Archive for category: Latest Articles

Welcome to the October issue of Trainees’ Corner

Objectives

To undertake a prospective multicentre national audit of penile prosthesis practice in the UK over a 3‐year period.

Patients and Methods

Data were submitted by urological surgeons as part of the British Association of Urological Surgeons Penile Prosthesis National Audit. Patients receiving a penile prosthesis (inflatable or malleable) were included as part of a prospective registry over a 3‐year period. Data were validated and then analysed using a software package (Tableau).

Results

A total of 1071 penile prosthesis procedures were included from 22 centres. The three commonest aetiological factors for erectile dysfunction were diabetes, prostate surgery and Peyronie’s disease. Of the recorded data, inflatable penile prostheses were the commonest devices implanted, with 665 devices used (62.1%), whereas malleable prostheses accounted for 14.2% of the implants. Recorded intra‐operative complications included urethral injury (0.7%, n = 7), corporal perforation (1.1%, n = 12) and cross‐over (0.6%, n = 6). Known postoperative complications were recorded in 9.8% of patients (74/752), with the two most frequently reported being postoperative penile pain (n = 11) and scrotal haematoma (n = 14).

Conclusion

This baseline analysis is the largest prospective registry of penile prostheses procedures to date. The data show that, over the 3‐year collection period in the UK, there are now fewer surgeons performing the procedure, together with a reduction in the number of centres. Peri‐operative complications were infrequent, and the rate of implant abortion (e.g. as a result of urethral injury) was very low. Further follow‐up data will be required to publish long‐term outcomes and patient satisfaction.

Nephrometry Scores: a validation of three systems for peri‐operative outcomes in retroperitoneal robotic partial nephrectomy

Objectives

To develop and validate a model to predict 12‐month continence status after robot‐assisted radical prostatectomy (RARP) from preoperative and 3‐month postoperative data; this model could help in informing patients on their individualised risk of urinary incontinence (UI) after RP in order to choose the best treatment option.

Patients and Methods

Data on 9421 patients in 25 Belgian centres were prospectively collected (2009–2016) in a compulsory regional database. The primary outcome was the prediction of continence status, using the International Consultation on Incontinence Urinary Incontinence Short Form (ICIQ‐UI‐SF) at 12‐months after RARP. Linear regression shrinkage was used to assess the association between preoperative 3‐month postoperative characteristics and 12‐month continence status. This association was visualised using nomograms and an online tool.

Results

At 12 months, the mean (sd) score of the ICIQ‐UI‐SF questionnaire was 4.3 (4.7), threefold higher than the mean preoperative score of 1.4. For the preoperative model, high European Association of Urology risk classification for biochemical recurrence (estimate [Est.] 0.606, se 0.165), postoperative radiotherapy (Est. 1.563, se 0.641), lower preoperative European Organisation for Research and Treatment of Cancer quality of life questionnaire 30‐item core (EORCT QLQ‐C30)/quality of life (QoL) score (Est. −0.011, se 0.003), higher preoperative ICIQ‐UI‐SF score (Est 0.214, se 0.018), and older age (Est. 0.058, se 0.009), were associated with a higher 12‐month ICIQ‐UI‐SF score. For the 3‐month model, higher preoperative ICIQ‐UI‐SF score (Est. 0.083, se 0.014), older age (Est. 0.024, se 0.007), lower 3‐month EORCT QLQ‐C30/QoL score (Est. −0.010, se 0.002) and higher 3‐month ICIQ‐UI‐SF score (Est. 0.562, se 0.009) were associated with a higher 12‐month ICIQ‐UI‐SF score.

Conclusions

Our models set the stage for a more accurate counselling of patients. In particular, our preoperative model assesses the risk of UI according to preoperative and early postoperative variables. Our postoperative model can identify patients who most likely would not benefit from conservative treatment and should be counselled on continence surgery.

Editorial Board

Abstract

Objective

To determine differences in perioperative outcomes between retroperitoneal and transperitoneal approaches for laparoscopic pyeloplasty (LP) to manage ureteropelvic junction obstruction (UPJO) through a meta‐analysis of comparative studies.

