Renorrhaphy techniques in minimally invasive partial nephrectomy: a systematic review of the literature

INTRODUCTION

In the absence of consensus on the optimal approach to renorrhaphy in partial nephrectomy, this systematic review aims to assess the various renorrhaphy techniques and their impact on surgical outcomes.

EVIDENCE ACQUISITION

A systematic review of the literature was performed in March 2022, using PubMed and Scopus, without time restrictions and research filters for studies investigating renorrhaphy techniques in partial nephrectomy. Studies providing sufficient details on renorrhaphy techniques and their outcomes during minimally invasive partial nephrectomy (PN) were included in this analysis.

EVIDENCE SYNTHESIS

Thirty-one studies with 5720 patients were included in the analysis. In most studies, tumor diameter was <4 cm. RENAL and PADUA scores as well as tumor locations were heterogeneous between the studies. The results of the use of hemostatic agents were conflicting among different studies with limited evidence regarding the benefits of its routine use in partial nephrectomy. The use of barbed and running sutures was associated with a reduced warm ischemia time. While some studies showed a decreased warm ischemia time when omitting cortical renorrhaphy, others found that it may lead to higher incidence of minor complications without any significant improvement in other outcomes.

CONCLUSIONS

There is ongoing research to determine the optimal approach to renorrhaphy. The current evidence on the routine use of hemostatic agents is limited. The use of certain techniques such as barbed sutures, sliding clips and running sutures reduced the warm ischemia time. The omission of cortical renorrhaphy is still controversial.

External validation of biochemical recurrence definition to predict oncologic outcomes following focal therapy for localized prostate cancer using high intensity focused ultrasound

PURPOSE

This is an external validation of several biochemical recurrence definitions based on prostate specific antigen criteria (PSA). The purpose is to predict the need of additional treatment and failure after focal therapy using high intensity focused ultrasound (HIFU) for localized prostate cancer (PCa).

MATERIALS AND METHODS

A total of 343 consecutive patients who underwent HIFU with Ablatherm® and Focal One® devices between June 2001 and November 2020 were identified. Treatment failure was defined as clinically significant PCa on postoperative biopsy, the need for salvage radical or systematic treatment, metastasis, or PCa-related death. The biochemical recurrence definitions tested were PSA nadir, time to PSA nadir, percentage of PSA reduction, Huber et al. criteria defined as PSA nadir + 1 ng/mL at 12 months or PSA nadir + 1.5 ng/mL at 24-36 months. Multivariable Cox regression analysis and decision-curve analysis were used to validate and compare criteria. Kaplan-Meier analysis was used to assess criteria associated with the highest accuracy.

RESULTS

One hundred seventy-eight patients met the inclusion criteria and were analyzed. Overall, 61 (34%) and 41 (23%) patients had an additional treatment and failure with a median follow-up of 52 months. At multivariable analysis, model including Huber et al. criteria exhibited the highest Harrell's C-index for the prediction of the need of additional treatment (hazard ratio [HR]: 10, p < 0.001, c-index: 84%) and treatment failure (HR: 9.1, p < 0.001, c-index: 82%) as well as higher net benefit. The 60-months need of additional treatment and treatment failure-free survival were 89% and 98% compared to 26% and 49%, respectively, when stratified according to Huber et al. criteria (Log-rank test, p < 0.001). Similar results were found after excluding patient with non-clinically significant PCa at initial biopsy.

CONCLUSIONS

We report an external validation of biochemical recurrence definitions predicting the need of additional treatment and failure after focal therapy using HIFU for localized PCa. Huber et al. criteria were identified as the most accurate and could be used to guide clinicians toward further evaluation and salvage treatments.

Urinary microbiota and prostatic diseases: the key for the lock? A systematic review

BACKGROUND

Urinary microbiota is implicated in many diseases of the urinary tract. The aim of this study was to perform a systematic review of the role of urinary microbiota in prostatic diseases.

METHODS

A PubMed/Medline search was undergone from inception through June 2022 for studies investigating urinary microbiota alterations in prostatic diseases, subdivided into benign prostatic hyperplasia (BPH), prostate cancer (PCa), and chronic prostatitis (CP). Study selection followed the PRISMA statement. Phylum, family, genus and species of each bacterium in cancer patients and controls were recorded. Quality of included studies was evaluated using the Critical Appraisal Skills Program (CASP) checklist for non-randomized studies.

RESULTS

A total of 16 studies (4 studies on BPH, 9 studies on PCa and 3 studies on CP) comprising 1486 patients were included in our final analysis. Patients with BPH had a different urinary microbial composition, with a certain pattern proven to be associated with a higher lower urinary tract symptoms severity. Regarding PCa, some bacterial phyla/genera/classes/species were more abundant in PCa and others predicted a higher grade disease. In patients with CP, a different microbiota composition and a higher diversity were found, with the symptom severity being influenced mainly by microbiota composition, favoring aerobic microorganisms.

CONCLUSION

Urinary microbiota is implicated in prostatic diseases, especially in BPH, PCa and CP. However, given the relative heterogeneity among published studies, this implication suggests better delineation is needed. Further studies are needed to confirm these findings.

Cost-analysis of robot-assisted radical cystectomy in Europe: A cross-country comparison

BACKGROUND

Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is surging worldwide. Aim of the study was to perform a multicentric cost-analysis of RARC by comparing the gross cost of the intervention across hospitals in four different European countries.

