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Chemsex is mostly approached through the prism of risk-taking, neglecting the pleasure and social linking dimensions. However, feedback from the field and few studies highlights a diversity of chemsex practices and relationships to chemsex (RtC). Using Q-methodology, we identified the main RtC and their divergences and convergences, to help develop tailored prevention and care programs. Q-methodology enables the exploration of complex subjective structures and provides a multifaceted picture of a phenomenon. In 2019-2020, we asked 126 men who have sex with men living in France and practicing chemsex to rank order 37 statements. RtC were defined through by-person factor analysis and interpreted using a holistic process. Five RtC emerged, highlighting various motivations for practicing chemsex, relationships to substance use and to sexuality, and regulation strategies implemented: (1) From compensation to fulfillment; (2) The pleasure-seeking manager; (3) Between addiction and management; (4) From curiosity to the destruction of sexuality; and (5) From the hope of compensation to disillusion. Respondents all agreed on two statements: the need to first accept oneself as a drug user in order to be able to manage drug use, and the possibility of harm reduction during chemsex sessions. Our results are the first to elicit the main RtC and the intricacies between the dimensions at stake. The five analysis-based narratives derived from RtC might facilitate discussion during interviews or support groups on chemsex, and could serve as a standardized survey tool. Our findings advocate longitudinal studies to identify factors associated with shifting from one RtC to another., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Objective: Prostate multiparametric magnetic resonance imaging (MRI) shows high sensitivity for International Society of Urological Pathology grade group (GG) ≥2 cancers. Many artificial intelligence algorithms have shown promising results in diagnosing clinically significant prostate cancer on MRI. To assess a region-of-interest-based machine-learning algorithm aimed at characterising GG ≥2 prostate cancer on multiparametric MRI., Methods: The lesions targeted at biopsy in the MRI-FIRST dataset were retrospectively delineated and assessed using a previously developed algorithm. The Prostate Imaging-Reporting and Data System version 2 (PI-RADSv2) score assigned prospectively before biopsy and the algorithm score calculated retrospectively in the regions of interest were compared for diagnosing GG ≥2 cancer, using the areas under the curve (AUCs), and sensitivities and specificities calculated with predefined thresholds (PIRADSv2 scores ≥3 and ≥4; algorithm scores yielding 90% sensitivity in the training database). Ten predefined biopsy strategies were assessed retrospectively., Key Findings and Limitations: After excluding 19 patients, we analysed 232 patients imaged on 16 different scanners; 85 had GG ≥2 cancer at biopsy. At patient level, AUCs of the algorithm and PI-RADSv2 were 77% (95% confidence interval [CI]: 70-82) and 80% (CI: 74-85; p = 0.36), respectively. The algorithm's sensitivity and specificity were 86% (CI: 76-93) and 65% (CI: 54-73), respectively. PI-RADSv2 sensitivities and specificities were 95% (CI: 89-100) and 38% (CI: 26-47), and 89% (CI: 79-96) and 47% (CI: 35-57) for thresholds of ≥3 and ≥4, respectively. Using the PI-RADSv2 score to trigger a biopsy would have avoided 26-34% of biopsies while missing 5-11% of GG ≥2 cancers. Combining prostate-specific antigen density, the PI-RADSv2 and algorithm's scores would have avoided 44-47% of biopsies while missing 6-9% of GG ≥2 cancers. Limitations include the retrospective nature of the study and a lack of PI-RADS version 2.1 assessment., Conclusions and Clinical Implications: The algorithm provided robust results in the multicentre multiscanner MRI-FIRST database and could help select patients for biopsy., Patient Summary: An artificial intelligence-based algorithm aimed at diagnosing aggressive cancers on prostate magnetic resonance imaging showed results similar to expert human assessment in a prospectively acquired multicentre test database., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: Laparoscopic adrenalectomy (LA) has emerged as the gold standard for the management of adrenal diseases. Despite its low complication rate, the utilization of LA in outpatient settings remains limited. This study explored the feasibility of outpatient LA for primary aldosteronism (PA)., Design & Methods: A retrospective analysis was conducted by reviewing the medical records of consecutive LA procedures performed for PA in our department from 2013 to 2021. A successful outpatient procedure was defined as same-day discharge, less than 12 hours after admission, with no readmission within 48 hours. A postoperative day one (D1) follow-up call by a nurse assessed complications, pain, and patient satisfaction (Numeric Rating Scale [0-10]). Follow-up visits were scheduled at one, three, and six months., Results: During the study period, 76 LAs were performed for PA, with 60 (78.9%) being outpatient procedures. Sixteen patients (21.9%) were not selected for outpatient procedures. The main reasons for contraindicating outpatient procedures were anesthetic or social issues. The success rate of the outpatient procedures was 95% (57/60), with no reported surgical complications. Prolonged hospitalization occurred due to medical reasons such as pain or vomiting. There were no readmissions within 48 hours after discharge. The mean pain and patient satisfaction, evaluated at D1, were 2.1/10 and 9.4/10, respectively. At 6 months, 32 patients (59.2%) were cured without any antihypertensive drugs, and 15 (27.8%) were improved (reduction of their antihypertensive treatment)., Conclusion: Outpatient LA for PA has demonstrated feasibility with a high success rate, no readmissions, low postoperative pain, and a high level of patient satisfaction., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Introduction:   Partial gland ablation (PGA) using high intensity focal ultrasound (HIFU) is an alternative to active surveillance for low to intermediate risk localized prostate cancer.  This pilot study assessed quality of life (QoL) outcomes during the implementation of PGA-HIFU at our institution., Materials and Methods:   We prospectively enrolled 25 men with a diagnosis of localized low/intermediate risk prostate cancer who elected to undergo PGA-HIFU in a pilot study at our institution between 2013 and 2016.  Patients underwent pre-treatment mpMRI and transrectal ultrasound-guided biopsies.  The primary endpoints were impact on patient-reported functional outcomes (erectile, urinary function, QoL) assessed at 1, 3, 6- and 12-months., Results:   The median age was 64 years old (IQR 59.5-67).  Baseline median International Index of Erectile Function-15 score was 50, which decreased to 18 at 1 month (p < 0.0005), returned to baseline by 3 months and thereafter. International Prostate Symptom Score median at baseline was 8, which worsened to 12 at 1 month (p = 0.0088), and subsequently improved to baseline thereafter.  On the UCLA-Expanded Prostate Cancer Index Composite urinary function, there was a decrease in median score from 92.7 at baseline to 76.0 at 1 month (p < 0.0001), which improved to or above baseline afterwards.  QoL remained similar to baseline at each follow up period as assessed by EQ-5D and the Functional Cancer Therapy-Prostate score., Conclusions:   In this initial cohort of PGA-HIFU men at our institution, patients demonstrated a slight, but transient, deterioration in urinary and erectile function at 1 month prior to normalization.  All QoL metrics showed no impact upon 1 year of follow up post-treatment.

