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Translational Andrology and Urology Dec 2019The influence of a previous transurethral resection of the prostate (TURP) on the outcomes of radical prostatectomy (RP) is still controversial. Therefore, we performed...
BACKGROUND
The influence of a previous transurethral resection of the prostate (TURP) on the outcomes of radical prostatectomy (RP) is still controversial. Therefore, we performed a meta-analysis to evaluate the perioperative, functional and oncological outcomes of RP with or without a previous TURP.
METHODS
We conducted a computerized literature search of PubMed, Embase, and the Cochrane Library and included 15 retrospective studies evaluating RPs with or without a previous TURP in this meta-analysis.
RESULTS
Fifteen studies, including 6,840 cases, were analyzed. RP after a previous TURP were related to smaller prostate volumes (WMD: -6.93 cm; 95% CI, -10.89 to -2.97; P<0.001), lower preoperative prostate-specific antigen (PSA) levels (WMD: -1.51; 95% CI, -2.49 to -0.53; P=0.002), longer operative times (WMD: 13.22 min; 95% CI, 4.55 to 21.89 min; P=0.003), more blood loss (WMD: 55.38 mL; 95% CI, 12.35 to 98.41 mL; P=0.01), higher overall complication rates (OR =1.98; 95% CI, 1.27 to 3.08; P=0.002), longer hospital stays (WMD: 1.16 days; 95% CI, 0.65 to 1.67; P<0.001), longer duration of catheter (WMD: 0.60 days; 95% CI, 0.56 to 0.64; P<0.001), higher positive surgical margin rates (OR =1.30; 95% CI, 1.09 to 1.55; P=0.004), lower complete continence rates at 3 months (OR =0.67; 95% CI, 0.56 to 0.81; P<0.001), 6 months (OR =0.52; 95% CI, 0.31 to 0.88; P=0.01), 12 months (OR =0.59; 95% CI, 0.46 to 0.74; P<0.001), and lower potency rates at 12 months (OR =0.62; 95% CI, 0.51 to 0.77; P<0.001). Subgroup analysis indicated that open RP after previous TURP could achieve better outcomes.
CONCLUSIONS
RP after a previous TURP leads to worse perioperative, oncological, and functional outcomes. For these patients an open procedure is recommended. Due to the low number of studies and known biases, further large-scale studies are needed to support this result.
PubMed: 32038968
DOI: 10.21037/tau.2019.11.13 -
Reviews on Recent Clinical Trials Feb 2024Paragangliomas of the urinary tract are exceptionally uncommon, and sporadic case reports of primary paraganglioma of the prostate have been reported in the literature.
BACKGROUND
Paragangliomas of the urinary tract are exceptionally uncommon, and sporadic case reports of primary paraganglioma of the prostate have been reported in the literature.
METHODS
Systematic research in PubMed/Medline and Scopus databases concerning primary prostatic paraganglioma was performed by two independent investigators.
RESULTS
This analysis included 25 adult males, with a mean age of 49.8 ± 22.4 years. 32% of included patients had a history of hypertension. Problems during urination (52%), blood loss (44%), either as hematuria or hemospermia, and catecholamine-related symptoms (36%) comprised the most frequently reported clinical manifestations. Digital rectal examination found a palpable nodule in 36% of patients, while prostatic specific antigen (PSA) was normal in all tested patients. Abdominal ultrasound (44%), computed tomography (44%) and magnetic resonance imaging (28%) helped to identify the primary lesion. 24-hour urine epinephrine, norepinephrine and vanillylmandelic acid (VMA) levels were elevated in 90%, 80% and 90% of included patients. Open surgical excision of the mass was performed in 40%, transurethral resection in 8%, open radical prostatectomy in 24%, transurethral resection of the prostate in 16% and robot-assisted radical prostatectomy in 4% of included patients.
CONCLUSION
Due to atypical clinical manifestation and scarcity of prostatic paraganglioma, urologists should be aware of this extremely rare entity.
PubMed: 38549519
DOI: 10.2174/0115748871293735240209052044 -
The Journal of Sexual Medicine Jan 2020Erectile function (EF) outcomes after radical pelvic surgery vary widely among different studies, partly as a consequence of heterogeneity with regard to the data...
INTRODUCTION
Erectile function (EF) outcomes after radical pelvic surgery vary widely among different studies, partly as a consequence of heterogeneity with regard to the data assessment and reporting methodology.
AIM
Review the methodology of data assessment and reporting of studies evaluating EF outcomes after radical prostatectomy (RP), radical cystectomy (RC), and rectal surgery (RS) and provide detailed recommendations to conduct future high-quality research.
