well-Being (QoL) questionnaires. Isolated strains were Escherichia coli (23 patients), Enterococcus spp. (3 patients), and Klebsiella oxytoca (2 patients). ESBL strain was found in 19 (67.8%) patients. Microbiological eradication was documented in 21 (75%) patients at the second follow-up visit and clinical cure was achieved in 20 (71.4%) patients. Significant changes on questionnaires were recorded between baseline and follow-up visits. Fifteen of 19 patients (78.9%) with ESBL strains were cured. No significant side effects were reported. FT in combination with NAC is a promising alternative therapy in difficult-to-treat CBP patients.

Prostate-specific antigen levels and proportion of biopsy positive cores are independent predictors of upgrading patterns in low-risk prostate cancer.

BACKGROUND: The aim of this study is to evaluate clinical factors associated with the risk of tumor upgrading patterns in low risk prostate cancer (PCA) patients undergoing radical prostatectomy. METHODS: In a period running from January 2013 to December 2016, 245 low risk patients underwent RP. Patients were classified into three groups, which included case with pathology grade group one (no upgrading pattern), two-three (intermediate upgrading pattern), and four-five (high upgrading pattern). The association of factors with the upgrading risk was evaluated by the multinomial logistic regression model. It was used a receiver operating characteristic (ROC) curve and area under the curve (AUC) analysis to assess the efficacy of predictors. RESULTS: Overall, tumor upgrading was detected in 158 patients (67.3%). Tumor upgrading patterns were absent in 80 patients (32.7%), intermediate in 152 cases (62%) and high in 13 subjects (5.3%). Median prostate specific (PSA) levels and proportion of biopsy positive core (BPC) were higher in patients with intermediate (PSA=6 ng/mL; BPC=0.28) and high (PSA=8.9 ng/mL; BPC=0.33) than those without (PSA=5.7 ng/mL; BPC=0.17) and the difference was significant (PSA: P=0.002; BPC: P=0.001). When compared to not upgraded cases, higher BPC proportions were independent predictors of intermediate upgrading patterns (odds ratio, OR=36.711; P<0.0001; AUC=0.613) while higher PSA values were independent predictors of high upgrading patterns (OR=2.033, P<0.0001; AUC=0.779). CONCLUSIONS: PSA and BPC were both independent predictors of tumor upgrading in low risk PCA. BPC associated with the risk of intermediate tumor upgrading patterns, but showed a low discrimination power. PSA associated with high upgrading patterns and showed a fair discrimination power in the model. Tumor upgrading risk patterns should be evaluated in low risk PCA patients before treatment.

Sutureless laparoscopic partial nephrectomy using fibrin gel reduces ischemia time while preserving renal function.

OBJECTIVES: We evaluated the efficacy of sutureless laparoscopic partial nephrectomy (LPN), using a fibrin gel in order to minimize renal ischemia time and preserve kidney function. MATERIALS AND METHODS: Nineteen patients (mean age 58.3 ± 7.1) undergoing sutureless LPN using a fbrin gel were compared with a control group consisting of 21 patients (mean age 57.9 ± 7.5) subjected to LPN with standard suturing. Intraand post-operative data for the two groups were compared. The following parameters were recorded: patient demographics, Charlson Comorbidity Index, tumor characteristics according to the RENAL score, warm ischemia and operative times, estimated blood loss, mean hospital stay, post-operative complications referring to the Clavien-Dindo classification, renal function parameters pathologic and follow-up data. The main outcome measure was renal ischemia time and maintenance of kidney function. RESULTS: Median warm ischemia time was 13 minutes (range 11-19) in the group treated with fibrin gel and 19 (range 17- 29) in the control group, with a statistically significant difference (p < 0.001). The two groups were homogeneous in terms of the Charlson Comorbidity Index (4.6 vs 4.8) and RENAL score (9.6 vs 9.4). Median operative time differed significantly in the two groups, 183 minutes (range 145-218) in the group treated with fibrin gel and 201 (range 197-231) in the control group (p < 0.001). A negative surgical margin was reported in 18 patients (94.7%) in the group treated with fibrin gel and in 21 patients (100%) in the control group. No difference in renal function was found between the two groups. CONCLUSIONS: Sutureless LPN with fibrin gel can reduce warm ischemia and total operative time while preserving kidney function.

Body mass index is an independent predictor of Clavien-Dindo grade 3 complications in patients undergoing robot assisted radical prostatectomy with extensive pelvic lymph node dissection.

