Composite urinary and sexual outcomes after Rezum: an analysis of predictive factors from an Italian multi-centric study

BACKGROUND

The Rezum system is one of the latest minimally invasive surgical treatments for benign prostatic hyperplasia.

METHODS

We retrospectively reviewed all patients who underwent the Rezum treatment in seven different Italian institutions. A successful urinary outcome was defined as: ≥50% improvement in the IPSS <7, improvement in peak flow ≥50% and/or more than 15 ml/s, ≥1-point improvement in the QoL questionnaire and in the absence of perioperative major complications (AUR, transfusion) or postoperative incontinence. A successful sexual outcome was defined as postoperative (latest follow up consultation) antegrade ejaculation or no variation in ejaculatory function and an increase, or stability or max 1 class reduction, in IIEF-5.

RESULTS

262 patients were enrolled with a follow-up period of 11 months (IQR 5-15). No early or late serious adverse events (Clavien III-IV) occurred. Early complications occurred in 39.3% of cases, with 4 cases of clot retention and one case of blood transfusion. Urge incontinence was reported by 6 patients (2.2%). A treatment failure requiring re-intervention occurred in 4 cases (1.5%). The preoperative antegrade ejaculation rate was 56.5%, and after the procedure it increased to 78.2%. The increase of ≥1-point in the QoL was achieved in 92.7% of the cases. Optimal urinary and sexual outcomes were achieved in 52.9% and 87.8%, respectively.

CONCLUSIONS

In our series, water vapor intraprostatic injections seem to be an effective and safe procedure.

Non-transecting dorsal mucosal anastomosis plus ventral oral graft for the treatment of urethral bulbar strictures: single surgeon experience

PURPOSE

To report our experience with the non-transecting dorsal mucosal anastomosis plus ventral oral graft urethroplasty (NTAVOG) for the repair of tight bulbar urethral strictures.

METHODS

Data of 68 men with tight bulbar strictures underwent NTAVOG urethroplasty between 2012 and 2019 were retrospectively revised. The urethra was opened ventrally; the dorsal scarred mucosa was excised preserving the spongiosum; the mobilized mucosal edges were anastomosed to recreate the dorsal urethral plate; the repaired urethral plate was augmented by the ventral oral graft and the spongiosum was closed over it. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Sexual function was investigated using a validated questionnaire.

RESULTS

Median follow-up was 58 months (IQR 38-63) and mean stricture length was 1 cm (IQR 1-1.5). Of 68 cases, 56 (82.4%) were successful and 12 (17.6%) were failures requiring re-treatment. At multivariable analysis, no preoperative factor was significantly associated with recurrence. None of the preoperatively sexually active 53 patients reported postoperative erectile impairment and all were satisfied with their sexual life. The main limitation is the retrospective design.

CONCLUSIONS

In cases of tight bulbar stricture, the NTAVOG urethroplasty provides adequate urethral augmentation by preserving the spongiosum and avoiding postoperative sexual complications. We presented a series of patients undergone non-transecting dorsal anastomosis plus ventral oral graft urethroplasty for tight bulbar stricture. This treatment seems to be safe and with limited postoperative complications thanks to the preservation of the corpus spongiosum.

Global experience and progress in GreenLight-XPS 180-Watt photoselective vaporization of the prostate

PURPOSE

To evaluate changes in global perioperative data of GreenLight-XPS 180-Watt photo-selective vaporization of the prostate (GL-XPS) of the Global Greenlight Group (GGG) database.

METHODS

3441 men, who underwent GL-XPS for symptomatic BPH between 2011 and 2019 at seven high volume international centers, were included. Primary outcome measurements were operative time (OT; min), effective laser time (LT; min of OT), as well as intraoperative and postoperative adverse events (AEs), all analyzed by year of surgery (2011-2019) and prostate volume (PV) group (< 80 ml vs. 80-150 ml vs. > 150 ml).