METHODS

Patients who underwent RARC + ICUD were recruited from eleven European centers in four European countries (Belgium, France, Netherlands, and UK) between 2015 and 2020. Costs were divided into six parts: cost for hospital stay, cost for ICU stay, cost for surgical theater occupation, cost for transfusion, cost for robotic instruments, and cost for stapling instruments. These costs were individually assessed for each patient.

RESULTS

A total of 490 patients were included. Median operative time was 300(270-360) minutes and median hospital length-of-stay was 11(8-15) days. The average total cost of RARC was 14.794€ (95%CI 14.300-15.200€). A significant difference was found for the total cost, as well as the various subcosts abovementioned, between the four included countries. Different sets and types of robotic instruments were used by each center, leading to a difference in cost of robotic instrumentation. Nearly 84% of costs of RARC were due to hospital stay (42%), ICU stay (3%) and operative time (39%), while 16% of costs were due to robotic (8%) and stapling (8%) instruments.

CONCLUSION

Costs and subcosts of RARC + ICUD vary significantly across European countries and are mainly dependent of hospital length-of-stay and operative time rather than robotic instrumentation. Decreasing length-of-stay and reducing operative time could help to decrease the cost of RARC and make it more widely accessible.

Antibody-Drug Conjugates in Prostate Cancer: Where Are we?

Antibody-drug conjugates (ADCs) reflect a new promising approach in prostate cancer, even more so after the practice-changing results in other malignancies, either hematologic or solid. ADCs consist of monoclonal antibodies (mAb) targeted at specific antigens overly expressed on cancer cells compared to normal cells. A cytotoxic payload is attached to the mAb using a stable linker. In prostate cancer, PSMA, STEAP1, TROP2, CD46 and B7-H3 are antigens currently being studied as targets for ADCs. In this paper, we discuss the composition of ADCs and focus on their application and challenges as treatment options in prostate cancer.

Do perioperative blood transfusions impact oncological outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion? Results from a large multi-institutional registry

BACKGROUND

Blood transfusions (BT) have been associated with adverse oncologic outcomes in multiple malignancies including open radical cystectomy (ORC) for urothelial carcinoma of the bladder (UCB). Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) delivers similar oncologic outcomes compared to ORC, yet with lower blood loss and reduced transfusions. However, the impact of BT after robotic cystectomy is still unknown.

METHODS

This is a multicenter study including patients treated for UCB with RARC and ICUD in 15 academic institutions, between January 2015 and January 2022. BT were administered during surgery (intraoperative blood transfusions, iBT) or during the first 30 days after surgery (post-operative blood transfusions, pBT). The association of iBT and pBT with recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) were evaluated by univariate and multivariate regression analysis.

RESULTS

A total of 635 patients were included in the study. Overall, 35/635 patients (5.51%) received iBT while 70/635 (11.0%) received pBT. After a mean follow-up of 23±18 months, 116 patients (18.3%) had died, including 96 (15.1%) from bladder cancer. Recurrence occurred in 146 patients (23%). iBT were associated with decreased RFS, CSS and OS (P<0.001) on univariate Cox analysis. After adjusting for clinicopathologic covariates, iBT were associated only with the risk of recurrence (HR: 1.7; 95% CI, 1.0-2.8, P=0.04). pBT were not significantly associated to RFS, CSS or OS on univariate and multivariate Cox regression models (P>0.05).

CONCLUSIONS

In the present study, patients treated by RARC with ICUD for UCB have a higher risk of recurrence after iBT, yet no significant association with CSS and OS was found. pBT are not associated with worse oncological prognosis.

Defining the morbidity of Robotic-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: adoption of the Comprehensive Complication Index

BACKGROUND & OBJECTIVE

The Clavien-Dindo Classification (CDC) only reports the post-operative complication of highest grade. It is thus of limited value for radical cystectomy after which patients usually experience multiple complications. The CCI is a novel scoring system which incorporates all post-operative events in one single value. To adopt the Comprehensive Complication Index (CCI) for the evaluation of complications in patients undergoing Robot-Assisted Radical Cystectomy (RARC) with Intra-Corporeal Urinary Diversion (ICUD) and explore its advantages in the analysis of the morbidity of RARC with ICUD.

PATIENTS AND METHODS

Multicentric cohort of 959 patients undergoing RARC+ICUD between 2015-2020, whose complications are encoded in local prospective registries. Post-operative complications at 30 days were assessed using both the CDC and CCI. The CCI was calculated using an online tool (assessurgery.com). Risk factors for overall, major complications (CDC≥III) and CCI were evaluated using uni- and multivariable logistic and linear regressions. To analyse the potential advantage of using the CCI in clinical trials, a sample size calculation of a hypothetic clinical trial was performed using as endpoint reduction of morbidity with either the CDC or CCI.

RESULTS

Overall, 885 post-operative complications were reported in 507 patients (53%). The CCI improved the definition of post-operative morbidity in 22.6% of patients. Male sex and neobladder were associated to major complications and to a significant increase in CCI on adjusted regressions. In a hypothetical clinical trial, 80 patients would be needed to demonstrate a ten point reduction in CCI, compared to 186 needed to demonstrate an absolute risk reduction of 20% in overall morbidity using the CDC.

