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Background Retroperitoneal lymph node dissection (RPLND) is a treatment option for men with stage 1 or 2 testis cancer and the standard of care for men with postchemotherapy retroperitoneal residual disease. Given the morbidity of RPLND, four important surgical modifications have been proposed: minimally invasive access, nerve-sparing resection, template resection, and en-bloc resection. Objective To describe the surgical steps and perioperative outcomes of robotic nerve-sparing unilateral template RPLND with en-bloc resection (roboRPLND-NS+). Design, setting, and participants From 2017 to 2019, five patients with suspicion of retroperitoneal metastatic testicular cancer on abdominopelvic computed tomography underwent roboRPLND-NS+ at a single referral center. All surgeries were carried out by a single surgeon who has performed more than 500 extended and more than 50 super-extended robot-assisted lymph node dissections. Surgical procedure A lateral transperitoneal robotic approach with a da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in six-arm configuration was used. The sympathetic chains, postganglionic sympathetic fibers, and hypogastric plexus were preserved as much as possible to ensure a nerve-sparing procedure. The template borders consisted of the renal vein cranially, the ureter laterally, the interaortocaval space medially, the common iliac artery caudally, and the psoas muscle dorsally for the right and left modified RPLND templates. Lymph nodes and the surrounding fatty tissue were progressively resected from the common iliac vessels and the abdominal aorta using the split-and-roll technique, and all of the template tissue was resected as a single specimen. Intraoperative and postoperative complications were recorded. Measurements Lymph node yield and perioperative and postoperative oncological and functional outcomes were measured. Results and limitations The median patient age was 38 yr (interquartile range [IQR] 32–41) and the median operative time was 274 min (IQR 238–280). Node metastases were pathologically confirmed in three patients. The median number of lymph nodes removed was 19 (IQR 18–21), and the median number of positive lymph nodes was 2 (IQR 1–3). No patient experienced intraoperative or postoperative complications. The postoperative hospital stay was either 3 or 4 d. Maintenance of antegrade ejaculation was achieved in all patients. After median follow-up of 15 mo (IQR 14–30), all patients were alive and no recurrence was observed. Limitations include the low number of patients and the single surgeon experience. Conclusions RoboRPLND-NS+ is a safe and feasible technique that allows removal of a high number of lymph nodes with good functional outcomes. Short-term survival outcomes were excellent, with no recurrences or deaths recorded. Patient summary We describe a feasible and safe robot-assisted surgical procedure for removal of lymph nodes in patients with testicular cancer. Our technique has potential to decrease the medical problems arising as side effects of the surgery while achieving good cancer control., Take Home Message Robotic-assisted nerve sparing retroperitoneal lymph node dissection with the monoblock technique for the treatment of patients with stage 1 or 2 testis cancer is a safe and feasible technique that can lead to good functional outcomes.

Diese Ubersichtsarbeit zeigt den derzeitigen Stand der diagnostischen und therapeutischen Moglichkeiten in der Behandlung der uberaktiven Blase (OAB) beim Mann. Grundsatzlich muss die idiopathische OAB (OAB im engeren Sinn) abgegrenzt werden zur OAB, welcher eine auslosende Ursache zugrundeliegt (OAB im erweiterten Sinn). Insbesondere beim Mann kommt hier eine Vielzahl von Differenzialdiagnosen in Frage. Grundvoraussetzung einer korrekten Abklarung ist eine grundliche Anamnese, bei welcher wegweisende Informationen gesammelt und erste Differenzialdiagnosen gestellt werden. Nebst der klinischen Untersuchung, einem Basisblutbild (inklusive PSA, Nierenwerte) und einer Urinanalyse soll die Diagnostik durch Spezialuntersuchungen durch den Facharzt fur Urologie erweitert werden (Zystoskopie/Video-Urodynamik). Die Therapie richtet sich nach der zugrundeliegenden Erkrankung im Falle einer OAB im erweiterten Sinn und sofern behandelbar. Ansonsten erfolgt eine symptomorientierte Therapie im Falle einer idiopathischen OAB. Konservative Therapieansatze umfassen die Beckenboden-Physiotherapie, nichtinvasive Elektrostimulationstherapien oder Lifestyle-Modifikationen, aber auch Medikamente wie Antimuskarinika oder Beta-Sympathomimetika. Invasivere Therapiemoglichkeiten wie Botox-Injektionen in die Harnblase oder die sakrale Neuromodulation sind je nach Ursache als sekundare Therapien zu sehen. Operative Ansatze wie die Blasenaugmentation oder Zystektomie sind bei Therapieversagen in Erwagung zu ziehen. Neben diesen Therapieansatzen nimmt die Patientenberatung eine zentrale Bedeutung ein, da ein Therapieerfolg oft erst nach langerer Zeit und nach mehreren frustranen Therapieversuchen verzeichnet werden kann.

Objective To perform a systematic review of the literature concerning postoperative peripheral neuropathies associated with patient positioning during robot-assisted laparoscopic radical prostatectomy (RARP). Patients and methods A systematic review on articles published from January 1, 1990 to March 15, 2020 was performed in accordance with the PRISMA declaration (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). The electronic search was done searching through the Cochrane Registry, PubMed/EMBASE, Medline, and Scopus. Relevant papers addressing postoperative peripheral neuropathies related to patient positioning during RARP were integrated into the analyses. Results After screening 4975 articles, one randomized controlled trial and five retrospective studies with a total of 63,667 patients were included in this review. Peripheral neuropathies of the upper extremities were documented in three articles with a total of 15 patients, peripheric neuropathies of the lower extremities were reported in five articles with a total of 76 patients. Analysis of the data was exploratory, since screening techniques, systematically reporting, and description of positioning techniques was not standardized or not reported. Conclusions The incidence of peripheral neuropathies at RARP varies between 1.3% and 10.8%. Lower extremities are more affected than upper extremities and the most important risk factors are intraoperative time duration, patients comorbidities, and ASA score. High-quality prospective randomized studies to better assess the impact of patient positioning during RARP on the development postoperative peripheral neuropathies are needed.

Objective: To assess the prevalence of frailty, a status of vulnerability to stressors leading to adverse health events, in bladder cancer patients undergoing radical cystectomy (RC), and test the impact of frailty measurements on postoperative adverse outcomes. Methods: A systematic review of English-language articles published up to April 2020 was performed. Electronic databases were searched to quantify the frailty prevalence in RC patients and assess the predictive ability of frailty indexes on RC-related outcomes as postoperative complications, early mortality, hospitalization length (LOS), costs, discharge dispositions, readmission rate. Results: Eleven studies were selected. Patients’ frailty was identified by Johns Hopkins indicator (JHI) in two studies, 11-item modified Frailty Index (mFI) in four, 5-item simplified FI (sFI) in three, 15-point mFI in one, Fried Frailty Criteria in one. Considering all the frailty measurements applied, 8% and 31% of patients were frail or pre-frail, respectively. Frail (43%) and pre-frail patients (35%) were more at risk of major complications compared to non-frail (27%) using sFI; with JHI the percentages of frail and non-frail were 53% versus 19%. According to JHI and mFI frailty was related to longer LOS and higher costs. JHI identified that 3% of frail patients experience in-hospital mortality versus 1.5% of non-frail. Finally, using sFI, frail (28%), and pre-frail (19%) were more likely to be discharged non-home compared to non-frail patients (8%) and had a higher risk of 30-day mortality (4% and 2% versus 1%). Conclusions: Almost half of RC patients were frail or pre-frail, conditions significantly related to an increased risk of postoperative adverse events with higher rates of major complications and early mortality. The most-used frailty index was mFI, while JHI and sFI resulted the most reliable to predict early postoperative RC-related adverse outcomes and should be routinely included in clinical practice after better standardization throughout prospective comparative studies. Abbreviations: ACG: Adjusted Clinical Groups; ACS: American College Surgeons; AUC: area under the curve; BCa: bladder cancer; CCI: Charlson Comorbidity Index; CSHA-FI: Canadian Study of Health and Aging Frailty Index; CCS: Clavien-Dindo Classification Score; ERAS: Enhanced Recovery After Surgery; FFC: Fried Frailty Criteria; (e)(m)(s)FI: (extended) (modified) (simplified) Frailty Index; ICU: intensive care unit; IQR: interquartile range; (p)LOS: (prolonged) length of hospital stay; NSQIP: National Surgical Quality Improvement Program; OR: odds ratio; (O)PN: (open) partial nephrectomy; PRISMA: Preferred Reporting Items for Systematic reviews and Meta-Analyses; (O)(RA)RC: (open)(robot-assisted) radical cystectomy; (O)RN: (open) radical nephrectomy; ROC: receiver operating characteristic; RNU: radical nephroureterectomy; (R)RP: (retropubic) radical prostatectomy; RR: relative risk; THCs: total hospital charges; nephrectomy; UD: urinary diversion

Background: Laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) are commonly used techniques for treating small renal masses. Regarding renal function (RF) preserva...

