V. Ficarra

Enhanced Recovery After Surgery Pathway in Patients Undergoing Open Radical Cystectomy Is Safe and Accelerates Bowel Function Recovery

OBJECTIVEnTo assess whether an Enhanced Recovery After Surgery pathway was associated with a faster bowel function recovery and no increase in morbidity compared with standard perioperative care in a contemporary series of patients undergoing radical cystectomy.nnnMETHODSnA prospective single-center single-surgeon cohort of 114 consecutive patients treated with open radical cystectomy between July 2013 and June 2016 was analyzed. A study group of 74 patients with Enhanced Recovery After Surgery pathway was compared with a control group of 40 patients with standard perioperative care. Primary outcome was recovery of bowel function, measured by resumption of bowel sounds, passage of flatus, and passage of stool. Secondary outcome was rate of overall and major 90-day postoperative complications.nnnRESULTSnBowel function recovery was significantly faster in the study group. Resumption of bowel sounds on postoperative day 1 was recorded in 43 (58%) vs 4 (10%) patients, passage of flatus within postoperative day 2 in 41 (55%) vs 11 (28%) patients, and passage of stool within postoperative day 3 in 37 (50%) vs no patients in the study vs control group, respectively (Pu2009<u2009.01 for all). Overall and major 90-day complications were observed in 35 (47.3%) and 13 (17.6%) patients in the study group, and in 25 (62.5%) and 9 (22.5%) patients in the control group (Pu2009=u2009.14 and 0.38, respectively).nnnCONCLUSIONnIn patients undergoing open radical cystectomy, an Enhanced Recovery After Surgery pathway allowed a significantly faster bowel function recovery with no increase in 90-day postoperative complications compared with standard perioperative care.

Efficacy and safety of a hexanic extract of Serenoa repens (Permixon®) for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH): systematic review and meta‐analysis of randomised controlled trials and observational studies

To comprehensively evaluate the efficacy and safety of the hexanic extract of Serenoa repens (HESr, Permixon®; Pierre Fabre Médicament, Castres, France), at a dose of 320 mg daily, as monotherapy for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH).

Will Image-guided Metastasis-directed Therapy Change the Treatment Paradigm of Oligorecurrent Prostate Cancer?

Although recent studies support the role of image-guided metastasis-directed therapies in the oligo-recurrent setting, several issues including the risk of possible underestimation of the true tumor burden at imaging, patient selection and the lack of studies comparing different approaches limit their implementation in the clinical practice. As such, metastasis-directed therapies should still be considered as investigational treatment options in oligo-recurrent prostate cancer patients.

Comparison between the diagnostic accuracies of 18F-fluorodeoxyglucose positron emission tomography/computed tomography and conventional imaging in recurrent urothelial carcinomas: a retrospective, multicenter study

