To describe the intermediate-term oncological and functional outcomes in patients with high-risk prostate cancer (HRPCa) who were treated with neoadjuvant lutetium-177-prostate-specific membrane antigen (LuPSMA) followed by robotic-assisted laparoscopic radical prostatectomy (RARP). An open-label, single-arm clinical trial enrolled patients with HRPCa and increased uptake on PSMA-PET/CT. Two or three LuPSMA doses (7.4 GBq) were given followed by RARP with lymph node dissection. Oncological outcomes (histological and radiological findings, biochemical recurrence-free survival [bRFS]), changes in urinary and sexual functions and quality of life were analyzed. Thirteen patients (median age 67) were included. Over a median follow-up of 58 months (IQR 52, 63), bRFS rate was 42

Background A bladder diverticulum is a source of infections, urinary stones, and malignancy. Until recent years, patients suffering from large obstructive prostate and diverticulum were treated with open surgery, which also allowed diverticulectomy. The transition to a closed approach has led to diverticulum preservation. The clinical implications of this preservation strategy have not been sufficiently studied. Materials and methods A retrospective comparison was made between holmium laser enucleation of the prostate (HoLEP) patients with a diverticulum (≥2 cm) and HoLEP patients without any diverticulum. For each patient with a diverticulum, two patients without a diverticulum who were operated on around the same time were matched (1:2). Patients operated on until March 2022 were included to allow for a relatively long follow-up period. Results Out of 602 HoLEP patients, 32 (5%) had a diverticulum ≥2 cm, and they were matched with 64 patients without a diverticulum. The median diverticulum size was 37 mm (interquartile range: 25, 51). A comparison of preoperative data between the two groups revealed no significant differences. Two patients with a diverticulum required a temporary urinary catheter at discharge, but there were no significant differences in surgical, perioperative, or postoperative measures between the two groups, except for a clinically insignificant difference in residual urine volume. With a median follow-up of 3.3 years (interquartile range: 2.5, 4.5), no patient required or was referred for diverticulectomy. Conclusions HoLEP is an effective treatment method for patients with bladder outlet obstruction and concomitant bladder diverticulum. By effectively relieving the bladder outlet obstruction, HoLEP can avoid the need for more invasive surgical interventions.

Circulating tumor cells (CTCs) in prostate cancer (PCa) have been an area of interest over the past 35 years. The aim of this narrative review is to summarize data on CTC application in PCa diagnosis. Several CTC detection tools have been developed; however, most of them only assess subpopulations expressing matching biomarkers. Thus, a combined detection system might be useful, and priority should be given to creating a universal panel that covers a broad spectrum of PCa subtypes. Expression of CD82 and several other markers carries prognostic value and correlates with stage and relapse risk. In metastatic PCa, CTC detection correlates with both survival and response to therapy. AR-V7 expression by CTCs is associated with resistance to androgen receptor signaling inhibitors (ARSis), while the response to taxanes remains unaffected. OCT4 expression in CTCs is associated with higher serum LDH levels, worse radiographic progression-free survival, and overall survival. Ezrin overexpression in CTCs is associated with bone metastasis in PCa patients. HER2-positive CTC detection correlates with worse overall and progression-free survival among patients treated with ARSis. Prostate-specific membrane antigen (PSMA) expression in CTCs was associated with metastases, lower overall survival and progression-free survival, as well as poor response to chemotherapy in mCRPCa. Overall, CTC detection for PCa screening, early diagnosis, and prognosis in localized disease offers limited added value. Conversely, in metastatic PCa it shows promising results as a prognostic marker. AR-V7 expression by CTCs is a predictor of response to ARS inhibitors, while PSMA expression in CTCs is associated with metastases, poor prognosis, and suboptimal treatment response. OCT4, HER2, and ezrin in CTCs were also predictors of poor prognosis and treatment response, but the data is limited. If explored further, microRNAs could serve as a potential alternative to circulating tumor cells, as they are - in theory - able to perform the same functions.