CONCLUSION

CCI improves the evaluation of post-operative morbidity by considering the cumulative aspect of complications compared to the CDC. Implementing the CCI for radical cystectomy would help reducing sample sizes in clinical trials.

Systematic review comparing Anterior vs Retzius-sparing robotic assisted radical prostatectomy: can the approach really make a difference?

INTRODUCTION

Retzius-Sparing Robotic Assisted Radical Prostatectomy (RS-RARP) is a novel surgical approach to radical prostatectomy. Its pioneers have suggested an improved recovery of urinary continence, while maintaining adequate cancer control. Aim of this systematic review is to explore available data on RS-RALP and compare functional, oncologic and perioperative results of RS-RARP compared to anterior RARP.

EVIDENCE ACQUISITION

A search following PRISMA guidelines was performed including the combination of the following words: retzius AND sparing AND radical AND prostatectomy. 93 articles were identified and 13 were included in the systematic review, including 3 randomized controlled trials (RCT), 4 prospective studies and 6 retrospective studies.

EVIDENCE SYNTHESIS

All available randomized trials confirmed an improved immediate continence for RS-RARP, with rates ranging 51-71%, compared to 21-48% for anterior RARP. However, this advantage was progressively lost with no significant difference found after 6 months. Moreover, a prospective study found no discrepancy in terms of quality of life across the two techniques. Erectile function was difficult to compare, as patients had different baseline erectile function across studies and rate of neurovascular preservation was not comparable. Surgical approach remains controversial regarding positive margin rate, although related to the surgeon's experience and clinical stage. Biochemical recurrence-free survival appears similar between the two approaches.

CONCLUSIONS

RS-RARP improves early urinary continence recovery compared to anterior RARP, with this advantage being lost after 3 to 6 months. Erectile function and quality of life were however comparable between the two techniques. The results concerning the rate of positive margins remained controversial. Future studies with longer follow-up are needed to better assess oncologic outcomes.

Urothelial carcinoma in COVID-19: lessons from a pandemic and their impact on clinical practice

The COVID-19 pandemic has modified the management of urothelial carcinoma (UC). Eighteen months after the onset of the pandemic, a scoping narrative review was able to state that radical cystectomy for UC should not be delayed beyond 10 weeks when neoadjuvant chemotherapy (NAC) was administered and 12 weeks when it was not. NAC should be considered when imminent chemotherapy cannot be performed. Early cystectomy should not be delayed when indicated for patients with high-risk non-MIBC. Patients with non-MIBC should still receive their induction doses of intravesical instillations. Diagnostic cystoscopy should not be deferred in symptomatic patients. Surgical management of upper tract urothelial carcinoma (UTUC) allows for a wider deferral interval.

Continuing acetylsalicylic acid during Robotic-Assisted Radical Cystectomy with intracorporeal urinary diversion does not increase hemorrhagic complications: results from a large multicentric cohort

OBJECTIVES

To evaluate whether continuing the antiplatelet drug acetylsalicylic acid≤100mg (ASA) during Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) increases the risk of peri-and postoperative hemorrhagic complications and overall morbidity. Indeed, guidelines recommend interrupting antiplatelet therapy before radical cystectomy; however, RARC with ICUD is associated to reduced estimated blood loss and blood transfusions compared to its open counterpart.

METHODS

Data from a multicentric European database were analyzed. All participating centers maintained a prospective database of patients undergoing RARC with ICUD. We identified patients receiving antiplatelet therapy by acetylsalicylic acid ≤100mg. Patients were divided into three groups: those not taking acetylsalicylic acid (no-ASA), those where ASA was continued perioperatively (c-ASA) and those where ASA was interrupted perioperatively (i-ASA). Estimated blood loss and peri-and post-operative transfusions were recorded. Hemorrhagic complications, ischemic, thrombotic and cardiac morbidity was recorded and classified using the Clavien-Dindo score by a senior urologist.

RESULTS

640 patients were analyzed. Patients on acetylsalicylic acid were significantly older and had more comorbidities. No significant difference was found for estimated blood loss between no-ASA, c-ASA and i-ASA (280 vs. 300 vs. 200ml respectively; P = 0.09). Similarly, no significant difference was found for intraoperative (5% vs. 9% vs. 11%; P = 0.07) and postoperative transfusion rate (11% vs. 13% vs. 18%; P = 0.17). Higher ischemic complications were noted in the i-ASA group compared to no-ASA and c-ASA (4% vs. 0.6% vs. 1.4%; P = 0.03). On uni and multivariate logistic regression, continuing acetylsalicylic acid was not significantly associated to either major complications or post-operative transfusions.

CONCLUSIONS

Peri-operative acetylsalicylic acid continuation in RARC with ICUD does not increase hemorrhagic complications. Interrupting acetylsalicylic acid peri-operatively may expose patients to a higher risk of ischemic events.

Focal therapy for prostate cancer: Making the punishment fit the crime

BACKGROUND

Focal therapy is recently gaining popularity as an intermediate option between active surveillance and whole-gland treatment for localized prostate cancer.

OBJECTIVE

This comprehensive review aims to present the different focal therapy technologies available to date while tackling the rationale for focal treatment, its indications, principles and outcomes of each technique.