To evaluate the trends in risk-group distribution and Pentafecta outcomes in patients treated with nerve-sparing (NS), robot-assisted radical prostatectomy (RARP) in a single low-intermediate volume prostate cancer (PCa) center over a 10-year period. We queried a prospectively maintained database for patients who underwent NS RARP between 2009 and 2018 in a low-intermediate volume PCa center. Risk-groups were defined according to the D’Amico classification. Pentafecta outcomes referred to the postsurgical presence of potency and continence, and the absence of biochemical recurrence (BCR), positive surgical margins (PSM), and perioperative complications. The Kruskall–Wallis test, the t test and the Mann–Whitney tests were used when appropriate. 603 patients underwent NS RARP and 484 patients were evaluated for Pentafecta outcomes. Median postsurgical follow-up was 28 months. Overall, 137 (22.7%), 376 (62.3%), and 90 (15%) patients were diagnosed in the low-, intermediate-, and high-risk groups, respectively. Patients undergoing NS RARP shifted from 33 to 20% in the low-risk group, from 52 to 62% in the intermediate-risk group, and from 10 to 13% in the high-risk group. Patients reaching Pentafecta increased from 38 to 44%. No postoperative potency was the main reason for non-achieving Pentafecta (71%). BCR strongly limited Pentafecta achievement in the high-risk group (61%), but not in intermediate (24%) and low-risk (30%) groups. Low-intermediate volume PCa centers show similar trends to high-volume centers regarding risk group distributions over time in PCa patients undergoing NS RARP. We reported an increase in Pentafecta outcomes achievement over time even for experienced surgeons. Pentafecta outcomes achievement is risk-group dependent.

Background Correct identification of variant histologies (VHs) of bladder cancer (BCa) at transurethral resection of the bladder (TURB) could drive the subsequent treatment. Objective To evaluate the concordance in detecting VHs between TURB and radical cystectomy (RC) specimens in BCa patients. Design, setting, and participants We retrospectively analyzed 1881 BCa patients who underwent TURB and subsequent RC at seven tertiary care centers between 1980 and 2018. VHs were classified as sarcomatoid, lymphoepithelioma-like, neuroendocrine, squamous, micropapillary, glandular, adenocarcinoma, nested, and other variants. Outcome measurements and statistical analysis Concordance between TURB and RC was defined as the ability to achieve histological subtypes at TURB confirmed at RC specimen, and was expressed according to Cohen’s kappa coefficient. Results and limitations Of the patients, 14.6% and 21% were diagnosed with VH at TURB and RC specimens, respectively. The most common VHs at TURB were squamous, neuroendocrine, and micropapillary carcinoma (5.2%, 1.5%, and 1.5%, respectively). At RC, the most frequent VHs were squamous, micropapillary, and sarcomatoid carcinoma (7.2%, 3.0%, and 2.7%, respectively). The overall concordance in detecting VH was defined as slight concordance (coefficient: 0.18). Moderate concordance was found for neuroendocrine, adenocarcinoma, and squamous carcinoma (coefficient: 0.49, 0.47, and 0.41, respectively). Micropapillary, glandular, and other variants showed slight concordance (coefficient: 0.05, 0.17, and 0.12, respectively), while nested and sarcomatoid carcinoma showed fair concordance (coefficient: 0.32 and 0.26, respectively). Results may be limited by the absence of centralized pathological analysis. Conclusions A non-negligible percentage of patients were diagnosed with VH at both TURB and RC. TURB showed relatively low accuracy, ranging from poor to moderate, in detecting VHs. Our study underlines the need of additional diagnostic tools in order to identify VHs properly at precystectomy time and to improve patient survival outcomes. Patient summary In this report, we underlined the low accuracy of transurethral resection of the bladder in detecting variant histologies and the need for additional diagnostic tools.

Purpose This study aims to specify and explain the previous findings of unexpectedly high rates of ejaculatory disorders, i.e. 56%, found after prostatic artery embolization (PAE) in a randomized controlled trial comparing safety and efficacy of PAE and transurethral resection of the prostate (TURP). Patients and methods Case report forms of the randomized controlled trial were analyzed to specify the grade of postoperative ejaculatory dysfunction 3 months postoperatively. In addition, study participants with assessable ejaculation were asked to complete the four-item Male Sexual Health Questionnaire-Ejaculation Dysfunction Short Form (MSHQ-EjD) referring to their ejaculatory function at present, as well as before treatment and 3 months after. Potential explanations for ejaculatory disorders after PAE were derived from histological examination of five radical prostatectomy specimens of patients that underwent PAE 6 weeks before radical prostatectomy within a proof-of-concept trial at the study site, St. Gallen Cantonal Hospital. An experienced uropathologist systematically examined the whole-gland embedded tissue with focus on structures that are involved into ejaculation. Results While patients after TURP predominantly suffered from anejaculation (52%), diminished ejaculation was found more often after PAE (40%). Significantly higher MSHQ-EjD scores were found 3 months after PAE and at a median follow-up of 31 months. Histological examination showed marked changes of structures involved into ejaculation (e.g., prostatic glands, seminal vesicles, ejaculatory ducts) after PAE. Conclusion Although anejaculation occurs less frequently after PAE (16%) compared to TURP (52%), patients have to be informed about the relevant risk of ejaculatory disorders, especially diminished ejaculation.

Prostatic artery embolization (PAE) has been introduced into clinical practice for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH-LUTS) despite a lack of high-level evidence.To perform a systematic review and meta-analysis of clinical trials comparing efficacy and safety of PAE versus established surgical therapies.Medline, Embase, and York CRD were searched up to June 23, 2018. Only comparative studies were included. The risk of bias was assessed by the Cochrane Collaboration tool. Meta-analyses were performed using RevMan 5.3.Five studies including 708 patients met the selection criteria. Risk of bias was rated high for most of the studies. Mean reduction in the International Prostate Symptom Score was lower after PAE compared with standard surgical therapies (mean difference 3.80 points [95% confidence interval: 2.77-4.83]; p0.001). PAE was less efficient regarding improvements in all functional parameters assessed including maximum urinary flow, post void residual, and reduction of prostate volume. In contrast, patient-reported erectile function (International Index of Erectile Function 5) was better after PAE and significantly fewer adverse events occurred after PAE.Moderately strong evidence confirms efficacy and safety of PAE in the treatment of BPH-LUTS in the short term. Significant advantages regarding safety and sexual function, but clear disadvantages regarding all other patient-reported and functional outcomes were found for PAE. Large-scale randomized controlled trials including longer follow-up periods are mandatory before PAE can be considered as a standard therapy and to define the ideal indication for PAE in the management of BPH-LUTS.We reviewed the role of prostatic artery embolization (PAE) in the treatment of symptoms associated with benign overgrowth of the prostate. The results suggest that PAE is not as effective as established surgical therapies but has fewer side effects. Further research is required to determine whether PAE is the best treatment for certain types of patients. PAE should, therefore, not yet be considered a standard treatment.