The current systematic review aims to summarize the existing data on intraoperative use of artificial intelligence (AI) during endoscopic lithotripsy in order to assess which particular applications are feasible and have prospects of wide implementation into practice. The review included studies where adult patients with urolithiasis underwent any type of endoscopic lithotripsy with intraoperative application of AI. Preclinical trials (on animals or phantom kidneys) focusing on modelling endoscopic lithotripsy and AI application for this procedure were also considered. Six articles were included. The primary AI applications can be categorized into three domains: intraoperative navigation; tissue and stone differentiation; stone classification according to chemical composition. AI enabled reconstruction of the 3D map of endoscope movement with an accuracy of 0.6 mm and stone size measurement with an accuracy of 0.06 mm, differentiating between laser interactions with stone and tissue and differentiating between 4 common stone types (calcium oxalate monohydrate, calcium oxalate dihydrate, uric acid, and brushite). However, most of the data was obtained in experimental setups, rendering AI performance in real clinical settings still unclear. This review found that AI technologies show promise in endoscopic lithotripsy, with current systems already capable of performing accurate tissue and stone segmentation, intraoperative navigation, and stone classification, although at the moment still there is no solid clinical background, and our conclusions are predominantly based on experimental studies. Currently AI clinical utility is still questionable due to lack of studies, especially validated ones. Continued development and clinical adoption are needed to further improve urological surgery outcomes.

INTRODUCTION:Patients with severe Factor XI deficiency face unique challenges during urological procedures due to an elevated risk of bleeding, balanced against the use of tranexamic acid (TXA), which may form blood clots. Given the limitations associated with plasma-based treatment, there have been reports of successful and safe off-label use of recombinant activated Factor VII (rFVIIa) in combination with TXA in general surgery. AIM:Report our experience with this approach in urological surgeries involving tissues with heightened fibrinolytic activity. METHODS:A retrospective case series analysed seven patients with severe FXI deficiency who underwent seven urological procedures. Five patients were classified as bleeders, and two developed antibodies to FXI following prior exposure to plasma. The use of off-label rFVIIa was approved by our institutional authorities. Patients received TXA 1 g four times daily for 7-10 days, and a single dose of 10-15 mcg/kg of rFVIIa at the end of surgery (based on previous thrombin generation studies). Patients were connected to a continuous irrigation system postoperatively and monitored for urinary bleeding. RESULTS:All procedures were performed without significant bleeding complications, except for one patient who remained on aspirin therapy and experienced manageable bleeding. None of the patients required discontinuation of TXA due to blood clots, nor did they require blood transfusions or additional doses of rFVIIa. No thrombotic complications were observed. CONCLUSION:Combination of low-dose rFVIIa with TXA is a feasible and attractive option for patients undergoing urologic procedures. Further implications of this protocol should be implemented in clinical practice.

ObjectiveMuscle-invasive bladder cancer is an aggressive disease. Yet, many patients, especially those with advanced age and multiple comorbidities, do not receive treatment with curative intent. We evaluated the disease course and health care burden of these patients.Materials and methodsBi-center, retrospective analysis of patients diagnosed with muscle-invasive bladder cancer who did not undergo curative-intent treatment (radical cystectomy or trimodal therapy) between 2016 and 2021. Patient characteristics and treatment burden were described. Metastasis-free, cancer-specific, and overall survivals were evaluated using the Kaplan-Meier method.ResultsSixty-six patients with a median age of 86 (IQR 78,90) were evaluated. The median follow-up for survivors was 29 months (IQR 9, 44). All patients were diagnosed with muscle-invasive bladder cancer, and 32 (48%) presented with clinical T3 and T4 disease. The median age adjusted Charlson comorbidity index at diagnosis was 7 (IQR 6,8). Treatment with curative intent was not provided due to comorbidities and low-performance status in 58 patients (88%) and patient refusal in 8 (12%). Two-year estimated metastasis-free survival, cancer-specific survival, and overall survival were 11%, 18%, and 12%, respectively.During follow-up, 7 patients (10%) were treated with chemotherapy, 4 (6%) received immunotherapy, 21 (32%) radiation, and 17 (26%) had emergent operations due to hematuria. Twenty-four patients (37%) required nephrostomy tubes, and 39 (59%) required an indwelling urinary catheter for various periods. Forty-three patients (65%) suffered from recurrent hematuria episodes. Overall, median emergency room visits were 4 (IQR 2, 6), and median hospital admission was 16 days (IQR 9, 29).ConclusionsUntreated muscle-invasive bladder cancer is associated with a limited lifespan and a high disease burden for the patient and health system. These data should be taken into consideration and portrayed to the patient when curative intent treatment is chosen to be avoided.