PurposeTo determine the performance accuracy of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) after primary tumor treatment for both bladder cancer (BC) and upper tract urothelial cancer (UTUC). To compare the accuracy of FDG PET/CT with that of contrast-enhanced-ceCT and magnetic resonance imaging (MRI).MethodsData of patients with recurrent urothelial carcinomas (UC) after primary treatment were collected in a retrospective, international multicenter study. Inclusion criteria were (1) patients with a known history of UC in the BC and/or in the UTUC; (2) PET/CT images after curative intent treatment of the primary tumor; (3) conventional imaging modalities (abdominal ceCT or MRI, or total body ceCT, and chest X-ray: called C.I.) performed no more than 3xa0months from PET/CT; (4) available standard of reference (e.g., histological data or follow-up imaging modalities) for the validation of PET/CT findings. Exclusion criteria were other abdominal tumors, chemotherapy administration prior to and/or concomitant to imaging, and non-urothelial histologic variants. Sensitivities, specificities, positive, and negative predictive values were evaluated for all patients and separately for bladder and UTUC.ResultsOverall, 287 patients were enrolled. Two-hundred thirteen patients underwent cystectomy (74.2%), 35 nephroureterectomy (12.2%), 31 both cystectomyxa0+xa0nephroureterectomy (10.8%), 5 both cystectomyxa0+xa0conservative treatment for UTUC (1.4%), and 3 (1%) other types of nephron-sparing treatments for UTUC. Neoadjuvant and adjuvant treatments were performed in 36 (12.5%) and 111 (38.7%) patients, respectively. Sensitivity and specificity (95% confidence intervals) of PET/CT for the detection of recurrent UC were 94% (91% to 96%) and 79% (68% to 88%), respectively. However, sensitivity was higher for BC than UTUC (95% vs. 85%) while specificity was lower in BC (78% vs. 85% for BC and UTUC, respectively). PET/CT and C.I. findings were available in 198 patients. The results were positively concordant in 137 patients, negatively concordant in 23 patients, and discordant in 38 patients (20 negative at C.I. vs. positive at PET/CT and 18 positives at ceCT/MRI vs. negative at PET/CT) (K Cohenxa0=xa00.426; pxa0<xa00.001). Sensitivities, specificities, and accuracies (95% confidence intervals) of PET/CT vs. C.I. for the detection of recurrent BC and UTUC were 94% (90% to 97%) vs. 86% (81% to 92%), 79% (67% to 92%) vs. 59% (44% to 74%), and 91% (87% to 95%) vs. 81% (75% to 86%), respectively.ConclusionsFDG PET/CT has a high diagnostic accuracy for the identification of recurrent UC, particularly in patients with BC. Moreover, its accuracy outperforms C.I. for both BC and UTUC.

Entero-neovesical fistula after radical cystectomy and orthotopic ileal neobladder: A report of two cases requiring surgical management:

Introduction: Entero-neovesical fistula is a rare complication after radical cystectomy and orthotopic ileal bladder substitution. Typical presenting symptoms are faecaluria, pneumaturia, recurrent urinary tract infections and abdominal pain. Risk factors include history of pelvic radiation, chemotherapy and abdominal surgery, as well as diverticular colonic disease, inflammatory bowel disease and traumatic pelvic injury. The paucity of cases reported in the literature makes the management of this threatening complication very challenging. Conservative treatment has only anecdotally been reported. Case description: We describe two cases of entero-neovesical fistula with different presentation, which both required an immediate surgical treatment. The former patient was admitted to the emergency room with faecaluria, complete urinary incontinence and fever 2u2009years after radical cystectomy, and a fistula between the Y-shaped neobladder and the bowel anastomosis was detected. He had previously undergone chemotherapy because of tumour progression. Undiversion into an ileal conduit was required. The latter patient presented with faecaluria 20u2009days after an uneventful radical cystectomy, and a fistula between the Vescica Ileale Padovana neobladder and the sigmoid was documented. Treatment included resection of the sigmoid with several small diverticula, temporary ileostomy and closure of the neobladder fistula. Conclusion: Conservative treatment of entero-neovesical fistula can be attempted only in patients with small openings in the small bowel and no systemic symptoms. In all other cases, surgical treatment with bowel resection and either closure of the neobladder opening or undiversion should be the preferred option.

Sliding-clip technique for renorrhaphy improves perioperative outcomes of open partial nephrectomy