RESULTS

The median age was 70 years (interquartile range 64-77), the median PV was 64 ml (IQR 47-90). The OT and LT slightly increased but stayed highly efficient all in all. Median OT was 60 min (IQR 45-83) and LT was 33 min (IQR 23-46). Median energy use was 253 kJ (IQR 170-375) with an energy density of 3.94 kJ/ml (IQR 2.94-5.02). The relative probability of perioperative AEs decreased by 17% each year (p < 0.001). The relative probability of perioperative transfusion dropped significantly from 2% in 2011 to 0% in 2019 (p = 0.007). The early postoperative complications (within 30 days after surgery) decreased significantly from 48.8% (n = 106) in 2011 to 24.7% (n = 20) in 2019 (p > 0.001).

CONCLUSION

These findings from the GGG demonstrate significant improvement secondary to growing experience with GL-XPS between 2011 and 2019 in intraoperative AEs, including transfusions, and postoperative AEs. While staying highly efficient in OT and LT of GL-XPS within a 9-year period of experience.

GreenLight photovaporization of the prostate in high-medical-risk patients: an analysis of the Global GreenLight Group (GGG) database

PURPOSE

We sought to characterize the adjusted outcomes of GreenLight photoselective vaporization of the prostate (PVP) in high-medical-risk (HMR) patients using data from the largest international database.

METHODS

Data were obtained from the Global GreenLight Group (GGG) database which pools data of eight high-volume, experienced surgeons, from a total of seven international centers. Eligible study participants underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019. HMR patients were defined as patients with ASA III or greater and were compared to non-HMR patients. Analyses were adjusted for patient age and prostate volume.

RESULTS

In the HMR group, patients on average were older and had smaller prostates than the non-HMR control group. Compared to non-HMR patients, transfusions occurred more frequently (2.6% vs. 0.14%, p < 0.01) and the odds of readmission were elevated [OR 2.0, (95% CI 1.4-2.8, p < 0.01)] among HMR patients. Twelve months postoperatively, HMR patients experience greater improvement in QoL than the control group [+ 0.54 (95% CI 0.07-1.0, p = 0.02)]. PVR also decreased 93.1 ml more in HMR than in non-HMR patients after 12 months (95% CI 33.6-152.6, p < 0.01).

CONCLUSION

We found that GreenLight PVP is safe and effective in improving functional outcomes in higher-risk patients with severe systemic disease compared to their lower-risk counterparts. Though absolute risks remain low, GreenLight PVP is associated with higher odds of transfusion and readmission in the high-risk cohort. The findings of our study reaffirm current guidelines that propose PVP as a viable treatment option for HMR patients.

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.

Role of Rezum in the treatment of benign prostate hyperplasia: A review of the literature

The aim of this study was to review the available literature on the efficacy and safety of the Rezum system for the treatment of symptomatic benign prostatic hyperplasia (BPH). A revision of literature up to January 2021 was carried out. Medline, Scopus, Web of Science, and PubMed archives were screened to identify all the relevant studies investigating the role of Rezum in the treatment of BPH. Randomized controlled trial (RCT), retrospective, prospective, observational, and comparative studies were included. Finally, 17 studies were included, five of which reporting data of a double blind Rezum RCT. Overall, 1,451 patients underwent Rezum procedure. All the studies performed a minimum of 3 months follow-up. Preoperatively, the mean International Prostate Symptom Score (IPSS) score was 19.8, mean Q_max was 9.2 mL s⁻¹, and mean PVR was 142 cc. At 3 months after surgery, the mean IPSS score was 1.5, mean Q_max was 13.7 mL s⁻¹, and mean PVR was 74 cc. Six studies investigated sexual function, most of them using the International Index of Erectile Function (IIEF)-5 questionnaire and a few also the Male Sexual Health Questionnaire (MSHQ). Preoperative mean IIEF-5 score was 18.5, and the mean MSHQ score was 7.4. At the 3 months follow-up, the mean IIEF-5 score was 16.4, and the mean MSHQ score was 9.62. None of the studies reported intraoperative complications. Rezum system is a novel minimally invasive treatment for symptomatic BPH using transurethral water vapor thermal energy. It represents a cost-effective and safe procedure with durable relief of lower urinary tract symptom, preservation of sexual function, low complications rate, and short recovery time.