EVIDENCE ACQUISITION

A comprehensive review of the PubMed, Embase, and Web of Science was done. Keywords used for research were: "prostate cancer"; "focal therapy"; "focal treatment"; "High-Intensity Focal Ultrasound"; "cryotherapy"; "photodynamic therapy"; "focal laser ablation"; "irreversible electroporation"; "focal brachytherapy" and "gold nanoparticle directed therapy". Accepted languages were English and French.

EVIDENCE SYNTHESIS

Choosing the best candidate for focal therapy is crucial (localized small to medium sized Gleason≤7 lesions). Focal high-intensity focal ultrasound has shown excellent survival rates at 5 years, while maintaining good functional outcomes (urinary continence and erectile function). Focal cryotherapy, one of the oldest focal treatments for prostate cancer, has shown good oncologic outcomes, with good continence rates and fair erectile function rates. Focal laser ablation seems a safe and feasible technique, with promising results. Irreversible electroporation has demonstrated good survival outcomes with no biochemical recurrence or disease relapse in the preliminary studies. Focal brachytherapy has a good toxicity profile, a good biochemical outcome, and gives a sustained quality of life. Finally, gold nanoparticle directed therapy is safe and is being studied in current trials.

CONCLUSION

While proven to be safe in terms of continence and sexual aspects, the challenge remains to better assess oncological outcomes of these techniques in randomized longer follow-up studies.

Antibodies targeting Prostate-Specific Membrane Antigen positive prostate cancer: from diagnostic imaging to theranostics

PURPOSE OF REVIEW

Targeting Prostate-Specific Membrane Antigen (PSMA) has paved the way for personalized medicine in prostate cancer (PCa) patients. This review aims to highlight the role of PSMA targeting antibodies in PCa, for diagnostic and therapeutic purposes.

RECENT FINDINGS

PSMA Positron Emission Tomography/Computed Tomography has been a game changer in the diagnosis of PCa in the recent decade. Two anti-PSMA monoclonal antibodies have been studied in PCa: 7E11-C35 (limited use) and J591. J591 antibody was used for diagnostic purposes coupled with different radionuclides. Most importantly, it was combined to numerous therapeutic radionuclides such as Lutetium-177 (177Lu), Yttrium-90 (90Y), Indium-111 (111In), and Actinium-225 (225Ac). It was also conjugated to drugs forming antibody-drug conjugates (e.g. MLN2704 and PSMA-ADC). These compounds were tested in recent phase I/II clinical trials.

SUMMARY

PSMA targeting antibodies are very promising for further clinical investigation and continue to be a momentous research area, for both imaging and therapeutic settings. Although some clinical trials resulted in unfavorably safety profiles for some antibodies, they validated PSMA as a crucial immunoconjugate target.

Contemporary management of benign uretero-enteric strictures after cystectomy: a systematic review

INTRODUCTION

Uretero-enteric stricture (UES) is a common post-operative complication after radical cystectomy with urinary diversion. The aim of this systematic review is to discuss the contemporary management of benign UES after cystectomy and to compare the different surgical approaches.

EVIDENCE ACQUISITION

A systematic review was performed from January 2000 through January 2021. Search engines used included PubMed, Embase and Medline databases. Search query was: ((ureteroileal OR uretero-ileal OR ureteroenteric OR ureteroenteric) AND (stricture OR stenosis)) AND (management OR treatment). Study selection followed the PRISMA statement. Studies tackling management of UES, either through open, endoscopic, laparoscopic or robot-assisted approaches, were included in our systematic review.

EVIDENCE SYNTHESIS

Forty-one studies were finally included in this systematic review. No prospective studies were found; all included studies were retrospective. Open surgical repair had a 78-100% success rate, a significant rate of complications, and a low recurrence rate (6-8%). Endourological management decreased complication rate, length-of-stay, and blood loss, with however lower success (15-50%) and higher recurrence rates (62%-91%) compared to open surgery. Robotic assisted surgery showed comparable success rates to open surgery (80-100%), while limiting the number of major complications and hospital length-of-stay.

CONCLUSIONS

Surgical management of UES remains challenging. Open surgery maintains a role given its high success rate, at the cost however of a significant morbidity. On the other hand, endourological procedures offer a favorable and low complication risk, but a low long-term success rate. Robotic-assisted surgery is emerging with a valid resolution of UES as it offers comparable success rates to an open approach, while reducing surgical morbidity. Head-to-head comparisons are awaited to confirm these findings.

Prognostic role of neutrophil-to-lymphocyte ratio (NLR) in urological tumors: an umbrella review of evidence from systematic reviews and meta-analyses

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) has been studied as a biomarker for cancer prognosis, predicting survival in many tumors. The aim of this umbrella review was to combine the results from all systematic reviews and meta-analyses related to the prognostic role of the NLR in patients with urological tumors.

METHODS

A PubMed, Scopus, Embase and Cochrane search was undergone from inception through September 2020 for systematic reviews and meta-analyses investigating the prognostic value of NLR in urological tumors, subdivided into prostate cancer, renal cell carcinoma, urothelial bladder and upper tract carcinomas PROSPERO (CRD42020216310).

RESULTS

The results have shown, with a high level of evidence, that an elevated NLR predicts worse overall survival (OS), progression-free survival (PFS) and relapse-free survival (RFS) in prostate cancer, worse OS, PFS and RFS in renal cell carcinoma, worse OS, PFS, RFS and cancer-specific survival (CSS) in muscle invasive bladder cancer, worse PFS and RFS in non-muscle invasive bladder cancer, and worse OS, PFS, RFS and CSS in urothelial upper tract carcinoma.

