Abstract Context There is a continuous decline in the number of transurethral resections of the prostate (TURP) and an increase use of minimally invasive surgical therapy (MIST) for lower urinary ...tract symptoms resulting from benign prostatic enlargement. Current results from randomised controlled trials (RCT) and methodologically sound prospective studies suggest that some of the proposed procedures have the potential to replace TURP. Objective To determine the contemporary status of TURP and of the currently most commonly applied transurethral MISTs: (1) bipolar TURP, (2) bipolar transurethral vaporisation of the prostate (bipolar TUVP), (3) holmium laser enucleation of the prostate (HoLEP), and (4) potassium-titanyl-phosphate (KTP) laser vaporisation of the prostate. Evidence acquisition This meta-analysis was based on a systematic Medline search assessing the period 1997–2009. All RCTs comparing TURP and the most commonly discussed ablative treatments were included. The end points of our analyses were functional outcomes and treatment-related adverse events. Evidence synthesis Twenty-seven publications involving 23 different RCTs with a total of 2245 patients provided the highest level of evidence available (level 1b) and were fully assessed. Meta-analysis was conducted with SAS v.9.1.3 (SAS Institute, Cary, NC, USA). Forest plots were produced using the R software. Pooled odds ratios and 95% confidence intervals were calculated between various operative techniques versus TURP. Functional results between the specific transurethral procedures versus TURP were summarised as differences in means. Conclusions This meta-analysis demonstrates statistically comparable efficacy and overall morbidity for MISTs versus contemporary TURP. Type, category (minor vs major), and the number of complications (safety profile) vary specifically for each of the different transurethral techniques. We feel that the individual patient’s clinical profile should be carefully assessed to identify the most appropriate transurethral technique.
Abstract Objectives To report 5-year follow-up results of a randomised clinical trial comparing holmium laser enucleation of the prostate (HoLEP) with open prostatectomy (OP). Methods One hundred ...twenty patients with prostates greater than 100 g in weight according to transrectal ultrasound were randomised to either the HoLEP or the OP group (ie, 60 patients to each group). Preoperative and postoperative assessments included American Urological Association Symptom Score (AUA-SS), maximum urinary flow rates (Qmax ), and postvoid residual urine (PVRU) volumes. Measurements were performed at 1, 3, 6, 12, 18, 24, 36, 48, and 60 mo. Postoperative outcome data were compared. All complications were recorded. Results Five years postoperatively, a total of 46 patients (38.3%) were lost to follow-up or had to be excluded from the study. All the remaining 74 patients (42 HoLEP vs. 32 OP patients, p = 0.11) had undergone the 5-yr follow-up assessments. Mean AUA-SS was 3.0 in both groups ( p = 0.98), mean Qmax was 24.4 ml/s in both groups ( p = 0.97) and PVRU volume was 11 ml in the HoLEP and 5 ml in the OP group ( p = 0.25). Late complications consisted of urethral strictures and bladder-neck contractures; reoperation rates were 5% in the HoLEP and 6.7% in the OP group ( p = 1.0). No patient developed benign prostatic hyperplasia recurrence. Conclusions Five years after the operation, the improvements in micturition obtained with HoLEP and OP were equally good, and reoperation rates similarly low. HoLEP seems to be a true endourological alternative to OP.
Abstract Objectives To report 3-yr follow-up results of a randomised clinical trial comparing holmium laser enucleation of the prostate (HoLEP) with transurethral resection of the prostate (TURP). ...Methods A total of 200 patients with urodynamic obstruction and a prostate volume of less than 100 cc were prospectively randomised and assigned to HoLEP or TURP. All patients were assessed preoperatively and followed at 1, 6, 12, 18, 24, and 36 mo postoperatively. American Urological Association Symptom Score (AUA SS), maximum flow rate (Qmax ), and postvoid residual (PVR) urine volume were obtained at each follow-up. Perioperative data and postoperative outcome were compared. All complications were recorded. Results AUA SS were significantly better 2 yr postoperatively in the HoLEP group (1.7 vs. 3.9, p < 0.0001) and similar at 3 yr (2.7 vs. 3.3, p = 0.17). PVR volume was significantly better 2 yr (5.6 vs. 19.9 ml, p < 0.001) and 3 yr (8.4 vs. 20.2 ml, p = 0.012) postoperatively in HoLEP patients. Qmax was similar in the HoLEP and TURP groups at 2 yr (28.0 vs. 29.1 ml/s, p = 0.83) and at 3 yr (29.0 vs. 27.5 ml/s, p = 0.41) postoperatively. Late complications consisted of urethral strictures, bladder-neck contractures, and BPH recurrence; reoperation rates were 7.2% in the HoLEP and 6.6% in the TURP group ( p = 1.0). Conclusions After 2 and 3 yr of follow-up, HoLEP micturition outcomes compare favourably with TURP. Late complications are equally low. HoLEP may be a real alternative to TURP.
