Search Results (206)

Background: Iatrogenic nerve injuries (NIs) are an under-recognized complication of urological surgery. Though less common than vascular or organ damage, they may cause lasting sensory and motor deficits, significantly affecting patients’ quality of life. With increasing complexity in pelvic procedures, a consolidated understanding of nerve injuries is essential. Purpose: This review aims to synthesize current knowledge regarding peripheral and autonomic NIs in urological surgery, highlighting mechanisms of injury, associated procedures, preventative strategies, and treatment options. Scope: Focused on common urological interventions such as radical prostatectomy, cystectomy, pelvic lymphadenectomy, and reconstructive techniques, the review explores injuries from positional compression, traction, and intraoperative transection to their surgical management. Key Findings: The review categorizes nerve injuries into crush and transection types and details intraoperative signs and repair techniques. Skeletonization of nerves, avoidance of energy devices near neural structures, and prompt end-to-end anastomosis using 7-0 polypropylene are central to management. Adoption of novel sutureless nerve coaptation devices have also been described with promising outcomes. Early repair offers a better prognosis. New intraoperative technologies like NeuroSAFE during robotic-assisted procedures may enhance nerve preservation. Conclusion: Iatrogenic NIs, although rare, are clinically significant and often preventable. Prompt intraoperative recognition and repair are critical. Further research is warranted to develop standardized preventative protocols and enhance intraoperative nerve monitoring. A multidisciplinary approach, extended across surgical specialties, could improve outcomes and guide timely treatment of nerve injuries. Full article

Background/Objectives: Prostate cancer ranks as the second-most prevalent cancer globally, and is the fifth-ranking cause of cancer-related mortality. Radical prostatectomy presents a significant risk of postoperative sequelae, including erectile dysfunction. Postoperative erectile dysfunction adversely affects the patient’s quality of life and can severely impact total treatment satisfaction. Nomograms have demonstrated efficacy in forecasting diverse outcomes in urology. We sought to create a nomogram to facilitate a more precise, evidence-based, and individualized prediction of erectile function outcomes following radical prostatectomy. Between January 2018 and January 2022, one hundred and eleven prostate cancer patients had robot-assisted radical prostatectomy, excluding those who had undergone prior transurethral prostatectomy, radiotherapy, or hormone therapy. Demographics, medical records, preoperative and postoperative erectile function statuses, and IIEF scores (≥17 indicating retained erections, <17 indicating full erectile dysfunction) were evaluated. Outcomes: Patients’ ages ranged from 45 to 76 years, with an average of 61.18 ± 6.72 years. Patients in the emergency department were considerably older (p = 0.004; p < 0.01) and exhibited elevated Charlson Comorbidity Indices (3.63 ± 0.85; p = 0.004; p < 0.01). Preoperative IIEF scores in ED patients were lower (14.29 ± 5.34), although obturator internus thickness (20.61 ± 2.91) and intraprostatic urethra length (36.48 ± 9.3) were considerably elevated. Altered surgical techniques were linked to maintained erections (p = 0.002; p < 0.01), but traditional approaches were connected with erectile dysfunction (p = 0.007; p < 0.01). Bilateral nerve-sparing procedures were more prevalent among patients preserving erectile function (p = 0.003; p < 0.01). Conclusions: The nomogram, which includes age, Charlson Comorbidity Index, preoperative IIEF, obturator internus thickness, intraprostatic urethra length, surgical technique, and degree of nerve preservation, provides clinicians with a pragmatic instrument for forecasting postoperative erectile dysfunction in prostate cancer patients. Full article

