-
Urologia Nov 2023Most genitourinary tract cancers have a negative impact on male fertility. Although testicular cancers have the worst impact, other tumors such as prostate, bladder, and... (Review)
Review
Most genitourinary tract cancers have a negative impact on male fertility. Although testicular cancers have the worst impact, other tumors such as prostate, bladder, and penis are diagnosed early and treated in relatively younger patients in which couple fertility can be an important concern. The purpose of this review is to highlight both the pathogenetic mechanisms of damage to male fertility in the context of the main urological cancers and the methods of preserving male fertility in an oncological setting, in light of the most recent scientific evidence. A systematic review of available literature was carried out on the main scientific search engines, such as PubMed, Clinicaltrials.Gov, and Google scholar. Three hundred twenty-five relevant articles on this subject were identified, 98 of which were selected being the most relevant to the purpose of this review. There is a strong evidence in literature that all of the genitourinary oncological therapies have a deep negative impact on male fertility: orchiectomy, partial orchiectomy, retroperitoneal lymphadenectomy (RPLND), radical cystectomy, prostatectomy, penectomy, as well as radiotherapy, chemotherapy, and hormonal androgen suppression. Preservation of fertility is possible and includes cryopreservation, hormonal manipulation with GnRH analogs before chemotherapy, androgen replacement. Germ cell auto transplantation is an intriguing strategy with future perspectives. Careful evaluation of male fertility must be a key point before treating genitourinary tumors, taking into account patients' age and couples' perspectives. Informed consent should provide adequate information to the patient about the current state of his fertility and about the balance between risks and benefits in oncological terms. Standard approaches to genitourinary tumors should include a multidisciplinary team with urologists, oncologists, radiotherapists, psycho-sexologists, andrologists, gynecologists, and reproductive endocrinologists.
Topics: Humans; Male; Fertility Preservation; Androgens; Infertility, Male; Testicular Neoplasms; Urologic Neoplasms
PubMed: 37491831
DOI: 10.1177/03915603221146147 -
International Journal of Surgery... Jul 2023Urology has been at the forefront of adopting laparoscopic and robot-assisted techniques to improve patient outcomes. This systematic review aimed to examine the...
BACKGROUND
Urology has been at the forefront of adopting laparoscopic and robot-assisted techniques to improve patient outcomes. This systematic review aimed to examine the literature relating to the learning curves of major urological robotic and laparoscopic procedures.
METHODS
In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic literature search strategy was employed across PubMed, EMBASE, and the Cochrane Library from inception to December 2021, alongside a search of the grey literature. Two independent reviewers completed the article screening and data extraction stages using the Newcastle-Ottawa Scale as a quality assessment tool. The review was reported in accordance with AMSTAR (A MeaSurement Tool to Assess systematic Reviews) guidelines.
RESULTS
Of 3702 records identified, 97 eligible studies were included for narrative synthesis. Learning curves are mapped using an array of measurements including operative time (OT), estimated blood loss, complication rates as well as procedure-specific outcomes, with OT being the most commonly used metric by eligible studies. The learning curve for OT was identified as 10-250 cases for robot-assisted laparoscopic prostatectomy and 40-250 for laparoscopic radical prostatectomy. The robot-assisted partial nephrectomy learning curve for warm ischaemia time is 4-150 cases. No high-quality studies evaluating the learning curve for laparoscopic radical cystectomy and for robotic and laparoscopic retroperitoneal lymph node dissection were identified.
CONCLUSION
There was considerable variation in the definitions of outcome measures and performance thresholds, with poor reporting of potential confounders. Future studies should use multiple surgeons and large sample sizes of cases to identify the currently undefined learning curves for robotic and laparoscopic urological procedures.
Topics: Male; Humans; Robotics; Urology; Robotic Surgical Procedures; Learning Curve; Laparoscopy; Treatment Outcome
PubMed: 37132184
DOI: 10.1097/JS9.0000000000000345 -
The Cochrane Database of Systematic... Apr 2019It has been suggested that in comparison with open radical cystectomy, robotic-assisted radical cystectomy results in less blood loss, shorter convalescence, and fewer...