CONCLUSION

NLR has a significant prognostic value in urological tumors and should be included in prognostic scores of these cancers.

Sexual dysfunction due to pudendal neuralgia: a systematic review

Background

The pudendal nerve is considered as the main nerve of sexuality. Pudendal neuralgia is an underdiagnosed disease in clinical practice. The aim of this systematic review is to highlight the role of pudendal neuralgia on sexual dysfunction in both sexes.

Methods

A PubMed search was performed using the following keywords: “Pudendal” AND “Sexual dysfunction” or “Erectile dysfunction” or “Ejaculation” or “Persistent sexual arousal” or “Dyspareunia” or “Vulvodynia”. The search involved patients having sexual dysfunction due to pudendal neuralgia. Treatment received was also reported.

Results

Five case series, seven cohort studies, two pilot studies, and three randomized clinical trials were included in this systematic review. Pudendal nerve and/or artery entrapment, or pudendal neuralgia, is a reversible cause of multiple sexual dysfunctions. Interventions such as anesthetic injections, neurolysis, and decompression are reported as potential treatment modalities. There are no studies describing the role of pudendal canal syndrome in the pathophysiology or treatment of delayed ejaculation or penile shortening.

Discussion

Pudendal neuralgia is an underestimated yet important cause of persistent genital arousal, erectile dysfunction (ED), premature ejaculation (PE), ejaculation pain, and vulvodynia. Physicians should be aware of this entity and examine the pudendal canal in such patients before concluding an idiopathic cause of sexual dysfunction.

Is pudendal nerve entrapment a potential cause for weak ejaculation?

Ejaculatory dysfunction is one of the most common complaints of patients with sexual disorders. While it encompasses several ejaculatory disorders, weak ejaculation is seldom described in the literature. Since the pudendal nerve is the main nerve of ejaculation, we aim to hypothesize that pudendal nerve entrapment could be a cause of weak ejaculation, and that pudendal nerve release could contribute to the improvement of the ejaculatory stream. We presented two cases suffering from a weak ejaculatory stream and sensation of incomplete semen emptying, accompanied with clinical features of pudendal nerve entrapment. Both cases improved after pudendal nerve block and then laparoscopic transperitoneal pudendal release, with a sustained amelioration of the ejaculatory stream after 3 weeks of surgery. Pudendal canal entrapment is therefore a potentially curable cause for weak ejaculation.

Immune checkpoint inhibitors for BCG-resistant NMIBC: the dawn of a new era

INTRODUCTION

High risk non-muscle invasive bladder cancer (NMIBC) is a recurring and potentially lethal disease. To date, with the exception of radical surgery, there are no validated strategies for patients not responding to intravesical BCG therapy. Immune checkpoint inhibitors (ICI) are currently being tested for BCG-resistant NMIBC. We report current available data and ongoing trials exploring the efficacy and safety of ICI in this setting.

EVIDENCE ACQUISITION

A narrative search was performed including the combination of the following words: ("immunotherapy") AND ("BCG" AND "resistant" OR "non-muscle AND invasive") AND ("bladder AND "cancer"). Three search engines: PubMed, Embase and Web of Science were queried up to November 1, 2020. Congress abstracts reporting results and not only trials' design were also referenced. The US National Library of Medicine was queried via clinicaltrials.gov to explore ongoing trials on the subject.

EVIDENCE SYNTHESIS

Pembrolizumab demonstrated a promising 40.6% (95% CI: 30.7-51.1) complete response within the KEYNOTE-057, with a median duration of response of 16.2 months. Preliminary data in the phase II SWOG S1605 trial with atezolizumab showed a 41.1% complete response at 3 months. Avelumab is being tested in the PREVERT phase II study exploring ICI with radiotherapy (60-66 Gy) of the whole bladder. CheckMate 9UT analyzes nivolumab monotherapy versus nivolumab + BMS-986205 (IDO-1 inhibitor) with or without BCG in patients with BCG-unresponsive, carcinoma in situ with or without papillary component. Finally, durvalumab is being studied in the BCG resistant space with radiotherapy in the ADAPT-BLADDER study. After proving its safety profile in the phase 1, the trial will randomize patients to durvalumab + BCG, durvalumab + radiation therapy (6Gy 3×) or BCG rechallenge.

CONCLUSIONS

Pembrolizumab has received FDA approval in the treatment of BCG-resistant NMIBC. All five other ICI molecules are currently being extensively tested within clinical trials. The results of the currently ongoing studies are awaited with impatience by the uro-oncologic community and will probably open a new era in the treatment of BCG-resistant NMIBC.

COVID-19 and the male susceptibility: the role of ACE2, TMPRSS2 and the androgen receptor

COVID-19 is the pandemic that hit the world starting December 2019. Recent studies and international statistics have shown an increased prevalence, morbidity as well as mortality of this disease in male patients compared to female patients. The aim of this brief communication is to describe the pathophysiology of this sex-discrepancy, based on the infectivity mechanism of the coronavirus including the Angiotensin-Converting Enzyme 2 (ACE2), the Type II transmembrane Serine Protease (TMPRSS2), and the androgen receptor. This could help understand the susceptibility of urological patients, especially those receiving androgen deprivation therapy for prostate cancer, and testosterone replacement therapy.