Methods

A systematic search was performed in January 2020. Comparative studies were evaluated according to Cochrane collaboration recommendations. Assessed outcomes included success and complication rates, conversion to open surgery, operative time (OT), length of hospital stay (LOS), estimated blood loss (EBL), analgesic requirements, regular diet resumption, and drain duration. Relative risk (RR) and standardized mean difference (SMD) with 95% confidence intervals (CI) were extrapolated. Subgroup analyses were performed according to study design and techniques. PROSPERO REGISTRATION (CRD42020163303).

Results

Eighteen studies describing 2,007 cases were included. Overall pooled effect estimates did not show statistically significant differences between the approaches with regards to success rate (RR=0.99; 95%CI 0.97, 1.01), complications (RR=1.09, 95%CI 0.82, 1.45), OT (SMD=0.61, 95%CI ‐0.04, 1.26), LOS (SMD=‐0.30, 95%CI ‐0.63, 0.04), EBL (SMD=‐0.53, 95%CI ‐1.26, 0.21), or analgesic requirements (SMD=‐0.51, 95%CI ‐1.23, 0.21). Compared to the transperitoneal approach, retroperitoneal laparoscopy likely had a higher conversion rate (RR=2.40; 95%CI 1.23, 4.66); however, patients resumed diets earlier (SMD=‐2.49, 95%CI ‐4.17, ‐0.82) and had shorter drain duration (SMD=‐0.31, 95%CI ‐0.57, ‐0.05).

Conclusion

The evidence suggests that there are no significant differences in success rate, operative time and complications between transperitoneal and retroperitoneal LP. Conversion rates are higher in the retroperitoneal approach; however, return to diet occurs faster and drain duration is shorter when compared to the transperitoneal approach.

Randomised trial of bipolar resection vs holmium laser enucleation vs Greenlight laser vapo‐enucleation of the prostate for treatment of large benign prostate obstruction: 3‐years outcomes

Objective

To compare transurethral resection in saline (TURIS), Greenlight laser vapo‐enucleation of the prostate (GL.PVEP), and holmium laser enucleation of the prostate (HoLEP), for controlling lower urinary tract symptoms secondary to large benign prostatic hyperplasia (BPH) and to assess non‐inferiority of 3‐year re‐treatment rates.

Patients and Methods

Eligible patients with BPH (prostate size 80–150 mL) were randomly assigned to one of the intervention groups. Non‐inferiority of re‐treatment rate was evaluated using a one‐sided test at 5% level of significance.

Results

At the time of analysis, 60 GL.PVEP, 60 HoLEP and 62 TURIS procedures were included. Perioperative parameters were comparable between groups; however, the operative time was longer in GL.PVEP vs HoLEP and TURIS, at a mean (SD) of 92 (32) vs 73 (30) and 83 (28) min (P = 0.005); and was less effective with a mean (SD) removal of 1.2 (0.4) vs 1.7 (0.7) and 1.4 (0.6) g/min (P < 0.001), respectively. Perioperative complications and need for auxiliary procedures were similar in the three groups; however, there was a significantly higher rate of capsular perforation in TURIS group (five, 8%) compared to one (1.6%) in the GL.PVEP group and none in the HoLEP group (P = 0.01). There was a significantly longer hospital stay, catheter‐time and higher rate of blood transfusion in the TURIS group. There was significant but comparable improvements in the International Prostate Symptom Score in three groups at different follow‐up points. At 3 years, re‐treatment for recurrent bladder outlet obstruction was required more after GL.PVEP and TURIS. More re‐do surgeries for recurrent obstructing prostate adenoma was reported after GL.PVEP (four, 6.7%) and TURIS (six, 9.7%) than for HoLEP (none) (P = 0.04).

Conclusion

The perioperative outcomes of GL.PVEP and HoLEP surpassed that of TURIS for the treatment of large prostates, but with a significantly prolonged operative time with GL.PVEP. The three techniques achieve good functional outcomes; however, 3‐year re‐treatment rates following TURIS and GL.PVEP were inferior to HoLEP.

Comparative effectiveness of neoadjuvant chemotherapy in bladder and upper urinary tract urothelial carcinoma

Abstract

Objective

To assess the differential response to neoadjuvant chemotherapy (NAC) in patients with UCB compared to UTUC treated with radical surgery.

Materials and methods

Data from 1299 patients with UCB and 276 with UTUC were obtained from multicentric collaborations. The association of disease location (UCB vs UTUC) with pathologic complete response (pCR; defined as ypT0N0) and pathologic partial response (pOR; defined as ypT0‐Ta‐Tis‐T1N0) after NAC was evaluated using logistic regression analyses. The association with overall (OS) and cancer‐specific survival (CSS) was evaluated using Cox regression analyses.