BACKGROUND
It has been suggested that in comparison with open radical cystectomy, robotic-assisted radical cystectomy results in less blood loss, shorter convalescence, and fewer complications with equivalent short-term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits.
OBJECTIVES
To assess the effects of robotic-assisted radical cystectomy versus open radical cystectomy in adults with bladder cancer.
SEARCH METHODS
Review authors conducted a comprehensive search with no restrictions on language of publication or publication status for studies comparing open radical cystectomy and robotic-assisted radical cystectomy. The date of the last search was 1 July 2018 for the Cochrane Central Register of Controlled Trials, MEDLINE (1999 to July 2018), PubMed Embase (1999 to July 2018), Web of Science (1999 to July 2018), Cancer Research UK (www.cancerresearchuk.org/), and the Institute of Cancer Research (www.icr.ac.uk/). We searched the following trials registers: ClinicalTrials.gov (clinicaltrials.gov/), BioMed Central International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com), and the World Health Organization International Clinical Trials Registry Platform.
SELECTION CRITERIA
We searched for randomised controlled trials that compared robotic-assisted radical cystectomy (RARC) with open radical cystectomy (ORC).
DATA COLLECTION AND ANALYSIS
This study was based on a published protocol. Primary outcomes of the review were recurrence-free survival and major postoperative complications (class III to V). Secondary outcomes were minor postoperative complications (class I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk of bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data.
MAIN RESULTS
We included in the review five randomised controlled trials comprising a total of 541 participants. Total numbers of participants included in the ORC and RARC cohorts were 270 and 271, respectively.Primary outomesTime-to-recurrence: Robotic cystectomy and open cystectomy may result in a similar time to recurrence (hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.77 to 1.43); 2 trials; low-certainty evidence). In absolute terms at 5 years of follow-up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations and imprecision.Major complications (Clavien grades 3 to 5): Robotic cystectomy and open cystectomy may result in similar rates of major complications (risk ratio (RR) 1.06, 95% CI 0.76 to 1.48); 5 trials; low-certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence for study limitations and imprecision.Secondary outcomesMinor complications (Clavien grades 1 and 2): We are very uncertain whether robotic cystectomy may reduce minor complications (very low-certainty evidence). We downgraded the certainty of evidence for study limitations and for very serious imprecision.Transfusion rate: Robotic cystectomy probably results in substantially fewer transfusions than open cystectomy (RR 0.58, 95% CI 0.43 to 0.80; 2 trials; moderate-certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations.Hospital stay: Robotic cystectomy may result in a slightly shorter hospital stay than open cystectomy (mean difference (MD) -0.67, 95% CI -1.22 to -0.12); 5 trials; low-certainty evidence). We downgraded the certainty of evidence for study limitations and imprecision.Quality of life: Robotic cystectomy and open cystectomy may result in a similar quality of life (standard mean difference (SMD) 0.08, 95% CI 0.32 lower to 0.16 higher; 3 trials; low-certainty evidence). We downgraded the certainty of evidence for study limitations and imprecision.Positive margin rates: Robotic cystectomy and open cystectomy may result in similar positive margin rates (RR 1.16, 95% CI 0.56 to 2.40; 5 trials; low-certainty evidence). This corresponds to 8 more (95% CI 21 fewer to 67 more) positive margins per 1000 participants based on 48 positive margins per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations and imprecision.
AUTHORS' CONCLUSIONS
Robotic cystectomy and open cystectomy may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive margin rates (all low-certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very low-certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate-certainty evidence) and may reduce hospital stay slightly (low-certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost-effectiveness.