Purpose
Holmium Laser Enucleation of the Prostate (HoLEP) is widely accepted as standard laser enucleation technique for patients with benign prostate obstruction (BPO). Initially developed as a ...three-lobe enucleation technique, several modifications have been published. Comparison of the enucleation techniques is lacking. Therefor we aimed to compare outcomes of three enucleation techniques (en-bloc vs. two-lobe vs. three-lobe).
Material and methods
We prospectively collected data of 600 patients treated between 01/2017 and 12/2017 with HoLEP for BPO. Patients were randomised to either enbloc, two-lobe, or three-lobe enucleation, respectively. Data collection consisted of parameters on operation time, perioperative parameters, and functional outcomes. Univariate and multivariate analyses (ANOVA-test for continuous variables; Chi2-test for categorical variables) were performed regarding differences between the three enucleation techniques.
Results
Patient characteristics were not significantly different (all
p
> 0.05). Significant differences were observed with respect to overall operation time (en-bloc vs. two-lobe vs. three-lobe: 40.5 vs. 40.7 vs. 47.9, respectively;
p
< 0.001), speed (g/min.) (en-bloc vs. two-lobe vs. three-lobe, 1.82 vs. 1.76 vs. 1.67, respectively;
p
0.006), and enucleation time (en-bloc vs. two-lobe vs. three-lobe: 31.7 vs. 32 vs. 37.7, respectively;
p
< 0.001). When solely comparing en-bloc vs. two-lobe enucleation, differences in terms of enucleation time, operation time, and speed were not significantly different (
p
0.8, 0.9, and 0.2, respectively). Postoperative outcomes were not significantly different.
Conclusion
All three HoLEP enucleation techniques show similar postoperative outcomes. However, enbloc and two-lobe enucleation are significantly faster with respect to enucleation, overall operation time, and speed compared to the three-lobe technique.
Abstract Background Preliminary research has suggested the potential prognostic value of circulating tumor cells (CTC) in patients with advanced nonmetastatic urothelial carcinoma of the bladder ...(UCB). Objective Prospectively analyze the clinical relevance and human epidermal growth factor receptor 2 (HER2) expression of CTC in patients with clinically nonmetastatic UCB. Design, setting, and participants Blood samples from 100 consecutive UCB patients treated with radical cystectomy (RC) were investigated for the presence (CellSearch system) of CTC and their HER2 expression status (immunohistochemistry). HER2 expression of the corresponding primary tumors and lymph node metastasis were analyzed using fluorescence in situ hybridization. Intervention Blood samples were taken preoperatively. Patients underwent RC with lymphadenectomy. Measurements Outcomes were assessed according to CTC status. HER2 expression of CTC was compared with that of the corresponding primary tumor and lymph node metastasis. Results and limitations CTC were detected in 23 of 100 patients (23%) with nonmetastatic UCB (median: 1; range: 1–100). Presence, number, and HER2 status of CTC were not associated with clinicopathologic features. CTC-positive patients had significantly higher risks of disease recurrence and cancer-specific and overall mortality ( p values: ≤0.001). After adjusting for effects of standard clinicopathologic features, CTC positivity remained an independent predictor for all end points (hazard ratios: 4.6, 5.2, and 3.5, respectively; p values ≤0.003). HER2 was strongly positive in CTC from 3 of 22 patients (14%). There was discordance between HER2 expression on CTC and HER2 gene amplification status of the primary tumors in 23% of cases but concordance between CTC, primary tumors, and lymph node metastases in all CTC-positive cases (100%). The study was limited by its sample size. Conclusions Preoperative CTC are already detectable in almost a quarter of patients with clinically nonmetastatic UCB treated with RC and were a powerful predictor of early disease recurrence and cancer-specific and overall mortality. Thus CTC may serve as an indication for multimodal therapy. Molecular characterization of CTC may serve as a liquid biopsy to guide individual targeted therapy in future clinical trials.
Introduction: Multiple factors influence postprostatectomy incontinence (PPI). This study evaluates the association between an intraoperative urodynamic stress test (IST) with PPI.
Materials and ...Methods: This is an observational, single-center, prospective evaluation of 109 robot-assisted laparoscopic radical prostatectomies (RALPs) performed between July 2020 and March 2021. All patients underwent an intraoperative urodynamic stress test (IST) in which the bladder is filled up to an intravesical pressure of 40 cm H2O to evaluate whether the rhabdomyosphincter is capable of withstanding the pressure and ensure continence. Early PPI was evaluated using a standardized 1-h pad test performed the day after removal of the urinary catheter. The association of IST and PPI was evaluated using univariate and multivariable logistic regression models.
