Homayoun Zargar

Partial Nephrectomy Versus Radical Nephrectomy for Clinical T1b and T2 Renal Tumors: A Systematic Review and Meta-analysis of Comparative Studies

BACKGROUNDnPartial nephrectomy (PN) is the reference standard of management for a cT1a renal mass. However, its role in the management of larger tumors (cT1b and cT2) is still under scrutiny.nnnOBJECTIVEnTo conduct a meta-analysis assessing functional, oncologic, and perioperative outcomes of PN and radical nephrectomy (RN) in the specific case of larger renal tumors (≥cT1b). The primary endpoint was an overall analysis of cT1b and cT2 masses. The secondary endpoint was a sensitivity analysis for cT2 only.nnnEVIDENCE ACQUISITIONnA systematic literature review was performed up to December 2015 using multiple search engines to identify eligible comparative studies. A formal meta-analysis was performed for studies comparing PN to RN for both cT1b and cT2 tumors. In addition, a sensitivity analysis including the subgroup of studies comparing PN to RN for cT2 only was conducted. Pooled estimates were calculated using a fixed-effects model if no significant heterogeneity was identified; alternatively, a random-effects model was used when significant heterogeneity was detected. For continuous outcomes, the weighted mean difference (WMD) was used as summary measure. For binary variables, the odds ratio (OR) or risk ratio (RR) was calculated with 95% confidence interval (CI). Statistical analyses were performed using Review Manager 5 (Cochrane Collaboration, Oxford, UK).nnnEVIDENCE SYNTHESISnOverall, 21 case-control studies including 11204 patients (RN 8620; PN 2584) were deemed eligible and included in the analysis. Patients undergoing PN were younger (WMD -2.3 yr; p<0.001) and had smaller masses (WMD -0.65cm; p<0.001). Lower estimated blood loss was found for RN (WMD 102.6ml; p<0.001). There was a higher likelihood of postoperative complications for PN (RR 1.74, 95% CI 1.34-2.2; p<0.001). Pathology revealed a higher rate of malignant histology for the RN group (RR 0.97; p=0.02). PN was associated with better postoperative renal function, as shown by higher postoperative estimated glomerular filtration rate (eGFR; WMD 12.4ml/min; p<0.001), lower likelihood of postoperative onset of chronic kidney disease (RR 0.36; p<0.001), and lower decline in eGFR (WMD -8.6ml/min; p<0.001). The PN group had a lower likelihood of tumor recurrence (OR 0.6; p<0.001), cancer-specific mortality (OR 0.58; p=0.001), and all-cause mortality (OR 0.67; p=0.005). Four studies compared PN (n=212) to RN (n=1792) in the specific case of T2 tumors (>7cm). In this subset of patients, the estimated blood loss was higher for PN (WMD 107.6ml; p<0.001), as was the likelihood of complications (RR 2.0; p<0.001). Both the recurrence rate (RR 0.61; p=0.004) and cancer-specific mortality (RR 0.65; p=0.03) were lower for PN.nnnCONCLUSIONSnPN is a viable treatment option for larger renal tumors, as it offers acceptable surgical morbidity, equivalent cancer control, and better preservation of renal function, with potential for better long-term survival. For T2 tumors, PN use should be more selective, and specific patient and tumor factors should be considered. Further investigation, ideally in a prospective randomized fashion, is warranted to better define the role of PN in this challenging clinical scenario.nnnPATIENT SUMMARYnWe performed a cumulative analysis of the literature to determine the best treatment option in cases of localized kidney tumor of higher clinical stage (T1b and T2, as based on preoperative imaging). Our findings suggest that removing only the tumor and saving the kidney might be an effective treatment modality in terms of cancer control, with the advantage of preserving the kidney function. However, a higher risk of perioperative complications should be taken into account when facing larger tumors (clinical stage T2) with kidney-sparing surgery.