Topics: Cystectomy; Humans; Postoperative Complications; Quality of Life; Randomized Controlled Trials as Topic; Robotic Surgical Procedures; Treatment Outcome; Urinary Bladder Neoplasms
PubMed: 31016718
DOI: 10.1002/14651858.CD011903.pub2 -
Translational Andrology and Urology Aug 2020The aim of this study was to evaluate the effect of enhanced recovery after surgery (ERAS) on perioperative outcomes in patients undergoing radical cystectomy (RC) and... (Review)
Review
Clinical efficacy and safety of enhanced recovery after surgery for patients treated with radical cystectomy and ileal urinary diversion: a systematic review and meta-analysis of randomized controlled trials.
The aim of this study was to evaluate the effect of enhanced recovery after surgery (ERAS) on perioperative outcomes in patients undergoing radical cystectomy (RC) and ileal urinary diversion (IUD). We performed a literature search of PubMed, Web of Science, EMBASE, the Cochrane Library and three main Chinese databases (WANFANG, CNKI and VIP) in December 2019 without language restrictions. Two reviewers independently selected studies, evaluated methodological quality and extracted data using Cochrane Collaboration's tools. Efficacy was assessed by the time to first flatus, first bowel movement, and hospitalization time. Safety was assessed by 30-day readmission and complications after surgery. Our searches identified 6 studies, including 628 patients. A total of 323 (51%) patients took ERAS. We observed that ERAS reduced the time to first flatus [standard mean difference (SMD): -1.65, 95% CI: -2.63 to -0.68, P=0.0009], first bowel movement (SMD: -1.14, 95% CI: -1.78 to -0.50, P=0.0005), and hospitalization time (MD: -4.09, 95% CI: -6.34 to -1.85, P=0.0004). We did not detect significant difference in terms of 30-day readmission [relative risk (RR): 1.33, 95% CI: 0.61-2.88, P=0.48] and postoperative complications (RR: 0.91, 95% CI: 0.65-1.26, P=0.56) between ERAS and conventional recovery after surgery (CRAS). Our findings indicated that ERAS protocols throughout the perioperative period of RC with IUD might reduce hospitalization expenses and contribute to higher turnover ward, more efficient utilization of medical resources and lower risk of nosocomial infection as a result of shorter length of stay. Besides, early rehabilitation of gastrointestinal function might not only facilitate wound healing and early mobilization, thereby reducing the incidence of basic complications such as cardiopulmonary disease, but also improve patients' psychological trauma and stress response, increase self-confidence and motivation in treatments, and then lead to unexpected benefits. Further large volume, multicenter randomized controlled studies are warranted before making the final clinical guidelines.
PubMed: 32944535
DOI: 10.21037/tau-19-941 -
Arab Journal of Urology Jan 2021: To compare cancer-specific mortality (CSM) and all-cause mortality (ACM) between patients with and without sarcopenia who underwent radical cystectomy for bladder... (Review)
Review
: To compare cancer-specific mortality (CSM) and all-cause mortality (ACM) between patients with and without sarcopenia who underwent radical cystectomy for bladder cancer. : We performed a systematic review and meta-analysis of original articles published from October 2010 to March 2019 evaluating the effect of sarcopenia on CSM and ACM. We extracted hazard ratios (HRs) and 95% confidence intervals (CIs) for CSM and ACM from the included studies. Heterogeneity amongst studies was measured using the -statistic and the index. Meta-analysis was performed using a random-effects model if heterogeneity was high and fixed-effects models if heterogeneity was low. : We identified 145 publications, of which five were included in the meta-analysis. These five studies represented 1447 patients of which 453 were classified as sarcopenic and 534 were non-sarcopenic. CSM and ACM were increased in sarcopenic vs non-sarcopenic patients (HR 1.64, 95% CI 1.30-2.08, < 0.01 and HR 1.41, 95% CI 1.22-1.62, < 0.01, respectively). : Sarcopenia is significantly associated with increased CSM and ACM in bladder cancer. Identifying patients with sarcopenia will augment preoperative counselling and planning. Further studies are required to evaluate targeted interventions in patients with sarcopenia to improve clinical outcomes. ACM: all-cause mortality; ASA: American Association of Anesthesiologists; BMI: body mass index; CCI: Charlson Comorbidity Index; CSM: cancer-specific mortality; CSS: cancer-specific survival; ECOG: Eastern Cooperative Oncology Group; HR: hazard ratio; NAC: neoadjuvant chemotherapy; NIH: National Institutes of Health; OS: overall survival; RC: radical cystectomy; RCT: randomised controlled trial; SMI: Skeletal Muscle Index.