Objectives: Adjuvant chemotherapy (ACT) is recommended for non-organ-confined bladder cancer (BCa) after radical cystectomy (RC) and pelvic lymph node dissection (PLND), but there are sparse data regarding its specific efficacy in patients with histological variants. The aim of our study was to evaluate the role of ACT on survival outcomes in patients with variant histology in a large multicenter cohort. Materials and methods: We retrospectively evaluated data of 3963 patients with BCa treated with RC and bilateral PLND with curative intent at several institutions between 1999 and 2018. The histological type was classified into six groups: pure urothelial carcinoma (PUC) or squamous, sarcomatoid, micropapillary, glandular and neuroendocrine differentiation. Multivariable competing risk analysis was applied to assess the role of ACT on recurrence and cancer-specific mortality (CSM) in each histological subtype. Results: Of the 3963 patients included in the study, 23% had variant histology at RC specimen and 723 (18%) patients received ACT. ACT was found to be significantly associated with reduced risk of recurrence (sub-hazard ratio [SHR]: 0.55, confidence interval [CI] 0.42–0.71, p < 0.001) and CSM (SHR: 0.58, CI 0.44–0.78, p < 0.001) in the PUC only, while no histological subtype received a significant benefit on survival outcomes (all p > 0.05) from administration of ACT. The limitation of the study includes the retrospective design, the lack of a central pathology review and the number of ACT cycles. Conclusion: In our study, the administration of ACT was associated with improved survival outcomes in PUC only. No histological subtype found a benefit in overall recurrence and CSM from ACT.

INTRODUCTION Radical cystectomy (RC) with bilateral pelvic lymph node dissection (PLND) is a complex surgical procedure, associated with substantial perioperative complications. Previous studies suggested reserving it to high-volume centers in order to improve oncological and perioperative outcomes. However, only limited data exist regarding low-volume centers with highly experienced surgeons. We aimed to assess oncological and perioperative outcomes after RC performed by experienced surgeons in the low-volume center of Luzerner Kantonsspital, Lucerne, CH. METHODS We retrospectively analyzed data of 158 patients who underwent RC and PLND performed between 2009 and 2019 at a single low-volume center by three experienced surgeons, each having performed at least 50 RCs. Complications were graded according to the 2004 modified Clavien-Dindo grading system. RESULTS A total of 110 patients (70%) received an incontinent urinary diversion (ileal conduit or ureterocutaneostomy) and 48 patients (30%) received a continent urinary diversion (ileal orthotopic neobladder, ureterosigmoidostomy, or Mitrofanoff pouch). Median operating time was 419 minutes (interquartile range [IQR] 346-461). Overall, at RC specimen, 71.5% of patients had urothelial carcinoma ,12.6% squamous, 3.1% sarcomatoid, 1.2%glandular, and 0.6% small cell carcinoma. Median number of lymph nodes removed was 23 (IQR 16-29.5). Positive margins were found in eight patients (5.1%). Overall, five-year survival rate was 52.4%. The complication rate was 56.3%: 143 complications were found in 89 patients, 36 (22.8%) with Clavien ≥3. The 30-day mortality rate was 2.5%. CONCLUSIONS RC could be safely performed in a low-volume center by experienced surgeons with comparable outcomes to high-volume centers., + ID der Publikation: unilu_54106 + Sprache: Englisch + Bemerkungen: Can Urol Assoc J 2021;15(11):E582-7. http://dx.doi.org/10.5489/cuaj.7171 Published online May 11, 2021 Copyright Notice You, the Author(s), assign your copyright in and to the Article to the Canadian Urological Association. This means that you may not, without the prior written permission of the CUA: Post the Article on any Web site Translate or authorize a translation of the Article Copy or otherwise reproduce the Article, in any format, beyond what is permitted under Canadian copyright law, or authorize others to do so Copy or otherwise reproduce portions of the Article, including tables and figures, beyond what is permitted under Canadian copyright law, or authorize others to do so. The CUA encourages use for non-commercial educational purposes and will not unreasonably deny any such permission request. You retain your moral rights in and to the Article. ... CUA may not assert its copyright in such a way that would negatively reflect on your reputation or right ... + Letzte Aktualisierung: 2022-02-23 18:13:20

Background Literature lacks clear evidence regarding the optimal treatment for non–muscle-invasive micropapillary bladder cancer (MPBC) due to its rarity and the presence of only small sample size and single-centre studies. Objective To assess cancer-specific mortality (CSM) and overall mortality (OM) between immediate radical cystectomy (RC) and conservative management among T1 high-grade (HG) MPBC. Design, setting, and participants We retrospectively analysed a multicentre dataset including 119 T1 HG MPBC patients treated between 2005 and 2019 at 15 tertiary referral centres. The median follow-up time was 35 mo (interquartile range: 19–64). Intervention Patients underwent immediate RC versus conservative management with bacillus Calmette-Guerin. Outcomes measurements and statistical analysis Cumulative incidence functions and Kaplan-Meier methods were applied to estimate survival outcomes. Multivariable Cox analyses were performed to assess independent predictors of disease recurrence and disease progression after conservative management; covariates consisted of pure MPBC, concomitant lymphovascular invasion (LVI), and carcinoma in situ at initial diagnosis. Results and limitations Immediate RC and conservative management were performed in 27% and 73% of patients, respectively. CSM and OM did not differ significantly among patient treated with immediate RC versus conservative management (Pepe-Mori test p = 0.5 and log-rank test p = 0.9, respectively). Overall, 66.7% and 34.5% of patients experienced disease recurrence and disease progression after conservative management, respectively. At multivariable Cox analyses, concomitant LVI was an independent predictor of disease recurrence (p = 0.01) and progression (p = 0.03), while pure MPBC was independently associated with disease progression (p = 0.03). The absence of a centralised re-review and the retrospective design represent the main limitations of our study. Conclusions Conservative management could achieve satisfactory results among T1 HG MPBC patients with neither pure MPBC nor LVI at initial diagnosis. Patient summary Bacillus Calmette-Guerin seems to be an effective therapy for T1 micropapillary bladder cancer patients with neither pure micropapillary disease nor lymphovascular invasion at initial diagnosis.

Intravesical chemotherapeutical agents after transurethral resection have shown to be effective in reducing the risk of recurrence and progression during the follow up. Specifically, an early single chemotherapeutical instillation (SI) might play an important role but the efficacy of this treatment has been questioned. For these reasons, we sought to review and summarize the current evidence with a non-systematic Medline/PubMed literature search. Level 1a evidence strongly supports the utility of SI in reducing recurrence in low-intermediate risk non-muscle invasive bladder cancer (NMIBC) patients, with about 35% of relative reduction rates in patients with single

PURPOSE To assess the frequency and potential predictors of prostatic central gland tissue detachment (CGD), an enucleation-like reaction that sporadically occurred in a randomized controlled trial assessing efficacy and safety of prostatic artery embolization (PAE). MATERIALS AND METHODS Trial data were analyzed to identify patients with CGD after PAE. Clinical parameters, MR imaging findings, technical details of PAE, and periinterventional data were compared between patients with and without CGD to identify parameters for prediction, induction, or early detection of CGD after PAE. RESULTS CGD occurred after PAE in 3 of 48 patients (6.3%); these cases had good functional outcomes, but CGD was associated with increased risk of ejaculatory dysfunction and occurrence of complications. Frequency of preoperative transurethral bladder catheterization (100% vs 13.3%; P = .005), central gland index (mean ± standard deviation, 0.86 ± 0.02 vs 0.69 ± 0.14; P < .001), amount of particles applied (1.93 mL ± 0.12 vs 0.96 mL ± 0.36; P < .001), maximum early postoperative pain score (7.33 ± 2.08 vs 1.89 ± 2.40; P = .009), and blood C-reactive protein (CRP) levels after 48 hours (69.0 vs 18.58 mg/dL; P = .045) and 1 week (113.50 vs 5.16 mg/dL; P = .004) were significantly higher in cases of CGD. CONCLUSIONS CGD is a rare reaction that might be triggered by prostatic zonal anatomy, embolization technique, and mechanical or inflammatory processes. It should be considered in patients with severe postoperative pain and high CRP levels who experience voiding dysfunction after PAE to avoid complications. Investigation of larger cohorts might further elucidate this tissue response.