METHODS
The MEDLINE database was searched for randomized clinical trials and open-label prospective or retrospective studies.
MAIN OUTCOME MEASURE
The panel reviewed the modality of data assessment and reporting concerning 3 specific areas: preoperative patients assessment, surgical technique description, and postoperative patients management and follow-up.
RESULTS
Overall, 280, 36, and 73 studies investigating EF after RP, RC, and RS, respectively, were included. Baseline EF was largely reported (88%) in studies on RP, but only 67% of the studies on either RC or RS assessed EF before surgery. Baseline comorbidities that could impact postoperative EF were reported in 62%, 64%, and 85% of studies on RP, RC, and RS, respectively. The type of surgical approach was provided in all studies, and surgical details relevant to EF (eg, nerve- or organ-sparing surgery) were reported by 86%, 81%, and 62% of studies on RP, RC, and RS, respectively. Conversely, surgeon experience was rarely reported across all studies. Validated tools were commonly used to assess postoperative EF (64% of studies for RP, 78% for RC, and 71% for RS). Only 41%, 17%, and 29% of studies on RP, RC, and RS, respectively, reported a follow-up of at least 2 years. Use of erectile dysfunction treatment after surgery was assessed by only 39%, 17%, and 4.1% of studies on RP, RC, and RS, respectively. Factors potentially influencing EF recovery (eg, urinary or fecal continence, urinary diversion) were commonly reported, but sexual desire after surgery was reported by only 18%, 42%, and 37% of studies on RP, RC, and RS, respectively.
CLINICAL IMPLICATIONS
The use of a shared methodology for the assessment and reporting of data on EF outcomes after pelvic surgery would allow better estimation of EF outcomes after pelvic surgery.
STRENGTHS & LIMITATIONS
The modality of data assessment and reporting among studies investigating EF outcome after pelvic surgery was systematically investigated to provide recommendations allowing a proper interpretation of data.
CONCLUSION
Studies on EF outcomes after radical pelvic surgery should fulfill specific criteria concerning preoperative patient assessment, reporting of surgical details, and postoperative functional outcome evaluation and management. Capogrosso P, Pozzi EP, Celentano V, et al. Erectile Recovery After Radical Pelvic Surgery: Methodological Challenges and Recommendations for Data Reporting. J Sex Med 2020;17:7-16.
Topics: Cystectomy; Erectile Dysfunction; Humans; Male; Pelvis; Penile Erection; Postoperative Period; Prostatectomy; Prostatic Neoplasms; Randomized Controlled Trials as Topic; Recovery of Function
PubMed: 31668729
DOI: 10.1016/j.jsxm.2019.09.013 -
Minerva Urologica E Nefrologica = the... Feb 2020In the past years several reviews have analysed different aspects of surgical techniques for patients with LUTS due to BPE however none of them have concentrated on...
INTRODUCTION
In the past years several reviews have analysed different aspects of surgical techniques for patients with LUTS due to BPE however none of them have concentrated on large prostates treatment exclusively. Moreover, none of the reviews have focused on level 1 evidence which is essential to avoid bias and wrong conclusions. With this knowledge in mind, aim of the present review is to analyze the available randomized clinical trials assessing the management of patients with big prostates (>80 cc).
EVIDENCE ACQUISITION
A systematic review of the literature using the Medline, Scopus and Web of Science databases for relevant articles published until January 2019 was performed using both the Medical Subjects Heading and free test protocols. The search was conducted by combining the following terms: "Enucleation," "Prostate," "Benign Prostatic Hyperplasia," "Holmium," "laser," "adenomectomy," "Randomized clinical trial," "Big" "large" "prostate," ">80," "≥80," "transurethral resection of prostate," "Thulium," "Diode," "laparoscopy," "robotic," "Plasmakinetic," "green light" "532 nm" "YAG" "Lower Urinary tract symptoms". Only randomized clinical trials were included in the analysis.
EVIDENCE SYNTHESIS
Overall 9 RCTs were retrieved with most of them reporting data at 1 year. The present trials compared enucleation, vaporization and open techniques between each other. In terms of perioperative outcomes all the techniques had similar operative times and resected weight however catheterization time and hospital stay were better in endoscopic techniques when compared to open surgery. In terms of functional outcomes (IPSS, QMAX and PVR) none of the techniques was proven superior to the other. When considering complications open procedures carried a higher risk of transfusions while no technique was proven superior to the others in terms of transient urge urinary incontinence, bladder neck contracture and reintervention. Only one trial was retrieved reporting five years data confirming the safety, efficacy and durability of simple prostatectomy SP and holmium laser enucleation of the prostate at five years.