Robot assisted radical prostatectomy (RARP) with extensive pelvic lymph node dissection (ePLND) is an effective procedure for treating and staging prostate cancer; however, high grade complications represent a critical issue. To investigate clinical factors associated with the risk of Clavien-Dindo grade 3 complications in patients undergoing RARP with ePLND. The study included 211 consecutive patients who were operated in a period running from June 2013 to March 2017. Factors associated with grade 3 complications were evaluated by the logistic regression model. Receiver operating characteristic curves and area under the curve (AUC) were used to assess the risk model. Of the 211 patients included in the study, 55 (26.1%) had complications, which were classified Clavien grade one in 36 cases (17.1%), two in 7 (3.3%), 3a in 9 (4.3%) and 3b in 3 (1.4%). Higher median measurements of body mass index (BMI) were detected in grade 3 subjects (27.6 kg/m2) when compared to grade 0-2 cases (25 kg/m2) and the difference was significant (P = 0.015). BMI increased the risk of high grade complications (odds ratio, OR 1.184; P = 0.047) with a fair discrimination power (AUC 0.709). It generated a risk curve by the model, which stratified patients in low (BMI < 26 kg/m2; probability risk less than 5%), intermediate (26 ≤ BMI (kg/m2) ≤ 30; risk between 5 and 10%), and high (BMI > 30 kg/m2; risk between 10 and 20%) risk classes for grade 3 complications. BMI is an independent predictor of grade 3 complications, which are increased by 18.4% for each unit rise. Patients may be stratified preoperatively by BMI into grade 3 risk categories, which include low (normal weight), intermediate (overweight), and high (obese) risk cases.

Fluorescence-guided selective arterial clamping during RAPN provides better early functional outcomes based on renal scan compared to standard clamping.

To compare the functional and operative outcomes of robot-assisted partial nephrectomy with selective arterial clamping guided by near infrared fluorescence imaging (NIRF-RAPN) versus a cohort of patients who underwent standard RAPN without selective arterial clamping (S-RAPN). 62 consecutive patients underwent RAPN from January 2016 to May 2017: the last 20 patients underwent NIRF-RAPN. Preoperative and postoperative renal scan at 1 month were performed to evaluate the glomerular filtration rate (GFR) of the operated renal unit and total function. Functional and operative outcomes of cases were compared with a cohort of 42 patients undergoing S-RAPN. Selective clamping was performed in 15 patients (75%), whereas five (25%) cases were converted to S-RAPN, due to incomplete ischemic appearance of the tumor after selective clamping. Median tumor diameter was 40 mm in both groups. Median selective clamping was 24 min in both groups. Operative time (206' vs 190') and blood loss (200 vs 170 cc) were comparable. No major complications have been reported in the NIRF-RAPN group, whereas three acute hemorrhages with embolization were found in the S-RAPN group. The analysis of renal scan data revealed that a greater loss of GFR in the operated renal unit was observed after S-RAPN compared to NIRF-RAPN [21.5% vs. 5.5%; p = 0.046], as well as total GFR loss [8% vs 0%; p = 0.007]. The use of NIRF imaging was associated with improved short-term renal functional outcomes compared to RAPN without selective arterial clamping. To our knowledge, this is the first comparative study analyzing the GFR obtained from renal scan.

Novel Diagnostic Biomarkers of Prostate Cancer: An Update.

OBJECTIVE: In recent years, several biomarkers alternative to standard prostate specific antigen (PSA) for prostate cancer (PCa) diagnosis have become available. The aim of this systematic review is to assess the current knowledge about alternative serum and urinary biomarkers for the diagnosis of PCa. MATERIAL AND METHODS: A research was conducted in Medline, restricted to English language articles published between December 2014 and June 2018 with the aim to update previously published series on PCa biomarkers. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria were used for selecting studies with the lowest risk of bias. RESULTS: Emerging role and actual controversies on serum and urine alternative biomarkers to standard PSA for PCa diagnosis, staging and prognosis assessment, such as prostate health index (PHI), PCA3, ConfirmMDx, Aberrant PSA glycosylation, MiPS, miRNAs are critically presented in the current review. CONCLUSION: Although the use of several biomarkers has been recommended or questioned by different international guidelines, larger prospective randomized studies are still necessary to validate their efficacy in PCa detection, discrimination, prognosis and treatment effectiveness. To date, only PHI and 4Kscore have shown clinical relevance for discriminating more aggressive PCa. Furthermore, a new grading classification based on molecular features relevant for PCa risk-stratification and tailoring treatment is still needed.

Role of increasing leukocyturia for detecting the transition from asymptomatic bacteriuria to symptomatic infection in women with recurrent urinary tract infections: A new tool for improving antibiotic stewardship.