Background and Objectives: Low-pressure pneumoperitoneum (PP) during robot-assisted radical prostatectomy (RARP) has been shown to improve postoperative recovery in patients with non-obesity. However, its efficacy in individuals with obesity remains unclear. This study aimed to evaluate postoperative outcomes in patients with obesity undergoing RARP with low-pressure (7 mmHg) versus standard-pressure (12 mmHg) PP. Materials and Methods: In this retrospective cohort study, 130 patients with obesity (BMI > 30 kg/m²) undergoing RARP were divided into low-pressure (n = 60) and standard-pressure (n = 70) groups. Postoperative recovery was assessed using the Quality of Recovery-15 (QoR-15) questionnaire on postoperative days (POD) 1, 3, and 30. Secondary outcomes included surgical workspace (SWS) scores, operative time, blood loss, intraoperative and postoperative complications, hospital stay, and pathological results. ANCOVA and chi-square tests were used for analysis. Results: QoR-15 scores were significantly higher in the low-pressure group on POD1 (123.58 vs. 111.41), POD3 (128.37 vs. 116.41), and POD30 (132.88 vs. 125.61; p < 0.001). Operative time (98.5 vs. 71.57 min; p < 0.001) and blood loss (129 vs. 97.07 mL; p = 0.039) were higher in the low-pressure group. SWS scores were lower in the low-pressure group (p < 0.001). There were no significant differences between groups in complication rates, hospital stay, or positive surgical margins. Conclusions: In patients with obesity undergoing RARP, low-pressure PP improves postoperative recovery without increasing complications. Despite longer operative times and higher blood loss, this approach is a viable option to enhance recovery in this population. Full article

Since its development in 1904, radical prostatectomy (RP) has remained a fundamental surgical option in the management of localised prostate cancer. Over time, continuous advancements in surgical techniques have improved oncological outcomes while reducing functional complications. This narrative review explores the evolution of RP, depicting its progression from the traditional open approach to minimally invasive laparoscopic and robotic-assisted techniques. Key developments in RP techniques, including nerve-sparing, bladder neck-sparing and Retzius-sparing techniques as well as enhanced perioperative management, have contributed to reduced postoperative complications, namely incontinence and erectile dysfunction. Additionally, technological innovations such as augmented reality, utilising indocyanine green for improved visualisation of prostatic boundaries and illuminare-1 to easily identify nerves intraoperatively, artificial intelligence, and novel molecular imaging technologies such as PSMA PETs for improved margin assessment are shaping the future of RPs. Despite these advancements, challenges persist, including a steep learning curve associated with newer techniques, disparities in access due to cost considerations, and a lack of standardised outcome measures across different surgical approaches. This review provides insight into current trends, ongoing challenges, and future directions that may further refine surgical precision, enhance patient safety, and improve long-term treatment success in prostate cancer management. Full article

Background: This study aimed to develop a predictive model for acute gastrointestinal (GI) and genitourinary (GU) toxicity in prostate cancer patients treated with salvage radiotherapy (SRT) post-prostatectomy, using machine learning techniques to identify key prognostic factors. Methods: A multicenter retrospective study analyzed 454 patients treated with SRT from three Italian radiotherapy centers. Acute toxicity was assessed using Radiation Therapy Oncology Group criteria. Predictors of grade ≥ 2 toxicity were identified through Least Absolute Shrinkage and Selection Operator (LASSO) regression and Classification and Regression Tree (CART) modeling. The analyzed variables included surgical technique, clinical target volume (CTV) to planning target volume (PTV) margins, extent of lymphadenectomy, radiotherapy technique, and androgen-deprivation therapy (ADT). Results: No patients experienced grade ≥ 4 toxicity, and grade 3 toxicity was below 1% for both GI and GU events. The primary determinant of acute toxicity was the surgical technique. Open prostatectomy was associated with significantly higher grade ≥ 2 GI (41.8%) and GU (35.9%) toxicity compared to laparoscopic/robotic approaches (18.9% and 12.2%, respectively). A CTV-to-PTV margin ≥ 10 mm further increased toxicity, particularly when combined with extensive lymphadenectomy. SRT technique and ADT were additional predictors in some subgroups. Conclusions: SRT demonstrated excellent tolerability. Surgical technique, CTV-to-PTV margin, and treatment parameters were key predictors of toxicity. These findings emphasize the need for personalized treatment strategies integrating surgical and radiotherapy factors to minimize toxicity and optimize outcomes in prostate cancer patients. Full article

