Multiparametric Magnetic Resonance Imaging for the Detection of Clinically Significant Prostate Cancer: What Urologists Need to Know. Part 1: Acquisition.

Abstract: Acquiring multiparametric magnetic resonance images of the prostate is not a simple “push-button” approach.To show how image acquisition of prostate multiparametric Magnetic Resonance Imaging (mpMRI) can be optimized.Image protocols, […]

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Effect of Behavioral and Pelvic Floor Muscle Therapy Combined With Surgery vs Surgery Alone on Incontinence Symptoms Among Women With Mixed Urinary Incontinence: The ESTEEM Randomized Clinical Trial.

Abstract: Mixed urinary incontinence, including both stress and urgency incontinence, has adverse effects on a woman’s quality of life. Studies evaluating treatments to simultaneously improve both components are lacking.To determine […]

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Diagnostic Accuracy of Prostate Biopsy for Detecting Cribriform Gleason Pattern 4 Carcinoma and Intraductal Carcinoma in Paired Radical Prostatectomy Specimens: Implications for Active Surveillance.

Abstract: Prostatic adenocarcinomas with cribriform morphology and/or intraductal carcinoma (CC/IDC) have higher recurrence and mortality rates after radiation and surgery. While the prognostic impact of these features is well-studied, concordance […]

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Improving Estimates of Perioperative Morbidity After Radical Cystectomy Using the European Association of Urology Quality Criteria for Standardized Reporting and Introducing the Comprehensive Complication Index.

Abstract: No procedure-specific definitions in complication reporting have been universally accepted in urological surgery, and conventional classification systems do not reflect cumulative morbidity.To conduct a rigorous assessment of 30-d complications […]

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PSMA-Targeted Positron Emission Tomography (PET) in Evaluation of Patients with Primary Prostate Cancer: Comparison of Pre-operative [68Ga]Ga-PSMA-11 PET/CT, Immediate Post-operative Specimen [68Ga]Ga-PSMA-11 Imaging, and Whole Mount Pathology.

Abstract: To evaluate what lesions are detected and missed on [68Ga]Ga-PSMA-11 PET scanning in primary prostate cancer.Patients undergoing radical prostatectomy were enrolled in this prospective observational study. Patients received a […]

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Randomised Trial of Adjuvant Radiotherapy Following Radical Prostatectomy Versus Radical Prostatectomy Alone in Prostate Cancer Patients with Positive Margins or Extracapsular Extension.

Abstract: It remains unclear whether patients with positive surgical margins or extracapsular extension benefit from adjuvant radiotherapy following radical prostatectomy.To compare the effectiveness and tolerability of adjuvant radiotherapy following radical […]

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The Influence of Stereotactic Body Radiation Therapy Adoption on Prostate Cancer Treatment Patterns.

In prostate cancer, it is unknown whether stereotactic body radiation therapy (SBRT) is substituting for other radiation treatments, substituting for surgery, or expanding the pool of patients receiving treatment instead of active surveillance.Using SEER-Medicare, we identified men diagnosed with prostate cancer between 2007 and 2011 and developed physician-hospital networks by identifying each patient’s treating physician based on the primary treatment received and subsequently assigning each physician to a hospital. We examined the relative distribution of prostate cancer treatments stratified by whether or not a network performed SBRT by fitting logistic regression models with robust standard errors to account for clustering of patients within networks.We identified 344 physician-hospital networks, 30 of which (8.7%) performed SBRT and 314 of which (91.3%) did not. Networks performing and not performing SBRT did not differ in their use of robotic prostatectomy, radical prostatectomy, and active surveillance over time (all p>0.05). The relationship with IMRT did not exhibit any consistent temporal pattern, with networks performing SBRT having less IMRT initially but similar rates in the later years. Trends in brachytherapy differed among networks performing and not performing SBRT with use of brachytherapy lower in networks performing SBRT (p=0.03).Networks performing and not performing SBRT did not differ in rates of surgery and active surveillance, yet networks performing SBRT had lower rates of brachytherapy. SBRT may represent an alternative to brachytherapy more so than for active surveillance.

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Treatment of Urinary Urgency Incontinence Using a Rechargeable SNM System: 6-month Results of the ARTISAN-SNM Study.