Robot-assisted Versus Standard Laparoscopy for Simple Prostatectomy: Multicenter Comparative Outcomes

OBJECTIVEnTo report a comparative analysis of laparoscopic simple prostatectomy (LSP) vs robot-assisted simple prostatectomy (RASP).nnnPATIENTS AND METHODSnConsecutive cases of LSP and RASP done between 2003 and 2014 at 3 participating institutions were included in this retrospective analysis. The effectiveness of the two procedures was determined by performing a paired analysis of main functional and surgical outcomes. A multivariate analysis was also conducted to determine the factors predictive of trifecta outcome (combination of International Prostate Symptom Score <8, Qmaxu2009>u200915u2009mL/second, and no perioperative complications).nnnRESULTSnA total of 319 patients underwent minimally invasive simple prostatectomy at the participating institutions over the study period. Total prostate volume was larger in the RASP group (median 118.5u2009mL vs 109u2009mL, Pu2009=u2009.02). Median estimated blood loss tended to be higher for LSP (300u2009mL vs 350u2009mL, Pu2009=u2009.07). There was no difference in terms of catheterization time (Pu2009=u2009.3) and hospital stay (Pu2009=u2009.42). A higher rate of overall postoperative complications was recorded in the RASP group (17.7% vs 5.3%), but rate of major complications was not significantly different between the two techniques (2.3 vs 2.1, Pu2009=u2009.6). Subjective and objective parameters significantly improved for both LSP and RASP. On multivariable analysis, only two factors were associated with likelihood of obtaining a favorable (trifecta) outcome: age (odds ratio: 0.94; Pu2009=u2009.03) and body mass index (odds ratio: 0.84; Pu2009=u2009.03).nnnCONCLUSIONnBoth LSP and RASP can be regarded as safe and effective minimally invasive surgical treatments for bladder outlet obstruction due to large prostate glands.

The impact of the United States Preventive Services Task Force (USPTSTF) recommendations against prostate-specific antigen (PSA) testing on PSA testing in Australia.

To assess the impact of the United States Preventive Services Task Force (USPTSTF) recommendations on prostate‐specific antigen (PSA) testing, prostate biopsy, and prostatectomy in Australian men based on the available Medicare data.

Urinary Continence after Robot-Assisted Laparoscopic Radical Prostatectomy: The Impact of Intravesical Prostatic Protrusion

Purpose To assess the impact of intravesical prostatic protrusion (IPP) on the outcomes of robot-assisted laparoscopic prostatectomy (RALP). Materials and Methods The medical records of 1094 men who underwent RALP from January 2007 to March 2013 were analyzed using our database to identify 641 additional men without IPP (non-IPP group). We excluded 259 patients who presented insufficient data and 14 patients who did not have an MRI image. We compared the following parameters: preoperative transrectal ultrasound, prostate specific antigen (PSA), clinicopathologic characteristics, intraoperative characteristics, postoperative oncologic characteristics, minor and major postoperative complications, and continence until postoperative 1 year. IPP grade was stratified by grade into three groups: Grade 1 (IPP≤5 mm), Grade 2 (5 mm10 mm). Results Of the 821 patients who underwent RALP, 557 (67.8%) experienced continence at postoperative 3 months, 681 (82.9%) at 6 months, and 757 (92.2%) at 12 months. According to IPP grade, there were significant differences in recovering full continence at postoperative 3 months, 6 months, and 12 months (p<0.001). On multivariate analysis, IPP was the most powerful predictor of postoperative continence in patients who underwent RALP (p<0.001). Using a generalized estimating equation model, IPP also was shown to be the most powerful independent variable for postoperative continence in patients who underwent RALP (p<0.001). Conclusion Patients with low-grade IPP have significantly higher chances of recovering full continence. Therefore, the known IPP grade will be helpful during consultations with patients before RALP.

Validation of the novel International Society of Urological Pathology 2014 five-tier Gleason grade grouping: biochemical recurrence rates for 3+5 disease may be overestimated.

