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Although multiparametric magnetic resonance imaging (MRI) has high sensitivity, its lower specificity leads to a high prevalence of false-positive lesions requiring biopsy.To develop and externally validate a scoring system for MRI-detected Prostate Imaging Reporting and Data System (PIRADS)/Likert ≥3 lesions containing clinically significant prostate cancer (csPCa).The multicentre Rapid Access to Prostate Imaging and Diagnosis (RAPID) pathway included 1189 patients referred to urology due to elevated age-specific prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE); April 27, 2017 to October 25, 2019.Visual-registration or image-fusion targeted and systematic transperineal biopsies for an MRI score of ≥4 or 3 + PSA density ≥0.12 ng/ml/ml.Fourteen variables were used in multivariable logistic regression for Gleason ≥3 + 4 (primary) and Gleason ≥4 + 3, and PROMIS definition 1 (any ≥4 + 3 or ≥6 mm any grade; secondary). Nomograms were created and a decision curve analysis (DCA) was performed. Models with varying complexity were externally validated in 2374 patients from six international cohorts.The five-item Imperial RAPID risk score used age, PSA density, prior negative biopsy, prostate volume, and highest MRI score (corrected c-index for Gleason ≥3 + 4 of 0.82 and 0.80-0.86 externally). Incorporating family history, DRE, and Black ethnicity within the eight-item Imperial RAPID risk score provided similar outcomes. The DCA showed similar superiority of all models, with net benefit differences increasing in higher threshold probabilities. At 20%, 30%, and 40% of predicted Gleason ≥3 + 4 prostate cancer, the RAPID risk score was able to reduce, respectively, 11%, 21%, and 31% of biopsies against 1.8%, 6.2%, and 14% of missed csPCa (or 9.6%, 17%, and 26% of foregone biopsies, respectively).The Imperial RAPID risk score provides a standardised tool for the prediction of csPCa in patients with an MRI-detected PIRADS/Likert ≥3 lesion and can support the decision for prostate biopsy.In this multinational study, we developed a scoring system incorporating clinical and magnetic resonance imaging characteristics to predict which patients have prostate cancer requiring treatment and which patients can safely forego an invasive prostate biopsy. This model was validated in several other countries.

To report outcomes within the Rapid Assessment for Prostate Imaging and Diagnosis (RAPID) diagnostic pathway, introduced to reduce patient and healthcare burdens and standardize delivery of pre-biopsy multiparametric magnetic resonance imaging (MRI) and transperineal biopsy.A total of 2130 patients from three centres who completed the RAPID pathway (3 April 2017 to 31 March 2020) were consecutively entered as a prospective registry. These patients were also compared to a pre-RAPID cohort of 2435 patients. Patients on the RAPID pathway with an MRI score 4 or 5 and those with PSA density ≥0.12 and an MRI score 3 were advised to undergo a biopsy. Primary outcomes were rates of biopsy and cancer detection. Secondary outcomes included comparison of transperineal biopsy techniques, patient acceptability and changes in time to diagnosis before and after the introduction of RAPID.The median patient age and PSA level were 66 years and 6.6 ng/mL, respectively. Biopsy could be omitted in 43% of patients (920/2130). A further 7.9% of patients (168/2130) declined a recommendation for biopsy. The percentage of biopsies avoided among sites varied (45% vs 36% vs 51%; P 0.001). In all, 30% (221/742) had a local anaesthetic (grid and stepper) transperineal biopsy. Clinically significant cancer detection (any Gleason score ≥3 + 4) was 26% (560/2130) and detection of Gleason score 3 + 3 alone constituted 5.8% (124/2130); detection of Gleason score 3 + 3 did not significantly vary among sites (P = 0.7). Among participants who received a transperineal targeted biopsy, there was no difference in cancer detection rates among local anaesthetic, sedation and general anaesthetic groups. In the 2435 patients from the pre-RAPID cohor, time to diagnosis was 32.1 days (95% confidence interval [CI] 29.3-34.9) compared to 15.9 days (95% CI 12.9-34.9) in the RAPID group. A total of 141 consecutive patient satisfaction surveys indicated a high satisfaction rate with the pathway; 50% indicated a preference for having all tests on a single day.The RAPID prostate cancer diagnostic pathway allows 43% of men to avoid a biopsy while preserving good detection of clinically significant cancers and low detection of insignificant cancers, although there were some centre-level variations.