Sacral Neuromodulation is a guideline-recommended treatment for urinary dysfunction and fecal incontinence in patients that have failed conservative treatments. Historically, SNM has been delivered using a non-rechargeable device with an average lifespan of 4.4 years requiring surgery to replace the implanted neurostimulator (INS) due to battery depletion. Implantation of a long-lived INS can eliminate the need for replacement surgeries, potentially reducing patient surgical risks and healthcare costs. The Axonics® r-SNM® System, is a miniaturized, rechargeable Sacral Neuromodulation (r-SNM) system designed to deliver therapy for at least 15 years. The ARTISAN-SNM study is a pivotal study using r-SNM therapy to treat urinary urgency incontinence (UUI). 6-month results are presented.129 eligible UUI patients were treated. All participants were implanted with a tined lead and the r-SNM system in a non-staged procedure. Efficacy data was collected using a 3-day bladder diary, a validated quality of life questionnaire (ICIQ-OABqol), and a participant satisfaction questionnaire. Therapy responders were identified as participants with ?50% reduction in UUI episodes compared to baseline. An as treated analysis was performed in all implanted participants.At 6 months, 90% of the participants were therapy responders. The average UUI episodes per day reduced from 5.6 ± 0.3 at baseline to 1.3 ± 0.2 (mean ± standard error). Participants experienced clinically meaningful improvements of 34 points on the ICIQ-OABqol questionnaire. There were no serious device-related adverse events.The Axonics r-SNM® System is safe and effective, with 90% of participants experiencing clinically and statistically significant improvements in UUI symptoms.

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A Novel Laser Lithotripsy System with Automatic Real Time Urinary Stone Recognition-Computer Controlled ex Vivo Lithotripsy is Feasible and Reproducible in Endoscopic Stone Fragmentation.

Urinary stone treatment has been strongly influenced by advances in technology. Nevertheless, the photonic characteristics of stones as treatment target itself have been neglected. Monitoring of fluorescence spectra is sufficient for automatic target differentiation and laser feedback control as previously described. Our study investigated the characteristics of fluorescence signals and clinical practicability of real time laser feedback control during lithotripsy.Fluorescence excitation light was superimposed on a Holmium laser beam into the treatment fiber. Spectra were recorded and signal amplitude changes were analyzed during increase in distance between fiber tip and stone to identify optimal threshold level for stone recognition. Ho:YAG lithotripsy was then performed under in vitro surgical conditions in porcine tissue while our feedback system autonomously controlled the laser impulse release during lithotripsy. The tissue was endoscopically and macroscopically examined for laser-induced lesions.Autofluorescence signal amplitudes from urinary stone samples varied between 142+/-29 and 1521+/-152 ADU, while emission from tissue and endoscope coating is negligible. Signal amplitude decreases rapidly at distances larger than 1-2 mm. Clinically reliable threshold values for target recognition can be set to prevent laser pulse emission if the stone is out of range or urothelial tissue at harm by laser irradiation. We observed no incorrectly released laser pulse or injury to tissue during autonomously controlled Holmium laser lithotripsy.Our laboratory study strengthens the evidence that tracking of real-time autofluorescence spectra during endoscopic stone surgery via automatic feedback control of laser impulse release may become a potentially useful clinical tool for surgeons navigating in the upper urinary tract.

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Retzius-Sparing Robot-Assisted Radical Prostatectomy Conveys Early Regain of Continence over Conventional Robot-Assisted Radical Prostatectomy: A Propensity Matched Analysis of 1,863 Patients.

We aimed to compare the early continence recovery after surgical treatment of prostate cancer between Retzius-sparing robot-assisted radical prostatectomy and conventional robot-assisted radical prostatectomy.Robot-assisted radical prostatectomy was performed by a single surgeon in 1,863 cases between October 2005 and May 2018. Conventional and Retzius-sparing robot-assisted radical prostatectomy were performed in 1,150 and 713 cases, respectively. To compare the continence outcome between groups, propensity score matching was performed using 9 preoperative variables, including age, body mass index, prostate-specific antigen, biopsy Gleason grade group, clinical T stage, prostate volume on trans-rectal ultrasound, International Prostate Symptom Score, International Prostate Symptom Score quality of life score, and International Index of Erectile Function-5 score. Assessment of continence was calculated by pad count every month after the surgery until the sixth month and was converted to binary outcome.After propensity score matching, 609 cases in each group were matched with no significant difference of all 9 variables. Kaplan-Meier curve analysis revealed that Retzius-sparing robot-assisted radical prostatectomy had significantly better continence recovery rate than did conventional robot-assisted radical prostatectomy during the 6-month study period (p<0.001).Based on the propensity score matched with multiple variables and large case series, Retzius-sparing robot-assisted radical prostatectomy can be a candidate for future robot-assisted radical prostatectomy, which achieves better early continence recovery, short operation time, and early recovery compared to conventional robot-assisted radical prostatectomy.