PubMed: 33763255
DOI: 10.1080/2090598X.2021.1876289 -
SAGE Open Medicine 2023Globally, urothelial bladder carcinoma is a disease which carries a poor prognosis. There are various treatment modalities for urothelial bladder carcinoma with... (Review)
Review
A systematic review on the available treatment modalities for Bacillus Calmette-Guérin-unresponsive carcinoma in situ and tumors in patients who are ineligible for or decline radical cystectomy.
INTRODUCTION
Globally, urothelial bladder carcinoma is a disease which carries a poor prognosis. There are various treatment modalities for urothelial bladder carcinoma with intravesical Bacillus Calmette-Guérin immunotherapy being the most efficacious intravesical therapy and the treatment of choice for patients with carcinoma in situ. A number of chemotherapeutic drugs are also available for the management of Ta/T1 tumors such as mitomycin C and epirubicin. However, relapse and progression is quite common. The optimal management of patients with Bacillus Calmette-Guérin-unresponsive disease remains to be a challenge. The purpose of this study was to conduct a systematic review on the treatment modalities available for the management of Bacillus Calmette-Guérin-unresponsive carcinoma in situ and urothelial bladder carcinoma in patients who are ineligible or decline radical cystectomy.
METHODS
Two authors independently searched three databases on the treatment modalities available for the management of Bacillus Calmette-Guérin-unresponsive carcinoma in situ and Bacillus Calmette-Guérin-unresponsive urothelial bladder carcinoma.
RESULTS
The systematic search resulted in 15 studies. We recommend the use of intravesical CG0070 adenovirus or hyperthermic intravesical chemotherapy mitomycin C in patients with carcinoma in situ only disease. In patients with carcinoma in situ ± Ta/T1 disease, we recommend the use of intravesical radiofrequency-induced chemohyperthermia or electromotive drug administration of mitomycin C. In patients who have Ta/T1 disease, we recommend the use of either hyperthermic intravesical chemotherapy epirubicin or electromotive drug administration mitomycin C followed by chemohyperthermia mitomycin C. If any of these second line therapies fail, an alternative regimen would be a combination of gemcitabine, cabazitaxel, and cisplatin.
CONCLUSION
This recommendation is subject to the available resources and clinical expertise available in different hospitals. More studies using study designs such as randomized controlled trials comparing multiple drugs with larger sample sizes and regular follow-up intervals should be performed to accurately assess the different medications and aid in designing guidelines to guide the management of Bacillus Calmette-Guérin-unresponsive non-muscle invasive intravesical bladder cancer.
PubMed: 36949824
DOI: 10.1177/20503121231160408 -
International Journal of Surgery... Jan 2016The aim of the study was to evaluate the efficacy of alvimopan on accelerates gastrointestinal recovery after radical cystectomy. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The aim of the study was to evaluate the efficacy of alvimopan on accelerates gastrointestinal recovery after radical cystectomy.
METHODS
We searched for all studies investigating alvimopan for bladder cancer patients undergoing radical cystectomy in Pubmed, Web of Knowledge, and the Cochrane Central Search Library. A systematic review and meta-analysis were performed. All studies that compared alvimopan with control group for patients undergoing radical cystectomy were included. Studies with overlapping or insufficient data were excluded. No language restrictions were made. Efficacy was assessed by the time to first toleration of clear liquids, first toleration of solid food, first bowel movement and length of stay.