INTRODUCTION AND OBJECTIVE:Concern about MRI-invisible clinically significant prostate cancer (csPCa) drives use of systematic non-targeted prostate sampling, alongside MRI-targeted biopsy. We aime...

INTRODUCTION AND OBJECTIVE:Our ‘one-stop’ Rapid Access Prostate Imaging and Diagnosis (RAPID) pathway across five hospitals in our region streamlined our one-stop mpMRI and if required, transperine...

INTRODUCTION AND OBJECTIVE:Targeted prostate biopsy can be done using visual-estimation (cognitive) targeting or using MRI-ultrasound fusion platforms. We compared cancer detection of these two app...

Objectives: To systematically review studies comparing extraperitoneal (E-RP) and transperitoneal minimally invasive radical prostatectomy (T-RP). Methods: The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in September 2015. Several databases were searched including Medline and Scopus. Only studies comparing E-RP and T-RP (either laparoscopic or robot-assisted approach) were evaluated. The follow-up of the included patients had to be â¥6 months. Results: In all, 1256 records were identified after the initial database search. Of these 20 studies (2580 patients) met the inclusion criteria. The hospital stay was significantly lower in the E-RP cohort, with a mean difference of â0.30 days (95% confidence interval [CI] â0.35, â0.24) for the laparoscopic group and 1.09 days (95% CI â1.47, â0.70) for the robotic group (PÂ

INTRODUCTION AND OBJECTIVE:Although multi-parametric MRI (mpMRI) has high sensitivity and negative predictive value, the lower specificity can lead to a high prevalence of equivocal lesions which a...

INTRODUCTION: To describe the technique of total extraperitoneal inguinal hernia repair performed during Robot-assisted Endoscopic Extraperitoneal Radical Prostatectomy (R-EERPE) and to present the initial outcomes. MATERIAL AND METHODS: 12 patients underwent inguinal hernia repair during 120 R-EERPEs performed between July 2011 and March 2012. All patients had a clinically palpable inguinal hernia preoperatively. The hernia was repaired using a Total Extraperitoneal Patch (TEP) at the end of the procedure. RESULTS: Sac dissection and mesh placement was simpler compared to conventional laparoscopy due to improved, magnified, 3-D vision along with 7° of movement, and better control of mesh placement. The median operating time was 185 minutes, with on average, an additional 12 minutes incurred per hernia repair. The median blood loss for the procedures was 250 ml, and the mean pathological prostate weight was 55 gm. No additional blood loss was noted and there were no postoperative complications. None of the patients had a recurrence at 12 months. We await long-term follow-up data. CONCLUSIONS: Robot-assisted TEP is feasible and should be considered in patients with hernia at the time of R-EERPE.

OBJECTIVE To describe our robot-assisted Boari flap ureteric reimplantation (RA-BFUR) technique, Please see Video S1. METHODS The RA-BFUR technique is based on the open surgical technique of Ubelhor, and the experience includes 11 cases. RESULTS Excellent results were achieved after a mean follow-up period of >12 months. CONCLUSION The RA-BFUR technique could be considered a safe and effective method of ureteric reimplantation for long distal ureteric strictures.