OBJECTIVES To perform a post-hoc analysis of in-hospital costs incurred in a randomized controlled trial comparing prostatic artery embolization (PAE) and transurethral resection of the prostate (TURP). PATIENTS AND METHODS In-hospital costs arising from PAE and TURP were calculated using detailed expenditure reports provided by the hospital accounts department. Total costs including those arising from surgical and interventional procedures, consumables, personnel, and accommodation were analysed for all of the study participants and compared between PAE and TURP using descriptive analysis and two-sided t-tests adjusted for unequal variance within groups (Welch t-test). RESULTS Mean total costs per patient (± SD) were higher for TURP at €9,137 ± 3,301 than for PAE at €8,185 ± 1,630. The mean difference (md) of €952 was not statistically significant (p=0.07). While the mean procedural costs were significantly higher for PAE (md €623 (p=0.009)), costs apart from the procedure were significantly lower for PAE with an md of €1,627 (p< 0.001). Procedural costs of €1,433 ± 552 for TURP were mainly incurred by anaesthesia, whereas €2,590 ± 628 for medical supplies were the main cost factor for PAE. CONCLUSIONS Since in-hospital costs are similar but PAE and TURP have different efficacy and safety profiles, the patient's clinical condition and expectations - rather than finances - should be taken into account when deciding between PAE and TURP. This article is protected by copyright. All rights reserved.

Aims To systematically assess all available evidence on efficacy and safety of desmopressin for treating nocturia in patients with multiple sclerosis (MS). Methods This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified by electronic search of Cochrane register, Embase, Medline, Scopus (last search March 3, 2018) and by screening of reference lists and reviews. Results After screening of 7015 abstracts, 8 prospective, and 1 retrospective studies were included enrolling a total of 178 patients. The mean patient age ranged between 43 and 51 years. A significant decrease in the number of micturitions per night was reported in 5 studies. An increase in the maximum hours of uninterrupted sleep was only found in two studies. A significant reduction of the volume of nocturnal incontinence was described in one study. The patient satisfaction rates ranged from 56% to 82%. The rate of adverse events was between 0% and 57.9%. The rate of hyponatremia ranged from 0% to 23.5% and other commonly reported adverse events were headache, nausea, fluid retention, rhinitis/epistaxis, malaise, and swollen ankles. Risk of bias and confounding was relevant in all studies. Conclusions Preliminary data suggest that desmopressin might be effective for treating nocturia in patients with MS. However, adverse events are relatively common, the overall quality of evidence is low and the number of studied patients is very limited. Further studies with newer formulations of desmopressin are highly warranted.

OBJECTIVES To identify predictive parameters of different treatment outcomes after prostatic artery embolization (PAE) in the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. PATIENTS AND METHODS A post-hoc analysis of data derived from the 48 patients undergoing PAE in a randomized, open label, non-inferiority trial was performed. Relative changes in the International Prostate Symptoms Score (IPSS), absolute changes in maximum flow rate, and relative changes in MRI-assessed prostate volume from baseline to 12 weeks were defined as the outcomes measures of interest. Their association with various baseline characteristics and measures, technical details of PAE, and early postoperative measures was analyzed using Spearman rank correlations and Wilcoxon rank-sum tests. The most promising predictors were further evaluated in ROC analyses. RESULTS Higher total prostate and central gland (i.e., central plus transitional zone) volumes were associated with more pronounced improvements in the IPSS (Spearman rank correlation (rs): -0.35 and -0.34; p = 0.01 and p = 0.02 respectively) and the maximum flow rate (rs: 0.31 and 0.39; p = 0.05 and p = 0.01, respectively). ROC analyses suggested that volumes of 39 and 38 mL for total prostate and central gland volume, respectively, would be optimal cutoff points to predict PAE success as measured by the IPSS. Other anatomical characteristics of the prostate such as the central gland index also showed an even more distinct correlation to the improvement in maximum flow rate (rs: 0.46, p = 0.003). The relative changes in prostate volume were clearly dependent on the technical performance of PAE. Occurrence of postoperative pain and blood levels of prostate-specific antigen (PSA) and C-reactive protein (CRP) emerged as potential early stage outcome predictors after PAE. CONCLUSION Baseline and perioperative findings might help to guide patient selection and outcome prediction for PAE. Patients with larger prostates have a higher chance of success with PAE. Larger scale clinical trials including a longer follow-up are warranted to further elucidate the most suitable patients for PAE. This article is protected by copyright. All rights reserved.

Background Radical nephroureterectomy (RNU) with the concomitant excision of the distal ureter and bladder cuff is the current standard of care for the treatment of muscle invasive and/or high-risk upper tract urothelial carcinoma (UTUC). In small uncontrolled studies, laparoscopic RNU has been suggested to be associated with better perioperative outcomes compared to open RNU. The aim of our study was to compare the perioperative oncological and functional outcomes of open RNU versus laparoscopic RNU after adjusting for preoperative baseline patient-related characteristics. Methods We evaluated a multi institutional retrospective database composed by 1512 patients diagnosed with UTUC and treated with open or laparoscopic RNU between 1990 and 2016. Perioperative outcomes included operative time, blood loss, and length of hospital stay, as well as postoperative complications, readmission, reoperation, and mortality rates at 30 and 90 days from surgery. A 1:1 propensity score matching estimated using logistic regression with the teffects psmatch function of STATA 13® (caliper 0.2, no replacement) was performed using preoperative parameters such as: age, gender, body mass index (BMI), and American Society of Anesthesiologists (ASA) score. Results Overall, 1007 (66.6%) patients were treated with open and 505 (33.4%) with laparoscopic RNU. Open RNU resulted into shorter median operative time (180 vs 230 min, p 0.05). At multivariable linear regression after propensity score matching adjusted for lymph node dissection and year of surgery, laparoscopic RNU resulted in longer operative time (Coefficient 43.6, 95% CI 27.9-59.3, p Conclusions Laparoscopic RNU is associated with shorter hospital stay, but longer operative time in comparison to open RNU. Otherwise, there were no differences in other perioperative outcomes between these surgical modalities even after propensity score matching. The choice to offer laparoscopic or open RNU in the treatment of UTUC should not be based on concerns of different safety outcomes.

Prostatic artery embolisation (PAE) for the treatment of lower urinary tract symptoms secondary to benign prostatic obstruction (LUTS/BPO) still remains under investigation.To compare the efficacy and safety of PAE and transurethral resection of the prostate (TURP) in the treatment of LUTS/BPO at 2 yr of follow-up.A randomised, open-label trial was conducted. There were 103 participants aged ≥40 yr with refractory LUTS/BPO.PAE versus TURP.International Prostate Symptoms Score (IPSS) and other questionnaires, functional measures, prostate volume, and adverse events were evaluated. Changes from baseline to 2 yr were tested for differences between the two interventions with standard two-sided tests.The mean reduction in IPSS after 2 yr was 9.21 points after PAE and 12.09 points after TURP (difference of 2.88 [95% confidence interval 0.04-5.72]; p = 0.047). Superiority of TURP was also found for most other patient-reported outcomes except for erectile function. PAE was less effective than TURP regarding the improvement of maximum urinary flow rate (3.9 vs 10.23 ml/s, difference of -6.33 [-10.12 to -2.54]; p 0.001), reduction of postvoid residual urine (62.1 vs 204.0 ml; 141.91 [43.31-240.51]; p = 0.005), and reduction of prostate volume (10.66 vs 30.20 ml; 19.54 [7.70-31.38]; p = 0.005). Adverse events were less frequent after PAE than after TURP (total occurrence n = 43 vs 78, p = 0.005), but the distribution among severity classes was similar. Ten patients (21%) who initially underwent PAE required TURP within 2 yr due to unsatisfying clinical outcomes, which prevented further assessment of their outcomes and, therefore, represents a limitation of the study.Inferior improvements in LUTS/BPO and a relevant re-treatment rate are found 2 yr after PAE compared with TURP. PAE is associated with fewer complications than TURP. The disadvantages of PAE regarding functional outcomes should be considered for patient selection and counselling.Prostatic artery embolisation is safe and effective. However, compared with transurethral resection of the prostate, its disadvantages regarding subjective and objective outcomes should be considered for individual treatment choices.