Background: Prostate-specific membrane antigen (PSMA)-PET imaging has significantly improved prostate cancer (PCa) staging, yet its interpretation remains challenging, even for experienced specialists. No prior study has assessed urologists’ ability to interpret PSMA-PET. Methods: We conducted a multicenter prospective study involving 63 urologists from eight Italian institutions. Participants evaluated 20 PSMA-PET scans of high-risk PCa cases, with no clinical information provided. Proficiency was defined as correctly identifying at least two of three staging components (T, N, M) in ≥75% of cases. Associations between performance and factors such as hierarchy (resident vs. consultant), institution type, surgical volume, and multidisciplinary team (MDT) presence were analyzed using univariable and multivariable logistic regression. Results: Only one participant achieved full staging proficiency, while 44% reached the ≥75% threshold for partial (almost correct) staging. Urologists from centers with ≥300 PCa diagnoses per year demonstrated better T and M stage identification. Institutions with ≥150 robot-assisted radical prostatectomies (RARPs) per year and those with MDTs showed higher accuracy in M staging. No significant predictors of proficiency emerged in the multivariable analysis, although hierarchy and surgical volume approached significance for nodal metastasis detection. Conclusion: PSMA-PET interpretation is complex for urologists, with particular challenges in T and M staging. High institutional case volumes and MDT involvement may enhance interpretation skills. Structured training programs and increased exposure to multidisciplinary imaging discussions are essential to optimize urologists’ diagnostic proficiency and ultimately improve patient care. Full article

Background/Objectives: Prostate cancer is the second most common malignancy in men, and robot-assisted radical prostatectomy (RARP) has become a preferred treatment for localized disease. Postoperative urinary continence is a key determinant of quality of life. The aim of this study was to evaluate the preoperative patient characteristics and multiparametric magnetic resonance imaging (mpMRI) data that determine early postoperative continence in patients who underwent robotic radical prostatectomy at our clinic. Methods: In this study, patients who underwent robotic radical prostatectomy at our clinic between March 2020 and June 2022 were evaluated. The patients’ demographic data, preoperative PSA levels, digital rectal examination findings, preoperative lower urinary tract symptoms, sexual function, mpMRI findings, Briganti scores, surgical techniques used during the procedure and postoperative continence status were assessed. Results: A total of 111 patients were included in the study. The mean age of the patients was 61.1 years. The median follow-up duration was twelve months. According to the postoperative continence status, 22% of the patients were incontinent, 53% had moderate continence and 24% were fully continent in the first month. At the third month, 16.8% of the patients were incontinent, 31.3% had moderate continence and 51.8% were fully continent. At the one-year postoperative follow-up, the percentages of incontinent, moderately continent and fully continent patients were 4.8%, 13.2% and 81.9%, respectively. Urethral width in mpMRI (p: 0.012), pelvic transverse (p: 0.002) and AP (anterior–posterior) diameters (p: 0.033), preoperative IPSS scores (p: 0.033) and the presence of bilateral nerve-sparing surgery (p: 0.047) were found to be associated with postoperative urinary continence. No significant differences were found between groups regarding the relationship of other parameters evaluated by mpMRI with continence. Conclusions: In our study, preoperative IPSS scores, urethral width in mpMRI, pelvic transverse and AP diameters and the performance of nerve-sparing surgery were associated with early postoperative continence. Further studies with larger patient populations are needed to better understand the long-term predictors of postoperative urinary incontinence following radical prostatectomy. Full article