RESULTS
Our searches identified 5 studies, including 613 patients. A total of 294 (47%) patients took alvimopan. On meta-analysis, alvimopan reduced time to first toleration of clear liquids (HR 1.34, 95% CI 1.19 to 1.51, p < 0.001), first toleration of solid food (HR 1.22, 95% CI 1.11 to 1.34, p < 0.001), first bowel movement (HR 1.27, 95% CI 1.12 to 1.43, p < 0.001) and length of stay (HR 1.17, 95% CI 1.10 to 1.25, p < 0.001).
CONCLUSIONS
This meta-analysis has shown that alvimopan significantly accelerates recovery of gastrointestinal function and reduces the length of stay in patients performed radical cystectomy. More large scale, multicenter randomized controlled studies are needed before final clinical recommendations can be made.
Topics: Cystectomy; Gastrointestinal Agents; Gastrointestinal Tract; Humans; Length of Stay; Piperidines; Postoperative Complications
PubMed: 26596716
DOI: 10.1016/j.ijsu.2015.11.013 -
European Urology Apr 2017Urothelial carcinoma is considered a pan-urothelial disease. As such, the remnant urothelium in the upper urinary tract and urethra following radical cystectomy (RC)... (Review)
Review
CONTEXT
Urothelial carcinoma is considered a pan-urothelial disease. As such, the remnant urothelium in the upper urinary tract and urethra following radical cystectomy (RC) remains at risk for secondary urothelial tumors (SUTs).
OBJECTIVE
To describe the incidence, diagnosis, treatment, and outcomes of patients with SUTs after RC.
EVIDENCE ACQUISITION
A systematic search was conducted using PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2016 reporting on malignant diseases of the urothelium after RC for bladder cancer. The search strategy separated between upper and lower tract urothelial tumors.
EVIDENCE SYNTHESIS
Of a total of 1069 studies, 57 were considered for evidence synthesis. SUTs occured in approximately 4-10% of patients after RC. Carcinoma in situ of the bladder, a history of nonmuscle invasive bladder cancer, and tumor involvement of the distal ureter are the strongest risk factors for secondary upper tract tumors. Risk factors for secondary urethral tumors represent urothelial malignancy in the prostatic urethra/prostate and bladder neck (in women), nonorthotopic diversions, and positive findings on permanent sections. The majority of patients (84%) with SUTs, presented with urothelial recurrence without evidence of metastasis. Of those, 84.0% were treated with surgery, 10.5% with systemic chemotherapy and/or radiotherapy, and 5.6% with topical chemotherapy and/or immunotherapy. After a median follow-up of 91 mo (range: 26-155), 65.9% of patients died of disease and 21.5% died of other causes. Detection and treatment of SUTs at an asymptomatic stage can reduce the risks of cancer-specfific and overall mortality by 30%. A limitation of the study is that the available data were retrospective.
CONCLUSIONS
SUTs are rare oncological events and most patients have an adverse prognosis despite absence of distant disease at diagnosis. Therefore, surveillance of the remnant urothelium should be implemented for patients with histological features of panurothelial disease as it may improve timely detection and treatment.
PATIENT SUMMARY
Secondary tumors of the renal pelvis, ureters, and urethra occur in approximately 4-10% of patients after radical removal of the bladder for bladder cancer. These patients' prognoses are reduced, likely due to delayed diagnosis. Therefore, routine surveillance might be important to detect tumors at an early stage.
Topics: Carcinoma, Transitional Cell; Cystectomy; Humans; Kidney Neoplasms; Neoplasms, Second Primary; Ureteral Neoplasms; Urethral Neoplasms; Urinary Bladder Neoplasms
PubMed: 27720534
DOI: 10.1016/j.eururo.2016.09.035 -
Systematic Reviews Aug 2017Radical cystectomy is associated with high rates of perioperative morbidity. Robotic-assisted radical cystectomy (RARC) is widely used today despite limited evidence for... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Radical cystectomy is associated with high rates of perioperative morbidity. Robotic-assisted radical cystectomy (RARC) is widely used today despite limited evidence for clinical superiority. The aim of this review was to evaluate the effect of RARC compared to open radical cystectomy (ORC) on complications and secondary on length of stay, time back to work and health-related quality of life (HRQoL).