Clinical effect of computed guided pudendal nerve block for patients with premature ejaculation: a pilot study

Background: Premature ejaculation has a complex etiology, and its pathophysiology is still unclear, with penile hypersensitivity being the most accepted hypothesis. The aim was to investigate the efficacy and safety of a computed tomography-guided pudendal nerve block at the level of the sacrospinous ligament and the Alcock's canal in patients with premature ejaculation refractory to conventional pharmacological treatment.Methods: This is a prospective pilot study involving five patients suffering from premature ejaculation refractory to standard treatment and clinical features of pudendal nerve entrapment. A CT-guided infiltration of ropivacaine and methylprednisone was done at the levels of sacrospinous ligament and Alcock's canal. Intra-vaginal ejaculatory latency time (IELT) was recorded several times for each patient before and after infiltration. International Index of Erectile Function (IIEF-5), Premature Ejaculation Diagnostic Tool (PEDT) and Sexual Quality of Life-Male version (SQoL-M) questionnaire were also evaluated before and after infiltration.Results: Overall IELT differed significantly before and after treatment (21.94 vs 215.42 s; p = 0.039). IIEF-5, PEDT and SQoL-M also differed significantly before and after treatment. No complications for the CT-guided infiltration were recorded.Conclusion: CT-guided pudendal nerve block at the sacrospinous ligament and the Alcock's canal was effective in improving premature ejaculation. Therefore, pudendal nerve entrapment may be a curable cause of sensory premature ejaculation.

Laparoscopic treatment of pudendal nerve and artery entrapment improves erectile dysfunction in healthy young males

Erectile dysfunction (ED) is increasingly becoming more common in young healthy males and is attributed mainly to psychogenic causes in these patients. Recent studies have reported that ED could be secondary to pudendal nerve or artery entrapment. This perspective assessed the efficacy of laparoscopic pudendal nerve and artery decompression in young patients suffering from refractory ED, associated to a pudendal nerve entrapment syndrome. After excluding patients with psychological ED and venous leakage, five young male patients with a history of both ED and pudendal nerve entrapment syndrome diagnosed based on the Nantes criteria were recruited. Pudendal nerve and artery release was performed using a laparoscopic transperitoneal approach. International Index for Erectile Function (IIEF-5) and erectile hardness score (EHS) improved significantly in all patients, 3 months after surgery. Pudendal nerve and artery entrapment could be therefore a reversible cause of ED in young healthy males, and its treatment by laparoscopic pudendal nerve and artery decompression seems to be safe and effective.

Management of chronic testicular pain due to thoracolumbar junction syndrome: A pilot study

INTRODUCTION

Thoracolumbar dysfunction (TLD) had been evoked as a possible etiology of chronic testicular pain. Our study investigated the efficacy of osteopathic diagnosis and treatment of TLD in men with chronic testicular pain.

METHODS

Patients suffering from testicular pain were examined for thoracolumbar dysfunction and enrolled in a prospective trial if they have both conditions. Following standardized examination, all patients were prescribed 1 to 3 osteopathic treatment sessions, usually at weekly interval. Treatment success was evaluated using the Visual Analog scale and durability was assessed by regular follow-up. Patient satisfaction was also assessed. Comparison of pain improvement was done using Wilcoxon matched-pairs signed-ranks test. Logistic regression was used to assess for risk factors of success. A P<0.001 was used for significance.

RESULT

Out of 62 patients enrolled, 41 patients (median age 32 years, IQR 24-37) were suffering from chronic testicular pain and TLD. 37 of the 41 participants completed the treatment and follow-up according to the plan. Patients underwent a median of 2 osteopathic treatment sessions (range 1-3). Overall, pain disappeared completely in 25 patients (67.5%) and improvement was noted in 7 patients (18.9%). After initial improvement, two patients experienced relapse at their last visit (5.4%). Five patients (13.5%) had no improvement of their symptoms after osteopathic treatment. Statistically, improvement was significant with a P<0.001 and on logistic regression, site of pain and duration of pain were the sole predictors of failure.

CONCLUSION

TLD is a pathology that should be considered in the differential diagnosis in patients with chronic testicular pain and osteopathic manipulation of the spine appears to be an effective treatment option.

The current state of immune checkpoint inhibitors in the first-line treatment of renal cancer

Until recently, tyrosine kinase inhibitors (TKI) were the only approved drugs for the first-line treatment of metastatic renal cell carcinoma (mRCC). Emerging trials of immune checkpoint inhibitors (ICI)-based regimens have shown survival benefits over the standard TKI. These studies challenge a paradigm shift in the management of mRCC concerning the identification of the subgroup of patients that would benefit from ICI in treatment-naive mRCC, the possibility of treatment discontinuation between TKI and ICI, and the sequencing of surgery and systemic treatment. This paper reviews the currently available data and discusses the paradigm shift concerning first-line treatments of mRCC.