Objectives: To review the causes and management of penile fracture and to compare between surgical and conservative management as well as immediate and delayed interventions in terms of overall and specific complications. Methods: A search of all reported literature was conducted for all articles reporting on the management and outcomes of penile fractures. Full texts of relevant articles were obtained and screened according to the inclusion criteria. Outcomes measures were numbers of patients receiving surgical or conservative management, aetiology of fracture, length of admission, complications as well as the specifics of diagnostic approaches and operative management. Data was collated and where possible meta-analysed using Revman software. Results: A total of 58 relevant studies involving 3,213 patients demonstrated that intercourse accounts for only 48% of cases with masturbation and forced flexion accounting for 39%. Meta-analysis shows that surgical intervention was associated with significantly fewer complications vs. conservative management (p < 0.000001). Surgical intervention results in significantly less erectile dysfunction (ED), curvature and painful erection than conservative management. There was no significant difference in the number of patients developing plaques/nodules (p = 0.94). Meta-analysis shows that overall early surgery is preferable to delayed surgery but that rates of ED are not significantly different. Discussion: Early surgical intervention is associated with significantly fewer complications than conservative management or delayed surgery. The combined outcome of rapid diagnosis by history and clinical examination and swift surgical intervention is key for reconstruction with minimal long-term complications.

Radical prostatectomy remains the gold-standard surgical treatment for clinically localized prostate cancer. Contrast imaging of the upper urinary tract is not part of the routine work-up of the patient before radical prostatectomy. This may lead to rare, albeit serious complications when anatomical anomalies are present. This article reports a case of delayed anastomotic leakage following radical prostatectomy due to an unrecognized duplex system on the left side and inclusion of the ureteric orifice draining the upper moiety in the anastomosis, which caused failure of healing and persistent leakage.

Introduction: There is a growing concern about the reduced clinical exposure to urology at undergraduate level in the United Kingdom. As a consequence, the competencies of junior doctors are considered inadequate. The views of these doctors in training towards urology remain under reported.Methods: A modified Delphi method was employed to construct a questionnaire. Given the rise of social media as a platform for scientific discussion, participants were recruited via a social networking site. Outcomes assessed included career preference, exposure to urology, perceived male dominance, and confidence at core procedures.Results: In total, 412 and 66 responses were collected from medical students and junior doctors, respectively. Overall, 41% of participants felt that they had received a good level of clinical exposure to urology as part of their training and 15% were considering a career in this speciality. Female students were significantly less likely to consider urology as a career option (p < 0.01). Of these, 37% of the students felt confident at male catheterization and 46% of students regarded urology as a male-dominated speciality.Conclusions: Urology is perceived as male dominated and is the least likely surgical speciality to be pursued as a career option according to our survey. Increased exposure to urology at the undergraduate level and dedicated workshops for core urological procedures are needed to address these challenges.

Objective To present the experience with the extraperitoneal approach for robotic-assisted simple prostatectomy (RASP) in a technique replicating the vesicocapsular incision technique of open surgery. Patients and Methods RASP was performed on patients with a prostate volume of >80 cm 3 with an indication for open enucleation of the prostate. Preoperatively, all patients were evaluated by uroflowmetry, prostate-specific antigen level, and postvoid residual measurement, as well as by the International Prostate Symptom Score questionnaire. All perioperative data were recorded in a prospective database. Follow-up appointments included the aforementioned measurements and were scheduled at 1 and 6 months postoperatively. Results Ten RASP procedures were successfully performed by the extraperitoneal approach. Mean patient age and prostate volume were 63.1 years (range, 55-74 years) and 129.4 cm 3 (range, 90-170 cm 3 ), respectively. Mean operative time was 122.5 minutes (range, 85-140 minutes) and represented the time from the first incision to the closure of the all incisions. The estimated blood loss was minimal (mean value, 230 mL). Transfusions were not necessary. Mean catheterization period was 7.4 days (range, 6-8 days). The symptomatology, as reported by the International Prostate Symptom Score, was improved at the follow-up appointments in comparison with the baseline values. One case of prolonged fever was noted postoperatively and managed by antibiotics. Conclusion The extraperitoneal approach for RASP proved to be efficient in the management of large prostates. The results are directly comparable with the current available experience with transperitoneal RASP. The extraperitoneal RASP seems to favorably compare with the open simple prostatectomy, while the results are at least comparable with those of conventional laparoscopic approach.

