Post-prostatectomy incontinence: a guideline of guidelines

AIM

To provide a comprehensive review of guidelines from various professional organisations on the work-up and management of post-prostatectomy Incontinence (PPI).

MATERIALS AND METHODS

The following guidelines were included in this review: European Association of Urology (EAU 2023), American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU 2019), International Consultation on Incontinence (ICI, 2018), the Canadian Urological Association (CUA, 2012) and the Urological Society of India (USI, 2018).

RESULTS

In general, the guidelines concur regarding the significance of conducting a comprehensive history and physical examination for patients with post-prostatectomy incontinence (PPI). However, there are variations among the guidelines concerning the recommended additional investigations. In cases of troublesome PPI, male slings are typically recommended for mild to moderate urinary incontinence (UI), while artificial urinary sphincters are preferred for moderate to severe UI, although the precise definition of this severity remains unclear. The guidelines provided by AUA/SUFU and the ICI have offered suggestions for managing complications or persistent/recurrent UI post-surgery, though some differences can be observed within these recommendations as well.

CONCLUSION

This is a first of its kind review encompassing Guidelines on PPI spanning over a decade. Although guidelines share overarching principles, nuanced variations persist, posing challenges for clinicians. This compilation consolidates and highlights both the similarities and differences among guidelines, providing a comprehensive overview of PPI diagnosis and management for practitioners. It is our expectation that as more evidence emerges in this and other areas of PPI management, the guidelines will converge and address crucial patient-centric aspects.

Multicentre clinical evaluation of the safety and performance of a simple transperineal access system for prostate biopsies for suspected prostate cancer: The CAMbridge PROstate Biopsy DevicE (CamPROBE) study

Objectives:

To report the prospective multicentre clinical evaluation of a first-in-man disposable device, Cambridge Prostate Biopsy Device, to undertake local anaesthetic outpatient transperineal prostate biopsies.

Material and methods:

Disposable single-use Cambridge Prostate Biopsy devices were manufactured based on a previous prototype. The lead site developed a user training course and disseminated the method to other sites. The Cambridge Prostate Biopsy Device (CamPROBE) was offered as an alternative to transrectal ultrasound guided biopsy to men due for a biopsy as part of their clinical management. Data on safety (infections and device performance), clinical utility, patient reported experience, biopsy quality and cancer detection were collected. Procedure time and local anaesthetic use was recorded in the lead site. The study was funded by a United Kingdom National Institute for Health Research (NIHR) i4i product development award.

Results:

A total of 40 patients were recruited (median age 69 y) across six sites; five sites were new to the procedure. Overall, 19/40 were first prostate biopsies and 21/40 repeat procedures. Both image-targeted and systematic biopsy cores taken. There were no infections, device deficiencies or safety issues reported. The procedure was well tolerated with excellent patient-reported perception and low pain scores (median of 3, scale 0–10). Histopathology quality was good and the overall cancer diagnosis rate (first diagnostic procedures) was 68% (13/19) and for significant cancers (⩾ histological Grade Group 2), 47% (9/19). In the lead centre (most experienced), median procedure time was 25 minutes, and median local anaesthetic use 11 ml (n=17).

Conclusions:

Data from this device evaluation study demonstrate that the United Kingdom-developed Cambridge Prostate Biopsy Device/method for transperineal biopsies is safe, transferable and maintains high diagnostic yields. The procedure is well tolerated by patients, suited to the local anaesthetic outpatient setting and could directly replace transrectal ultrasound guided biopsy.

Level of evidence:

Level III

Estrogen and progesterone receptor expression in the mammary gland tumors

In the primary mammary malignant tumors, including in situ carcinoma, it is recommended the carrying out of immunohistochemical diagnosis for the estrogen (ER) and the progesterone receptors (PR). We have studied the ER and the PR expression in malignant tumors, trying to identify the corresponding phenotypes according to the presence of these tumors. We have carried out a study on a total number of 80 carcinomas, divided into two groups: the first one constituted of 54 cases of carcinomas on which we had clinical data, and another group, constituted of 26 cases of mammary carcinoma, where no clinical data was available. We have observed that the values and the distribution of the ER and PR taken from the biopsies made in the patients with mammary carcinoma are influenced by the age and menopausal status. The combination of the ER/PR results lead to the definition of many tumoral phenotypes.

About the urachus and its pathology. A clinical case of urachus tumor

Urachus diseases represent a relatively rare kind of affliction in child or adult abdominal or urological surgical pathology. The preservation of the urachus lumen leads to rare afflictions, noticed mostly after birth or when they become clinically manifest by various complications. More often than not, these pathological entities require surgical interventions (if the urachal lumen does not close by itself), consisting of partial or total excision of the urachus. Tumor pathology is mostly malign, to a large extent represented by urachus adenocarcinoma. Its initial symptomatology is scarce and confusing. Its treatment is mainly by surgery and consists of the surgical excision of the urachal ligament, of the umbilicus, of a part of the front abdominal wall and partial or total cystectomy, as necessary. The prognosis is unfavourable, since urachal adenocarcinoma is deemed to be a particularly aggressive tumor, strongly influenced by the status of the excision edges, that is by the radicalness of the surgical intervention. Irrespective of the latter, an adjuvant oncological treatment is to be prescribed, mainly systemic cytostatic therapy. Urachus adenocarcinoma is rarely encountered and very often diagnosed in late metastatic stages, when the only solution is at most paleative surgery.

The management of primitive retroperitoneal tumors--problems of clinical, imaging diagnosis, and treatment

Retroperitoneal tumors, whether primary or resulting from the metastasis of other tumors, are a real challenge for the surgeon, in terms of their diagnosis and treatment. They are relatively rare, under 0.2% of the total number of tumors. The clinical examination of retroperitoneal tumors is uncharacteristic and misleading, consisting mainly in palpation of the tumor proper and in assessment of pain. The other signs and symptoms often result from the affected neighboring organs. The imaging investigations used in diagnosing retroperitoneal tumors are ecography, intravenous pyelography, computed tomography, MRI, PET/CT. The main treatment is surgical, consisting either in total or partial excision of the tumor, or in biopsy samples to make a histopathologic diagnosis. Post-operative course depends mainly on the thoroughness of the surgical treatment, that is the complete excision of the tumor, which increases the chances of survival, while lowering the risk of relapse.

Notes concerning the peritonitis of urinary aetiology

Urinary peritonitis (the uroperitoneum) is categorized as a difficult to diagnose clinical entity due to its poor manifestations. Vesical trauma following pelvis bone fracture is the most frequently involved in the uroperitoneum aetiology, followed by spontaneous vesical rupture and intraoperative iatrogenic lesions. One of the most important and constant signs that can occur is diffuse abdominal tension, without tenderness. The imagistic procedure that sets the diagnosis is retrograde cystography showing intraperitoneal urine effusion. Vesical rupture is a surgical emergency. The uroperitoneum is a particular type of peritonitis that has hidden and misleading symptoms which can delay the diagnosis long enough to endanger the patient's life.