Introduction: This study aimed to evaluate the feasibility of switching from transrectal to transperineal prostate biopsy (TPPBx) by urologists with no previous experience with TPPBx. Material A monocentric clinical study with exhaustive and consecutive inclusions was conducted between January and November 2021, including 105 consecutive patients who underwent TPPBx performed by two senior urologists with no previous experience of TPPBx (GR, FB). Biopsies were performed under local anesthesia (LA) without antibioprophylaxis. The main objective was to assess the safety of this procedure. Adverse events were classified according to the Clavien-Dindo score. The secondary objectives were to assess the level of pain experienced during the different steps of the procedure using a numerating rating scale (NRS), the rate of clinically significant prostate cancer (csPCa) detected, and the level of anxiety using the Hospital Anxiety and Depression Scale (HAD)., Results: No major complications (Clavien-Dindo score≥3) were reported. One patient presented with acute urinary retention (1%) and a urinary tract infection (1%). Other adverse events were hematuria (43%), hemospermia (23%), rectal bleeding (1%), perineal hematoma (3%), persistent perineal pain (5%), and de novo erectile dysfunction (2%). The median level of pain on NRS for the procedure was 2.00 (IQ: 1.00-4.00); it was 3.00 (IQ: 2.00-5.00) during LA and 3.00 (IQ: 2.00-5.00) during punctions. In anxious patients (HAD score>10), the level of pain during the procedure was 2.5 (IQ: 2.00-3.00). Overall, csPCa was detected in 63%., Conclusion: TPPBx under LA without antibioprophylaxis provides few complications, an acceptable pain threshold, and a satisfactorily rate of csPCa detection, even if performed by urologists with no previous experience of TPPBx., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Introduction: In recent years, improved diagnosis of prostate cancer has allowed the development of focal therapy, in order to reduce the morbidity of treatments. Our study assesses the medium-term oncological and functional results of FocalOne® HIFU treatment in localized prostate cancer., Methods: This is a retrospective, multicentre study including patients with low- or intermediate-risk localized prostate cancer treated with Focal one HIFU between November 2014 and December 2019. The primary endpoint was the retreatment rate and subgroup analyses were performed to identify predictive factors of retreatment., Results: One hundred and thirty-seven patients were included with a median follow-up of 25.5 months. Seventy percent of patients had clinical stage T2, 64% had an ISUP score of 2 or 3 on initial biopsies and 38% were treated with hemi-ablation. Follow-up biopsies were performed in 76.6% of patients during follow-up with 21.8% having clinically significant cancers. The retreatment rate at 24 months was 37.2%, with positive biopsies being the primary criterion for retreatment. Patients with a PSA>8ng/mL had a significantly higher retreatment rate. Finally, morbidity remained acceptable with 5.8% of patients requiring reoperation for complications and 21% for de novo erectile dysfunction., Conclusion: Our results are in agreement with those of the literature, seeming to indicate a lower morbidity of the focal treatment by HIFU compared to the radical treatments while offering an acceptable oncological control. Prospective randomized trials are ongoing., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Purpose: To evaluate the feasibility, safety, and early oncologic outcomes after post-chemotherapy robot-assisted retroperitoneal lymph node dissection (PC-RARPLND) for metastatic germ cell tumors (mGCT)., Methods: We retrospectively analyzed patients from four tertiary centers who underwent PC-RARPLND for mGCT, from 2011 to 2021. Previous treatment of mGCT, intraoperative and postoperative complications, and early oncologic outcomes were assessed., Results: Overall, 66 patients were included. The majority of patients had non-seminoma mTGCT (89%). Median size of retroperitoneal lymph node (RLN) before surgery was 26 mm. Templates of PC-RARPLND were left modified, right modified, and full bilateral in 56%, 27%, and 14%, respectively. Median estimated blood loss and length of stay were 50 mL [50-150] and 2 [1-3] days. Four patients (6.1%) had a vascular injury, only one with significant blood loss and conversion to open surgery (OS). Two other patients had a conversion to OS for difficulty of dissection. No patient had transfusion, most frequent complications were ileus (10.6%) and symptomatic lymphorrea (7.6%) and no complications grade IIIb or more occurred. With a median follow-up of 16 months, two patients had a relapse, all outside of the surgical template (one in the retrocrural space with reascending markers, one in lungs)., Conclusion: PC-RARPLND is a challenging surgery. In expert centers and for selected patients, it seemed safe and feasible, with a low morbidity. Further prospective evaluation of this procedure and long-term oncologic results are needed., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Context: Surgical activity contributes to global warming though the production of greenhouse gases and consumption of resources. To date, no clinical practice guidelines have been made to promote and implement climate-smart actions., Objective: To perform a systematic review of the available actions that could limit CO 2 emission in the operating room (OR) and their potential benefits upon the environment, whilst preserving quality of care., Evidence Acquisition: MEDLINE and Cochrane databases were searched from January 1, 1990 to April 2021. We included studies assessing carbon footprint (CF) in the OR and articles detailing actions that limit or reduce CF., Evidence Synthesis: Thirty-eight studies met the inclusion criteria. We identified six core climate-smart actions: (1) waste reduction by segregation; (2) waste reduction by recycling, reuse, and reprocessing; (3) sterilisation; (4) anaesthesia gas management; and (5) improvement of energy use. Quantitative analysis regarding the CF was not possible due to the lack of homogeneous data. For climate-smart actions, the analysis was limited by discrepancies in study scope and in the methodology of CO 2 emission calculation. Improvement of education and awareness was found to have an important impact on waste segregation and reduction. Waste management is the area where health care workers could have the strongest impact, whereas the main field to reduce CF in the OR was found to be energy consumption., Conclusions: This review provides arguments for many climate-smart actions that could be implemented in our daily practice. Improving awareness and education are important to act collectively in a sustainable way. Further studies are mandatory to assess the impact of these climate-smart actions in the OR., Patient Summary: We performed a systematic review of the available scientific literature to reference all the climate-smart actions proposed to improve the sustainability of surgical activities. Waste segregation, waste reduction and recycling, reuse and reprocessing, sterilisation, anaesthesia gas changes, and improvement of energy use in the operating room were found to be the main areas of research. There is still a long way to go to homogenise and improve the quality of our climate-smart actions., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Considering the wide range of therapeutic options for localized prostate cancer (e.g., active surveillance, radiation-beam therapy, focal therapy, and radical prostatectomy), accurate assessment of the aggressiveness and localization of primary prostate cancer lesions is essential for treatment decision making. National Comprehensive Cancer Network guidelines recognize prostate-specific membrane antigen (PSMA) PET/CT for use in initial staging of high-risk primary prostate cancer. The gastrin-releasing peptide receptor (GRP-R) is a neuropeptide receptor overexpressed by low-risk prostate cancer cells. We aimed to perform the first (to our knowledge) prospective head-to-head comparison of PSMA- and GRP-R-targeted imaging at initial staging to understand how PSMA PET and GRP-R PET can be used or combined in clinical practice. Methods: This was a prospective, single-center, diagnostic cross-sectional imaging study using anonymized, masked, and independent interpretations of paired PET/CT studies in 22 patients with 68 Ga-PSMA-617 (a radiolabeled PSMA inhibitor) and 68 Ga-RM2 ( 68 Ga-DOTA-4-amino-1-carboxymethylpiperidine-d-Phe-Gln-Trp-Ala-Val-Gly-His-Sta-Leu-NH2, a radiolabeled GRP-R antagonist). We enrolled patients with newly diagnosed, biopsy-proven prostate cancer. None had received neoadjuvant hormone therapy or chemotherapy, and all underwent extended pelvic lymph node dissection. Histologic findings served as a reference. Results: On a lesion-based analysis (including lesions < 0.1 cm 3 ), 68 Ga-PSMA-617 PET/CT detected 74.3% (26/35) of all tumor lesions and 68 Ga-RM2 PET/CT detected 78.1% (25/32; 1 patient could not be offered 68 Ga-RM2 PET/CT). Paired examinations showed positive uptake of the 2 tracers in 21 of 32 lesions (65.6%), negative uptake in 5 of 32 lesions (15.6%), and discordant uptake in 6 of 32 lesions (18.8%). Uptake of 68 Ga-PSMA-617 was higher when the International Society of Urological Pathology (ISUP) score was at least 4 versus at least 1 ( P < 0.0001) or 2 ( P  = 0.0002). There were no significant differences in uptake between ISUP scores for 68 Ga-RM2. Median 68 Ga-RM2 SUV max was significantly higher than median 68 Ga-PSMA-617 SUV max in the ISUP-2 subgroup ( P  = 0.01). Conclusion: 68 Ga-PSMA-617 PET/CT is useful to depict higher, more clinically significant ISUP score lesions, and 68 Ga-RM2 PET/CT has a higher detection rate for low-ISUP tumors. Combining PSMA PET and GRP-R PET allows for better classification of intraprostatic lesions., (© 2023 by the Society of Nuclear Medicine and Molecular Imaging.)

Introduction: Minimally invasive partial nephrectomy (MIPN) has become the standard of care for localized kidney tumors over the past decade. The characteristics of each tumor, in particular its size and relationship with the excretory tract and vessels, allow one to judge its complexity and to attempt predicting the risk of complications. The recent development of virtual 3D model reconstruction and computer vision has opened the way to image-guided surgery and augmented reality (AR)., Objective: Our objective was to perform a systematic review to list and describe the different AR techniques proposed to support PN., Materials and Methods: The systematic review of the literature was performed on 12/04/22, using the keywords "nephrectomy" and "augmented reality" on Embase and Medline. Articles were considered if they reported surgical outcomes when using AR with virtual image overlay on real vision, during ex vivo or in vivo MIPN. We classified them according to the registration technique they use., Results: We found 16 articles describing an AR technique during MIPN procedures that met the eligibility criteria. A moderate to high risk of bias was recorded for all the studies. We classified registration methods into three main families, of which the most promising one seems to be surface-based registration., Conclusion: Despite promising results, there do not exist studies showing an improvement in clinical outcomes using AR. The ideal AR technique is probably yet to be established, as several designs are still being actively explored. More clinical data will be required to establish the potential contribution of this technology to MIPN., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Robot-assisted partial nephrectomy (RAPN) is a difficult procedure with risk of significant perioperative complications. The objective was to evaluate the impact of preoperative planning and intraoperative guidance with 3D model reconstructions on perioperative outcomes of RAPN., Methods: We conducted a retrospective analysis of all patients who underwent RAPN for kidney tumor by three high-volume expert surgeons from academic centers. Clinical data were collected prospectively after written consent into the French kidney cancer network database UroCCR (CNIL-DR 2013-206; NCT03293563). Our cohort was divided into two groups: 3D-Image guided RAPN group (3D-IGRAPN) and control group. A propensity score according to age, pre-operative renal function and RENAL tumor complexity score was used. Both surgical techniques were compared in terms of perioperative outcomes., Results: The initial study cohort included 230 3D-IGRAPN and 415 control RAPN. Before propensity-score matching, patients in the 3D-IGRAPN group had a larger tumor (4.3 cm vs. 3.5 cm, P < 0.001) and higher RENAL complexity score (9 vs. 8, P < 0.001). Following propensity-score matching, there were 157 patients in both groups. The rate of major complications was lower for patients in the 3D-IGRAPN group (3.8% vs. 9.5%, P = 0.04). The median percentage of eGFR variation recorded at first follow-up was lower in the 3D-IGRAPN group (- 5.6% vs. - 10.5%, P = 0.002). The trifecta achievement rate was higher in the 3D-IGRAPN group (55.7% vs. 45.1%; P = 0.005)., Conclusion: Three-dimensional kidney reconstructions use for pre-operative planning and intraoperative surgical guidance lowers the risk of complications and improve perioperative clinical outcomes of RAPN., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Robot-assisted partial nephrectomy (RAPN) reduces morbidity, enabling development of Enhanced Recovery After Surgery (ERAS) and day-case protocols. Additional financial costs limit its integration into clinical practice. We evaluated the medico-economic impact of RAPN using a nurse-led coordinated pathway of care (NLC-RAPN)., Methods: All tumor RAPNs performed in 2017 were prospectively included in nurse-led protocols: NP-RAAC (ERAS) or Ambu-Rein (day case). Clinico-biological and pathological data were prospectively collected within the French Research Network for Kidney Cancer database (NCT03293563). Estimated costs were compared to "average" patients at the national level operated by open partial nephrectomy (OPN) or RAPN, using data from the 2017 French hospital discharge database and the national cost scale., Results: The NLC-RAPN cohort (n = 151) included 27 (18%) outpatients and the average hospital length of stay (LOS) was 2.4 days. In the national control cohorts for OPN (n = 2475) and RAPN (n = 3529), the average LOS were 8.0 and 5.2 days, respectively. The mean incomes per group were €7607 for NLC-RAPN, €9813 for OPN, and €8215 for RAPN. The mean daily cost of stay was €659 for NLC-RAPN, €838 for OPN, and €725 for RAPN. The overall cost for NLC-RAPN was €6594, €8733 for OPN, and €8763 for RAPN. The best operational margin was obtained for day-case NLC-RAPN (€1967)., Conclusion: Combining RAPN with nurse-led coordinated pathways of care led to a shorter hospital stay and reduced costs versus OPN. This may facilitate the economic sustainability of robotic assistance for hospitals where the extra cost is not covered by the healthcare system., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Recent studies suggested that the neutrophil-to-lymphocyte ratio (NLR) could play a key role in tumor initiation, progression and response to treatments. The main objective was to assess the prognostic value of the pre-operative NLR on recurrence-free survival (RFS) in patients with non-hereditary localized renal cell carcinoma. From the UroCCR database (NCT03293563), factors influencing the disease recurrence of consecutive patients who underwent nephrectomy for cT1-T4 N0M0 were analyzed using multi-variate cox regression and log-rank methods. We included 786 patients, among which 135 (17.2%) experienced a recurrence at a median time of 23.7 [8.5-48.6] months. RFS for patients with a pre-operative NLR of <2.7 was 94% and 88% at 3 and 5 years, respectively, versus 76% and 63% for patients with a NLR of ≥2.7 ( p < 0.001, log-rank test). To predict the risk of post-operative recurrence, the NLR was combined with the UCLA integrated staging system (UISS), and we defined four groups of the UroCCR-61 predictive model. The RFS rates at 3 and 5 years were 100% and 97% in the very-low-risk group, 93% and 86% in the low-risk group, 78% and 68% in the intermediate-risk group and 63% and 46% in the high-risk group ( p < 0.0001). The pre-operative NLR seems to be an inexpensive and easily accessible prognostic bio-marker for non-metastatic RCCs.