Robotic radical cystectomy (RRC) has been growing in popularity across the world as a treatment option for bladder cancer.To compare early surgical outcomes for RRC and open radical cystectomy (ORC) with an emphasis on complications and postoperative mortality rates.A literature review was conducted from 2000 to 2013, including studies comparing RRC and ORC. The main outcome measures analyzed were the complications and mortality rates, in addition to patient demographics, pathological parameters, operating time, estimated blood loss (EBL), transfusion rates, and type of urinary diversion. A meta-analysis was conducted. For continuous data, the Mantel-Haenszel chi-square test was used, and for dichotomous data, inverse variance was used and each expressed as risk ratio with 95% CI.In total, 748 patients were included, 461 patients in the robotic group and 287 patients in the open group (seven studies). There were no significant differences in the demographic parameters of the two groups, except for age (age: p=0.03). There was no difference in the number of muscle-invasive diseases: p=0.47. No difference in positive surgical margin rates (p=0.21).The overall (p=0.32) and lower grade (Clavien I-II) (p=0.10) complication rates between the two cohorts did not achieve statistical significance. The high-grade (Clavien III-IV) (p=0.007) complication rates in the ORC group were significantly higher. The mortality rate (Clavien V) was higher in the ORC group (2.2%) compared with the RRC group (0.35%) and this did achieve statistical significance on a meta-analysis (p=0.04).The EBL and transfusion rates were statistically significantly lower in the RRC cohort (p0.00001). The operating time was statistically significantly higher in the RRC cohort (p0.00001). There was no statistically significant difference in the margin positivity between the two cohorts (p=0.08).In early experience, RRC appears to be feasible and a safe alternative to the ORC. RRC appears to have lower high-grade complications and mortality rates compared with the open approach. Although these results are promising, the authors would suggest caution while interpreting these results due to concerns with methodological flaws in the included studies in this review.

Delivery of surgical education has multiple impediments in the contemporary era. This is of particular concern for minimally invasive surgery in urology because there is not a relatively simple mainstream laparoscopic procedure that junior trainees can use to initiate their training process [1,2]. There is a need to impart consistent surgical teaching and to negate training issues such as decreasing training hours with the introduction of the European Working Time Directive, time pressures faced by individual surgeons, financial implications, and increasing litigation [3,4]. For these reasons, the development of a validated, structured curriculum in surgical training is crucial. The emphasis of such a curriculum must be on time-efficient training methods using validated training tools. Wong and Matsumoto discuss a theory by Kopta that describes cognitive, integrative, and autonomic phases as essential steps in mastering a specific motor skill [4]. In this month’s issue of European Urology, under the auspices of the European Association of Urology (EAU) Robotic Urology Section (ERUS), Volpe et al present the curriculum for robotic prostatectomy and outcomes of the pilot study [5]. The curriculum designed by ERUS is comprehensive and has admirably managed to include the three components of the Kopta’s theory—theoretical learning (cognitive), simulation-based training (integrative), and modular training (autonomous)—in a safe and controlled environment [5]. Surgical education has evolved in recent decades, and the traditional apprenticeship model of training is generally consideredobsolete [4]. These viewswere reflected in a nationwide survey of training programme directors (TPDs) in the United Kingdom, in which 15 of 16 TPDs felt that simulators were at least desirable in urologic training [6]. A plethora of sophisticated tools for simulation-based training are available, including box trainers, high-fidelity virtual reality simulators, animal models, and advanced human cadaveric models [1,2,4,7]. Each of these tools has pros and cons. The current curriculum has very efficiently included all these available tools, making it extremely indepth and comprehensive [5]. The integration of a modular training process in the curriculum is of paramount importance and is vital to success [5]. We previously reported the requirement of a mere 32–43 endoscopic extraperitoneal radical prostatectomy procedures for a novice to achieve the desired learning curve with modular training, even for such a complex technique [8]. Apart from reducing learning curves, this training curriculum—through accreditation and certification—can ensure that future robotic prostatectomy surgeons can performwith the desired quality and hence not compromise patient care. The predictive validity of this programme remains to be seen; however the promising outcomes from this pilot study would suggest that predictive validation should be achievable [5]. This curriculumalso serves as an excellent framework for future training curriculums in other complex robotic techniques such as radical cystectomy and partial nephrectomy. A concern about this programme [5] is its widespread applicability across all training institutions in Europe. In this study, most participants were from high-volume centres, and hence the desired training goals were achievable. Whether low-volume centres have the ability to achieve similar outcomes is debateable. It may be necessary to confer training status only on centres with the appropriate caseload per trainee. This will require ERUS to define what the appropriate institutional caseload should be. E U RO P E AN URO LOG Y 6 8 ( 2 0 1 5 ) 3 0 0 – 3 0 1