Objectives: In this study, the effect of positive surgical margin (PSM) length on predicting postoperative biochemical recurrence (BCR) after radical prostatectomy was evaluated, and based on the findings, an additional R subclassification to the TNM-R system was proposed. Methods: We retrospectively analyzed patients who underwent robot-assisted radical prostatectomy between 30 July 2008 and 31 December 2019. Only patients with PSM were included. Those with negative margins, those receiving neoadjuvant/adjuvant hormone therapy, or those with prior pelvic radiotherapy were excluded. A total of 353 pathology specimens were re-evaluated by a uropathologist, and the PSM length was quantitatively measured. BCR was defined as a PSA level of ≥0.2 ng/mL in two consecutive measurements. Results: The median follow-up time of the patients was 49.5 ± 33.4 months. BCR occurred in 27.1% (n = 96) of patients. A PSM cut-off length of 3.5 mm was identified for predicting BCR (p < 0.001). Among patients with PSM < 3.5 mm, 9.8% experienced BCR, while 54.3% of those with PSM ≥ 3.5 mm did. A PSM length ≥ 3.5 mm was associated with a higher risk of recurrence (OR: 1.249, 95% CI: 1.160–1.345, p < 0.001). In multivariate logistic regression analysis, PSM length remained an independent prognostic factor for BCR (p < 0.001). Conclusions: Quantitative measurement of PSM length serves as an independent predictor of BCR following radical prostatectomy. We propose subclassifying R1 margins into R1a (<3.5 mm) and R1b (≥3.5 mm), which may enhance prognostic accuracy in pathological reporting. Full article

Background/Objectives: This study evaluates and compares the diagnostic accuracy of [68Ga]Ga-PSMA-11 and [18F]F-PSMA-1007 for lymph node staging in patients with prostate cancer (PCa) scheduled for robot-assisted radical prostatectomy (RARP) and lymphadenectomy (LND). Methods: We retrospectively reviewed prospectively collected data on patients referred to our hospital from October 2020 to January 2023. We included all patients who underwent [68Ga]Ga-PSMA-11 or [18F]F-PSMA-1007 PET/CT for primary staging and subsequently had RARP with concomitant LND. The maximum standard uptake value (SUVmax) for lymph nodes (LNs) and the SUV node-to-background ratio were reported. Two different cut-off values for the SUV node-to-background ratio (i.e., ≥2 vs. <2 and ≥15.5 vs. <15.5) were used to evaluate the diagnostic performance of both tracers. The first cut-off was empirically chosen, while the second was based on Liu’s method. Results: A total of 156 patients were included (median age: 67 years). Among them, 83 underwent [68Ga]Ga-PSMA-11 and 73 underwent [18F]F-PSMA-1007 PET/CT. Suspicious lymph nodes were identified in 21 patients (13.5%). Pathological nodal involvement (pN1) was confirmed in 25 cases (16%). Of the 21 patients with suspicious pathological lymph nodes on PSMA PET/CT, 9 (42.9%) had positive nodes on the final pathology report. With an SUV node-to-background ratio cut-off of ≥2, [68Ga]Ga-PSMA-11 showed 37.5% sensitivity (SE) and 98.5% specificity(SP), while [18F]F-PSMA-1007 demonstrated 33.3% SE and 100% SP. Using the ≥15.5 cut-off, SE and SP were 31.3% and 100% for [68Ga]Ga-PSMA-11 and 11.1% and 100% for [18F]F-PSMA-1007, respectively. Conclusions: [18F]F-PSMA-1007 PET/CT showed, even if not statistically significantly, slightly lower SE and higher SP for nodal staging compared to [68Ga]Ga-PSMA-11 PET/CT, irrespective of the SUV ratio used. Full article

Background/Objectives: Innovations in robotic prostatectomy have transformed a highly morbid operation to a procedure with fewer complications and shorter hospital stays, yet techniques continue to evolve. Our objective is to discuss the most recent advances in robotic prostatectomy techniques designed to minimize morbidity related to urinary incontinence and erectile dysfunction. Methods: This review is adapted from a comprehensive committee chapter on published in the 3rd WUOF/SIU (World Urologic Oncology Federation/Société Internationale d’Urologie) International Consultation on Urologic Diseases on Localized Prostate Cancer. Results: This review article describes both traditional and emerging techniques in robotic prostatectomy techniques and discusses their respective outcomes. Conclusions: Improved understanding of pelvic anatomy has enabled robotic-assisted techniques to preserve key structures and enhance recovery and functional outcomes while preserving oncologic safety Full article