The SARS-CoV-2 outbreak overwhelmed the healthcare systems worldwide. Saturation of hospitals and the risk of contagion led to a reduction in the care of other diseases., Objective: To determine the impact of SARS-CoV-2 pandemic on urological surgery in France during the year 2020., Design, Setting and Participants: An observational descriptive study was conducted on anonymised data collected from the national healthcare database established each year as part of the Program for the Medicalization of Information Systems in Medicine, Surgery, Obstetrics and Odontology., Intervention: None., Primary and Secondary Outcome Measures: We gathered the number of urology surgical procedures carried out between 2010 and 2019, and we observed the difference between the forecast and actual number of urological surgeries performed in 2020., Results: Urological surgeries decreased by 11.4%, non-oncological surgeries being more affected (-13.1%) than oncological ones (-4.1%). Among the most relevant surgeries, female urinary incontinence (-44.7%) and benign prostatic hyperplasia (-20.8%) were the most impacted ones, followed by kidney cancer (-9%), urolithiasis (-8.7%), radical cystectomy for bladder cancer (-6.1%), prostate cancer (-3.6%) and transurethral resection of bladder tumour (-2%). Public hospitals had a more reduced activity (-17.7%) than private ones (-9.1%). Finally, the distribution of the reduction in urological activities by region did not correspond to the regional burden of SARS-CoV-2., Conclusions: Urological care was severely affected during SARS-CoV-2 pandemic. Even if oncological surgeries were prioritised, the longer it takes to receive appropriate care, the greater the risk on survival impact., Trial Registration: The data collection and analysis was authorised by the French Data Protection Authority (CNIL) under the number1 861 282v2., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Preserved sexual function is one of the endpoints of the surgical management of lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Our aim was to investigate the evolution of erectile function (EF) at 3 and 12 months after holmium laser enucleation of the prostate (HoLEP)., Methods: A multicentric retrospective study was performed including 235 sexually active patients who underwent HoLEP between January 2016 and June 2017. Evaluation of EF was carried out with the five-item version of the International Index of Erectile Function (IIEF-5) completed before surgery and at 3 and 12 months after surgery. A change of more than five points in either direction in the IIEF-5 score compared to baseline was considered as an improvement or impairment of EF., Results: No significant differences were found between median pre-operative IIEF-5 and median scores at 3 and 12 months (p  =  0.15 and p  =  0.45). At 3 and 12 post-operative months, respectively, 10% and 13% of patients reported an improvement, whereas 15% and 16% reported an impairment. The reduction in IIEF-5 score was only statistically significant within the sub-group of patients with normal pre-operative EF (p < 0.001). In this sub-group, 15% of patients reported a decrease of more than five points in total IIEF-5 score., Conclusion: This multicentric evaluation confirmed that median IIEF-5 score was not significantly impaired after HoLEP. However, for patients with normal pre-operative EF, a significant decrease in EF after HoLEP was observed. These results may be taken into account when counselling patients before HoLEP., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Prostate cancer (PCa) clinical heterogeneity underscores tumor heterogeneity, which may be best defined by cell subtypes. To test if cell subtypes contributing to progression can be assessed noninvasively, we investigated whether 14 genes representing luminal, neuroendocrine, and stem cells are detectable in whole blood RNA of patients with advanced PCa. For each gene, reverse transcription quantitative polymerase chain reaction assays were first validated using RNA from PCa cell lines, and their traceability in blood was assessed in cell spiking experiments. These were next tested in blood RNA of 40 advanced PCa cases and 40 healthy controls. Expression in controls, which was low or negative, was used to define stringent thresholds for gene overexpression in patients to account for normal variation in white blood cells. Thirty-five of 40 patients overexpressed at least one gene. Patients with more genes overexpressed had a higher risk of death (hazard ratio 1.42, range 1.12-1.77). Progression on androgen receptor inhibitors was associated with overexpression of stem (odds ratio [OR] 7.74, range 1.68-35.61) and neuroendocrine (OR 13.10, range 1.24-142.34) genes, while luminal genes were associated with taxanes (OR 2.7, range 1.07-6.82). Analyses in PCa transcriptomic datasets revealed that this gene panel was most prominent in metastases of advanced disease, with diversity among patients. Collectively, these findings support the contribution of the prostate cell subtypes to disease progression. Cell-subtype specific genes are traceable in blood RNA of patients with advanced PCa and are associated with clinically relevant end points. This opens the door to minimally invasive liquid biopsies for better management of this deadly disease., (© 2022 The Authors. Clinical and Translational Science published by Wiley Periodicals LLC on behalf of American Society for Clinical Pharmacology and Therapeutics.)

Robot Assisted Partial Nephrectomy (RAPN) is a standard of care for localized renal tumors. It allows a good carcinological control while limiting complications. Despite numerous benefits, the economic sustainability of robotic assistance remains a challenge in the French health care system. The introduction in our institution of two perioperative nurse-coordinated protocols for patients undergoing RAPN (Enhanced Recovery After Surgery: NP-RAAC in 2015 and Outpatient: Ambu-Rein in 2016) is associated with a shortening of the average length of hospital stay, thus reducing the cost of robotic assisted procedures. With the aim of improving efficiency of nursing support within these protocols, we have introduced digitalized nursing coordination by developing a urological perioperative application: UroConnect®. This device is offered to patients by the coordinating nurses during a preoperative visit. It provides information on the pathology and its surgical management. Self-completed questionnaires sent at key moments collect data from the first month after surgery and detect patients presenting difficulties or complications, allowing the nurses to respond with appropriate care. The application allows a secure discharge, a personalised follow-up and an increase in the patient's autonomy and compliance with care., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Objective. To assess the performance and added value of processing complete digital endoscopic video sequences for the automatic recognition of stone morphological features during a standard-of-care intra-operative session. Approach. A computer-aided video classifier was developed to predict in-situ the morphology of stone using an intra-operative digital endoscopic video acquired in a clinical setting. Using dedicated artificial intelligence (AI) networks, the proposed pipeline selects adequate frames in steady sequences of the video, ensures the presence of (potentially fragmented) stones and predicts the stone morphologies on a frame-by-frame basis. The automatic endoscopic stone recognition (A-ESR) is subsequently carried out by mixing all collected morphological observations. Main results. The proposed technique was evaluated on pure (i.e. include one morphology) and mixed (i.e. include at least two morphologies) stones involving 'Ia/Calcium Oxalate Monohydrate' (COM), 'IIb/Calcium Oxalate Dihydrate' (COD) and 'IIIb/Uric Acid' (UA) morphologies. The gold standard ESR was provided by a trained endo-urologist and confirmed by microscopy and infra-red spectroscopy. For the AI-training, 585 static images were collected (349 and 236 observations of stone surface and section, respectively) and used. Using the proposed video classifier, 71 digital endoscopic videos were analyzed: 50 exhibited only one morphological type and 21 displayed two. Taken together, both pure and mixed stone types yielded a mean diagnostic performances as follows: balanced accuracy = [88 ± 6] (min = 81)%, sensitivity = [80 ± 13] (min = 69)%, specificity = [95 ± 2] (min = 92)%, precision = [78 ± 12] (min = 62)% and F1-score = [78 ± 7] (min = 69)%. Significance. These results demonstrate that AI applied on digital endoscopic video sequences is a promising tool for collecting morphological information during the time-course of the stone fragmentation process without resorting to any human intervention for stone delineation or the selection of adequate steady frames., (© 2022 Institute of Physics and Engineering in Medicine.)