Abstract Introduction: the aim of this work is to assess whether renorrhaphy with the sliding-clip technique improves perioperative and early functional outcomes compared with traditional renorrhaphy in a contemporary series of patients undergoing open partial nephrectomy (PN). Material and Methods: A single-center single-surgeon cohort of 107 consecutive patients treated with open PN between July 2013 and March 2017 was analyzed. A study group of 48 patients undergoing renorrhaphy with the sliding-clip technique was compared with a control group of 59 patients receiving traditional renorrhaphy. Outcome measures were operative room (OR) time, warm ischemia time (WIT), estimated blood loss (EBL), rate of overall 90-day postoperative complications, and percentage change in estimated glomerular filtration rate (PCE)u2009>u200910% and >20% 1 month postoperatively. Results: OR time (pu2009=u20090.02), WIT (pu2009=u20090.01) and EBL (pu2009<u20090.001) were significantly lower in the study versus control group. Overall 90-day postoperative complications were observed in 8 (16.7%) versus 21 (35.7%) patients in the study versus control group (pu2009=u20090.02). PCEu2009>u200910% and >20% 1 month postoperatively were observed in approximately 40% and 20% of patients, respectively, with no significant differences between groups. On multivariable analysis, a sliding-clip technique was an independent predictor of WITu2009>20u2009min and/or EBLu2009>500u2009ml (OR 0.238, 95%CI 0.074–0.767; pu2009=u20090.01) and overall 90-day postoperative complications (OR 0.360, 95%CI 0.151-0.856; pu2009=u20090.02). Conclusions: In patients undergoing open PN, renorrhaphy with the sliding-clip technique was associated with better intraoperative and postoperative outcomes compared with traditional renorrhaphy. No significant differences were observed in terms of early renal function change.

Outcomes and Complications of Robotic Kidney Surgery

From its first developments, robot-assisted surgery had a rapid and wide diffusion into the field of urology and its indications have been expanded to several urological procedures and, as experience increased in the last years, even to challenging and complex cases with an acceptably low complication rate in the hands of high-volume surgeons. Robot-assisted radical prostatectomy (RARP) is currently the most common treatment modality for surgical management of clinically localized prostate cancer in the US. The consequence of the widespread adoption of RARP was the use of the robotic platform to treat other urological malignancies as well as benign conditions.

The Potential Role of MicroRNAs as Biomarkers in Benign Prostatic Hyperplasia: A Systematic Review and Meta-analysis

CONTEXTnBenign prostate hyperplasia (BPH) is one of the most common urologic diseases. However, the molecular and cellular mechanisms involving the stromal and epithelial components of the prostate that lead to BPH remain unclear.nnnOBJECTIVEnTo review and evaluate the evidence implicating microRNAs (miRNAs) in the pathogenesis of BPH.nnnEVIDENCE ACQUISITIONnA systematic search of the PubMed and Embase databases was performed using the terms benign prostate hypertrophy and miRNA or (benign prostate hypertrophy and microRNAs or miRNA or miR) on July 31, 2017.nnnEVIDENCE SYNTHESISnSixty-four miRNAs from 37 selected articles were ranked according to p values (p≤0.05). To avoid false positive results, Benjamini-Hochberg correction of p values was performed. Application of the robust rank aggregation method identified miR-221 as significantly associated with BPH (p=0.013). The effect size (ES) was calculated for studies with miR-221 data to generate an estimate of the overall ES and its confidence interval. The ES for miR-221 was measured by the standardized mean difference obtained by dividing the difference in the average gene expression between the PCa and BPH groups by a pooled estimate of standard deviation. The random effects model was used to calculate the pooled ES due to the presence of heterogeneity among studies. Publication bias of the seven included studies was assessed by the Funnel plot and Eggers test and it was detected in the overall analysis of the seven studies (p<0.01). After the trim and fill procedure, Eggers test revealed no evidence of publication bias (p=0.76) CONCLUSIONS: miR-221 has the potential to be used both as a biomarker and novel target in the early diagnosis and therapy of BPH. Technological advances should enable the synthesis of pre-RNA or anti-RNA molecules within carrier vehicles that can be safely delivered into patients. The development of such new pharmacologic therapies should be lastly investigated as possible therapy of one of the most common urologic diseases among elderly men. PATIENT SUMMARY: miR-221 has the potential to be used both as a biomarker and novel target in the early diagnosis and therapy of benign prostate hyperplasia. The development of new pharmacologic therapies enabling the synthesis of anti-miR-221 should be lastly investigated as a possible therapy of one of the most common urologic diseases among elderly men.