1 Russo GI, Castelli T, Privitera S et al. Increase of Framingham cardiovascular disease risk score is associated with severity of lower urinary tract symptoms. BJU Int 2015; 116: 791–6 2 Jackson G, Kirby MG, Rosen R. Editorial: Lower urinary tract symptoms (LUTS) an independent risk factor for cardiovascular disease (CVD). BJU Int 2015; 116: 679–80 3 Prasad K, Jaeschke R, Wyer P, Keitz S. Guyatt G; Evidence-Based Medicine Teaching Tips Working Group. Tips for teachers of evidencebased medicine: understanding odds ratios and their relationship to risk ratios. J Gen Intern Med 2008; 23: 635–40 4 Bouwman II, Voskamp MJ, Kollen BJ, Nijman RJ, van der Heide WK, Blanker MH. Do lower urinary tract symptoms predict cardiovascular diseases in older men? A systematic review and meta-analysis. World J Urol 2015; 33: 1911–20 Correspondence: Marco H. Blanker, Department of General Practice, University Medical Centre Groningen, University of Groningen, Groningen 9713, The Netherlands.

Salvage robotic prostatectomy for radio recurrent prostate cancer: technical challenges and outcome analysis.

INTRODUCTIONnThe published data on salvage robot assisted radical prostatectomy (sRARP) is limited. Our aim was to perform a systematic review of the literature on sRARP after radiation failure in patients with prostate cancer and systematically analyse the available evidence for operative and oncological outcomes.nnnEVIDENCE ACQUISITIONnA systematic review of the literature using Pubmed, Scopus, Cochrane library and ScienceDirect databases was performed in June 2016 using medical subject headings and free-text protocol. The search was conducted by applying the following search terms: salvage therapy, salvage, prostatectomy and robotics.nnnEVIDENCE SYNTHESISnWe report on ten case series including 197 men undergoing sRARP after varying modalities of radiotherapy. Over two thirds are recurrence free at the time of follow-up but with continence rates of only 60% and potency rates of only 26%. Complications requiring intervention are few at 16% though higher than primary RARP.nnnCONCLUSIONSnsRARP is increasingly acceptable as a treatment modality to be offered to men who fail initial radiation treatment but should be accompanied by appropriate counselling regarding the potential functional outcomes and complications. Series with longer follow up will be helpful to assess the durability of oncological outcomes while improvements in patient selection and adaption of meticulous surgical technique around the apex could improve continence rates. The concept of concomitant extended PLND remains an issue for debate and the experience with this approach at the time of sRARP and its benefit need further scrutiny.

Surgical Advances in Inguinal Lymph Node Dissection: Optimizing Treatment Outcomes.

Lymphadenectomy (LND) for locally advanced penile cancer is often necessary in patients with suspected disease within the inguinal or pelvic lymph nodes because the results of systemic therapy are somewhat marginal. It has utility in staging, disease prognosis, and treatment in certain men because early dissection of involved lymph nodes improves survival. Despite its mainstay in the management of this disease, inguinal and pelvic lymph node dissection can be associated with significant postoperative complications and patient morbidity. Recent refinements in surgical technique, however, and appropriate patient selection can minimize these risks and lead to better short-term and long-term outcomes.

Re: Medical Expulsive Therapy in Adults with Ureteric Colic: A Multicentre, Randomised, Placebo-controlled Trial

specialists, whereby general practitioners, cardiologists, and endocrinologists are regularly informed of any need to adapt comorbidity treatments. We must keep in mind that shortterm ADT is recommended for intermediate-risk PCa and long-term ADT for high-risk PCa in the case of external irradiation [1,2]; adjuvant ADT for patients with positive pelvic lymph nodes after surgery [3]; and intermittent instead of continuous ADT for metastatic PCa with a good initial response to ADT [4]. Clinicians should advise patients during follow-up to maintain the hope that new medical options could be available should relapse occur.