Results

pCR was found in 250 (19.2%) patients with UCB and in 23 (8.3%) patients with UTUC (p < 0.01). pOR was found in 523 (40.3%) patients with UCB and in 133 (48.2%) patients with UTUC (p = 0.02). On multivariable logistic regression analysis, UTUC patients were less likely to have pCR (OR 0.45, 95%CI 0.27 – 0.70, p <0.01) and more likely to have pOR (OR 1.57, 95%CI 1.89 – 2.08, p < 0.01). On univariable Cox regression analyses, UTUC was associated with better OS (HR 0.80, 95%CI 0.64 – 0.99, p = 0.04) and CSS (HR 0.63, 95%CI 0.49 – 0.83, p < 0.01). On multivariable Cox regression analyses, UTUC remained associated with CSS (HR 0.61, 95%CI 0.45 – 0.82, p <0.01) but not with OS.

Conclusions

Our findings suggest that the benefit of NAC in UTUC is similar to that which is known in UCB. These data can be used as a benchmark to contextualize survival outcomes and plan future trial design with NAC in urothelial cancer.

A cross‐section of UK prostate cancer diagnostics during the COVID‐19 era ‐ a shifting paradigm?

Abstract

Objective

To assess the differential response to neoadjuvant chemotherapy (NAC) in patients with UCB compared to UTUC treated with radical surgery.

Materials and methods

Data from 1299 patients with UCB and 276 with UTUC were obtained from multicentric collaborations. The association of disease location (UCB vs UTUC) with pathologic complete response (pCR; defined as ypT0N0) and pathologic partial response (pOR; defined as ypT0‐Ta‐Tis‐T1N0) after NAC was evaluated using logistic regression analyses. The association with overall (OS) and cancer‐specific survival (CSS) was evaluated using Cox regression analyses.

Results

pCR was found in 250 (19.2%) patients with UCB and in 23 (8.3%) patients with UTUC (p < 0.01). pOR was found in 523 (40.3%) patients with UCB and in 133 (48.2%) patients with UTUC (p = 0.02). On multivariable logistic regression analysis, UTUC patients were less likely to have pCR (OR 0.45, 95%CI 0.27 – 0.70, p <0.01) and more likely to have pOR (OR 1.57, 95%CI 1.89 – 2.08, p < 0.01). On univariable Cox regression analyses, UTUC was associated with better OS (HR 0.80, 95%CI 0.64 – 0.99, p = 0.04) and CSS (HR 0.63, 95%CI 0.49 – 0.83, p < 0.01). On multivariable Cox regression analyses, UTUC remained associated with CSS (HR 0.61, 95%CI 0.45 – 0.82, p <0.01) but not with OS.

Conclusions

Our findings suggest that the benefit of NAC in UTUC is similar to that which is known in UCB. These data can be used as a benchmark to contextualize survival outcomes and plan future trial design with NAC in urothelial cancer.

NeuroSAFE frozen section during robot‐assisted radical prostatectomy (RARP): Peri‐operative and Histopathological Outcomes from the NeuroSAFE PROOF Feasibility Randomised Controlled Trial

Abstract

Objectives

To report on the methods, peri‐operative outcomes and histopathological concordance between frozen and final section from the NeuroSAFE PROOF Feasibility study (NCT03317990).

Patients and Methods

Between May 2018 and March 2019 49 men at 2 UK centres underwent robot‐assisted robotic prostatectomy (RARP). 25 men were randomised to NeuroSAFE RARP (intervention arm) vs. 24 men to standard RARP (control arm). Frozen section was compared to final paraffin section margin assessment in the 25 men in the NeuroSAFE arm. Operation timings and complications were collected prospectively in both arms.

Results

50 NVB from 25 patients in the NeuroSAFE arm were analysed. When analysed by each pathological section (n=250, average 5 per side) we note sensitivity 100%, specificity 99.2%, AUC was 0.994 (95% CI 0.985 to 1, P= <.001). On an NVB basis (n=50) we note sensitivity of 100%, specificity 92.7%, and AUC of 0.963 (95% CI 0.914 to 1, p = <0.001. NeuroSAFE RARP lasted a mean 3 hours 16 minutes (knife to skin to off table, 95% CI 3 hrs 2 mins ‐ 3 hrs 30 mins) compared to 2 hours 14 minutes (2 hrs 2 mins ‐ 2 hours 25 mins, P=<0.001) for standard RARP. There was no morbidity associated with the additional length of operation in the NeuroSAFE arm.