Potential prognostic value of miR-132 and miR-212 expression in mCRPC patients

To the Editor, we have been very pleased to read the interesting work proposed by Salemi et al. regarding the expression of specific fragments of microRNA (miRNA), particularly miR-132 and miR-212, as potential key regulators in prostate cancer (PCa). As outlined by the Authors, the altered expression of miRNAs in cancer pathogenesis represents a well-consolidated knowledge in the current literature. More specifically, both miR-212 and miR-132 regulate subsets of genes involved in tumor progression in several tumor cell types as PCa, proving a central role in tumorigenesis, cell adhesion, and angiogenesis. In addition, a strong association between miR-132 expression and high Gleason score PCa has been lately depicted [...].

The prognostic power of inflammatory indices and clinical factors in metastatic castration-resistant prostate cancer patients treated with radium-223 (BIO-Ra study)

Purpose

To combine peripheral blood indices and clinical factors in a prognostic score for metastatic castration-resistant prostate cancer (mCRPC) patients treated with radium-223 dichloride ([²²³Ra]RaCl₂).

Patients and methods

Baseline neutrophil-to-lymphocyte ratio (NLR), derived NLR (donor), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), systemic inflammation index (SII), Eastern Cooperative Oncology Group performance status (ECOG PS), Gleason score (GS) group, number of bone metastases, prostate-specific antigen (PSA), alkaline phosphatase (ALP), line of therapy, previous chemotherapy, and the presence of lymphadenopathies were collected from seven Italian centers between 2013 and 2020. Lab and clinical data were assessed in correlation with the overall survival (OS). Inflammatory indices were then included separately in the multivariable analyses with the prognostic clinical factors. The model with the highest discriminative ability (c-index) was chosen to develop the BIO-Ra score.

Results

Five hundred and nineteen mCRPC patients (median OS: 19.9 months) were enrolled. Higher NLR, dNLR, PLR, and SII and lower LMR predicted worse OS (all with a p < 0.001). The multivariable model including NLR, ECOG PS, number of bone metastases, ALP, and PSA (c-index: 0.724) was chosen to develop the BIO-Ra score. Using the Schneeweiss scoring system, the BIO-Ra score identified three prognostic groups (36%, 27.3%, and 36.6% patients, respectively) with distinct median OS (31, 26.6, and 9.6 months, respectively; hazard ratio: 1.62, p = 0.008 for group 2 vs. 1 and 5.77, p < 0.001 for group 3 vs. 1).

Conclusions

The BIO-Ra score represents an easy and widely applicable tool for the prognostic stratification of mCRPC patients treated with [²²³Ra]RaCl₂ with no additional costs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05550-6.

Clinical and penile Doppler outcomes using a modified, tourniquet free, Nesbit plication for severe Peyronie's disease

Background

Penile curvature (PC) can be surgically corrected by plication techniques or Nesbit corporoplasty. These shortening techniques can be complicated by post-operative: penile shortening, recurrent PC, palpable suture knots and erectile dysfunction. Furthermore, Nesbit procedures require the use of a penile tourniquet to avoid intraoperative bleeding. This observational study aims to assess the results of Nesbit modified corporoplasty, avoiding intraoperative use of tourniquet without risk of bleeding. The objective is to reduce penile ischemic anatomical and functional damages such as long-term erectile dysfunction.

Methods

Between January 2010 and March 2019, a total of 64 patients with congenital penile curvature (CPC) and Peyronie’s disease (PD) underwent surgical correction with a Nesbit modified technique first time described by Rolle et al., with minimal technical differences. The operation notes were retrospectively reviewed. In particular, we evaluated pre- and post-operative erectile functions using IIEF-5 score, penile Doppler ultrasonography and overall patient satisfaction.

Results

During operations, no intraoperative bleeding was noted, and no short-term complications such as hematomas or neurovascular bundle lesions were reported. At 6 months, no palpable subcutaneous indurations and no sensory change were detected. Post-operative penile shortening was reported in 38 (59.4%) patients (mean 0.83±0.79 cm), but it did not influence the high overall satisfaction rate of 91.4%. Only 2 patients reported a slightly partial recurrence of curvature (<15%) with no need for a redo surgery. Mean IIEF-5 score increased from 17.1±5.2 to 20.8±3.9 at 6 months and 21.8±3.4 at 12 months (P<0.001 in both cases). Mean PSV also significantly increased at the end of follow-up (28.5±6.1 at baseline vs. 31.0±7.1 at 12 months, P=0.03).