Radical prostatectomy is the gold standard surgical treatment for organ-confined prostate cancer. There is no consensus on the impact of previous laparoscopic experience on the learning curve of robot-assisted laparoscopic prostatectomy (RALP). We compared the perioperative complications and early patient outcomes from our initial 100 cases of RALP with laparoscopic prostatectomy (LRP) cases performed well beyond the learning curve.Between July 2011 and January 2012, 110 RALP were performed by one of two surgeons, each with previous experience of more than 1000 LRP. The cases were pair matched from among the last 208 patients who had undergone LRP by the same surgeons at the same time. The clinical parameters, operative details, postoperative complications, and short-term outcomes from these patients, collected prospectively, were compared between the two groups.The prostate-specific antigen (PSA) level and age of the two groups was similar. The operative time (128.4 vs 153.9 min; P=0.01) and blood loss (200 vs 254 mL; P=0.01) was significantly less for the LRP group, but the duration of catheterization was similar (5.89 vs 6.2 days). The complication rate was low. No procedures needed conversions, and no patient had a visceral injury or blood transfusion. Twenty-three patients in the LRP group and 33 patients in the RALP group had extraprostatic disease, and the positive margin rate was 14% and 19% for these respective groups. At 3 months, PSA level was undetectable in 94% of LRP and 92% RALP patients, while 56% and 65% (P=0.062) patients in these groups were using 0 to 2 pads per day.The initial results of the outcome of RALP are at least at par with those of LRP and with those of previously published RALP series. This suggests the lack of a steep learning curve for experienced laparoscopic surgeons in performing RALP.

The epithelial-mesenchymal transition (EMT) contributes to cancer metastasis. Two ZEB family members, ZEB1 and ZEB2(SIP1), inhibit transcription of the E-cadherin gene and induce EMT in vitro. However, their relevance to human cancer is insufficiently studied. Here, we performed a comparative study of SIP1 and ZEB1 proteins in cancer cell lines and in one form of human malignancy, carcinoma of the bladder. Whereas ZEB1 protein was expressed in all E-cadherin-negative carcinoma cell lines, being in part responsible for the high motility of bladder cancer cells, SIP1 was hardly ever detectable in carcinoma cells in culture. However, SIP1 represented an independent factor of poor prognosis ( P = 0.005) in a series of bladder cancer specimens obtained from patients treated with radiotherapy. In contrast, ZEB1 was rarely expressed in tumor tissues; and E-cadherin status did not correlate with the patients' survival. SIP1 protected cells from UV- and cisplatin-induced apoptosis in vitro but had no effect on the level of DNA damage. The anti-apoptotic effect of SIP1 was independent of either cell cycle arrest or loss of cell-cell adhesion and was associated with reduced phosphorylation of ATM/ATR targets in UV-treated cells. The prognostic value of SIP1 and its role in DNA damage response establish a link between genetic instability and metastasis and suggest a potential importance for this protein as a therapeutic target. In addition, we conclude that the nature of an EMT pathway rather than the deregulation of E-cadherin per se is critical for the progression of the disease and patients' survival.