The aim of our study is to assess the differences in functional outcomes during the perioperative and postoperative period after RASP depending on BPH volume. We searched 2 databases: MEDLINE (PubMed) and Google Scholar using the following search query: robot* AND “simple prostatectomy”. The search strategy and review protocol are available at Prospero (CRD42024508071). We included 25 articles published between 2008 and 2023. Preoperatively, patients with prostate size < 100 cm3 had more severe symptoms while postoperatively all of them had only mild lower urinary tract symptoms (LUTS). In larger BPH, two authors reported moderate LUTS after RASP: Fuschi [1] (mean IPSS 8.09 ± 2.41) and Stolzenburg [2] (mean IPSS 8 ± 2.7). Postoperative Qmax was also noticeably higher in smaller BPH (mean value range 28.5–55.5 ml/s) compared to larger BPH (mean Qmax 18–29.6 ml/s), although in both groups it was within the normal range. Postoperative post-void residual (PVR) was normal as well except in one study by Stolzenburg et al. [2]. Blood loss was comparable between the groups. The complications rate in general was low. RASP is effective in terms of subjective and objective urination indicators, and a safe procedure for BPH. In the lack of data on implementation of RASP in small prostate volumes, this procedure can be seen as an upper size «limitless» treatment alternative. Currently, comparative data regarding prostate volume is lacking, and future trials with subgroups analysis related to BPH volume might help to address this issue.

Background and objectiveWe compared the oncologic outcomes of patients with non-muscle invasive bladder cancer (NMIBC) who underwent transurethral resection of bladder tumor (TUBRT) using sterile water vs glycine irrigation. The tumoricidal and immunogenic effects of these solutions on urothelial cancer cell lines were investigated.MethodsThe medical records of 530 consecutive patients who underwent TURBT using sterile water or glycine irrigation for NMIBC were reviewed. Recurrence and progression rates were evaluated using time dependent analyses.Bladder cancer cell lines (RT4, T24 and 5637) were treated with glycine and sterile water. Cell viability was evaluated with the XTT assay. Cell membrane calreticulin levels were evaluated with flow cytometry. Extracellular high mobility group box 1 (HMGB1) and heat shock 70 (HSP70) protein levels were evaluated using western blots.Key findings and limitationsAfter propensity score matching each study arm comprised 161 patients. Median follow-up was 13.6 months (IQR 6.2, 24.5). The 2-year recurrence free survival was significantly lower in the sterile water vs glycine group (43% vs 71%, respectively, p<0.0001). Similarly, the 2-years progression free survival was significantly lower in the sterile water vs glycine group (85% vs 94%, respectively, p<0.014). Sterile water treatment resulted in the lowest number of viable cells. Early and late immunogenic cell death markers were markedly elevated in cells treated with glycine.Conclusions and clinical implicationsSterile water compared to glycine irrigation during TURBT for NMIBC was associated with higher recurrence and progression rates. Possible explanation for these findings is the diminished immune response associated with sterile water reflected in a comparatively lesser expression of immune response inducers.Patient summaryWe compared two irrigation fluids in non–muscle-invasive bladder cancer surgery: glycine and sterile water. Glycine outperformed sterile water in cancer recurrence, possibly boosting immunogenicity over sterile water.

BACKGROUND: En bloc resection of bladder tumor (ERBT) is an established surgical treatment method for patients with non-muscle invasive bladder cancer (NMIBC) in tumors less than 3 cm. Data regarding the efficacy and safety of ERBT on larger than 3 cm tumors are sparse and its efficacy compared to conventional transurethral resection (TURBT) remains unclear. The aim of this study was to prospectively compare the feasibility, safety and oncological outcomes of laser (Tm-fiber) ERBT and TURBT in patients with primary bladder lesions >= 3 cm. METHODS: A cohort of 45 patients who underwent surgery for primary NMIBC between February 2018 and March 2022 was collected prospectively. There was no randomization. All procedures were performed by two experienced surgeons. Inclusion criteria were as follows: age >18 years, primary Ta or T1 bladder tumor with a diameter of >= 3 cm, no more than 3 tumors and no history of upper tract urothelial carcinoma. Exclusion criteria were carcinoma in situ or invasion into muscle layer (>= T2). ERBT was performed with thulium fiber laser (IPG, Russia). Primary endpoints included efficacy with recurrence-free survival (RFS) at 3, 6 and 12 months. Secondary endpoints were safety parameters, perioperative data and specimen quality (the presence of muscle layer in specimens). RESULTS: Twenty-eight patients underwent laser ERBT and 17 conventional TURBT. The location and size of the tumors were comparable in both groups. The success rate was 93.3% in the ERBT group with two cases of conversion from ERBT to TURBT. Detrusor muscle was present in 92.8% patients in the ERBT group versus 70.5% in the TURBT group (P=0.04). Obturator nerve reflex was observed only in the TURBT group: 17.6% vs. 0.0% (P=0.02). The frequency of other complications was comparable between the two groups. RFS was not statistically different between the two methods at 3 (93.9% vs. 94.1%, P=0.87), 6 (89.3% vs. 82.3%, P=0.5) and 12 months (89.3% vs. 70.6%, P=0.11). CONCLUSIONS: Laser ERBT is a feasible and safe procedure to manage bladder tumors larger than 3 cm. While it seems safer than TURBT, its effect on efficacy remains to be assessed in larger trials.