Conclusions

Considering the optimal results in terms of erectile functions increasing and absence of PC recurrence (>15°), we think that Nesbit modified corporoplasty without tourniquet application during reconstruction is a safe and effective surgical procedure for all kind of shortening corporoplasty to reduce the time of penile ischemia, preventing even serious consequences for the normal physiology of erection.

Post-Operative Acute Urinary Retention After Greenlight Laser. Analysis of Risk Factors from A Multicentric Database

PURPOSE

Greenlight laser is a mini-invasive technique used to treat Benign Prostatic Obstruction (BPO). Some of the advantages of GreenLight photoselective vaporization (PVP) are shorter catheterization time and hospital stay compared to TURP. Post-operative acute urinary retention (pAUR) leads to patients' discomfort, prolonged hospital stay and increased health care costs. We analyzed risk factors for urinary retention after GreenLight laser PVP.

MATERIALS AND METHODS

In a multicenter experience, we retrospectively analyzed the onset of early and late post-operative acute urinary retention in patients undergoing standard or anatomical PVP. The pre-, intra- and post-operative characteristics were compared betweene patients who started to void and the patients who developed post-operative urinary retention.

RESULTS

The study included 434 patients suitable for the study. Post-operative acute urinary retention occurred in 39 (9%). Patients with a lower prostate volume (P < .001), an adenoma volume lower than 40 mL (P < .001), and lower lasing time (P = .013) had a higher probability to develop pAUR at the univariate analysis. The multivariate logistic regression confirmed that lower lasing time (95% CI: 0.86-0.99, OR = 0.93, P = .046) and adenoma volume (95% CI: 0.89-0.98, OR = 0.94, P = .006) are correlated to pAUR. Furthermore IPSS ≥ 19 (95% CI: 1.19- 10.75, OR = 2.27, P = .023) and treatment with 5-ARI (95% CI: 1.05-15.03, OR = 3.98, P = .042) are risk factors for pAUR.

CONCLUSION

In our series, post-operative acute urinary retention was related to low adenoma volume and lasing time, pre-operative IPSS ≥ 19 and 5-ARI intake. These data should be considered in deciding the best timing for urethral catheters removal.

Emerging minimally invasive transurethral treatments for benign prostatic hyperplasia: a systematic review with meta-analysis of functional outcomes and description of complications

INTRODUCTION

Several minimally invasive surgical procedures have been proposed as alternative therapies for benign prostatic hyperplasia (BPH). The present systematic review aimed to describe the functional outcomes and complications of emerging minimally invasive transurethral treatments for BPH.

EVIDENCE ACQUISITION

A comprehensive bibliographic search on the MEDLINE and Cochrane Library databases was conducted. No chronological restriction was applied. Retrospective and prospective primary studies were included. A meta-analysis of IPSS, IPSS-QoL, Qmax, and PVR was performed. Data on adverse events were presented narratively.

EVIDENCE SYNTHESIS

A total of 18 studies were included. Thirteen papers were eligible for the meta-analysis. iTIND, Rezūm, and Aquablation were associated with a significant improvement in IPSS (p<0.001), IPSS-QoL (p<0.001), and Qmax (p<0.001) compared to baseline. A significant reduction of PVR from baseline was found with Rezūm (p<0.001) and Aquablation (p<0.001) but not iTIND (p=0.22). A significant difference in IPSS, IPSS-QoL, and Qmax was shown in favor of Aquablation compared to Rezūm and iTIND (p<0.001). Rezūm and iTIND were mainly associated with mild to moderate adverse effects. Hematuria or bleeding was reported in all studies regarding Aquablation (0.8%-26%), the need for transfusion or intervention for bleeding varied between 1.8% and 9%.

CONCLUSIONS

Aquablation, Rezūm, and iTIND significantly improve urinary functional outcomes compared to baseline; however, Aquablation would seem to lead to better functional results compared to the other procedures. Rezūm and iTIND appear to have an excellent safety profile, while Aquablation would seem to expose patients to a nonnegligible risk of bleeding.

