Marta Rossanese

Critical analysis of phase II and III randomised control trials (RCTs) evaluating efficacy and tolerability of a β3‐adrenoceptor agonist (Mirabegron) for overactive bladder (OAB)

To critically analyse available phase II and III randomised control trials (RCTs) reporting clinical data about the efficacy and tolerability of Mirabegron (a β3‐adrenoceptor agonist) in the treatment of overactive bladder (OAB) syndrome. A review of the literature was performed in September 2013 using the MEDLINE database. A ‘free text’ protocol was used for the search strategy using ‘overactive bladder’ and ‘Mirabegron’ as keywords. Subsequently, the searches were pooled and limited to phase II and III RCTs. Two phase II and five phase III RCTs were selected and analysed. The available phase II studies showed the efficacy and tolerability of different doses of Mirabegron compared with placebo. Moreover, a dose‐ranging study showed that 50 mg once daily should be considered the most promising dose for clinical use. The 12‐week phase III studies confirmed the effectiveness of Mirabegron to significantly reduce the mean number of incontinence episodes/24 h and the mean number of micturitions/24 h compared with placebo. A post hoc analysis confirmed that favourable results with Mirabegron were reported both in patients with OAB who were antimuscarinic naïve and in those who had discontinued prior antimuscarinic therapy. Moreover, a phase III trial showed the safety and tolerability of 12‐month treatment of Mirabegron. Discontinuation due to adverse events was low both using the 50 and 100 mg dose of Mirabegron. Mirabegron is the first of a new class of drugs for the treatment of OAB able to influence non‐voiding activity and produce an increased storage capacity and inter‐void interval. Recently published phase II and III RCTs have shown that the β3‐adrenoceptor‐selective agonist, Mirabegron, is an effective and safe drug for the symptomatic treatment of OAB syndrome. Mirabegron represents a valid medical option both for patients with OAB who are antimuscarinic naïve, as well as in those where antimuscarinics are ineffective or not tolerated.

Outcomes and limitations of laparoscopic and robotic partial nephrectomy.

Purpose of review The objective of this review article is to summarize and critically analyze the studies published in the previous year and report perioperative, functional, and oncologic outcomes after laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN). Recent findings Recent case series studies evaluating LPN confirmed the good oncologic results of this approach at intermediate and long-term follow-ups. Recent studies investigating RAPN confirmed the promising perioperative outcomes reported in the initial case series. Many studies tested and demonstrated the feasibility of both procedures in the treatment of very complex cases represented by tumors larger than 4 cm, hilar/central tumors, endophytic tumors, or tumors located in solitary kidney. Comparative studies confirm advantages in favor of RAPN in comparison with LPN, mainly in terms of warm ischemia time and perioperative outcomes. A recent matched pair analysis showed equivalent perioperative and functional outcomes between RAPN and open partial nephrectomy (OPN). Summary LPN and above all RAPN represent valid alternatives to OPN in the conservative treatment of renal tumors. Both procedures can be proposed also for the treatment of complex cases. Further, well conducted, comparative studies between RAPN and OPN are needed to test the ability of RAPN as an alternative to OPN in the treatment of more complex cases.

Will Multi-Parametric Magnetic Resonance Imaging be the Future Tool to Detect Clinically Significant Prostate Cancer?

Multi-parametric magnetic resonance imaging is an emerging imaging modality for diagnosis, staging, characterization, and treatment planning of prostate cancer. In this report, we reviewed the literature for studies assessing the accuracy of multi-parametric magnetic resonance imaging in detecting clinically significant prostate cancer, and we critically examined the future role of this imaging tool in various clinical diagnostic settings. There is accumulating evidence suggesting a high accuracy of multi-parametric magnetic resonance imaging in ruling out clinically significant disease. Although definition for clinically significant disease widely varies, the negative predictive value is very high at up to 98%. Multi-parametric magnetic resonance imaging should, thus, be further evaluated for application in different clinical scenarios in which it is desirable to reduce the proportion of unnecessary prostate biopsies and to limit the detection of indolent disease, such as opportunistic screening, persistent prostate cancer suspicion in men with previous negative prostate biopsies, and eligibility for active surveillance. Continued improvement in standardization of technical parameters, functional sequences, and image reporting systems is a pre-requisite for a rapid and successful dissemination of this imaging modality.