Background/Objectives: Single-port radical prostatectomy (SP-RARP) has been demonstrated to be a feasible and safe procedure, even in older patients. This study aims to compare multi-port radical prostatectomy (MP-RARP) with SP-RARP, with a particular focus on elderly patients. Methods: Patients who underwent SP-RARP or MP-RARP between January 2018 and December 2023 were retrospectively analyzed. Patients undergoing concomitant surgical procedures or diagnosed with locally advanced prostate cancer were excluded from this study. Patients were then stratified into two groups: Group A (age < 65 years) and Group B (age ≥ 65 years). Results: A total of 338 patients (153 MP-RARP and 185 SP-RARP) were retrospectively collected. In Group B, the length of stay (in hours) was significantly shorter for SP procedures compared to MP (18 (20.8) vs. 35 (17); p = 0.002), with a higher rate of same-day discharge in favor of SP (45 (54.9%) vs. 9 (16.7%); p < 0.001). Additionally, MP patients in Group B had a higher incidence of postoperative complications at both 30 days (19(35.2%) vs. 13 days (15.9%); p = 0.009) and 90 days (21(38.9%) vs. 14 days (17.1%); p = 0.004) compared to those undergoing SP. Multivariable logistic regression analysis identified SP as a protective factor against postoperative complications at 30 days (Odds ratio: 0.41; 95% CI: 0.15, 0.97; p value = 0.027) and 90 days (Odds ratio: 0.38; 95% CI: 0.17,0.788; p = 0.024). Additionally, length of stay was associated with postoperative complications at 30 days (Odds ratio: 1.02; 95% CI: 1.01, 1.13; p value = 0.046). Conclusions: SP-RARP is a safe and feasible option for elderly patients, offering a lower incidence of short-term postoperative complications compared to MP-RARP. Furthermore, same-day discharge is feasible even in elderly patients undergoing SP-RARP. Full article

Background: Cold dissection (CD) during nerve-sparing robot-assisted radical prostatectomy (nsRARP) in patients with prostate cancer has been proposed to improve functional outcomes by reducing the thermal damage to neurovascular bundles (NVBs). This study compares the impact of CD versus thermal dissection (TD) on postoperative early continence and erectile function recovery. Methods: A prospective comparative analysis was conducted on patients undergoing nsRARP, comparing CD and TD techniques. Continence was assessed at 15, 30, and 90 days, while erectile function was evaluated at 30, 90, and 180 days using IIEF-5 scores. Logistic and linear regression analyses were performed to identify predictors of functional recovery. Results: CD significantly improved early continence at 15 and 30 days (p < 0.05), although the difference diminished by 90 days. Erectile function recovery was consistently higher in the CD group at all time points (p < 0.01). Age negatively impacted continence and erectile function recovery, while preoperative IIEF-5 scores were strong predictors of erectile function. Prostate volume, BMI, and metabolic syndrome showed no significant influence on outcomes. Conclusions: CD enhances early continence and erectile function recovery following nsRARP by preserving NVBs and minimizing thermal damage. This technique offers a valuable approach to improving patient functional outcomes. Further studies are required to validate its long-term benefits. Full article