INTRODUCTION:The associations among SARS-CoV-2 infection, vaccination and total serum prostate serum antigen (PSA) levels in men undergoing screening for prostate cancer are unknown.METHODS:A retrospective analysis of data from a large health maintenance organization. Records of individuals aged 50 to 75 years with two serum PSA tests taken between March 2018 and November 2021 were included. Individuals with prostate cancer were excluded. Changes in PSA levels were compared between individuals who had at least 1 SARS-CoV-2 vaccination and/or infection between the two PSA tests and individuals who did not have an infection and were not vaccinated between the two PSA tests. Subgroup analyses were performed to assess the impact of the elapsed time between the event and the second PSA test on the results.RESULTS:The study and control groups included 6,733 (29%) and 16 286 (71%) individuals, respectively. Although the median time between PSA tests was shorter in the study vs. the control group (440 vs. 469 days, P<.001), PSA elevation between the tests was higher in the study group (0.04 vs. 0.02, P<.001). The relative risk for PSA elevation ≥1 ng/dL was 1.22 (95% CI 1.1, 1.35). Among individuals who were vaccinated, PSA increased by 0.03 ng/dL (IQR -0.12, 0.28) and 0.09 ng/dL (IQR -0.05, 0.34) after 1 and 3 doses, respectively (P<.001). Multivariate linear regression showed that SARS-CoV-2 events (β 0.043; 95% CI 0.026-0.06) were associated with a greater risk for PSA elevation, after adjusting for age, baseline PSA and days between PSA tests.CONCLUSION:SARS-CoV-2 infection and vaccinations are associated with a slight increase in PSA, with the third anti-COVID vaccine dose having a more prominent impact, but its clinical significance is unknown yet. Any significant increase in PSA must be investigated and cannot be dismissed as secondary to SARS-CoV-2 infection or vaccination.

PURPOSE:The Butterfly Prostatic Retraction Device ("Butterfly") is a permanent nitinol implant for benign prostatic hyperplasia. This study examines the chronic response of prostate tissue to the Butterfly in histological specimens from patients in the Butterfly pilot clinical study.METHODS:Retrospective qualitative and semi-quantitative review of histological specimens of seven (7) patients who participated in the Butterfly pilot clinical study. Patients had at least 1-month implantation with the Butterfly prior to implant removal and TURP. Tissue samples were graded by two pathologists.RESULTS:Four out of six patients had IPSS decreased from baseline. All seven patients' samples had signs of chronic inflammation; one demonstrated acute inflammation and one demonstrated fibrosis. In three cases, intraglandular calcification was identified. There was no ischemic necrosis induced by the implant, and no encrustation, urethral edema, or cellular atypia was noted.CONCLUSION:The Butterfly demonstrated an overall favorable safety profile in terms of tissue response. This study demonstrates that there is no significant tissue reaction in the prostatic urethra due to presence of Butterfly device.

INTRODUCTION AND OBJECTIVES:Medical treatments for overactive bladder (OAB) have proven efficacy in controlled trials. However, 1-year treatment persistence is reported to be as low as 25% for anticholinergics and 40% for β3 agonists. Real-world data on treatment continuation and treatment sequence is limited. Therefore, we aimed to study treatment persistence trends in women initiated on OAB medications.MATERIALS AND METHODS:We used advanced data-mining techniques to query the largest regional provider's medication purchase database, dispensing for patients, for all women initiating OAB pharmacotherapy between 2010 and 2020. Treatment persistence was measured as days in which the patient was in possession of medication and nonpersistence was defined as prescription nonrefilling for 90 days. We employed a Sankey diagram to explore trends in OAB medication acquisition and treatment sequence. We compared treatment persistence using Kaplan-Meier survival curves and pairwise log-rank analysis.RESULTS:Here, 46 079 women made 791 681 unique claims of OAB medications. Only 39% of the patients tried more than one OAB formulation, including dose change. The overall persistence rate for all drugs was 55% in 30 days, 46% in 90 days, and 37% per year. The persistence rate for Mirabegron at 30 days was 54%, 42% at 90 days, and 17% at 1 year. Overall, persistence rates were unchanged when stratifying by the time Mirabegron insurance acceptance into coverage (p > 0.05).CONCLUSIONS:Real-world OAB pharmacotherapy persistence rates are lower than previously reported. The introduction of Mirabegron did not seem to improve these rates or affect the treatment sequence.