To investigate the impact of preoperative nutritional factors [body mass index (BMI)], hypoalbuminemia (

Background For a large proportion of patients with spinal cord injury, sexuality and reproduction are important issues. However, sparse data exist regarding available treatment options for this patient population. Objectives We sought to review performance and safety rates of all currently available treatment options for erectile dysfunction in spinal cord injury men. Materials and methods A systematic literature review without time restrictions was performed using PubMed/EMBASE database for English-, Italian-, German-, and Spanish-language articles. Articles' selection was performed according to the PRISMA guidelines. Relevant papers on erectile dysfunction in spinal cord injury patients were included in the final analyses. Results and discussion Overall, 47 studies were eligible for inclusion in this review. Of these, most evidence dealt with phosphodiesterase 5-inhibitors and intracavernous drug injection. Both treatment options are associated with high levels of performance and with patients/partners' satisfaction; side effects are acceptable. Overall, penile prostheses and vacuum erection devices are in general less approved by spinal cord injury patients and are correlated with increased rates of complications in comparison with phosphodiesterase 5-inhibitors and intracavernous drug injection. Sacral neuromodulation, transcutaneous electrical nerve stimulation, and intraurethral suppositories have been poorly studied, but preliminary studies did not show convincing results. Conclusion The best treatment options for erectile dysfunction in spinal cord injury patients emerged to be phosphodiesterase 5-inhibitors and intracavernous drug injection. The choice of erectile dysfunction treatment should be based on several aspects, including residual erectile function, spinal cord injury location, and patients' comorbidities. Future studies assessing the applicability of less well-studied treatments, as well as evaluating innovative options, are needed in this specific population.

The most common cause of acute renal colic is a ureteral obstruction caused by ureterolithiasis. Urgent intervention is often necessary due to intractable pain. Early extracorporeal shockwave lithotripsy (SWL) as an alternative treatment option to ureteral stenting becomes forgotten in times of rising Ureterorenoscopy. Definitive guidelines are lacking which urgent treatment should be preferred in absence of signs of infection. Therefore, we assessed efficacy and safety of early SWL (eSWL) to secondary SWL (sSWL) after urgent ureteral stenting.

Extended pelvic lymph node dissection (ePLND) remains the most accurate procedure for lymph node staging in intermediate- and high-risk prostate cancer (PCa) patients undergoing radical prostatectomy (RP). A superextended pelvic lymph node dissection (sePLND) can be considered in selected very-high-risk PCa patients.To demonstrate a reproducible robot-assisted technique for sePLND at the time of RP for PCa.From June 2016 to August 2019, 41 consecutive patients with localized PCa and very high risk for lymph node invasion (LNI) received a robot-assisted RP and a standardized 10-step monoblock ePLND, followed by a 5-step monoblock sePLND. Very high risk for LNI was defined as ≥30% risk for LNI, as calculated by the Briganti 2017 nomogram.After performing the ePLND template resection (harvesting lymph nodes from the obturator region, external and internal iliac vessels, and common iliac vessels up to the ureter crossing), the 5-step monoblock sePLND approach was performed. The sePLND template was tailored to the common iliac vessels up to the aortic and caval bifurcation as well as the presacral region.Lymph node yield, perioperative complications.Overall, 41 patients received sePLND, reporting a median (interquartile range [IQR]) number of nodes removed of 23 (19-29). Median operative time (including RP, ePLND, and sePLND) was 256 min. Median preoperative prostate-specific antigen was 12 ng/mL (IQR 6.45-17.6). Disease stage pT3 was found in 10 (24.4%) patients, pT3a in nine (22%) patients, pT3b in 21 (51.2%) patients, and pT4 in one (2.4%) patient. Of the treated patients, 54% revealed LNI: five (4.9%) in a solitary node, five (4.9%) in two to five nodes, and 12 (29.3%) in more than five nodes. Considering perioperative complications, three (7.3%) patients experienced Clavien I-II and four (9.7%) experienced Clavien ≥ III complications. Median hospital stay was 6 d. No patient underwent postoperative blood transfusion.The 5-step sePLND approach is a reproducible and feasible technique for PCa patients at a very high risk of LNI.In our study, we aimed to provide surgeons with a step-by-step technique for lymph node dissection, which aims to collect possibly metastatic lymph nodes of prostate cancer in an even more extended version ("superextended") than a standard ("extended") lymph node dissection.

Aim To systematically assess all available evidence on efficacy and safety of catheterization for treating neurogenic lower urinary tract dysfunction (NLUTD) in patients with multiple sclerosis (MS). Methods This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified by electronic search of Embase, Medline, Scopus, Cochrane register (last search March 3, 2018) and by screening of reference lists and reviews. Results After screening 7'015 articles, we included four studies (one prospective and two retrospective cohort studies, one retrospective cross-sectional study), in which a total of 445 patients were enrolled. No randomized controlled trial was available. Catheterization substantially increased quality of life, post void residual, and incontinence episodes in all included studies. Pooling of data for meta-analysis was not possible due to the heterogeneity of reported outcomes. Adverse events were reported in two studies only. Risk of bias and confounding was intermediate. Conclusions Preliminary data suggests beneficial effects of catheterization on the urological outcome in patients with MS. However, although intermittent and indwelling catheterization is used frequently in daily clinical practice in the MS population, the evidence base is very limited and well-designed, properly sampled, and powered studies are urgently needed.

Purpose To provide initial data on tumoricidal efficacy of embolization on prostate cancer via histopathologic examination of prostatectomy specimens after embolization. Materials and Methods In this bicentric prospective trial, 12 men with localized prostate cancer underwent radical prostatectomy 6 weeks after prostatic artery embolization (PAE) from October 2016 to May 2017. PAE was performed with the use of 100-μm Embozene microspheres (Boston Scientific, Natick, Massachusetts). Response of prostate cancer tissue to PAE was assessed according to tumor regression grades. The major outcome measure was complete histopathologic absence of viable cancer cells, including secondary foci, in the prostatectomy specimens. Results Complete necrosis of the index lesion was found in 2 patients and partial necrosis in 5. Considering secondary cancerous foci, viable cancer cells were found in all 12 patients. Pathologic specimens were characterized by demarcated zones of necrotic tissue predominantly located in the central gland. Two patients required additional surgery to remove necrotic bladder tissue caused by PAE. Conclusions PAE with the use of 100-μm microspheres failed to achieve complete elimination of tumor cells. Extensive tumor regression was induced in some lesions, highlighting the need for further assessment of PAE as a potential treatment option for prostate cancer.

GreenLight photoselective vaporization (GL-PV) is now established in the treatment of benign prostatic enlargement. The present review outlines the available technical armamentarium and summarizes the current best evidence on functional and safety outcomes. Moreover, future technical developments and refinements are presented.GL-PV has evolved to be the most commonly performed procedure, second to conventional transurethral resection of the prostate (TURP) for surgical management of benign prostatic obstruction (BPO). On the basis of the data published in the randomized controlled Goliath study, GL-PV with 180-W technology is noninferior in terms of functional outcomes compared with TURP considering short and intermediate follow-up with a complication-free rate of around 80% after 24 months.The ongoing push towards high-power lasers can be explained by their more effective tissue ablative effect, leading to shorter operating times. Comparative analysis between high-power and low-power laser systems demonstrated similar retreatment rates and most institutions are, therefore, now performing 180-W GL-PV.Performed as an outpatient procedure, GL-PV is cost-effective with a low hospital re-admission rate. Plasma kinetic vaporization of the prostate (PKVP) has recently emerged as a potential contender in the field; also GreenLight enucleation of the prostate (GreenLEP) might be even more effective than GL-PV.GL-PV appears to be a well tolerated surgical alternative for patients suffering from BPO. Long-term follow-up data from 120-W and 180-W laser systems are still pending. Potential competitors have recently been brought to the market and further trials and long-term data will show, whether GL-PV will stand the test of time. Regardless of technical specifications, surgeon's experience remains essential to achieve good functional and safety outcomes.

Aims To systematically assess all available evidence on efficacy and safety of vanilloids for treating neurogenic lower urinary tract dysfunction (NLUTD) in patients with multiple sclerosis (MS). Methods This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified by electronic search of Cochrane register, Embase, Medline, Scopus, (last search January 8, 2016). Results After screening of 7848 abstracts, 4 randomized controlled trials (RCTs) and 3 prospective cohort studies were included. Pooled data from three RCTs evaluating intravesical capsaicin showed the standardized mean difference to be −2.16 (95% confidence interval [CI] −2.87 to −1.45) in incontinence episodes per 24 h and −0.54 (95%CI −1.03 to −0.05) in voids per 24 h. There was no statistically significant effect on maximum cystometric capacity and maximum storage detrusor pressure. Overall, adverse events were reported by >50% of the patients, most commonly were pelvic pain, facial flush, worsening of incontinence, autonomic dysreflexia, urinary tract infection and haematuria. Risk of bias and confounding was relevant in both RCTs and non-RCTs. Conclusions Preliminary data suggest that intravesical vanilloids might be effective for treating NLUTD in patients with MS. However, the safety profile seems unfavorable, the overall quality of evidence is low and no licensed substance is currently available warranting well-designed, adequately sampled and properly powered RCTs.