Objectives: To describe the incidental prostate cancer (iPCa) rate and identify predictive factors for PCa progression after holmium laser enucleation of the prostate (HoLEP)., Methods: A retrospective review of all iPCa cases diagnosed after HoLEP procedures between April 2012 and May 2020 was conducted. iPCa was defined as a symptom-free cancer diagnosed after HoLEP in patients without any diagnosis or suspicion of PCa before surgical treatment. PCa progression was suspected by rise in PSA from baseline after HoLEP and confirmed by progressive disease detected on transrectal needle biopsy or by the appearance of metastatic disease. Univariate and multivariate logistic regression were used to identify predictive factors for cancer progression., Results: The iPCa rate in our cohort was 10.7% (n = 134). Among patients with iPCa, 25 (18.6%) progressed with a mean follow-up of 32 months. Regarding predictive factors, post-operative PSA (OR 2.35, p < 0.001) was significantly associated with PCa progression in multivariate analysis. The cutoff value for post-operative PSA was determined at 2 ng/mL. Among iPCa cases, 14 patients (10.4%) had both T1b stage disease and PSA ≥ 2 ng/mL, while 68 (50.7%) had neither of these factors. Univariate logistic regression analysis showed that patients with both factors had the highest risk of progression (OR 49.4; p < 0.001)., Conclusion: In this study, post-operative PSA above 2 ng/mL was the only independent risk factor for iPCa progression after HoLEP. Patients with post-operative PSA ≥ 2 ng/mL must be considered to be at risk of progression and may require early curative treatment or closer follow-up in the post-operative period, especially when this is associated with T1b stage disease., (© 2022. The Author(s) under exclusive licence to Japan Society of Clinical Oncology.)

Introduction: Guidelines do not recommend FDG-PET CT for the staging of MIBC as a standard. The objectives of the study are to assess the accuracy of the FDG-PET CT for LN staging and to determine the rate of treatment modification according to FDG-PET CT results in MIBC., Patients and Methods: From January 2005 to December 2017, we carried out a retrospective analysis of patients with MIBC who had a FDG-PET CT for staging in two expert centres in Bordeaux, France, and analyzed its clinical value in this setting. Nodal and metastatic staging on CT scan (CT) and FDG-PET CT were done independently., Results: Accuracy of LN staging from CT and FDG-PET CT at initial diagnosis was analyzed in 85 patients (including 70 patients treated with neoadjuvant chemotherapy (NAC)) and compared to pathological examination of resected LN. Sensitivity of FDG-PET CT was better than CT (80.8% versus 26.9%) but the specificity was low (54.2% vs. 83.1%). The Youden index was better for FDG-PET CT (0.35; 0.1 for CT) and FDG-PET CT appeared to be more accurate for determining LN staging of MIBC. FDG-PET CT findings enabled a treatment decision modification in 34/130 patients (26.1%): a therapeutic intensification (9.2%), including surgery not previously planned and/or modified fields of radiotherapy; or a de-escalation (16.9%), mostly avoiding surgery., Conclusion: FDG-PET CT was more sensitive for detection of LN involvement at initial diagnosis of MIBC than CT alone. In our study, treatment decisions were modified, according to FDG-PET CT results, in almost a quarter of patients., (Copyright © 2022. Published by Elsevier Inc.)

Background: Ablative therapies (AT) are increasingly being offered to patients with kidney tumors. In cases of failure or local relapse, salvage surgery may be required. Such procedures often require an open approach, are difficult and have received little attention in the literature. We aim to evaluate the feasibility of salvage robot-assisted partial nephrectomy (sRAPN) after AT., Methods: We conducted a monocentric retrospective study of all patients who benefited from sRAPN. Clinical data were collected prospectively after written consent in the French UroCCR database., Results: Between 2013 and 2020, 724 RAPN were performed in our center; of these, 11 patients underwent salvage RAPN and four (36.4%) had an imperative indication for a solitary kidney. The median patient age was 54 (49-72) years, median preoperative glomerular filtration rate (GFR) was 65.5 (42.9-88.4) mL/min/1.73 m 2 , and median tumor diameter was 34 (16-38) mm. Extensive perinephric fibrosis was present in 90.9% of cases. Postoperative complications occurred in 36.4% of patients, including major complications in 18.2%. The median GFR at three months (56.8 [45.9-63.9] mL/min/1.73 m 2 ) and at last follow-up (52.1 [45.85-68.3] mL/min/1.73 m 2 ) were not significantly different to the preoperative GFR (P=0.51 and P=0.65, respectively). During follow-up (median 12 months), three patients (all with Von Hippel Lindau disease) developed a recurrence, but none were on the sRAPN site., Conclusions: Our series of sRAPN following AT failure confirms that such surgery is feasible with good functional and oncological results. However, these surgeries remain difficult, are associated with significant complication rate and should be performed in expert centers.

Introduction: Urolift implant placement may be preferred to conventional endoscopic surgery for patients who wish to preserve their sexuality or for those who prefer a rapid post-operative recovery. The absence of general anaesthesia is an important element that reinforces the minimally invasive aspect of the procedure and improves the speed of recovery. The aim of this work was to report our preliminary experience of Urolift treatment under local anaesthesia., Materials and Methods: A retrospective analysis was conducted including all patients treated with Urolift between 2017 and 2021 in our centre. Local anaesthesia was based on the instillation of 2 Xylocaine gels at 4°C into the urethra 15minutes before the procedure. The primary endpoint was the successful completion of the procedure without interruption due to pain or the need for any other form of anaesthesia or analgesia., Results: Twenty-seven patients were included with a median age of 65 years and a prostate volume of 46mL. The International Prostate Symptom Score (IPSS) was 23. The first 3 patients were operated on under general anaesthesia. Local anaesthesia was introduced from the fourth patient onwards. There was no recourse to other modalities of analgesia or anaesthesia or interruption of the procedure. The operating time was 10minutes and pain was assessed at 1 on a visual analogue scale. At 3 months, the IPSS score was 9 (P=0.001)., Conclusion: This preliminary experience confirms the feasibility of placing the Urolift implant under local anaesthesia without any failure of the proposed management. The improvement in IPSS score was consistent with previously published clinical trials., Level of Evidence: 3., (Copyright © 2021. Published by Elsevier Masson SAS.)

Objective: To assess automatic computer-aided in situ recognition of the morphological features of pure and mixed urinary stones using intra-operative digital endoscopic images acquired in a clinical setting., Materials and Methods: In this single-centre study, a urologist with 20 years' experience intra-operatively and prospectively examined the surface and section of all kidney stones encountered. Calcium oxalate monohydrate (COM) or Ia, calcium oxalate dihydrate (COD) or IIb, and uric acid (UA) or IIIb morphological criteria were collected and classified to generate annotated datasets. A deep convolutional neural network (CNN) was trained to predict the composition of both pure and mixed stones. To explain the predictions of the deep neural network model, coarse localization heat-maps were plotted to pinpoint key areas identified by the network., Results: This study included 347 and 236 observations of stone surface and stone section, respectively; approximately 80% of all stones exhibited only one morphological type and approximately 20% displayed two. A highest sensitivity of 98% was obtained for the type 'pure IIIb/UA' using surface images. The most frequently encountered morphology was that of the type 'pure Ia/COM'; it was correctly predicted in 91% and 94% of cases using surface and section images, respectively. Of the mixed type 'Ia/COM + IIb/COD', Ia/COM was predicted in 84% of cases using surface images, IIb/COD in 70% of cases, and both in 65% of cases. With regard to mixed Ia/COM + IIIb/UA stones, Ia/COM was predicted in 91% of cases using section images, IIIb/UA in 69% of cases, and both in 74% of cases., Conclusions: This preliminary study demonstrates that deep CNNs are a promising method by which to identify kidney stone composition from endoscopic images acquired intra-operatively. Both pure and mixed stone composition could be discriminated. Collected in a clinical setting, surface and section images analysed by a deep CNN provide valuable information about stone morphology for computer-aided diagnosis., (© 2021 The Authors BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Introduction: Urinary retention in the acute phase of a spinal cord injury (SCI) requires bladder drainage (BD). International scientific societies recommend early implementation of intermittent catheterisation (IC) to prevent lower urological complications, preserve fertility, the urological future of the patient and improve its quality of life. The aim of our study was to analyze the mode of BD in the acute phase of a trauma in patients with SCI., Materials and Methods: We retrospectively analyzed the mode of BD of patients with SCI in the acute phase of trauma at the Bordeaux University Hospital from 2013 to 2018., Results: The care pathways of 81 patients were analyzed; patients were hospitalized in intensive care unit (ICU) (42%, n=34), in orthopaedic ward (19.8%, n=16) or in ICU and orthopaedic ward (38.2%, n=31). All of them had an indwelling catheter (IUD) inserted before IC was introduced in 56 of them (69%). On hospital discharge, IC was the BD for only 37% of patients, with differences according to the care pathway: 65% of patients leaving ICU were on IC, compared with 11% leaving orthopaedic ward. 80% of patients who had IC in ICU had an IUD installed in orthopaedic ward., Conclusion: In this study, during the acute phase of a trauma in the majority of SCI patient, IC was introduced only in a minority of patients and the promotion was different within the hospital care pathways. Those results enhanced the need for IC awareness in different hospital units to standardize the best patient care., Level of Evidence: 3., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Purpose: Partial gland ablation (PGA) using high-intensity focused ultrasound (HIFU) is currently under investigation for clinically significant prostate cancer (Cs-PCa). Our primary objective was to assess the role of systematic control biopsies following HIFU-PGA in a cohort of Cs-PCa patients., Materials and Methods: We studied a single-center retrospective cohort of 77 men treated with HIFU-PGA between October 2015 and December 2019. Patients with unilateral Cs-PCa, defined as Gleason grade group (GGG) ≥2, with visible lesion on multiparametric magnetic resonance imaging (mpMRI) and prostate specific antigen (PSA) ≤15 ng/ml were included. All patients underwent mpMRI with systematic and targeted biopsies before and after HIFU-PGA. The primary outcome was the rate of Cs-PCa at control biopsy within 1 year of treatment. Logistic regression was performed to identify predictive factors of our primary outcome., Results: Median age was 67 years (IQR 61-71), median PSA was 7 ng/ml (IQR 5.5-8.9). Pre-treatment biopsies revealed 48 (62.3%) GGG2 lesions, 24 (31.2%) GGG3 and 5 (6.5%) GGG4 lesions. Cs-PCa was found in 24 (31.2%) patients at systematic control biopsy post-HIFU; Cs-PCa was in the treated lobe for 18 (27%) patients. No variables were identified as significant predictors of Cs-PCa at control biopsy, including PSA kinetics and control mpMRI. Median followup time was 17 months (95% CI 15-21). Median time to any retreatment was 32 months (95% CI 23-42)., Conclusions: Systematic control biopsy within a year after PGA for Cs-PCa can identify the presence of residual Cs-PCa in up to a third of patients. From our early experience, control biopsy should be systematically offered patients regardless of PSA kinetics or control mpMRI results.