METHODS
The databases PubMed, The Cochrane Library, Embase and CINAHL were searched. A systematic review according to the PRISMA guidelines and cumulative analysis was conducted. Randomized controlled trials (RCTs) that examined RARC compared to ORC were included in this review. We assessed the quality of evidence using the Cochrane Collaboration's 'Risk of bias' tool and Grading of Recommendations Assessment, Development and Evaluation approach. Data were extracted and analysed.
RESULTS
The search retrieved 273 articles. Four RCTs were included involving overall 239 patients. The quality of the evidence was of low to moderate quality. There was no significant difference between RARC and ORC in the number of patients developing complications within 30 or 90 days postoperatively or in overall grade 3-5 complications within 30 or 90 days postoperatively. Types of complications differed between the RARC and the ORC group. Likewise, length of stay and HRQoL at 3 and 6 months did not differ.
CONCLUSION
Our review presents evidence for RARC not being superior to ORC regarding complications, LOS and HRQoL. High-quality studies with consistent registration of complications and patient-related outcomes are warranted.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42016038232.
Topics: Cystectomy; Humans; Length of Stay; Postoperative Complications; Quality of Life; Randomized Controlled Trials as Topic; Robotics; Treatment Outcome
PubMed: 28768530
DOI: 10.1186/s13643-017-0547-y -
World Journal of Urology Aug 2023The present systematic review and network meta-analysis (NMA) compared the current different neoadjuvant chemotherapy (NAC) regimes for bladder cancer patients to rank... (Meta-Analysis)
Meta-Analysis
Comparison between different neoadjuvant chemotherapy regimens and local therapy alone for bladder cancer: a systematic review and network meta-analysis of oncologic outcomes.
PURPOSE
The present systematic review and network meta-analysis (NMA) compared the current different neoadjuvant chemotherapy (NAC) regimes for bladder cancer patients to rank them.
METHODS
We used the Bayesian approach in NMA of six different therapy regimens cisplatin, cisplatin/doxorubicin, (gemcitabine/cisplatin) GC, cisplatin/methotrexate, methotrexate, cisplatin, and vinblastine (MCV) and (MVAC) compared to locoregional treatment.
RESULTS
Fifteen studies comprised 4276 patients who met the eligibility criteria. Six different regimes were not significantly associated with a lower likelihood of overall mortality rate compared to local treatment alone. In progression-free survival (PFS) rates, cisplatin, GC, cisplatin/methotrexate, MCV and MVAC were not significantly associated with a higher likelihood of PFS rate compared to locoregional treatment alone. In local control outcome, MCV, MVAC, GC and cisplatin/methotrexate were not significantly associated with a higher likelihood of local control rate versus locoregional treatment alone. Nevertheless, based on the analyses of the treatment ranking according to SUCRA, it was highly likely that MVAC with high certainty of results appeared as the most effective approach in terms of mortality, PFS and local control rates. GC and cisplatin/doxorubicin with low certainty of results was found to be the best second options.
CONCLUSION
No significant differences were observed in mortality, progression-free survival and local control rates before and after adjusting the type of definitive treatment in any of the six study arms. However, MVAC was found to be the most effective regimen with high certainty, while cisplatin alone and cisplatin/methotrexate should not be recommended as a neoadjuvant chemotherapy regime.
Topics: Humans; Cisplatin; Neoadjuvant Therapy; Methotrexate; Bayes Theorem; Network Meta-Analysis; Gemcitabine; Antineoplastic Combined Chemotherapy Protocols; Urinary Bladder Neoplasms; Doxorubicin; Vinblastine; Cystectomy
PubMed: 37347252
DOI: 10.1007/s00345-023-04478-w