CONCLUSIONS
According to our review no technique may be considered better than the other when treating large adenomas. Studies are still lacking to prove long term efficacy and future studies should clarify the role of prostatic artery embolization and minimally invasive simple prostatectomy in the management of prostates larger than 80 mL.
Topics: Humans; Male; Prostatic Hyperplasia; Randomized Controlled Trials as Topic; Urologic Surgical Procedures, Male
PubMed: 31619035
DOI: 10.23736/S0393-2249.19.03589-6 -
International Wound Journal Jan 2024In this article, we analysed the therapeutic efficacy of open radical prostatectomy (ORP) and minimally invasive surgery (MIS) after operation for the treatment of... (Meta-Analysis)
Meta-Analysis
In this article, we analysed the therapeutic efficacy of open radical prostatectomy (ORP) and minimally invasive surgery (MIS) after operation for the treatment of post-operation complications. In summary, because of the broad methodology of the available trials and the low number of trials, the data were limited. The investigators combined the results of six of the 211 original studies. We looked up 4 databases: PubMed, EMBASE, Web of Science and the Cochrane Library. A total of six publications were selected. The main result was the rate of post-operation wound complications. Secondary results were the time of operation and the duration of hospitalization. Our findings indicate that the minimal invasive operation can decrease the incidence of wound infections (OR, 0.61; 95% CI: 0.42,0.90, p = 0.01), bleeding (MD, -293.09; 95% CI: -431.48, -154.71, p < 0.0001), and length of stay in the hospital compared with open surgery (MD, -1.85; 95% CI: -3.52, -0.17, p = 0.03), but minimally invasive surgery increased patient operative time (MD, 51.45; 95% CI: 40.99, 61.92, p < 0.0001). Compared with the open operation, the microinvasive operation has the superiority in the treatment of the wound complications following the operation of radical prostatic carcinoma. But the operation time of the microinvasive operation is much longer. Furthermore, there is a certain amount of bias among the various studies, so it is important to be cautious in interpretation of the findings.
Topics: Humans; Male; Minimally Invasive Surgical Procedures; Postoperative Complications; Prostate; Prostatectomy; Treatment Outcome
PubMed: 37706271
DOI: 10.1111/iwj.14367 -
Andrologia Sep 2020An increasing number of evidences demonstrate the safety and efficacy of endoscopic enucleation of the prostate (EEP) using various energy devices. We performed a... (Meta-Analysis)
Meta-Analysis
An increasing number of evidences demonstrate the safety and efficacy of endoscopic enucleation of the prostate (EEP) using various energy devices. We performed a systemic literature search for all relevant randomised controlled trials (RCTs) comparing any EEP technique with TURP or open prostatectomy (OP). A total of 21 RCTs with 2,957 patients were included; the majority were studies of holmium laser or bipolar diathermy. Compared to TURP, EEP resulted in greater improvement in IPSS (MD: -0.56, 95% CI: -0.90 to -0.23), PVR (MD: -2.24, 95% CI: -4.45 to -0.03) and Qmax (MD: -1.07, 95% CI: -1.53 to -0.61). EEP was associated with more prostate tissue removed (MD: -9.73, 95% CI: -15.71 to -3.75), less haemoglobin loss (MD: -0.47, 95% CI: -0.70 to -0.23), shorter catheterisation time (MD: -22.82, 95% CI: -30.11 to -15.52) and shorter length of hospitalisation (MD: -1.05, 95% CI: -1.33 to -0.78). Compared to OP, EEP resulted in equivalent functional outcomes. However, EEP was associated with less haemoglobin loss (MD: -1.17, 95% CI: -1.98 to -0.37), shorter catheterisation time (MD: -89.74, 95% CI: -112.60 to -66.88) and shorter length of hospitalisation (MD: -3.91, 95% CI: -4.63 to -3.60). The current evidence supports that EEP can be considered as a new standard of the surgical management for BPH.
Topics: Humans; Laser Therapy; Male; Prostatic Hyperplasia; Transurethral Resection of Prostate; Treatment Outcome
PubMed: 32400026
DOI: 10.1111/and.13612 -
Progres En Urologie : Journal de... Apr 2021The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and...
OBJECTIVE
The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO).
METHODS
All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions.
RESULTS/GUIDELINES
Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols.
CONCLUSION
Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.