Corrigendum to: Can Medical Therapy Fix Sexual Dysfunction after Major Pelvic and Prostate Surgery and does it Work for Kidney Stones? Chemotherapy before Cystectomy, New Schemes for which Patients?

Due to an editorial oversight, we would like to apologize for an error that occurred in the both print and online version of an editorial entitled "Can Medical Therapy Fix Sexual Dysfunction after Major Pelvic and Prostate Surgery and does it Work for Kidney Stones? Chemotherapy before Cystectomy, New Schemes for which Patients?. It was published without the co-authors' names in the journal "Current Drug Targets" 2021; 22(1): 2 [1]. The original editorial can be found online at https://doi.org/10.2174/138945012201201231123209 REFERENCE [1] Petros S, Ioannis M, Ioannis V, Luca C, Can medical therapy fix sexual dysfunction after major pelvic and prostate surgery and does it work for kidney stones? chemotherapy before cystectomy, new schemes for which patients? Curr Drug Targets 2021; 22(1): 1.

Is off-clamp robot-assisted partial nephrectomy beneficial for renal function? Data from the CLOCK trial

OBJECTIVES

To compare the functional outcomes of on- vs off-clamp robot-assisted partial nephrectomy (RAPN) within a randomized controlled trial (RCT).

MATERIALS AND METHODS

The CLOCK study (CLamp vs Off Clamp the Kidney during robotic partial nephrectomy; NCT02287987) is a multicentre RCT including patients with normal baseline function, two kidneys and masses with RENAL scores ≤ 10. Pre- and postoperative renal scintigraphy was prescribed. Renal defatting and hilum isolation were required in both study arms; in the on-clamp arm, ischaemia was imposed until the completion of medullary renorraphy, while in the off-clamp condition it was not allowed throughout the procedure. The primary endpoint was 6-month absolute variation in estimated glomerular filtration rate (AV-GFR); secondary endpoints were: 12, 18 and 24-month AV-GFR; 6-month estimated glomerular filtration rate variation >25% rate (RV-GFR >25); and absolute variation in ipsilateral split renal function (AV-SRF). The planned sample size was 102 + 102 cases, after taking account crossover of cases to the alternate study arm; a 1:1 randomization was performed. AV-GFR and AV-SRF were compared using analysis of covariation, and RV-GFR >25 was assessed using multivariable logistic regression. Intention-to-treat (ITT) and per-protocol analyses (PP) were performed.

RESULTS

A total of 160 and 164 patients were randomly assigned to on- and off-clamp RAPN, respectively; crossover was observed in 14% and 43% of the on- and off-clamp arms, respectively. We were unable to find any statistically significant difference between on- vs off-clamp with regard to the primary endpoint (ITT: 6-month AV-GFR -6.2 vs -5.1 mL/min, mean difference 0.2 mL/min, 95% confidence interval [CI] -3.1 to 3.4 [P = 0.8]; PP: 6-month AV-GFR -6.8 vs -4.2 mL/min, mean difference 1.6 mL/min, 95% CI -2.3 to 5.5 [P = 0.7]) or with regard to the secondary endpoints. The median warm ischaemia time was 14 vs 15 min in the ITT analysis and 14 vs 0 min in the PP analysis.

CONCLUSION

In patients with regular baseline function and two kidneys, we found no evidence of differences in functional outcomes for on- vs off-clamp RAPN.

Efficacy and Safety of the 64Cu(II)Cl2 PET/CT for Urological Malignancies: Phase IIa Clinical Study

PURPOSE OF THE REPORT

The aim of this study was to evaluate safety and efficacy of copper-64(II)dichloride (64Cu(II)Cl2) as a new PET tracer for urological malignancies (UMs).

METHODS

Patients with UM were enrolled in a prospective study. All patients were staged with preoperative CT and 64Cu(II)Cl2 PET/CT. Patient characteristics, anatomical and functional imaging, and final histopathology were recorded. Surgical specimens for histopathological examination were collected. To determine time-activity curves for 64Cu(II)Cl2 uptake in UM and normal tissues, SUVs were calculated. The safety of 64Cu(II)Cl2 was assessed.