Die Embolisation der Prostataarterien zur Behandlung des benignen Prostatasyndroms findet weltweit zunehmend Verwendung. Auch im deutschsprachigen Raum wird diese Therapie immer haufiger, jedoch uberwiegend relativ unkritisch angeboten. Dabei liegen kaum Daten vor, welche die Anwendung auserhalb klinischer Studien rechtfertigen wurden. Eine randomisierte Studie am Kantonsspital St. Gallen soll dabei helfen, den Stellenwert der Behandlung und ihre optimale Indikation genauer zu beleuchten.

To assess the prevalence and extent of irrigation fluid absorption during thulium laser vaporization of the prostate.Fifty-four patients undergoing thulium laser vaporization of the prostate were prospectively included into the trial at a tertiary referral center. Isotonic saline containing 1% ethanol was used for intraoperative irrigation. Absorption of irrigation fluid was measured periodically during the operation using the expired breath ethanol technique. Among others, intra- and postoperative changes in biochemical and hematological laboratory findings were assessed.Absorption of irrigation fluid was detected in 7 out of 54 (13%) patients with a median absorption volume of 265 mL (227-615). No significant differences of intra- and postoperative blood parameters were observed between absorbers and nonabsorbers. No risk factor (i.e., age, prostate size, surgery duration, applied energy, and amount of irrigation fluid) for the occurrence of fluid absorption could be identified.Absorption of irrigation fluid also occurs during thulium laser vaporization of the prostate and should be kept in mind, especially in patients at a high cardiovascular risk. However, compared with previously assessed resection and vaporization techniques, thulium vaporization might have a favorable safety profile regarding fluid absorption.

INTRODUCTION AND OBJECTIVE:Retroperitonal lymph node dissection (RPLND) is performed for both staging and curative purposes in patients with retroperitoneal residual masses after chemotherapy for m...

Bladder cancer (BCa) is a common malignancy, with about 81,190 estimated new cases and 17,240 estimated deaths in the United States in 2018 (1). Neoadjuvant cisplatin-based combination chemotherapy (NAC) followed by radical cystectomy (RC) with bilateral pelvic lymph node dissection is currently considered the standard of care in muscle-invasive bladder cancer (MIBC) patients (2). However, 5 years survival after surgery is approximately 50% (3). In this regard, adjuvant cisplatin based-chemotherapy (AC) improves survival outcomes and should be administered in medically fit, NAC naive patients with pT3/4 and/or positive nodes diseases at RC (2).

Background: To assess the differential effect of robotic assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) on survival outcomes in matched analyses performed on a large multicentric cohort. Methods: The study included 9757 patients with urothelial bladder cancer (BCa) treated in a consecutive manner at each of 25 institutions. All patients underwent radical cystectomy with bilateral pelvic lymphadenectomy. To adjust for potential selection bias, propensity score matching 2:1 was performed with two ORC patients matched to one RARC patient. The propensity-matched cohort included 1374 patients. Multivariable competing risk analyses accounting for death of other causes, tested association of surgical technique with recurrence and cancer specific mortality (CSM), before and after propensity score matching. Results: Overall, 767 (7.8%) patients underwent RARC and 8990 (92.2%) ORC. The median follow-up before and after propensity matching was 81 and 102 months, respectively. In the overall population, the 3-year recurrence rates and CSM were 37% vs. 26% and 34% vs. 24% for ORC vs. RARC (all p values &gt, 0.1), respectively. On multivariable Cox regression analyses, RARC and ORC had similar recurrence and CSM rates before and after matching (all p values &gt, 0.1). Conclusions: Patients treated with RARC and ORC have similar survival outcomes. This data is helpful in consulting patients until long term survival outcomes of level one evidence is available.

To improve patient selection for neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) in bladder cancer patients (BCa). Retrospective evaluation of 1057 patients with cT2–4N0M0 BCa treated with RC and pelvic lymph node dissection between 1990 and 2018 at 3 referral centers. Adverse pathologic features (APF) were defined as pT3–pT4/pN + disease at RC. A regression tree model (CART) was used to assess preoperative risk group classes. A multivariable logistic regression (MVA) was performed to identify predictors of APF at RC. Median age was 70 years and most of the patients were men (83%). Of the 1057 patients included in our study, 688 (65%) had APF. CART analysis was able to stratify patients into 3 risk groups: low (cT2 and single disease, odds ratio [OR] 0.62), intermediate (cT2 and multiple disease, OR 1.08), and high (cT3–cT4, OR 1.28). On MVA APF were associated with variant histology (odds ratio [OR] 3.97, 95% confidence interval [CI] 1.46–10.83, p = 0.007), multifocality at TUR (OR 2.56, CI 1.27–5.17, p = 0.09), completeness of resection (OR 0.47, CI 0.23–0.96, p = 0.04) and clinical extravesical disease (OR 3.42, CI 1.63–7.14, p = 0.001). We defined three pre-operative risk classes. Our results indicate that patients with a cT3–T4 disease are those who might benefit more from NAC whereas those with T2 single disease should be those to whom NAC probably shouldn’t be proposed. Given the high rate of understaging in BCa patients, NAC can be proposed in selected cases of cT2/multifocal disease.

Objective: To assess the economic burden of temporary ureteral stenting. Methods: The German version of the ureteral stent symptom questionnaire was completed by 74 patients with unilateral inserted indwelling stents. Cost accounting was performed considering the costs of ureteral stents, drugs, consultation of healthcare professionals, hospitalization, stent extraction and work incapacity due to stent-related problems. Results: Total costs arising from stent-related problems amounted to US dollars (USD) 133,355, median USD 455 (113-11,948) for the entire stent indwelling time, and USD 15 (4-398) per patient per day. Costs (USD total/median (range)) arose mainly from work incapacity (104,154/0 (0-11, 498)), followed by healthcare professional consultation (9,177/0 (0-612)), drug costs (8,736/111 (0-427)), stent material (8,390/113), stent removal (2,235/0 (0-1,769)) and outpatient hospital care (663/0 (0-663)). Most patients also showed a reduced capacity for work due to symptoms associated with indwelling stents. Conclusion: The economic burden of morbidity associated with indwelling ureteral stents is considerably high and should be taken into account when performing ureteral stenting, especially in cases where it is not strictly indicated and when stent removal is scheduled.

INTRODUCTION AND OBJECTIVE:The most common cause of acute colic flank pain is a ureteral obstruction caused by ureterolithiasis. Emergency intervention is often necessary due to intractable pain. O...

Objective To compare prostatic artery embolisation (PAE) with transurethral resection of the prostate (TURP) in the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia in terms of patient reported and functional outcomes. Design Randomised, open label, non-inferiority trial. Setting Urology and radiology departments of a Swiss tertiary care centre. Participants 103 patients aged ≥40 years with refractory lower urinary tract symptoms secondary to benign prostatic hyperplasia were randomised between 11 February 2014 and 24 May 2017; 48 and 51 patients reached the primary endpoint 12 weeks after PAE and TURP, respectively. Interventions PAE performed with 250-400 μm microspheres under local anaesthesia versus monopolar TURP performed under spinal or general anaesthesia. Main outcomes and measures Primary outcome was change in international prostate symptoms score (IPSS) from baseline to 12 weeks after surgery; a difference of less than 3 points between treatments was defined as non-inferiority for PAE and tested with a one sided t test. Secondary outcomes included further questionnaires, functional measures, magnetic resonance imaging findings, and adverse events; changes from baseline to 12 weeks were compared between treatments with two sided tests for superiority. Results Mean reduction in IPSS from baseline to 12 weeks was −9.23 points after PAE and −10.77 points after TURP. Although the difference was less than 3 points (1.54 points in favour of TURP (95% confidence interval −1.45 to 4.52)), non-inferiority of PAE could not be shown (P=0.17). None of the patient reported secondary outcomes differed significantly between treatments when tested for superiority; IPSS also did not differ significantly (P=0.31). At 12 weeks, PAE was less effective than TURP regarding changes in maximum rate of urinary flow (5.19 v 15.34 mL/s; difference 10.15 (95% confidence interval −14.67 to −5.63); P Conclusions The improvement in lower urinary tract symptoms secondary to benign prostatic hyperplasia seen 12 weeks after PAE is close to that after TURP. PAE is associated with fewer complications than TURP but has disadvantages regarding functional outcomes, which should be considered when selecting patients. Further comparative study findings, including longer follow-up, should be evaluated before PAE can be considered as a routine treatment. Trial registration Clinicaltrials.gov NCT02054013.