Conclusion

This feasibility study demonstrates the safety, the reproducibility and the excellent histopathological concordance of the NeuroSAFE technique in the NeuroSAFE PROOF trial. Though the technique increases the duration of RARP, this does not cause short‐term harm. Confirmation of feasibility has led to the opening of the fully powered NeuroSAFE PROOF RCT, which is currently underway at 4 sites in the UK.

Complications of synthetic mesh inserted for stress urinary incontinence

Abstract

Objective

To assess the differential response to neoadjuvant chemotherapy (NAC) in patients with UCB compared to UTUC treated with radical surgery.

Materials and methods

Data from 1299 patients with UCB and 276 with UTUC were obtained from multicentric collaborations. The association of disease location (UCB vs UTUC) with pathologic complete response (pCR; defined as ypT0N0) and pathologic partial response (pOR; defined as ypT0‐Ta‐Tis‐T1N0) after NAC was evaluated using logistic regression analyses. The association with overall (OS) and cancer‐specific survival (CSS) was evaluated using Cox regression analyses.

Results

pCR was found in 250 (19.2%) patients with UCB and in 23 (8.3%) patients with UTUC (p < 0.01). pOR was found in 523 (40.3%) patients with UCB and in 133 (48.2%) patients with UTUC (p = 0.02). On multivariable logistic regression analysis, UTUC patients were less likely to have pCR (OR 0.45, 95%CI 0.27 – 0.70, p <0.01) and more likely to have pOR (OR 1.57, 95%CI 1.89 – 2.08, p < 0.01). On univariable Cox regression analyses, UTUC was associated with better OS (HR 0.80, 95%CI 0.64 – 0.99, p = 0.04) and CSS (HR 0.63, 95%CI 0.49 – 0.83, p < 0.01). On multivariable Cox regression analyses, UTUC remained associated with CSS (HR 0.61, 95%CI 0.45 – 0.82, p <0.01) but not with OS.

Conclusions

Our findings suggest that the benefit of NAC in UTUC is similar to that which is known in UCB. These data can be used as a benchmark to contextualize survival outcomes and plan future trial design with NAC in urothelial cancer.

Perioperative Outcomes and Cost of Robotic Versus Open Simple Prostatectomy in the Modern Robotic Era: Results from the National Inpatient Sample

Abstract

Objective

To assess the differential response to neoadjuvant chemotherapy (NAC) in patients with UCB compared to UTUC treated with radical surgery.

Materials and methods

Data from 1299 patients with UCB and 276 with UTUC were obtained from multicentric collaborations. The association of disease location (UCB vs UTUC) with pathologic complete response (pCR; defined as ypT0N0) and pathologic partial response (pOR; defined as ypT0‐Ta‐Tis‐T1N0) after NAC was evaluated using logistic regression analyses. The association with overall (OS) and cancer‐specific survival (CSS) was evaluated using Cox regression analyses.

Results

pCR was found in 250 (19.2%) patients with UCB and in 23 (8.3%) patients with UTUC (p < 0.01). pOR was found in 523 (40.3%) patients with UCB and in 133 (48.2%) patients with UTUC (p = 0.02). On multivariable logistic regression analysis, UTUC patients were less likely to have pCR (OR 0.45, 95%CI 0.27 – 0.70, p <0.01) and more likely to have pOR (OR 1.57, 95%CI 1.89 – 2.08, p < 0.01). On univariable Cox regression analyses, UTUC was associated with better OS (HR 0.80, 95%CI 0.64 – 0.99, p = 0.04) and CSS (HR 0.63, 95%CI 0.49 – 0.83, p < 0.01). On multivariable Cox regression analyses, UTUC remained associated with CSS (HR 0.61, 95%CI 0.45 – 0.82, p <0.01) but not with OS.

Conclusions

Our findings suggest that the benefit of NAC in UTUC is similar to that which is known in UCB. These data can be used as a benchmark to contextualize survival outcomes and plan future trial design with NAC in urothelial cancer.

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