RESULTS

Twenty-three patients were included. An administered activity of 174.7 MBq (4.72 mCi) for 64Cu(II)Cl2 was equal to 9.80 mSv of the effective dose. The median SUVmax values were 5.7, 0.9, 1.8, and 9.8 for the prostate, bladder, penis, and kidney, respectively. Median SUVmax values were higher in organs with a malignancy in comparison with healthy tissue (prostate [11.5 vs 5.3, P < 0.001], bladder [6.2 vs 0.9, P = 0.007], and penis [3.9 vs 1.3, P = 0.027]), but not in the kidneys (5.0 vs 10.4, P = 0.998). The highest area under the curve (AUC) was reported for prostate cancer (AUC, 0.978), and the lowest for penile cancer (AUC, 0.775). The detection rates based on the best suggested cutoff according to the SUVmax were 85.7% (6/7) for prostate and bladder and 83.3% (5/6) for penile cancer. Neither drug-related effects nor physiologic responses occurred, nor adverse reactions.

CONCLUSIONS

64Cu(II)Cl2 is an effective and well-tolerated tracer in patients with UM. Our results show higher SUVmax in cancer patients than in healthy subjects. Our findings suggest that 64Cu(II)Cl2 PET/CT is useful in patients affected by prostate, bladder, and penis cancer.

Prognostic role of inflammatory biomarkers from peripheral blood and clinical factors in metastatic castration-resistant prostate cancer (mCRPC) patients (pts) treated with radium-223 (Ra-223) (BIO-Ra-223 study)

e17026

Background: Ra-223 is a treatment option for mCRPC pts with bone metastases according to the survival benefit observed compared to placebo in the ALSYMPCA trial. In the last years, many studies showed this benefit in the real-life pts is lower than that reported in the trial, probably due to a suboptimal selection of pts with poor prognostic characteristics. Therefore, the identification of prognostic factors to select mCRPC pts most likely to benefit from Ra-223 is needed. The multicentre retrospective BIO-Ra-223 study has investigated the prognostic role of peripheral blood immune cells and clinical factors to develop a novel prognostic score for mCRPC pts treated with Ra-223. Methods: Complete blood count was assessed before Ra-223 treatment calculating neutrophil-to-lymphocyte ratio (NLR), derived NLR (dNLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), systemic inflammation index (SII). Clinical factors included pre-treatment Eastern Cooperative Oncology Group performance status (ECOG PS), Gleason Score (GS) group, number of bone metastases, alkaline phosphatase (ALP), line of therapy, previous chemotherapy and the presence of lymphadenopathies. Statistical analyses included survival ROC curves for biomarkers’ cutoffs, univariable and multivariable Cox analyses, internal validation, c-index calculation and Schneeweiss scoring system. Results: From September 2013 to July 2020, 519 mCRPC pts received Ra-223 as 1st-2nd, 3rd-4th and further-line in 48%, 38% and 14% of pts. The median overall survival (mOS) of the entire cohort was 19.9 months. All biomarkers and clinical factors (except for GS group) significantly predicted OS at the univariable analyses. In the multivariable ones, all biomarkers, ECOG PS, number of bone metastases and ALP significantly correlated with OS. The multivariable model with NLR (< 3.1 vs ≥3.1), ECOG PS (0-1 vs 2-3), number of bone metastases (< 6, 6-20, > 20) and ALP (< 220 vs ≥220) showed the highest c-index (0.711), which was maintained after internal validation (bootstrap re-sampling) (c-index: 0.707). Using the Schneeweiss scoring system, ten categories were identified in 494 pts with complete data and merged in two prognostic groups with distinctive OSs: group 1 (score 0-4, 337 pts) with a mOS of 27.8 months and group 2 (score 5-10, 157 pts) with a mOS of 9.7 months (HR 4.03, p < 0.001). Conclusions: The obtained score, composed of NLR, ECOG PS, number of bone metastases, and ALP identifies two distinctive prognostic groups of mCRPC pts. Moreover, this score is easily and widely applicable for clinical practice and trials at no additional costs. Although external validation is needed, these preliminary results showed that this novel prognostic score is promising and could help the patients’ selection for Ra-223 treatment.