Objective To assess long term functional and safety follow-up data after 80-W GreenLight photoselective vaporization (GL PV) of the prostate and transurethral resection of the prostate (TURP). Materials and Methods Prospective randomized trial at a single tertiary referral center (Geneva, Switzerland). Patients were recruited in the outpatient clinic if they met the criteria for surgical treatment of benign prostatic obstruction. At baseline, 238 patients were treated either with the 80-W GL PV or monopolar TURP. After 5 years, data were available from 105 patients: 44 GL PV patients and 61 TURP patients. The primary outcome measure was the International Prostate Symptom Score (IPSS). Secondary outcome measures included maximum urinary flow rate (Qmax), postvoidal residual (PVR) and reoperation rate. Statistical analyses were performed using Stata 14 (StataCorp). Results After 5 years of follow-up, mean improvements in International Prostate Symptom Score, postvoidal residual and maximum urinary flow rate were similar in both groups. The re-treatment rate was 14.3% in the GL PV group vs 11.9% in the TURP group (P = .9). Conclusion Noninferiority of the GL PV to TURP was confirmed in all functional and safety outcomes at 5-year follow-up. GL-PV could be a safe surgical alternative for patients suffering from benign prostatic obstruction.

BACKGROUND The imaging method most frequently employed to identify brain areas involved in neuronal processing of nociception and brain pain perception is blood oxygenation level-dependent (BOLD) magnetic resonance imaging (MRI). Arterial spin labelling (ASL), in contrast, offers advantages when slow varying changes in brain function are investigated. Chronic pelvic pain syndrome (CPPS) is a disorder of, mostly, young males that leads to altered pain perceptions in structures related to the pelvis. We aimed to investigate the potential of ASL to monitor longitudinal cranial blood flow (CBF) changes in patients with CPPS. METHODS In a randomised, placebo-controlled, double-blind single centre trial, we investigated treatment effects in CPPS after 12 weeks in patients that underwent sono-electro-magnetic therapy vs placebo. We investigated changes of CBF related to treatment outcome using pseudo-continuous arterial spin labelling (pCASL)-MRI. RESULTS We observed CBF downregulation in the prefrontal cortex and anterior cingulate cortex and upregulation in the dorsolateral prefrontal cortex in responders. Nonresponders presented with CBF upregulation in the hippocampus. In patients with a history of CPPS of less than 12 months, there were significant correlations between longitudinal CBF changes and the Chronic Prostatitis Symptom Index pain subscore within the joint clusters anterior cingulate cortex and left anterior prefrontal cortex in responders, and the right hippocampus in nonresponders. CONCLUSIONS We demonstrated therapy-related and stimulus-free longitudinal CBF changes in core areas of the pain matrix using ASL. ASL may act as a complementary noninvasive method to functional MRI and single-photon emission computed tomography / positron emission tomography, especially in the longitudinal assessment of pain response in clinical trials.

OBJECTIVES: To systematically review all available evidence on efficacy and safety of cannabinoids for treating neurogenic lower urinary tract dysfunction (NLUTD) in patients with multiple sclerosis (MS). PATIENTS AND METHODS: The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified by electronic search of Cochrane register, Embase, Medline, Scopus (last search on 11 November 2016). RESULTS: After screening 8469 articles, two randomized controlled trials and one open label study enrolling a total of 426 patients, were included. Cannabinoids relevantly decreased incontinence episodes in all three studies. Pooling data showed mean difference in incontinence episodes per 24 hours to be -0.35 (95% confidence interval -0.46 to -0.24). Mild adverse events were frequent (38-100%), but only two patients (0.7%) reported a serious adverse event. CONCLUSIONS: Preliminary data imply, that cannabinoids might be an effective and safe treatment option for NULTD in patients with MS. However, evidence base is poor and more high-quality, well-designed, adequately powered and sampled studies are urgently needed to reach definitive conclusions. This article is protected by copyright. All rights reserved.

Lymphocele is the most common complication after pelvic lymph node dissection (PLND). Over the years, various techniques have been introduced to prevent lymphocele, but no final conclusion can be drawn regarding the superiority of one technique over another. In this prospective study, 220 patients undergoing robot-assisted radical prostatectomy between 2012 and 2015 were randomized to receive titanium clips (group A, n =110) or bipolar coagulation (group B, n =110) to seal lymphatic vessels at the level of the femoral canal during extended PLND (ePLND). Ultrasound examination was used to detect lymphoceles at 10 and 90 d after surgery. Lymphocele was defined as any clearly definable fluid collection and was considered clinically significant when requiring treatment. There were no statistically significant differences between groups A and B regarding overall lymphocele incidence (47% vs 48%; difference −0.91%, 95% confidence interval [CI] −2.6 to 0.7; p =0.9) and the rate of clinically significant lymphocele [5% vs 4%; difference 0.75%, 95% CI, 0.1–3.2; p =0.7]. The two groups were comparable regarding mean (±SD) lymphocele volume (30±32 vs 35±39ml; p =0.6), lymphocele location (unilateral, 37% vs 35%, p =0.7; bilateral, 13% vs 14%, p =0.9), and time to lymphocele diagnosis (95% vs 98% on postoperative day 10; p =0.5). In conclusion, this trial failed to identify a difference in lymphocele occurrence between clipping and coagulation of the lymphatic vessels at the level of the femoral canal during robot-assisted ePLND for prostate cancer. Patient summary In this study we compared the frequency of postoperative complications after sealing lymphatic vessels from the leg to the abdomen using metallic clips or electrical coagulation during robot-assisted surgery for prostate cancer. We found no difference in postoperative complications between the two methods.

AIMS: To investigate urologists' referral attitude for sacral neuromodulation (SNM) for treating refractory idiopathic overactive bladder syndrome (OAB) and to quantify the weight they attribute to clinical parameters to refrain from SNM referral. METHODS: We set up a vignette study using a discrete-choice design. The questionnaires were distributed at two national urological meetings. RESULTS: One hundred eight urologists completed the questionnaire. Three parameters were significantly associated with the decision to refrain from referral: absolute contraindications for SNM (anatomical low bladder compliance, current urinary tract infection, progressive neurological disease, urinary tumors) had the strongest association (0.78, 95% CI 0.58 to 0.97; P

Objective To evaluate the effect of transcutaneous electrical nerve stimulation (TENS) for treating men with refractory chronic pelvic pain syndrome (CPPS). Patients and Methods A consecutive series of 60 men treated with TENS for refractory CPPS was evaluated prospectively at an academic tertiary referral centre. The effects of treatment were evaluated by a pain diary and by the quality of life item of the National Institutes of Health Chronic Prostatitis Symptom Index at baseline, after 12 weeks of TENS treatment, and at last known follow-up. Adverse events related to TENS were also assessed. Results The mean (95% confidence interval, CI; range) age of the 60 men was 46.9 (43.5–50.3; 21–82) years. TENS was successful after 12 weeks of treatment in 29 (48%) patients and a positive effect was sustained during a mean (95%, CI; range) follow-up of 43.6 (33.2–56; 6–88) months in 21 patients. After 12 weeks of TENS treatment, mean (95% CI) pain visual analogue scale decreased significantly (P < 0.001) from 6.6 (6.3–6.9) to 3.9 (3.2–4.6). Patients' quality of life changed significantly after TENS treatment (P < 0.001). Before TENS, all 60 patients felt mostly dissatisfied (n = 17; 28%), unhappy (n = 28; 47%) or terrible (n = 15; 25%). After 12 weeks of TENS treatment, 29 (48%) patients felt mostly satisfied (n = 5), pleased (n = 18) or delighted (n = 6). No adverse events related to TENS were noted. Conclusion TENS may be an effective and safe treatment for refractory CPPS in men, warranting randomized, placebo-controlled trials.