Objective: To improve endoscopic recognition of the most frequently encountered urinary stone morphologies for a better aetiological approach in lithiasis by urologists., Materials and Methods: An expert urologist intraoperatively and prospectively (between June 2015 and June 2018) examined the surface, the section, and the nucleus of all encountered kidney stones. Fragmented stones were subsequently analysed by a biologist based on both microscopic morphological (i.e. binocular magnifying glass) and infrared (i.e. Fourier transform-infrared spectroscopy) examinations (microscopists were blinded to the endoscopic data). Morphological criteria were collected and classified for the endoscopic and microscopic studies. The Wilcoxon-Mann-Whitney test was used to detect differences between the endoscopic and microscopic diagnoses. A diagnosis for a given urinary stone was considered 'confirmed' for a non-statistically significant difference., Results: A total of 399 urinary stones were included in this study: 51.4% of the stones had only one morphological type, while 48.6% were mixed stones (41% had at least two morphologies and 7.6% had three morphologies). The overall matching rate was 81.6%. Diagnostics were confirmed for the following morphologies: whewellite (Ia or Ib), weddellite (IIa or IIb), uric acid (IIIa or IIIb), carbapatite-struvite association (IVb), and brushite (IVd)., Conclusions: Our preliminary study demonstrates the feasibility of using endoscopic morphology for the most frequently encountered urinary stones and didactic boards of confirmed endoscopic images are provided. The present study constitutes the first step toward endoscopic stone recognition, which is essential in lithiasis. We provide didactic boards of confirmed endoscopic images that pave the way for automatic computer-aided in situ recognition., (© 2020 The Authors BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Background: The aim of this paper was to assess the feasibility of robot-assisted radical nephrectomy (RN) with inferior vena cava thrombectomy (RRVCT) and compare perioperative and oncological outcomes of this approach to open surgery for renal tumors with level 1-2 inferior vena cava (IVC) thrombus., Methods: We performed a retrospective analysis of patients surgically treated for renal cancer with IVC level 1-2 thrombus in the Urology department of Bordeaux University Hospital between December 2015 and December 2019. Patients were stratified by surgical approach in two groups: open vs. robotic procedures. Pre-, per- and postoperative data were collected within the framework of the UroCCR project (NCT03293563). Univariate and multivariate analysis using regression models were performed., Results: A total of 40 patients underwent RN with IVC tumor thrombus. Open and robotic surgery represented respectively 30 and 10 cases. The two groups were comparable regarding pre-operative tumor and patient characteristics. Robotic procedures were associated with lower estimated blood loss (EBL) (500 vs. 1250 mL, P=0.02), shorter Intensive Care Unit stay (2 vs. 4 days, P=0.03) and decrease of global length of stay (LOS) (7 vs. 10 days, P<0.01). Operative Time (OT) was significantly longer in the robotic group (350.5 vs. 208 min, P<0.01). No difference were observed between the two approaches regarding complications and oncological outcomes., Conclusions: Robotic approach induced lower bleeding and shorter LOS but required longer OT. This technique is feasible and safe for selected cases and experimented surgical teams. Complications rate and oncological outcomes are not different compared to standard open procedures.

Objective: To report a contemporary series of Miami pouch (MP) enriched with a full technical description and step-by-step video to contribute to wider use., Patients and Methods: A retrospective charts review of all patients who had a MP at our center between January 2016 and December 2017 was performed. The MP technique uses the terminal 15cm of ileum and the right colon to build an intestinal heterotopic pouch located in the right iliac fossa and connected to the skin by an efferent catheterizable tube. Primary outcome was continence defined as the absence of leakage between clean intermittent self-catheterization (CISC) with a maximal interval of 4 hours between each CISC., Results: Fifteen patients had MP during the study period. Thirty-day postoperative Clavien III complications were observed in 2 (13.3%) patients. At 39 months of median follow-up, continence was obtained for all patients except for 2 patients whom reported intermittent night-time leakages due to long intervals (5 to 7 hours) between 2 CISC. No significant alteration of renal function was reported and no stenosis of the efferent tube neither difficulty to perform CISC was observed., Conclusions: For patients who are candidates for radical cystectomy and not eligible for orthotopic neobladder, intestinal heterotopic pouch with a cutaneous continent urinary diversions as MP may be a reliable alternative. Patients should be informed of the existence of a valid alternative to ileal conduit since it may fit their expectations of a preserved body image without urine collecting appliances., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Importance: Magnetic resonance imaging (MRI) with targeted biopsy is an appealing alternative to systematic 12-core transrectal ultrasonography (TRUS) biopsy for prostate cancer diagnosis, but has yet to be widely adopted., Objective: To determine whether MRI with only targeted biopsy was noninferior to systematic TRUS biopsies in the detection of International Society of Urological Pathology grade group (GG) 2 or greater prostate cancer., Design, Setting, and Participants: This multicenter, prospective randomized clinical trial was conducted in 5 Canadian academic health sciences centers between January 2017 and November 2019, and data were analyzed between January and March 2020. Participants included biopsy-naive men with a clinical suspicion of prostate cancer who were advised to undergo a prostate biopsy. Clinical suspicion was defined as a 5% or greater chance of GG2 or greater prostate cancer using the Prostate Cancer Prevention Trial Risk Calculator, version 2. Additional criteria were serum prostate-specific antigen levels of 20 ng/mL or less (to convert to micrograms per liter, multiply by 1) and no contraindication to MRI., Interventions: Magnetic resonance imaging-targeted biopsy (MRI-TB) only if a lesion with a Prostate Imaging Reporting and Data System (PI-RADS), v 2.0, score of 3 or greater was identified vs 12-core systematic TRUS biopsy., Main Outcome and Measures: The proportion of men with a diagnosis of GG2 or greater cancer. Secondary outcomes included the proportion who received a diagnosis of GG1 prostate cancer; GG3 or greater cancer; no significant cancer but subsequent positive MRI results and/or GG2 or greater cancer detected on a repeated biopsy by 2 years; and adverse events., Results: The intention-to-treat population comprised 453 patients (367 [81.0%] White, 19 [4.2%] African Canadian, 32 [7.1%] Asian, and 10 [2.2%] Hispanic) who were randomized to undergo TRUS biopsy (226 [49.9%]) or MRI-TB (227 [51.1%]), of which 421 (93.0%) were evaluable per protocol. A lesion with a PI-RADS score of 3 or greater was detected in 138 of 221 men (62.4%) who underwent MRI, with 26 (12.1%), 82 (38.1%), and 30 (14.0%) having maximum PI-RADS scores of 3, 4, and 5, respectively. Eighty-three of 221 men who underwent MRI-TB (37%) had a negative MRI result and avoided biopsy. Cancers GG2 and greater were identified in 67 of 225 men (30%) who underwent TRUS biopsy vs 79 of 227 (35%) allocated to MRI-TB (absolute difference, 5%, 97.5% 1-sided CI, -3.4% to ∞; noninferiority margin, -5%). Adverse events were less common in the MRI-TB arm. Grade group 1 cancer detection was reduced by more than half in the MRI arm (from 22% to 10%; risk difference, -11.6%; 95% CI, -18.2% to -4.9%)., Conclusions and Relevance: Magnetic resonance imaging followed by selected targeted biopsy is noninferior to initial systematic biopsy in men at risk for prostate cancer in detecting GG2 or greater cancers., Trial Registration: ClinicalTrials.gov Identifier: NCT02936258.

Objectives: To describe the evolution of day-case success rate over the years and to identify predictive factors for prolonged hospitalization or readmissions. Methods: Retrospective review of all consecutive day-case holmium laser enucleation of the prostate (HoLEP) performed by a single surgeon between January 2013 and February 2019 using a prospective database. Day-case success was defined as discharge within less than 12 hours from admission without any readmission within 48 hours after discharge. Protocol for day-case treatment included systematic bladder catheter insertion with continuous irrigation for ∼2 hours and catheter removal on postoperative day 1. Patients were reached by phone on postoperative day 1 to ensure voiding. For the descriptive statistics, an analysis of variance was performed. Univariate and multivariate analyses were used to identify risk factors. Results: A total of 266 patients were retrieved and dispatched as follows: group 1 ( n  = 88) from January 2013 to July 2015, group 2 ( n  = 89) from August 2015 to June 2017, and group 3 ( n  = 89) from July 2017 to February 2019. The overall success rate was 80.5% (214/266) over the study period. It significantly improved over time from 70% in group 1 to 84% in group 2 and 87% in group 3 ( p  = 0.014). In the meantime, the operating time and the total energy delivered to the tissue decreased from 77 minutes in the first group to 60.4 minutes in the second group and 55.4 minutes in the third group ( p  < 0.001), and from 95.2 kJ in the first group to 84 kJ in the second group and 77.9 kJ in the third group ( p  = 0.041). On multivariate analysis, the only risk factor significantly associated with day-case failure was prostate volume greater than 90 cc (odds ratio = 2.041, p  = 0.047). Conclusion: Day-case HoLEP is a reliable and safe procedure with a high success rate. The surgeon's experience seems to be crucial to improve perioperative outcomes, but prostate volume greater than 90 cc remains associated with higher failure rates.