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Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel.

Bladder stones (BS) constitute 5% of urinary stones. Currently, there is no systematic review of their treatment.To assess the efficacy (primary outcome: stone-free rate [SFR]) and morbidity of BS treatments.This systematic review was conducted in accordance with the European Association of Urology Guidelines Office. Database searches (1970-2019) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and nonrandomised studies (NRSs) with ?10 patients per group. Quality of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.A total of 2742 abstracts and 59 full-text articles were assessed, and 25 studies (2340 patients) were included. In adults, one RCT found a lower SFR following shock wave lithotripsy (SWL) than transurethral cystolithotripsy (TUCL; risk ratio 0.88, p=0.03; low QoE). Four RCTs compared TUCL versus percutaneous cystolithotripsy (PCCL): meta-analyses demonstrated no difference in SFR, but hospital stay (mean difference [MD] 0.82d, p<0.00001) and procedure duration (MD 9.83min, p<0.00001) favoured TUCL (moderate QoE). Four NRSs comparing open cystolithotomy (CL) versus TUCL or PCCL found no difference in SFR; hospital stay and procedure duration favoured endoscopic surgery (very low QoE). Four RCTs compared TUCL using a nephroscope versus a cystoscope: meta-analyses demonstrated no difference in SFR; procedure duration favoured the use of a nephroscope (MD 22.74min, p<0.00001; moderate QoE). In children, one NRS showed a lower SFR following SWL than TUCL or CL. Two NRSs comparing CL versus TUCL/PCCL found similar SFRs; catheterisation time and hospital stay favoured endoscopic treatments. One RCT comparing laser versus pneumatic TUCL found no difference in SFR. One large NRS comparing CL techniques found a shorter hospital stay after tubeless CL in selected cases; QoE was very low.Current available evidence indicates that TUCL is the intervention of choice for BSs in adults and children, where feasible. Further high-quality research on the topic is required.We examined the literature to determine the most effective and least harmful procedures for bladder stones in adults and children. The results suggest that endoscopic surgery is equally effective as open surgery. It is unclear whether stone size affects outcomes. Shock wave lithotripsy appears to be less effective. Endoscopic treatments appear to have shorter catheterisation time and convalescence compared with open surgery in adults and children. Transurethral surgery, where feasible, appears to have a shorter hospital stay than percutaneous surgery. Further research is required to clarify the efficacy of minimally invasive treatments for larger stones and in young children.

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Robotic Renal Artery Aneurysm Repair.

Renal artery aneurysm (RAA) is a rare condition, traditionally managed with endovascular or open surgical techniques.To report our experience with robotic RAA repair.Nine consecutive patients underwent intracorporeal robotic surgery for 10 RAAs.Two patients underwent concomitant robotic partial nephrectomy. One patient had RAA in a solitary kidney. Median RAA diameter was 2.2 (1.8-3)cm. Intracorporeal transarterial hypothermic renal perfusion was performed in five patients. Robotic techniques included tailored aneurysmectomy and repair (n=5), excision with end-to-end anastomosis (n=2), aneurysmectomy with branch reimplantation (n=1), prosthetic interposition graft repair (n=1), and simple nephrectomy (n=1; this patient’s data were excluded from analysis).Demographics, RAA characteristics, intraoperative techniques, perioperative outcomes, and follow up data were analyzed. Aneurysms were diagnosed by computed tomography, angiography, or incidentally during the performance of a partial nephrectomy.All cases were performed robotically, without conversion to open surgery. Median (range) operative time was 3.8 (3-6)h, warm ischemia time 26 (19-32)min, hypothermic renal perfusion time 34 (29-69)min, and estimated blood loss 100 (25-400)ml. No intraoperative blood transfusion was required. Median hospital stay was 3 (2-6)d. One patient had a Clavien-Dindo grade II complication. At median follow-up of 16 (2-67)mo, all patients had preserved renal function. Follow-up imaging confirmed normal caliber reconstructed renal arteries with globally perfused kidneys, except for two kidneys with small segmental infarcts due to an intentionally ligated small polar vessel. Limitations include the small number of patients and the retrospective nature of the study.Robotic repair of complex RAAs is feasible. Surgical expertise, patient selection, and RAA-specific vascular reconstruction are critical for success. Greater experience is needed to evaluate the proper place of robotic repair of RAAs.We report intracorporeal robotic repair for complex renal artery aneurysms. This robotic operation is feasible and safe, and replicates open principles. However, it requires considerable experience and expertise.

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