Antegrade scrotal sclerotherapy of internal spermatic veins for varicocele treatment: technique, complications, and results

 Varicocele repair is mainly indicated in young adult patients with clinical palpable varicocele and abnormal semen parameters. Varicocele treatment is associated with a significant improvement in sperm concentration, motility, morphology, and pregnancy rate. Antegrade scrotal sclerotherapy (ASS) represented one of the main alternatives to the traditional inguinal or suprainguinal surgical ligation. This article reviews the use of ASS for varicocele treatment. We provide a brief overview of the history of the procedure and present our methods used in ASS. In addition, we review complication and success of ASS, including our own retrospective data of treating 674 patients over the last 17 years. Herein, we analyzed step by step the ASS technique and described our results with an original modified technique with a long follow-up. Between December 1997 and December 2014, we performed 674 ASS. Mean operative time was 14 min (range 9 to 50 min). No significant intraoperative complications were reported. Within 90 days from the procedure, postoperative complications were recorded in overall 49 (7.2%) patients. No major complications were recorded. A persistent/recurrent varicocele was detected in 40 (5.9%) cases. In 32/40 (80%) cases, patients showed preoperative grade III varicoceles. In patients with a low sperm number before surgery, sperm count improved from 13 × 10 6 to 21 × 10 6 ml−1 (P < 0.001). The median value of the percentage of progressive motile forms at 1 h improved from 25% to 45% (P < 0.001). Percentage of normal forms increased from 17% before surgery to 35% 1 year after the procedure (P < 0.001). In the subgroup of the 168 infertile patients, 52 (31%) fathered offspring at a 12-month-minimum follow-up. Therefore, ASS is an effective minimal invasive treatment for varicocele with low recurrence/persistence rate.

Anatomical study of renal arterial vasculature and its potential impact on partial nephrectomy

To validate Graves’ classification of the intrarenal arteries and to verify the absence of collateral arterial blood supply between different renal segments, in order to maximize peri‐operative and functional outcomes of partial nephrectomy.

Dismiss Systematic Transrectal Ultrasound-guided and Embrace Targeted Magnetic Resonance Imaging-informed Prostate Biopsy: Is the Paradigm Ready to Shift?

Prostate biopsy (PB) is, and is likely to remain, one of the most commonly performed urologic procedures worldwide. Until recently, it has been performed using blinded, systematic, template-based sampling under transrectal ultrasound (TRUS) guidance, with inherent drawbacks of undersampling of significant and oversampling of insignificant prostate cancer (PCa). The introduction of prostate magnetic resonance imaging (MRI) and the increasing use of functional sequences (so-called multiparametric MRI [mpMRI]) and refinements in equipment, protocols, and standardisation of data reporting have revolutionised this practice, and a rationale for image-based targeted sampling has rapidly been built. Data available so far have demonstrated the advantage of mpMRI-targeted PB in detecting a higher proportion of clinically significant cancers using fewer cores compared to conventional sampling [1,2]. Since a substantial change in how PB is performed will have enormous consequences for routine clinical practice anddiagnostic/treatmentpathwaysofone themost common malignancies (ie, PCa), it is legitimate to pose the question as to whether the urologic community on a global scale is truly ready to absorb this change. This approach has rapidly attracted interest among practicing urologists, and is now considered a possible new gold standard, especially in the repeat PB setting. However, despite accumulating evidence favouring mpMRI-targeted PB, there are still some open questions and concerns.

Multiparametric Magnetic Resonance Imaging Targeted Biopsy for Early Detection of Prostate Cancer: All That Glitters Is Not Gold!