Introduction: We aimed to assess the transferability of basic robotic skills from the simulator to the operating room (OR) while performing robotic-assisted radical prostatectomy (RARP)., Methods: Fourteen urology residents were randomized into two groups: group A was required to practice three sessions (nine tasks each) on the simulator, whereas group B was required to practice (same nine tasks) until they reached competency. Both groups were recorded while practicing on the da Vinci Surgical Skills Simulator. Both groups were then recorded while performing bladder mobilization during RARP. Senior residents from both groups were also recorded while performing urethro-vesical anastomosis during RARP. Recordings were assessed blindly using the validated Global Evaluative Assessment of Robotic Skills (GEARS) tool by C-SATS. Spearman's correlation coefficient (rho) was used to assess correlation between GEARS scores from practice sessions on the da Vinci Simulator and the GEARS scores from bladder mobilization and urethro-vesical anastomosis during RARP., Results: There was no difference in total GEARS scores between the two groups in the OR. Total GEARS scores for "ring and rail 2" and "suture sponge" tasks correlated with the total GEARS scores during urethro-vesical anastomosis (rho=0.86, p=0.007; rho=0.90, p=0.002, respectively). GEARS' efficiency component during "energy and dissection" task on the da Vinci Simulator correlated with GEARS' efficiency component during bladder mobilization (rho=0.62, p=0.03). GEARS' force sensitivity component during "ring and rail 2" and "dots and needles" tasks on the da Vinci Simulator correlated with GEARS' force sensitivity component during bladder mobilization (rho=0.58, p=0.047; rho =0.65, p=0.02, respectively)., Conclusions: Objective assessments of urology residents on the da Vinci Surgical Skills Simulator tasks ring and rail 2 and suture sponge correlated with their objective assessments of bladder mobilization and urethro-vesical anastomosis. Therefore, basic robotic skills could be transferred from the simulator to the OR.

Background: Renal tumor biopsies (RTB) have been proposed as a means to diminish overtreatment of small renal masses. A potential concern of RTB is tumor seeding along the biopsy tract leading to worse clinical outcomes., Objectives: To evaluate whether RTB was associated with greater upstaging to pT3a compared to patients without a biopsy and to determine if pathologic upstaging affects the risk of recurrence., Design, Setting and Participants: The Canadian Kidney Cancer information system was used to identify patients who underwent radical or partial nephrectomy for malignant renal tumors ≤ 4cm (cT1a) between January 1, 2011 and July 2, 2019., Intervention: RTB prior to nephrectomy or nephrectomy without biopsy., Outcomes Measurements and Statistical Analysis: Upstaging to pT3a and cancer recurrence were compared between subjects that had a RTB compared to those who did not. A multivariable analysis was used to evaluate factors associated with disease upstaging and recurrence., Results and Limitations: The cohort consisted of 1993 cT1a patients, followed for a median of 17.5 months. Of these patients, 502 (25%) had a preoperative RTB. There was no difference in the proportion with tumor upstaging to pT3a between patients that had RTB compared to those who did not (7.2% vs. 6.3%; P = 0.5). On multivariable analysis, RTB was not associated with pathological upstaging (Odds Ratio 0.90; 95% Confidence Interval 0.61-1.34) or recurrence (Odds Ratio 1.04; 95% Confidence Interval 0.57-1.89). The main limitation is that the study is underpowered to detect small differences between groups., Conclusions: In this large, multi-institution cohort, RTB was not associated with increased risk of tumor upstaging or recurrence. Hence, tumor tract seeding, although possible, should not be a clinical deterrent to using RTBs as a means of personalizing renal masses management and diminishing overtreatment., Patient Summary: Recent evidence suggests that tumor seeding following RTB may be more common than initially perceived. Our results have demonstrated that RTB was not associated with an increased risk of tumor upstaging or disease recurrence., (Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.)

Background: Prostate cancer is supposedly more aggressive among Afro-Caribbean men. There is a lack of data in this population for active surveillance. Published series are retrospective or have small samples and results are discordant. The objective was to determinate whether actual active surveillance modalities can be applied for Afro-Caribbean men by comparing their oncological outcomes with Caucasian men., Methods: A total of 449 consecutive patients who underwent active surveillance for favorable-risk prostate cancer in two French University-Medical-Centers between 2005 and 2018: 261 in Guadeloupe, French West Indies, and 188 in Bordeaux, metropolitan France. Median follow-up was 56 months, (95% CI [32-81]) and 52 months (95% CI [30-75]), respectively (P=0.07). Curative treatment was given in case of histological, biological, or imaging progression, or upon patient demand. Primary endpoints were treatment-free, overall and specific survival. Secondary outcomes were reasons of discontinuating active surveillance, histological poor prognosis factors after prostatectomy, CAPRA-S score, biochemical-recurrence-free after treatment and metastasis-free survival. Kaplan-Meier method was used., Results: Median treatment free survival was 58.4 months (CI 95% [48.6-83.1]) for ACM and not reached at 120 months for CM (P=0.002). Overall survival (P=0.53), and specific survival (P=0.21) were similar in the two groups. CM were likely to have poor prognosis factor on prostatecomy piece (57 vs 30%, P=0.01). No difference for repartition of the CAPRA-S score (P=0.86), biochemical-recurrence-free (P=0.92) and metastasis-free (P=0.44) survival., Conclusions: Oncological outcomes for active surveillance of Afro-Caribbean and Caucasian men were similar in terms of mortality, recurrence and metastasis in our bicentric study, showing usability of current criteria for Afro-Caribbean. The higher rate of disease progression in the Afro-Caribbean population requires close monitoring., Level of Evidence: 3., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Introduction and Purpose: The objective of this work was to identify the risk factors (RFs) of active surveillance (AS) interruption in a prostate cancer (PCa) single-center retrospective cohort of patients., Material and Method: All patients in AS between January 2011 and October 2019 were retrospectively included in a computerized database. The group of patients who had an AS interruption was compared to the one still under AS, in order to identify potential risk factors for the interruption of the surveillance protocol., Results: Two hundred and two patients have been included in the AS cohort with a median follow-up of 32months. At the time of analysis, 72 patients (36%) were not under the AS protocol anymore, 118 (58%) were still under AS and 12 (6%) were lost of follow-up. Sixty-six patients (92%) had left SA due to PCa progression, 4 (5%) by personal choice and 2 (3%) switched to watchful waiting. A PSA doubling Time<3years (PSADT<3years) has been identified as the only statistically significant RF for AS interruption, both in the unvaried (P<0.001) and multivariate (OR=5.403, P<0.01) analysis. It was also the only RF of AS interruption in the early analysis in the first three years of AS, in the unvaried analysis (P=0.021) and the multivariate analysis (OR=3.612, P=0.018)., Conclusion: PSADT was the only RF of AS early and late interruption in our study. It represents a major inclusion criterion in AS protocol during the initial assessment., Level of Evidence: 3., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Docetaxel-based chemotherapy has been the cornerstone of the management of symptomatic metastatic castration-resistant prostate cancer (mCRPC) since 2004. This study aimed to describe how real-world clinical practice was changed with the public funding of novel hormonal agents (abiraterone and enzalutamide) in Quebec., Methods: We conducted a retrospective cohort study in two McGill University hospitals. Hospital-based cancer registries were used to select mCRPC patients in medical oncology departments from January 2010 to June 2014. Two groups according to mCRPC diagnosis year were built, with 2012 chosen as the cut-off year, corresponding to the year abiraterone was approved for public reimbursement in second-line in Quebec. Kaplan-Meier analysis was used to estimate time to first docetaxel prescription since mCRPC diagnosis before and after 2012. Cox regression was used to identify predictive factors of docetaxel and novel hormonal agent use., Results: In our cohort, 308 patients diagnosed with mCRPC were selected with 162 patients in the pre-2012 group and 146 patients in the post-2012 group. The median age at mCRPC was 74.0 years old. At 12 months from diagnosis, 69% of patients received a prescription for docetaxel in the pre-2012 group comparatively to 53% in the post-2012 group. Factors that decreased the likelihood of docetaxel utilization were: age older than 80 at mCRPC diagnosis (HR: 0.5; 95%CI: 0.3-0.7), mCRPC diagnosis after 2012 (HR: 0.6; 95%CI: 0.4-0.8), and asymptomatic disease at mCRPC diagnosis (HR: 0.5; 95%CI: 0.3-0.7)., Conclusion: The introduction of novel hormonal agents reduced first-line and overall docetaxel utilization and delayed time to its initiation.

Introduction: We sought to evaluate the diagnostic performance of 18 F-fluorocholine positron emission tomography-computed tomography ( 18 F-FCH PET/CT) for initial staging of patients with high-risk prostate cancer. Secondary objectives were to compare the value of 18 F-FCH PET/CT to conventional imaging modalities and to evaluate its clinical impact., Methods: We conducted a retrospective study of 76 patients who underwent 18 F-FCH PET/CT for initial staging of high-risk prostate cancer. Using pre-established validation criteria, sensitivity and specificity were determined for metastatic disease. Results were compared to findings on magnetic resonance imaging (MRI), computed tomography (CT), and bone scan (BS) when available., Results: Twenty-two (29%) PET/CT scans were positive, 49 (64%) negative, and five (7%) equivocal for nodal or metastatic disease. Of the positive scans, 17 showed regional lymph node involvement, 12 distant nodes, five bone metastases, and three lung metastases. Overall per-patient sensitivity, specificity, positive and negative predictive values for metastatic disease were 65%, 100%, 100%, and 78%, respectively. Sensitivity, specificity, and positive and negative predictive values were 64%, 100%, 100%, and 80%, respectively, for nodal involvement and 86%, 100%, 100%, and 98%, respectively, for bone and other metastases. Conventional imaging was negative for the lesion(s) found on PET/CT in five patients. PET/CT changed the clinical management in nine patients (12%)., Conclusions: Although 18 F-FCH PET/CT offers some benefits over conventional imaging and demonstrates a high specificity, it remains limited by its sensitivity in the context of high-risk prostate cancer staging. PET with novel urea-based small molecule prostate-specific membrane antigen (PSMA) inhibitors may overcome some of these limitations. However, the interpretation of the study result is limited by the lack of available histological gold standard, the inclusion of several patients who received androgen-deprivation therapy (ADT) prior to PET/CT, our retrospective design, and a relatively small sample size.