The impact of neutrophil-to-lymphocyte, platelet-to-lymphocyte and haemoglobin-to-platelet ratio on localised renal cell carcinoma oncologic outcomes

INTRODUCTION

The neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR) are established markers of systemic inflammation. Moreover, anemia is a known adverse prognostic factor and reduced haemoglobin to platelet ratio (HPR) seems associate to poor outcomes in urothelial cancer. Aim of the current study was to explore the prognostic value of NLR, HPR and PLR in patients harboring localized RCC. Materials and Methods 184 patients undergoing partial and radical nephrectomy for renal mass in a single hospital were retrospectively analyzed. Uni- and multivariate logistic regressions were performed to assess associations between various risk factors, including NLR, PLR and HPR and locally advanced disease (≤pT2 vs.≥pT3) and tumor grade. Kaplan Meier curves and Cox regressions were constructed to assess the association of NLR, PLR and HPR to recurrence free survival (RFS), cancer specific survival (CSS) and overall survival (OS). To determine thresholds for variables, we considered the 75^th percentile of our distribution of values, which was computed at 3.45 for NLR, 189 for PLR and 0.48 for HPR. A two-sided P<0.05 defined statistical significance.

RESULTS

Patients with an elevated NLR (>3.45) were more likely to present with≥pT3 stage (p=0.046). RFS was significantly different according to NLR value, with patients having an NLR>3.45 experiencing significantly worst RFS (P=0.019); similarly, an increased PLR was significantly associated to a reduced RFS (P=0.012). Restricting the Cox regression to patients with locally advanced disease (≥pT3), NLR was even more associated to recurrence (HR 3.22; 95%CI: 1.06-9.81, P=0.039). Patients exhibiting an NLR>3.45 (p=0.03) or a PLR>189 (P=0.005) did have a significantly worse CSS, while a HPR<0.48 did not predict CSS (P=0.12) on Kaplan Meier curves. Finally, an increased NLR (P=0.047), increased PLR (P=0.0006) and decreased HPR (P=0.05) were all associated to a poor overall survival on univariate analysis. On multivariate analysis, only HPR remained significantly predictive of OS (HR 0.077; 95%CI: 0.02-0.37, P=0.001).

CONCLUSIONS

In this single-center study analyzing non-metastatic RCC, an increased NLR was significantly associated to a reduced RFS, CSS and OS on univariate analyses and to RFS on multivariate analysis. Larger prospective studies are needed to validate our findings.

LEVEL OF EVIDENCE

4.

Validated Prospective Assessment of Quality of Life After Robot-Assisted Laparoscopic Prostatectomy: Beyond Continence and Erections

Continence and erectile function represent major concerns after robot-assisted laparoscopic prostatectomy (RALP), although the analysis of only these results may underestimate the impact of surgery on quality of life (QoL). The aim of the study is to prospectively analyze QoL after RALP according to the validated European Organization for Research and Treatment of Cancer Quality of Life Questionnaire prostate cancer-specific module (EORTC-QLQ-PR25) and C30 and explore risk factors for the deterioration of QoL after surgery. A total of 584 patients undergoing RALP were prospectively enrolled. QoL was assessed with the validated EORTC-QLQ-PR25 and C30. Differences across QoL items were assessed via Wilcoxon rank-sum test and associations between risk factors and QoL scores were tested via univariate and multivariate linear regression analyses. All items of the PR25 questionnaire showed a significant deterioration at 1 month after RALP and began to normalize 3 months after surgery. At 24 months follow-up, urinary, bowel, and sexual activity scores were not significantly different from preoperative scores, while incontinence aid, treatment-related symptoms, and sexual functioning remained significantly worse. Preoperative sexual activity was more important in determining 3-month sexual outcomes than preoperative 5-item version of the International Index of Erectile Function (IIEF-5) or nerve-sparing approach. An overall return to preoperative QoL was registered at 3 months after RALP in global and physical QoL, and most important, global, physical, social, and role-functioning QoL scores were improved at 12 and 24 months compared to preoperative scores. In this prospective study, detailed data on QoL are reported via the EORTC-PR25 and C30 questionnaires. While urinary, bowel, and sexual activity scores return to baseline values 24 months after surgery, incontinence aid, treatment-related symptoms, and sexual functioning may remain significantly deteriorated. Larger studies are needed to validate these findings.

Current Imaging Techniques for Lymph Node Staging in Prostate Cancer: A Review

Introduction: Lymph node metastases (LNM) represent a proven prognostic factor for biochemical recurrence (BCR)-free survival, metastatic free survival and overall survival in prostate cancer (PCa). Although pelvic node dissection remains the gold standard for the detection of LNM, novel imaging techniques are entering clinical practice, in the effort to improve LNM detection and spare unnecessary surgeries. Aim of the current review is to describe such imaging techniques and explore their advantages and limitations.

Evidence Acquisition: The National Library of Medicine Database was searched for relevant articles published between January 2013 and August 2018. A wide search was performed including the combination of following words: “Prostate” and “Cancer” and “staging” and “Lymph Node” and “imaging” and (“MRI” or “PET”). The initial list of selected papers was enriched by individual suggestions of the authors of the present review.

Evidence Synthesis: DWI-MRI in detection of lymph node invasion has a sensitivity and specificity of 41 and 94%, respectively. For SPIO MRI using ferumoxtran-10, the sensitivity for detection of LNM with short axis diameter of 5–10 mm is reported at 96.4%, compared to 28.5% with MRI alone. PSMA PET/CT is growing exponentially, both in the initial detection of LNM and for BCR evaluation. Fluciclovine PET could improve detection of subcentimetric pathologic lymph nodes. Sentinel lymph node techniques remain experimental and not validated in the field of PCa.