Topics: Humans; Male; Prostatectomy; Prostatic Hyperplasia; Urethral Obstruction
PubMed: 33478868
DOI: 10.1016/j.purol.2020.12.006 -
The Cochrane Database of Systematic... Aug 2020Robotic-assisted laparoscopic prostatectomy (RALP) is widely used to surgically treat clinically localized prostate cancer. It is typically performed using an approach... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Robotic-assisted laparoscopic prostatectomy (RALP) is widely used to surgically treat clinically localized prostate cancer. It is typically performed using an approach (standard RALP) that mimics open retropubic prostatectomy by dissecting the so-called space of Retzius anterior to the bladder. An alternative, Retzius-sparing (or posterior approach) RALP (RS-RALP) has been described, which is reported to have better continence outcomes but may be associated with a higher risk of incomplete resection and positive surgical margins (PSM).
OBJECTIVES
To assess the effects of RS-RALP compared to standard RALP for the treatment of clinically localized prostate cancer.
SEARCH METHODS
We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of the grey literature, and conference proceedings, up to June 2020. We applied no restrictions on publication language or status.
SELECTION CRITERIA
We included trials where participants were randomized to RS-RALP or standard RALP for clinically localized prostate cancer.
DATA COLLECTION AND ANALYSIS
Two review authors independently classified and abstracted data from the included studies. Primary outcomes were: urinary continence recovery within one week after catheter removal, at three months after surgery, and serious adverse events. Secondary outcomes were: urinary continence recovery six and 12 months after surgery, potency recovery 12 months after surgery, positive surgical margins (PSM), biochemical recurrence-free survival (BCRFS), and urinary and sexual function quality of life. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using the GRADE approach.
MAIN RESULTS
Our search identified six records of five unique randomized controlled trials, of which two were published studies, one was in press, and two were abstract proceedings. There were 571 randomized participants, of whom 502 completed the trials. Mean age of participants was 64.6 years and mean prostate-specific antigen was 6.9 ng/mL. About 54.2% of participants had cT1c disease, 38.6% had cT2a-b disease, and 7.1 % had cT2c disease. Primary outcomes RS-RALP probably improves continence within one week after catheter removal (risk ratio (RR) 1.74, 95% confidence interval (CI) 1.41 to 2.14; I = 0%; studies = 4; participants = 410; moderate-certainty evidence). Assuming 335 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 248 more men per 1000 (137 more to 382 more) reporting continence recovery. RS-RALP may increase continence at three months after surgery compared to standard RALP (RR 1.33, 95% CI 1.06 to 1.68; I = 86%; studies = 5; participants = 526; low-certainty evidence). Assuming 750 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 224 more men per 1000 (41 more to 462 more) reporting continence recovery. We are very uncertain about the effects of RS-RALP on serious adverse events compared to standard RALP (RR 1.40, 95% CI 0.47 to 4.17; studies = 2; participants = 230; very low-certainty evidence). Secondary outcomes There is probably little to no difference in continence recovery at 12 months after surgery (RR 1.01, 95% CI 0.97 to 1.04; I = 0%; studies = 2; participants = 222; moderate-certainty evidence). Assuming 982 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 10 more men per 1000 (29 fewer to 39 more) reporting continence recovery. We are very uncertain about the effect of RS-RALP on potency recovery 12 months after surgery (RR 0.98, 95% CI 0.54 to 1.80; studies = 1; participants = 55; very low-certainty evidence). RS-RALP may increase PSMs (RR 1.95, 95% CI 1.19 to 3.20; I = 0%; studies = 3; participants = 308; low-certainty evidence) indicating a higher risk for prostate cancer recurrence. Assuming 129 per 1000 men undergoing standard RALP have positive margins, this corresponds to 123 more men per 1000 (25 more to 284 more) with PSMs. We are very uncertain about the effect of RS-RALP on BCRFS compared to standard RALP (hazard ratio (HR) 0.45, 95% CI 0.13 to 1.60; I = 32%; studies = 2; participants = 218; very low-certainty evidence).
AUTHORS' CONCLUSIONS
Findings of this review indicate that RS-RALP may result in better continence outcomes than standard RALP up to six months after surgery. Continence outcomes at 12 months may be similar. Downsides of RS-RALP may be higher positive margin rates. We are very uncertain about the effect on BCRFS and potency outcomes. Longer-term oncologic and functional outcomes are lacking, and no preplanned subgroup analyses could be performed to explore the observed heterogeneity. Surgeons should discuss these trade-offs and the limitations of the evidence with their patients when considering this approach.
Topics: Aged; Humans; Kallikreins; Laparoscopy; Male; Margins of Excision; Middle Aged; Organ Sparing Treatments; Penile Erection; Postoperative Complications; Prostate-Specific Antigen; Prostatectomy; Prostatic Neoplasms; Randomized Controlled Trials as Topic; Robotic Surgical Procedures; Time Factors; Treatment Outcome; Urinary Incontinence
PubMed: 32813279
DOI: 10.1002/14651858.CD013641.pub2