Purpose: Use of quantitative imaging features and encoding the intra-tumoral heterogeneity from multi-parametric magnetic resonance imaging (mpMRI) for the prediction of Gleason score is gaining attention as a non-invasive biomarker for prostate cancer (PCa). This study tested the hypothesis that radiomic features, extracted from mpMRI, could predict the Gleason score pattern of patients with PCa. Methods: This analysis included T2-weighted (T2-WI) and apparent diffusion coefficient (ADC, computed from diffusion-weighted imaging) scans of 99 PCa patients from The Cancer Imaging Archive (TCIA). A total of 41 radiomic features were calculated from a local tumor sub-volume (i.e., regions of interest) that is determined by a centroid coordinate of PCa volume, grouped based on their Gleason score patterns. Kruskal-Wallis and Spearman's rank correlation tests were used to identify features related to Gleason score groups. Random forest (RF) classifier model was used to predict Gleason score groups and identify the most important signature among the 41 radiomic features. Results: Gleason score groups could be discriminated based on zone size percentage, large zone size emphasis and zone size non-uniformity values ( p < 0.05). These features also showed a significant correlation between radiomic features and Gleason score groups with a correlation value of -0.35, 0.32, 0.42 for the large zone size emphasis, zone size non-uniformity and zone size percentage, respectively (corrected p < 0.05). RF classifier model achieved an average of the area under the curves of the receiver operating characteristic (ROC) of 83.40, 72.71, and 77.35% to predict Gleason score groups (G1) = 6; 6 < (G2) < (3 + 4) and (G3) ≥ 4 + 3, respectively. Conclusion: Our results suggest that the radiomic features can be used as a non-invasive biomarker to predict the Gleason score of the PCa patients.

Background: Multiparametric magnetic resonance imaging (MRI), with or without targeted biopsy, is an alternative to standard transrectal ultrasonography-guided biopsy for prostate-cancer detection in men with a raised prostate-specific antigen level who have not undergone biopsy. However, comparative evidence is limited., Methods: In a multicenter, randomized, noninferiority trial, we assigned men with a clinical suspicion of prostate cancer who had not undergone biopsy previously to undergo MRI, with or without targeted biopsy, or standard transrectal ultrasonography-guided biopsy. Men in the MRI-targeted biopsy group underwent a targeted biopsy (without standard biopsy cores) if the MRI was suggestive of prostate cancer; men whose MRI results were not suggestive of prostate cancer were not offered biopsy. Standard biopsy was a 10-to-12-core, transrectal ultrasonography-guided biopsy. The primary outcome was the proportion of men who received a diagnosis of clinically significant cancer. Secondary outcomes included the proportion of men who received a diagnosis of clinically insignificant cancer., Results: A total of 500 men underwent randomization. In the MRI-targeted biopsy group, 71 of 252 men (28%) had MRI results that were not suggestive of prostate cancer, so they did not undergo biopsy. Clinically significant cancer was detected in 95 men (38%) in the MRI-targeted biopsy group, as compared with 64 of 248 (26%) in the standard-biopsy group (adjusted difference, 12 percentage points; 95% confidence interval [CI], 4 to 20; P=0.005). MRI, with or without targeted biopsy, was noninferior to standard biopsy, and the 95% confidence interval indicated the superiority of this strategy over standard biopsy. Fewer men in the MRI-targeted biopsy group than in the standard-biopsy group received a diagnosis of clinically insignificant cancer (adjusted difference, -13 percentage points; 95% CI, -19 to -7; P<0.001)., Conclusions: The use of risk assessment with MRI before biopsy and MRI-targeted biopsy was superior to standard transrectal ultrasonography-guided biopsy in men at clinical risk for prostate cancer who had not undergone biopsy previously. (Funded by the National Institute for Health Research and the European Association of Urology Research Foundation; PRECISION ClinicalTrials.gov number, NCT02380027 .).

Introduction: Magnetic resonance imaging (MRI) is being more widely used in the detection of prostate cancer (PCa), particularly after an initial negative biopsy. In this study, we compared 12-core systematic biopsy (SYS), MRI-targeted biopsy (TAR), and the association of systematic and MRI-targeted (SYS+TAR) prostate biopsy in patients with previous biopsy and those who were biopsy-naive to evaluate the differences in terms of cancer detection and clinically significant cancer detection between the three modalities., Methods: Overall, 203 consecutive patients with suspicion of PCa were analyzed; 48.2% were biopsy-naive and 51.7% had at least one previous negative prostate biopsy. The median age was 66 years, median prostate-specific antigen (PSA) level was 7.9 ng/mL and median prostate volume was 46 mL. 38.9% had SYS, 19.2% TAR only, and 41.8% had SYS+TAR biopsy., Results: Overall, the PCa detection (PCaDR) was 63%. The SYS+TAR biopsy detected significantly more cancer than SYS and TAR only biopsies (72.9% vs. 56.9% and 53.8% respectively; p=0.03). Detection rate of clinically significant cancer (csPCaDR) was 50.7% overall; 65.8% in the SYS+TAR biopsy vs. 39.2% in the SYS and 48.7% in the TAR groups (p=0.002). In the biopsy-naive group, PCaDR and csPCaDR were significantly higher in the SYS+TAR group than in the SYS and TAR groups (p=0.01). In the repeat biopsy group, PCaDR and csPCaDR were equivalent in the TAR and SYS+TAR groups and higher than in the SYS group (p=0.001)., Conclusions: TAR biopsy, when added to SYS biopsy, was associated with a higher detection rate of csPCa in biopsy-naive patients when compared to TAR and SYS only biopsies. In patients after previous negative biopsy, detection rates of csPCa were equivalent for SYS+TAR and TAR only biopsies, but higher than SYS.

A 74-year-old man with newly diagnosed prostate cancer underwent Ga-PSMA PET/CT, which demonstrated intense uptake in and adjacent the L2 vertebral body. Subsequent MRI of the lumbar spine showed an aggressive L2 hemangioma with adjacent soft tissue extension. There was congruence of the intraosseous and extraosseous components of the hemangioma and the PSMA PET uptake. This is a rare but important potential pitfall in Ga-PSMA PET/CT-a soft tissue lesion with intense tracer uptake related not to a nodal metastasis of prostate cancer but to extraosseous extension of an aggressive vertebral body hemangioma.

Background: Androgens have been shown to influence both the immune system and lung tissue, raising the hypothesis that androgen deprivation therapy (ADT) for prostate cancer may increase the risk of pneumonia. Thus, the aim of this study was to determine whether ADT is associated with an increased risk of hospitalisation for community-acquired pneumonia in patients with prostate cancer., Methods: This was a population-based cohort study using the United Kingdom Clinical Practice Research Datalink linked to the Hospital Episode Statistics repository. The cohort consisted of 20 310 men newly diagnosed with non-metastatic prostate cancer between 1 April 1998 and 31 March 2015. Time-dependent Cox proportional hazards models were used to estimate adjusted HRs and 95% CIs for hospitalisation for community-acquired pneumonia associated with current and past use of ADT compared with non-use., Results: During a mean follow-up of 4.3 years, there were 621 incident hospitalisations for community-acquired pneumonia (incidence rate: 7.2/1000 person-years). Current ADT use was associated with an 81% increased risk of hospitalisation for community-acquired pneumonia (12.1 vs 3.8 per 1000 person-years, respectively; HR 1.81, 95% CI 1.47 to 2.23). The association was observed within the first six months of use (HR 1.73, 95% CI 1.23 to 2.42) and remained elevated with increasing durations of use (≥25 months; HR 1.79, 95% CI 1.39 to 2.30). In contrast, past ADT use was not associated with an increased risk (HR 1.23, 95% CI 0.95 to 1.60)., Conclusions: The use of ADT is associated with an increased risk of hospitalisation for community-acquired pneumonia in men with prostate cancer., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Purpose: Partial nephrectomy (PN) represents the treatment of choice for localized renal tumor<7cm. Minimally invasive approaches are considered standard of care in many institutions. Maintaining acceptable warm ischemic time (WIT) while teaching robotic PN (RPN) remains challenging. The goal of the present study was to assess the effect of teaching RPN on WIT and renal function in patients undergoing RPN., Methods: Patients undergoing RPN for cT1-T2 renal tumors were included. RENAL nephrometry score was used to adjust for tumor complexity. Glomerular filtration rates (GFR) were determined preoperatively, at day 2 and at ≥3-month follow-up. Patients in whom the attending surgeon (staff) performed tumorectomy and renorraphy were compared with those in whom the fellow performed these steps. Primary outcomes were WIT and GFR decrease at follow-up visit. Morbidity and margin positivity represented secondary outcomes., Results: Overall, 69 patients (46 "staff" vs. 23 "fellow") were included. Patient׳s characteristics did not differ significantly between the 2 groups. In particular, RENAL score and preoperative GFR were similar between both groups. Mean WIT was 22±9 in the staff and 24±7 in the fellow group (P = 0.09). At follow-up, a GFR reduction of 9% was observed in the staff group vs. 13% in the fellow group (P = 0.38). Complication rates (13% vs. 17%, P = 0.63) and positive margins (9% vs. 4%, P = 0.47) did not differ significantly between staff and fellow., Conclusions: In our experience, teaching RPN with a strict supervision and stepwise standardized procedure was oncologically and functionally safe after 3 to 6 months of follow-up., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: We sought to determine predictive factors (patient and prostate-specific antigen [PSA] characteristics) for 18F-fluoromethylcholine positron emission tomography-computed tomography (18F-FCH PET/CT) positivity in the context of biochemical recurrence after local treatment of prostate cancer (PCa) with curative intent., Methods: This is a retrospective study including 60 18F-FCH PET/CT scans of patients with biochemical recurrence after initial radical prostatectomy (RP), external beam radiation therapy (EBRT), or focal high-intensity focused ultrasound (HIFU) with curative intent. The results were compared to findings on magnetic resonance imaging (MRI), computed tomography (CT), bone scan (BS), and histological analysis when available. Univariate analysis was performed to correlate results with patient characteristics., Results: Thirty-eight (63.3%) scans were positive, 17 (28.3%) negative, and 5 (8.3%) equivocal. Of the positive scans, 16 demonstrated local recurrence, 12 regional/distant lymph nodes, five bone metastasis, and five local and distant recurrences. Among the 22 PET/CTs showing metastasis, conventional imaging was performed in 16 patients (72.7%). Of these, it demonstrated the lesion(s) found on PET/CT in eight patients (50.0%), was negative in seven (43.8%), and equivocal in one (6.3%). The trigger PSA (p=0.04), prostate-specific antigen velocity (PSAV) (p=0.03), and prostate-specific antigen doubling time (PSADT) (p=0.046) were significantly different when comparing positive and negative scans. Patients with positive scans were more likely to have received EBRT initially (odds ratio [OR] 11.0, 95% confidence interval [CI] 2.2-55.3). A trigger PSA of 2.6 ng/mL had a sensitivity of 84% and specificity of 65% for a positive scan. PET/CT changed the clinical management plan in 17 patients (28.3%)., Conclusions: 18F-FCH PET/CT demonstrates a high detection rate for local and distant recurrences after localized PCa treatment. A trigger PSA above 2.6 ng/mL seems optimal for appropriate patient selection.