BACKGROUND: In a previous observational study, thoracic epidural analgesia (TEA) after open renal surgery resulted in clinically relevant postvoid residuals (PVRs). This study aimed to investigate the individual contribution of epidurally administrated drugs and surgery in bladder dysfunction. METHODS: In this single-center, parallel-group, randomized (computer-generated list), double-blind superiority trial, 40 patients undergoing open renal surgery were equally allocated to receive epidural bupivacaine (0.125%) alone or with fentanyl (2 µg/ml). Patients underwent urodynamic investigations before TEA and during TEA preoperatively and postoperatively. Primary outcome was the difference (Δ) in PVR between before TEA and postoperatively during TEA. Secondary outcomes were changes in detrusor pressure at maximum flow rate, bladder compliance, and ΔPVR between different time points. RESULTS: Median ΔPVR (ml) from baseline to postoperatively was 180 (range, -85 to 645; P = 0.001) in the bupivacaine group and 235 (range, 0-580; P value less than 0.001) in the bupivacaine/fentanyl group, with no difference between groups (95% confidence interval, -167 to 103; P = 0.634). Detrusor pressure at maximum flow rate (cm H(2)O) from baseline was more pronounced in the bupivacaine/fentanyl than that in the bupivacaine group preoperatively (-10; range, -64 to -2; P value less than 0.001 vs. -3; range, -35 to 13; P = 0.397) (P = 0.045) and postoperatively (-18; range, -64 to 0; P value less than 0.001 vs. -12; range, -34 to 22; P = 0.006) (P = 0.135). Surgery did not affect PVRs, but a decreased bladder compliance was observed in both groups. No adverse events occurred. CONCLUSIONS: Thoracic epidurally administrated bupivacaine resulted in clinically relevant PVRs based on impaired detrusor function. The addition of fentanyl enhanced this effect without generating greater PVRs. After surgery, the voiding phase was not further impaired; however, bladder compliance was decreased.

Although chronic pelvic pain syndrome impairs the life of millions of people worldwide, the exact pathomechanisms involved remain to be elucidated. As with other chronic pain syndromes, the central nervous system may have an important role in chronic pelvic pain syndrome. Thus, we assessed brain alterations associated with abnormal pain processing in patients with chronic pelvic pain syndrome.Using brain morphology assessment applying structural magnetic resonance imaging, we prospectively investigated a consecutive series of 20 men with refractory chronic pelvic pain syndrome, and compared these patients to 20 gender and age matched healthy controls. Between group differences in relative gray matter volume and the association with bother of chronic pelvic pain syndrome were assessed using whole brain covariate analysis.Patients with chronic pelvic pain syndrome had a mean (± SD) age of 40 (± 14) years, a mean NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index) total score of 28 (± 6) and a mean pain subscale of 14 (± 3). In patients with chronic pelvic pain syndrome compared to healthy controls there was a significant reduction in relative gray matter volume in the anterior cingulate cortex of the dominant hemisphere. This finding correlated with the NIH-CPSI total score (r = 0.57) and pain subscale (r = 0.51).Reduction in relative gray matter volume in the anterior cingulate cortex and correlation with bother of chronic pelvic pain syndrome suggest an essential role for the anterior cingulate cortex in chronic pelvic pain syndrome. Since this area is a core structure of emotional pain processing, central pathomechanisms of chronic pelvic pain syndrome may be considered a promising therapeutic target and may explain the often unsatisfactory results of treatments focusing on peripheral dysfunction.

Background Data on safety and efficacy of robot-assisted radical prostatectomy (RARP) after previous abdominal surgery are scarce. Hence, we assessed perioperative, oncological and functional outcomes, and complications of RARP in patients with previous abdominal surgery after 1-year minimum follow-up. Materials and methods Prospectively collected data from 339 consecutive patients undergoing transperitoneal RARP by a single surgeon (AM) between November 2008 and May 2014 were analysed. Complications were classified according to Modified Clavien System. Biochemical recurrence (BCR) was defined as two consecutive PSA values ≥ 0.2 ng/ml. Functional outcomes were assessed using validated, self-administered questionnaires. In particular, only patients undergoing nerve-sparing RARP with no erectile dysfunction (baseline IIEF-5 score >21) and no use of phosphodiesterase-5 inhibitors preoperatively who were interested in erections and required no adjuvant therapy (radiation, orchiectomy and androgen-deprivation therapy) were evaluated concerning potency recovery. Patients without and with previous abdominal surgery were compared using Mann-Whitney and chi-square tests (or Fisher exact test). Results On 339 patients, 247 (71.6%) had not undergone previous abdominal surgery (Group 1) and 92 (28.4%) were pre-operated (Group 2). There were no statistically significant differences between Groups 1 and 2 regarding mean operative time (260 vs. 257 min; p = 0.597), median number of resected nodes (16 vs. 17; p = 0.484), mean length of stay (7.2 vs. 7.1 d; p = 0.151), positive surgical margin (12.5% vs. 16.3%; p = 0.233) and complication rates (26.7% vs. 31.5%; p = 0.187). Median (IQR) follow-up was 36 (12–48) months. For Groups 1 and 2, BCR-free survival rates were 78.5% and 79.8% (p = 0.467); continence rates were 97.9% and 100% (p = 0.329), whereas a potency recovery was achieved in 69.5% and 62.2% of patients (p = 0.460), respectively. Conclusions Transperitoneal RARP is a safe and efficient treatment for clinically localised prostate cancer even in patients with previous abdominal surgery. However, further studies with higher number of patients are warranted.

The bleeding of peristomal varices due to a portosystemic shunt is rare but potentially life-threatening in cirrhotic patients with portal hypertension. The scarce case reports in the literature recommend transjugular intrahepatic portosystemic shunt (TIPS) to prevent further bleeding. We report on a 72-year-old man who was referred to our hospital because of life-threatening bleeding from peristomal varices, three years after radical cystoprostatectomy for invasive bladder cancer. CT imaging showed liver cirrhosis with a prominent portosystemic shunt leading to massively enlarged peristomal varices. TIPS was taken into consideration, but not possible due to hepatic encephalopathy (HE). Medical therapy with lactulose and the nonselective beta-blocker carvedilol was initiated to treat HE and portal hypertension. In a second step, the portosystemic shunt was percutaneously embolized. Here, we present a multimodal approach to treat intractable bleeding from peristomal varices in a patient with ileal conduit urinary diversion, not suitable for TIPS.

BACKGROUND: The Baxter Amicus Version 2.51 (A) and the Gambro BCT Trima Accel Version 5.0 (T) cell separators may produce multiple platelet (PLT) concentrates within a single donation. STUDY DESIGN AND METHODS: The single-needle multiple plateletpheresis procedures of the two devices were compared in a prospective, randomized, paired crossover study in 60 donors. The 120 donations were compared for donor comfort, collection efficiency, residual white blood cell (WBC) count, and (in selected patients) corrected count increment (CCI). RESULTS: The mean PLT yield and the resultant mean number of units per donation were significantly lower for A (6.06 x 10(11) vs. 7.48 x 10(11) and 2.57 vs. 3.19, respectively, both p < 0.001), in spite of a longer apheresis duration (89 min vs. 79 min; p < 0.001). This resulted in a higher collection rate of T (5.68 x 10(11) PLTs/hr vs. 4.10 x 10(11) PLTs/hr, p < 0.001). Residual WBC count of every unit was fewer than 5 x 10(6), but significantly fewer A-PLT donations contained more than 10(5) WBCs per unit (1 vs. 9, p = 0.008). Although the ACD-A consumption was slightly higher for A (489 mL vs. 469 mL, p = 0.04), a trend to a higher frequency of side effects was found for T (42.4% vs. 23.7%, p = 0.06). The 1-hour CCIs of 33 transfused A-PLT units were comparable with those of 43 T-PLT units (11.8 vs. 13.9, p = 0.480). CONCLUSIONS: Both cell separators showed safe collections of up to 4 PLT units per donation with adequate CCI. T produced a higher PLT yield despite shorter apheresis duration, but with slightly higher residual WBC counts and a trend to a higher side-effect frequency.