Conclusions: Molecular imaging, particularly PSMA ligand PET imaging, present interesting diagnostic accuracy in LN diagnosis even in subcentimetric LN. DWI-MRI yields good results in LN involvement evaluation and the use of contrast agent such SPIO may improve the detection rate. The SLN technique is limited to experimental protocols and for intermediate or high-risk PCa. Prospective trials are awaited to evaluate the true clinical impact of these imaging techniques on PCa oncologic outcomes.

Focal Treatment for Unilateral Prostate Cancer Using High-Intensity Focal Ultrasound: A Comprehensive Study of Pooled Data

BACKGROUND

Focal therapy for prostate cancer (PCa) remains experimental. Aim of the current study is to review available evidence and perform a pooled analysis exploring oncologic and functional results of high intensity focus ultrasound (HIFU) focal therapy for the treatment of unilateral PCa.

METHODS

The National Library of Medicine Database was searched for relevant articles. A wide search was performed, including the combination of following words: "HIFU," "prostate," "cancer," and "focal." Overall, 167 articles were reviewed. Of these, seven articles were identified and eligible for the pooled analysis. Data on HIFU hemiablation or focal prostate ablation, oncologic and functional results were pooled from these seven studies that included 366 men with unilateral PCa.

RESULTS

In the 366 analyzed cases, mean age was 67 years (95% confidence interval 66-69), and mean preoperative prostate-specific antigen was 6.4 ng/cc (5.5-7.4). Three studies included PCa up to Gleason 7 (3 + 4), three studies did include also Gleason 7 (4 + 3), whereas one study had no limitation in terms of Gleason score. Regarding early complications, low-grade Clavien-Dindo I-II were reported in 26% (16-37), whereas high-grade Clavien-Dindo ≥III were found in 3.8% (0-8.6). Analyzing oncologic outcomes mean follow-up was 26 months (23-31): at one year after HIFU, negative biopsy rate for clinically significant PCa was 87% (79-96), whereas salvage treatment-free survival rate was 92% (85-98). Regarding functional outcomes, reported potency rates were 74% (64-84), and continence 96% (91-100), although definitions of potency and continence were not homogenous across studies.

CONCLUSIONS

This pooled analysis of the results of focal HIFU treatment of PCa shows promising oncologic and functional outcomes. Well-selected patients may be candidates for such a conservative partial treatment of the gland. Well-designed trials are awaited to compare HIFU focal treatment with current standard of care.

Association between phosphodiesterase type 5 inhibitors and prostate cancer: A systematic review

INTRODUCTION

We aim to assess the effect of phosphodiesterase type 5 inhibitors (PDE5I) on prostate cancer risk as well on biochemical recurrence after radical prostatectomy.

METHOD

We performed a research using the following keywords "Phosphodiesterase type 5 inhibitors" and "Prostate cancer". Only trials examining the effect of PDE5I on prostate cancer risk and recurrence after radical prostatectomy were included.

RESULTS

Seventeen preclinical trials and seven clinical trials were included. Preclinical studies demonstrate a pivotal role for PDE5I as a modulator of apoptosis preventing prostate carcinogenesis. The clinical benefit of PDE5I was not demonstrated. PDE5I use was not associated with decreased prostate cancer diagnosis in two retrospective cohort studies. Biochemical recurrence after radical prostatectomy was not lower (nor higher) in patients taking PDE5I in three retrospective case match studies.

CONCLUSION

Based on this review, a change in our practice regarding pharmacological reeducation after radical prostatectomy is not justified.

Prognostic utility of neutrophil-to-lymphocyte and platelets-to-lymphocyte ratio in predicting biochemical recurrence post robotic prostatectomy

Aim: Utility of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting biochemical recurrence (BCR) in patients with localized prostate cancer. Materials & methods: Retrospective analysis of patients operated by robot-assisted radical prostatectomy. Variables included were: NLR, PLR pre-operative prostate specific antigen, pathological Gleason score, surgical margins status, extracapsular extension, seminal vesical invasion, and lymph node status. Results: Out of 321 patients, no association between NLR or PLR and BCR was detected. Predictors of BCR were pathological Gleason score, extracapsular extension and positive surgical margins. On multivariate analysis, the Gleason Score, extracapsular extension and positive surgical margins remained the only predictors of BCR. Conclusion: Neither elevated NLR nor PLR predicted an increased risk of BCR.

A network meta-analysis of the PD(L)-1 inhibitors in the salvage treatment of urothelial bladder cancer

Aim: To determine which of the approved immune checkpoint inhibitors is the optimal treatment in metastatic urothelial bladder cancer. Methods & materials: Only the pivotal Phase III trials of second-line metastatic urothelial bladder cancer were included in this network meta-analysis. Results: This NMA included three pooled trials (NCT00315237, NCT02256436 and NCT02302807) of 1125 participants. Pembrolizumab was the only treatment with positive effect on overall survival compared with the best supportive care. The treatment discontinuation rates due to adverse events of the pembrolizumab and atezolizumab did not differ from that of the best supportive care. C onclusion: Our results confirmed the superiority of pembrolizumab in the management of metastatic urothelial bladder cancer.