Re: Robot-assisted Radical Cystectomy Versus Open Radical Cystectomy in Patients with Bladder Cancer (RAZOR): An Open-label, Randomised, Phase 3, Non-inferiority Trial

Experts’ summary: The RAZOR trial is the first randomised (1:1) phase 3 study assessing cancer control for both surgical approaches. The primary objective of this noninferiority trial was to compare 2-yr progression-free survival (PFS) among patients with radical treatment for bladder cancer. Between 2011 and 2014, 159 and 153 patients were included in the intentionto-treat analysis and underwent robot-assisted (RARC) and open radical cystectomy (ORC), respectively. All urinary diversions were extracorporeal. Patients were randomly allocated by institutions (n = 15) and stratified by urinary diversion type, cT stage and Eastern Cooperative Oncology Group performance status. Surgeons who participated in the study were required to have performed at least ten RARC or ORC procedures in the year before the study. A noninferiority margin of 15% points was considered on the basis of previous trials in colon and rectal cancers comparing open to minimally invasive surgery. Baseline characteristics were similar between the groups, and 2-yr PFS was 72.3% in the RARC versus 71.6% in the ORC arm, showing noninferiority of RARC to ORC (0.7% difference, 95% confidence interval 9.6% to 10.9%; p = 0.90). PFS was worse for positive surgical margins (PSMs) or higher pT stage, with no significant differences between treatment groups.

Re: Stenting Prior to Cystectomy Is an Independent Risk Factor for Upper Urinary Tract Recurrence

Experts’ summary: Kiss and colleagues explored the association between type of temporary preoperative upper urinary tract (UUT) drainage (ie, ureteric stenting vs percutaneous nephrostomy) because of hydronephrosis and rate of UUT recurrence in a retrospective single-centre cohort of nearly 1000 bladder cancer (BCa) patients treated with radical cystectomy (RC) and followed for median 36 mo. The authors’ hypothesis was that ureteric stenting would favour retrograde spillage of tumour cells from BCa, thus increasing the risk of UUT recurrence. Of the 226 patients presenting with hydronephrosis prior to RC, 114 received UUT drainage—53 with ureteric stenting and 61 with percutaneous nephrostomy. At median postoperative time of 17 mo, 31 patients had UUT recurrence: seven of 53 (13%) in the ureteric stenting, zero of 61 (0%) in the percutaneous nephrostomy, and 24 of 891 (3%) in the no drainage group. Of note, all recurrences in the ureteric stenting group were detected in the ipsilateral UUT. On multivariable analysis adjusting for clinical variables (including age, BCa stage, and previous intravesical instillations), ureteric stenting, but neither percutaneous nephrostomy nor hydronephrosis, and previous intravesical instillations were independent risk factors for UUT recurrence. 1. Since the group of patients receiving percutaneous nephrostomy had lower survival compared with their counterparts in the stenting group due to more advanced disease and a sicker comorbidity profile, a competing risk analysis with landmark time analysis should have been run to estimate the cumulative incidence of UUT recurrence and determine whether the risk of UUT recurrence changes over time after RC in a different manner in the two groups [3]. 2. Established risk factors for UUT recurrence, such as BCa multifocality, direct tumour involvement of the ureteric orifice, concomitant invasion of the prostatic urethra, and a history of UUT tumour, remain unreported. It might well be that patients in the stenting group had a higher risk for UUT recurrence already at the time of RC because of a higher prevalence of these factors. 3. It remains unknown whether (and how many) patients in the three groups had had retrograde UUT manipulations in their previous course of the disease, since it emerges that a fair proportion of them underwent RC after multiple treatments for recurrent non–muscle-invasive BCa. 4. It is impossible to ascertain whether the so-called UUT recurrence was generated by a retrograde tumour cell implantation or was indeed a second primary UUT tumour. Since preoperative UUT evaluation with standard imaging, as done in this study, may miss cancer, it might well be that more patients in the stenting group E U R O P E A N U R O L O G Y X X X ( 2 0 18 ) X X X – X X X