Re: Robot-assisted Laparoscopic Prostatectomy Versus Open Radical Retropubic Prostatectomy: Early Outcomes from a Randomised Controlled Phase 3 Study

patients. The longer-term outcomes of the study are yet to be reported, and oncologic, functional, and complication outcomes — in particular bladder neck stricture rates — are also worthy of close scrutiny. The issue is not if RARP is advantageous; the question remainswhether it is cost-effective. Thismay not be relevant in some health systems; for example, >85% of prostatectomies in the USA are already performed robotically [5]. Arguably, some of the benefits mentioned here may potentially balance thecostofRARPagainstORP.However, the initial cost of obtaining the robot and the ongoing cost of consumables are always against robot-assisted surgery.With the potential arrival of other competing systems, costs associated with robotic surgery may become less of an issue in the future. In conclusion, we agree with the authors that the surgeon is the key element affecting the outcomes of radical prostatectomy. However, on the basis of the secondary outcomes of this study, we would like to highlight that the robotic platform allows the surgeon to improve results by shortening the learning curve, minimising blood loss and perioperative adverse events, and reducing postoperative pain and the length of hospital stay.

Anatomy of Contemporary Partial Nephrectomy: A Dissection of the Available Evidence

In this issue of European Urology, Klatte et al [1] provide a comprehensive and balanced evaluation of current knowledge of the renal surgical anatomy and related surgical strategies during contemporary partial nephrectomy (PN). With the advent and widespread uptake of minimally invasive surgery, and in particular robotic surgery, we have fortunately witnessed a steady increase in the rate of PN for the management of small renal masses over the last decade [2]. As pointed out in this collaborative review, a complete understanding of underlying normal and aberrant renal anatomy, coupled with patientand tumor-specific anatomical characteristics, defined by aptly performed crosssectional imaging, represents the foundation for proper preoperative surgical planning for state-of-the-art PN in 2015. Currently available standardized nephrometry systems allow clinicians to summarize imaging data into a simple and reproducible complexity score forecasting surgical difficulties [3]. It could be speculated that they might represent a purely academic exercise. In this respect, it remains to be determined to what extent standardized nephrometry systems are applied in current daily clinical practice. However, growing evidence suggests that they allow, at least to some extent, the prediction of surgical, pathologic, oncologic, and functional outcomes, as Klatte and co-authors appropriately remind us [1]. However, it is certainly fair to state that despite their elaborate designs, current nephrometry scores do not always capture the entire clinical picture, and two tumors with similar nephrometry scores do not necessarily pose the same technical challenges. As an example, a 2-cm, left-sided, lower-pole exophytic renal neoplasm (RENAL score 4a) is potentially far simpler to resect than a similarsized, right-sided, upper-pole posterior renal neoplasm (RENAL score 4p). To clarify this further, suppose the former patient is a 35-yr-old female with a body mass index (BMI) of 20 kg/m and the latter is a 50-yr-old man with a large fatty liver and BMI of 50 kg/m. Despite relatively similar tumor complexity scores, the two procedures could not be more dissimilar in term of challenges faced by the surgeon. Assessment of the tumor surface area in contact with the unaffected renal parenchyma is a relatively novel concept and, despite the limitations of the initial study, may also have a role in preoperative planning [4]. The goals of a PN procedure are oncologic safety and functional preservation with minimal complications, and any strategy to improve these outcomes should be pursued. Application of minimally invasive surgical techniques to PN has certainly translated into a reduction in postoperative recovery time [5]. Complete tumor excision with maximal parenchymal preservation and negative surgical margins is a universally acknowledged concept in parenchymasparing oncologic surgery. As for open surgery in the past, experts have been debating about the two main strategies for robotic surgery: a formal PN procedure, in which a (possibly minimal) amount of peritumoral parenchyma is resected (and sacrificed), versus enucleation of the mass, whereby unaffected renal parenchyma is completely spared but with some inherent risks of non-radicality. With regard to functional outcomes, although we have witnessed a plethora of technical PNmodifications in recent years, some basic elements of PN have not changed for E U RO P E AN URO LOGY 6 8 ( 2 0 1 5 ) 9 9 3 – 9 9 5