One of the major unmet needs in early detection of prostate cancer (PCa) is the lack of a biopsy test capable of identifying clinically significant disease with high accuracy and efficiency. Current practice supported by most representative guidelines, that is, systematic, template-based sampling under transrectal ultrasound (TRUS) guidance, has the inherent drawbacks of missing PCa and of undersampling significant disease and oversampling insignificant disease in a substantial proportion of cases [1]. The recent advent of multiparametric magnetic resonance imaging (MP-MRI) with high field strength has revolutionised this practice, and rapidly built a rationale for targeted sampling of suspicious regions of interest (ROIs) identified on imaging. Available data, mainly from highvolume tertiary centres of excellence, have shown that targeted MRI-informed biopsy detects a higher proportion of clinically significant cancers with fewer cores compared to systematic sampling [1]. Enthusiasm has grown to the point that several researchers have elected targeted MRIinformed biopsy as the new gold standard. However, as experience with MP-MRI and targeted MRI-informed biopsy matures, pitfalls and limitations emerge. In this issue of European Urology, Schouten and colleagues report a critical analysis of potential reasons for failure of targeted in-bore MRI-guided biopsy in detecting clinically significant cancers by studying the spatial distribution of ROIs and cancers [2]. This is a secondary analysis of a previously published prospective trial of diagnostic accuracy comparing targeted MRI-guided biopsy and systematic TRUS-guided biopsy in biopsy-naı̈ve men [3]. ROIs were originally scored by three independent

A prospective accuracy study of Prostate Imaging Reporting and Data System version 2 on multiparametric magnetic resonance imaging in detecting clinically significant prostate cancer with whole-mount pathology

OBJECTIVE To assess the accuracy of Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) in detecting clinically significant prostate cancer (csPCa) on multiparametric magnetic resonance imaging (mpMRI) using whole-mount sections after radical prostatectomy (RP) as reference standard. METHODS Forty-eight patients undergoing mpMRI before RP were prospectively enrolled. Two experienced radiologists independently scored and mapped imaging findings according to PI-RADS v2. One experienced uropathologist mapped cancers detected on whole-mount sections using the PI-RADS v2 sector scheme. Per-lesion and per-patient analyses were run. Primary outcomes were sensitivity and false discovery rate (FDR) in detecting csPCa using PI-RADS v2 score ≥3 and ≥4 as thresholds. Secondary outcome was inter-reader agreement. RESULTS On the per-lesion analysis, sensitivity and FDR at the PI-RADS v2 threshold score ≥3 were 0.75 and 0.17 for Reader 1, and 0.67 and 0.13 for Reader 2, respectively. At the PI-RADS v2 threshold score ≥4, sensitivity was slightly lower, and FDR nearly halved for both readers. On the per-patient analysis, sensitivity for csPCa at the PI-RADS v2 threshold score ≥3 was 0.85 for Reader 1, and 0.78 for Reader 2. At the PI-RADS v2 threshold score ≥4, sensitivity was slightly lower for both readers. Inter-reader agreement was substantial (k 0.72 and 0.65 for PI-RADS v2 threshold score ≥3 and ≥4, respectively). CONCLUSION In our prospective study with pathology after RP as standard of reference, PI-RADS v2 showed good sensitivity in detecting csPCa on mpMRI with substantial agreement between 2 experienced readers. Threshold score ≥4 had lower FDR.

Surgical Treatment of Eosinophilic Cystitis in Adults: A Report of Two Cases and a Literature Review

Eosinophilic cystitis is a rare disease that presents with either urinary frequency, hematuria, suprapubic pain or urinary retention. Although benign, this entity may progress to diffuse bladder involvement with the need for surgical treatment. We report on 2 cases of advanced disease that required cystectomy with very complex lower urinary tract reconstruction, and review the literature of surgically treated cases.

Open radical cystectomy: lessons from the British Association of Urological Surgeons (BAUS) registry

In their recent paper published on the BJU International , Jefferies et al . performed a very interesting analysis of the British Association of Urological Surgeons (BAUS) radical cystectomy (RC) registry capturing approximately 83% of all open RC (ORC) cases performed in England in the period between 2014 and 2015 (1).