Introduction: In the field of prostate cancer there is a growing tendency for more and more studies to emphasise the predominant role of the zone situated between the tumour and the host: the tumour microenvironment. The aim of this article is to describe the structure and the functions of the prostate cancer microenvironment as well as the principal treatments that are being applied to it., Material and Methods: PubMed and ScienceDirect databases have been interrogated using the association of keywords "tumour microenvironment" and "neoplasm therapy" along with "microenvironnement tumoral" and "traitements". Of the 593 articles initially found, 50 were finally included., Results: The tumour microenvironment principally includes host elements that are diverted from their primary functions and encourage the development of the tumour. In it we find immunity cells, support tissue as well as vascular and lymphatic neovascularization. Highlighting the major role played by this microenvironment has led to the development of specific treatments, notably antiangiogenic therapy and immunotherapy., Conclusion: The tumour microenvironment, the tumour and the host influence themselves mutually and create a variable situation over time. Improvement of the knowledge of the prostate cancer microenvironment gradually enables us to pass from an approach centred on the tumour to a broader approach to the whole tumoral ecosystem. This enabled the emergence of new treatments whose place in the therapeutic arsenal still need to be found., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Introduction: Transrectal ultrasound-guided biopsy (TRUSGB) is the recommended approach to diagnose prostate cancer (PCa). Overdiagnosis and sampling errors represent major limitations. Magnetic resonance imaging (MRI)-targeted biopsy (MRTB) detects higher proportion of significant PCa and reduces diagnosis of insignificant PCa. Costs prevent MRTB from becoming the new standard in PCa diagnosis. The present study aimed at assessing whether added costs of MRI outweigh benefits of MRTB in a cost-utility model., Materials and Methods: A Markov model was developed to estimate quality-adjusted life-year gained (QALY) and costs for 2 strategies (the standard 12-core TRUSGB strategy and the MRTB strategy) over 5, 10, 15, and 20 years. MRI was used as triage test in biopsy-naive men with clinical suspicion of PCa. The model takes into account probability of men harboring PCa, diagnostic accuracy of both procedures, and probability of being assigned to various treatment options. Direct medical costs based on health care system perspective were included., Results: Following standard TRUSGB pathway, calculated cumulative effects at 5, 10, 15, and 20 years were 4.25, 7.17, 9.03, and 10.09 QALY, respectively. Cumulative effects in MRTB pathway were 4.29, 7.26, 9.17, and 10.26 QALY, correspondingly. Costs related to TRUSGB strategy were $8,027, $11,406, $14,883, and $17,587 at 5, 10, 15, and 20 years, respectively, as compared with $7,231, $10,450, $13,267, and $15,400 for the MRTB strategy. At 5, 10, 15, and 20 years, MRTB was the established dominant strategy., Conclusions: Incorporation of MRI and MRTB in PCa diagnosis and management represents a cost-effective measure at 5, 10, 15, and 20 years after initial diagnosis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: To incorporate the da Vinci Surgical Skills Simulator (dVSSS) into Objective Structured Clinical Examinations (OSCEs) and to assess basic robotic skills of urology Post-Graduate Trainees (PGTs)., Materials and Methods: PGTs in post-graduate years (PGY-3 to PGY-5) from two Quebec urology training programs were recruited. During a 20 minute OSCE station, PGTs were asked to fill in a questionnaire and perform two tasks: pick and place, and energy dissection level 1. For each exercise, the norm-referenced method was used to establish a passing score to determine competency. The participant was considered competent in these two basic dVSSS exercises if he/she gained the passing score on both tasks., Results: All nine PGTs who attended the OSCE voluntarily participated in the study. They had performed a median of 10 (IQR: 2.5-16) laparoscopic procedures, 2 (0-8) robotic procedures, and assisted 10 (IQR: 0-15) robotic procedures at the bedside prior to this OSCE. Based on a passing score of 90 for task 1 and 72 for task 2, there were 3 (33%) competent PGTs, all of whom were from PGY-5 level. Therefore, there was significant difference among PGY levels in terms of competency for the basic robotic skills tested (p = 0.01). When compared with PGTs, experts had performed significantly higher numbers of robotic procedures (5.2 +/- 2.4 versus 25 +/- 8.7; p = 0.02). However, there was no significant difference in the performance parameters between PGTs and experts in both tasks., Conclusion: This study confirms the feasibility of incorporating dVSSS into OSCEs to assess basic robotic skills of urology PGTs. Future studies need to include more complex exercises and larger sample size to expand on these results.

Purpose: Prostate cancer (PCa) diagnosis relies on clinical suspicion leading to systematic transrectal ultrasound-guided biopsy (TRUSGB). Multiparametric magnetic resonance imaging (mpMRI) allows for targeted biopsy of suspicious areas of the prostate instead of random 12-core biopsy. This method has been shown to be more accurate in detecting significant PCa. However, the precise spatial accuracy of cognitive targeting is unknown., Methods: Consecutive patients undergoing mpMRI-targeted TRUSGB with cognitive registration (MRTB-COG) followed by robot-assisted radical prostatectomy were included in the present analysis. The regions of interest (ROIs) involved by the index lesion reported on mpMRI were subsequently targeted by two experienced urologists using the cognitive approach. The 27 ROIs were used as spatial reference. Mapping on radical prostatectomy specimen was used as reference to determine true-positive mpMRI findings. Per core correlation analysis was performed., Results: Forty patients were included. Overall, 40 index lesions involving 137 ROIs (mean ROIs per index lesion 3.43) were identified on MRI. After correlating these findings with final pathology, 117 ROIs (85 %) were considered as true-positive lesions. A total of 102 biopsy cores directed toward such true-positive ROIs were available for final analysis. Cognitive targeted biopsy hit the target in 82 % of the cases (84/102). The only identified risk factor for missing the target was an anterior situated ROI (p = 0.01)., Conclusion: In experienced hands, cognitive MRTB-COG allows for an accuracy of 82 % in hitting the correct target, given that it is a true-positive lesion. Anterior tumors are less likely to be successfully targeted.

Purpose: We assessed whether a combination of the fibrin tissue adhesive Tisseel® (human fibrinogen and thrombin) plus the hemostatic matrix FloSeal® (bovine derived gelatin matrix/human thrombin) could safely replace the conventional deep medullary suture without compromising outcomes., Materials and Methods: Laparoscopic mid pole and one-third partial nephrectomy was performed on the right kidney of 12 female pigs. The only difference between the 2 groups of 6 pigs each was the use of a fibrin tissue adhesive plus hemostatic matrix combination in group 2 instead of the deep medullary running suture in control group 1. Renal scans and angiograms were performed at baseline and before sacrifice at 5-week followup. Retrograde in vivo pyelogram was also done., Results: No significant difference was seen in operative parameters or postoperative course between the groups. Renal scans revealed a statistically insignificant trend toward greater uptake loss in group 1 and angiograms showed 3 major vessel occlusions in that group. No active bleeding was detected. Those 3 kidneys had significantly poorer postoperative uptake on renal scan than that of other kidneys (18.6% vs 39.4%, p = 0.013). Only 1 small asymptomatic pseudoaneurysm was noted in group 1. No urine leakage was found in either group. No major vessel occlusion, pseudoaneurysm or urinary complications developed in group 2., Conclusions: Even after deep one-third partial nephrectomy FloSeal with concurrent Tisseel appeared sufficient to control major medullary vascular injuries and replace the deep medullary conventional suture without compromising operative outcomes. The potential advantages seen during functional and vascular examinations by decreasing the risk of unnecessary segmental vessel occlusion need further clinical evaluation., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)