Background/Objectives: The aim of this research was to compare perioperative outcomes, functional results, quality of life, and complications between robot-assisted simple prostatectomy (RASP) and holmium laser prostate enucleation (HoLEP) as minimally invasive techniques for treating benign prostatic hyperplasia (BPH) in large prostates (>150 cm³). Methods: This retrospective, multicenter, observational study (2007–2023) included patients with >150 cm³ prostate volumes who underwent either HoLEP or robot-assisted prostatectomy. Primary outcomes: success rate (complete enucleation, without transfusion or reintervention), good postoperative quality of life (IPSS 8th question score: 0–2), and continence at 6 months (no pads). Secondary outcomes: operative and catheterization time, hospital stay, enucleated gland weight, PSA reduction, Qmax improvement, and perioperative complications. Results: We included 95 HoLEP and 50 RASP patients with similar demographics and prostate volume (HoLEP: 187.72 cm³; RASP: 203.38 cm³). The success rate (HOLEP: 83.2%; RASP: 74%), continence rate (HoLEP: 85.1%; RASP: 86%), and quality of life (HoLEP: 83.2%; RASP 94%) were similar (p = 0.275, p = 1, and p = 0.075, respectively). HoLEP had a shorter operative time (97.58 vs. 122.4 min) and catheterization duration, with similar hospitalization duration (HoLEP: 3.46 days; RASP: 4.22 days). Although there was no significant difference in enucleated gland weight, HoLEP was more efficient (1.28 g/min vs. 1.06 g/min). Complication rates were similar (HOLEP: 15.5%; RASP: 26%; p = 0.12). Conclusions: Both RASP and HoLEP are safe for treating BPH in prostates >150 cm³, reporting similar success and continence rates and good quality of life after surgery. However, HoLEP achieved results with shorter operative time and catheterization duration. Full article

Background/Objectives: Radical prostatectomy is a standard treatment for localized prostate cancer. We aimed to compare perioperative outcomes and functional results between laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP). Methods: A retrospective analysis was conducted on 120 patients who underwent LRP (n = 60) or RARP (n = 60). Perioperative parameters, including operative time, hospitalization duration, blood transfusion rate, wound healing complications, urinary catheterization duration, urinary tract infections (UTIs), and urinary incontinence, were assessed. Statistical analyses included Student’s t-, Mann–Whitney U, and χ² tests. Results: RARP was associated with significantly shorter operative time, compared with LRP (147.25 vs. 188.30 min, p < 0.0001). No significant differences were observed in hospitalization duration, transfusion rates, or overall complication rates. However, impaired wound healing was less frequent in the RARP group, with a 10% lower incidence, compared with the LRP group (p = 0.0946). Similarly, UTIs occurred less often in the RARP group (six vs. one cases; p = 0.0544). Urinary incontinence was significantly less frequent following RARP, with its incidence being more than twice as low, compared with the LRP group (p = 0.0032). Additionally, the RARP group had significantly lower International Prostate Symptom Scores, with a mean difference of 7.83 points, indicating improved urinary function. No significant differences were found in sexual function (IIEF-5 scores). Conclusions: RARP offers advantages over LRP, including reduced operative time, lower rates of wound healing complications, decreased incidence of urinary incontinence, and improved postoperative urinary function. Further studies with larger cohorts are warranted to confirm these findings and assess long-term functional and oncological outcomes. Full article

Background: In prostate cancer (PCa) patients, discrepancies between biopsy-assigned Gleason Scores and those determined from surgical specimens are frequently reported. This phenomenon, known as Gleason score upgrade (GSU), can have significant clinical implications. This work aims to understand the factors contributing to GSU for refining prostate cancer management strategies. Methods: Data from 779 patients diagnosed with histologically confirmed PCa who underwent robot-assisted radical prostatectomy at a single tertiary care institution between January 2005 and December 2020 were examined. Results: In the univariable setting, 5-alpha reductase inhibitor (5-ARI) use was associated with a higher percentage of upgrading (42.3% vs. 30.4% among non-users; p = 0.03942). A more advanced pathological T stage (p = 0.01114) and lymph node positivity (p < 0.00001) correlated significantly with GSU. In the logistic regression model, advanced pathological stage increased the odds more than twofold (OR = 2.807, p = 0.00135). 5-ARI use was associated with notably higher odds of upgrading (OR = 3.809, p = 0.00004). Younger age slightly increased the likelihood of GSU (OR = 0.951 per year increase in age, p = 0.01101). Conclusions: Younger age, advanced pathological stage, and the use of 5-alpha reductase inhibitors were identified as significant predictors of GSU. Full article