OBJECTIVES: To evaluate the importance of leukocyturia in detecting the transition from asymptomatic bacteriuria to symptomatic infection in women with recurrent urinary tract infections. METHODS: In this cross-sectional study, we evaluated all women with recurrent urinary tract infection and asymptomatic bacteriuria who had been enrolled in two previous studies. Data from urological visits, urine analyses and microbiological evaluations were collected. Patients were divided into two groups: patients with symptomatic recurrence (group A) and patients without recurrence (group B), with a mean follow-up period of 38.8 months. Data on leukocyturia and clinical data were compared. Logistic regression analyses were carried out and areas under the receiver operating characteristic curves were calculated. RESULTS: A total of 301 women with symptomatic urinary tract infection were included in group A, whereas 249 women without clinical infection were included in group B. Group A showed a higher level of leukocytes in the urinary analysis taken at the moment of recurrence when compared with the baseline value (mean leukocytes per high power field 54 ± 5 vs 19 ± 6 at baseline; P < 0.0001). When an increase of leukocytes/mm3 of >150% from baseline was used for logistic regression, the area under the receiver operating characteristic of the model was 0.82 (95% CI 0.78-0.94; P = 0.01). An increase of leukocytes/mm3 of >150% from baseline had a sensitivity of 90.1% and a specificity of 91.2% for symptomatic urinary tract infection. CONCLUSIONS: This study shows that an increase of leukocyturia of >150% from baseline has a predictive role for the transition from asymptomatic bacteriuria to symptomatic urinary tract infection in women with recurrent urinary tract infections.

Prostate-specific antigen associates with extensive lymph node invasion in high-risk prostate cancer.

OBJECTIVE: To evaluate clinical predictors of lymph node invasion (LNI) in patients with high-risk prostate cancer undergoing radical prostatectomy (RP) with extended pelvic lymph node dissection (ePLND). METHODS: A contemporary cohort of 116 patients, who underwent ePLND during RP, was retrospectively evaluated. Patients were classified into 3 groups including cases without LNI (group 1), with 1 to 3 positive nodes (group 2; limited LNI), and with more than 3 positive nodes (group 3; extensive LNI). The multinomial logistic regression model (multivariate analysis) evaluated the risk of LNI. RESULTS: Overall, 30 patients (25.9%) had LNI, which was limited in 17 cases (14.7%) and extensive in 13 subjects (11.2%). Median prostate-specific antigen (PSA) was higher in cases with limited (11.4 ng/mL) or extensive (23.5 ng/mL) LNI than cases without (7.3 ng/mL) and the difference was significant ( p <.0001). Median proportion of biopsy-positive cores was higher in limited (0.64) or extensive (0.54) LNI than cases without (0.34) and the difference was significant ( p < .0001). The distribution of other factors did not show any significant difference among the groups. On multivariate analysis, only higher values of PSA significantly affected the odds of extensive LNI when compared to cases without (odds ratio, 1.054; p = .005); PSA showed a fair discrimination power (area under the curve 0.792). CONCLUSION: PSA was the only independent predictor of extensive LNI and could be an important preoperative factor for stratifying high-risk patients.

Associations of Transitional Zone Volume with Intraprostatic Chronic Inflammation and Prostate Cancer Risk in Patients Undergoing a First Random Biopsy Set.

OBJECTIVES: To investigate associations of the transitional zone volume (TZV) with intraprostatic chronic inflammatory infiltrate (CII) and prostate cancer (PCa) risk in patients undergoing a first random biopsy set. MATERIALS AND METHODS: The study included a homogenous population of 596 patients. The volume of the prostate and TZV were separately measured. Independent associations were investigated by multivariate logistic regression analysis. RESULTS: The median TZV was 18 ml, CII was detected in 157 cases (26.3%), and PCa was present in 292 patients (49%). TZV was the only independent clinical factor associated with CII risk (OR = 1.014). After correcting for CII (OR = 0.276; p < 0.0001), independent factors associated with PCa risk included age (OR = 1.066), prostate specific antigen (OR = 1.177), TZV (OR = 0.919), and an abnormal digital rectal exam (OR = 2.024). CONCLUSION: In a patient population undergoing a first random prostate biopsy set because of suspected cancer, independent associations were detected among TZV, CII, and PCa. The association between TZV and CII was direct, but the relation between TZV and PCa was inverse. The measurement of the volume of the transitional zone was a useful parameter for evaluating chronic intraprostatic inflammation and PCa risk.