Results: Nearly 76.6% of the patients showed no urine loss during the IST ("sufficient" population group). There was no significant correlation between this group and PPI after catheter removal (P = 0.5). Subgroup analyses of the "sufficient" patient population showed a 3.1 higher risk of PPI when no nerve sparing was performed (95% confidence interval: 1.05-9.70, P = 0.045).
Conclusion: A sufficient IST, as a surrogate variable for a fully obtained rhabdomyosphincter, has no significant predictive value on its own but seems to be the optimal prerequisite for continence, since the data shows that the lack of neurovascular supply required for a functioning sphincter leads up to a 3.1 times higher risk for PPI.
Abstract Background Urinary prostate cancer antigen 3 (PCA3) assay in combination with established clinical risk factors improves the identification of men at risk of harboring prostate cancer (PCa) ...at initial biopsy (IBX). Objective To develop and validate internally the first IBX-specific PCA3-based nomogram that allows an individual assessment of a man's risk of harboring any PCa and high-grade PCa (HGPCa). Design, setting, and participants Clinical and biopsy data including urinary PCA3 score of 692 referred IBX men at risk of PCa were collected within two prospective multi-institutional studies. Intervention IBX (≥10 biopsy cores) with standard risk factor assessment including prebiopsy urinary PCA3 measurement. Outcome measurements and statistical analysis PCA3 assay cut-off thresholds were investigated. Regression coefficients of logistic risk factor analyses were used to construct specific sets of PCA3-based nomograms to predict any PCa and HGPCa at IBX. Accuracy estimates for the presence of any PCa and HGPCa were quantified using area under the curve of the receiver operator characteristic analysis and compared with a clinical model. Bootstrap resamples were used for internal validation. Decision curve analyses quantified the clinical net benefit related to the novel PCA3-based IBX nomogram versus the clinical model. Results and limitations Any PCa and HGPCa were diagnosed in 46% ( n = 318) and 20% ( n = 137), respectively. Age, prostate-specific antigen, digital rectal examination, prostate volume, and PCA3 were independent predictors of PCa at IBX (all p < 0.001). The PCA3-based IBX nomograms significantly outperformed the clinical models without PCA3 (all p < 0.001). Accuracy was increased by 4.5–7.1% related to PCA3 inclusion. When applying nomogram-derived PCa probability thresholds ≤30%, only a few patients with HGPCa (≤2%) will be missed while avoiding up to 55% of unnecessary biopsies. External validation of the PCA3-based IBX-specific nomogram is warranted. Conclusions The internally validated PCA3-based IBX-specific nomogram outperforms a clinical prediction model without PCA3 for the prediction of any PCa, leading to the avoidance of unnecessary biopsies while missing only a few cases of HGPCa. Our findings support the concepts of a combination of novel markers with established clinical risk factors and the superiority of decision tools that are specific to a clinical scenario.
Immune checkpoint inhibitors (ICIs) have revolutionized systemic anti-tumor treatments across different types of cancer. Nevertheless, predictive biomarkers regarding treatment response are not ...routinely established yet. Apart from T-lymphocytes, the humoral immunity of B-lymphocytes is studied to a substantially lesser extent in the respective setting. Thus, the aim of this study was to evaluate peripheral blood B-cell subtypes as potential predictors of ICI treatment response.
Thirty-nine cancer patients receiving ICI therapy were included into this prospective single-center cohort study. All had a first blood draw at the date before treatment initiation and a second at the time of first response evaluation (after 8-12 weeks). Seven different B-cell subtypes were quantified by fluorescence-activated cell sorting (FACS). Disease control- (DCR) and objective response rate (ORR) were co-primary study endpoints.
Overall, DCR was 48.7% and ORR was 25.6%, respectively. At baseline, there was no significant association of any B-cell subtype with neither DCR nor ORR. At the first response evaluation, an increase in the frequency of CD21
B-cells was a statistically significant negative predictor of response, both regarding DCR (OR=0.05, 95%CI=0.00-0.67,
=0.024) and ORR (OR=0.09, 95%CI=0.01-0.96,
=0.046). An increase of the frequency of switched memory B-cells was significantly associated with reduced odds for DCR (OR=0.06, 95%CI=0.01-0.70,
=0.025). Patients with an increased frequency of naïve B-cells were more likely to benefit from ICI therapy as indicated by an improved DCR (OR=12.31, 95%CI=1.13-134.22,
=0.039).
In this study, certain B-cell subpopulations were associated with ICI treatment response in various human cancer types.
Purpose
To prospectively investigate early and consecutive changes of lower urinary tract symptoms (LUTS), specifically storage symptoms after holmium laser enucleation of the prostate (HoLEP).
...Methods
Patients referred for HoLEP completed the International Prostatic Symptom Score (IPSS) the day before, at discharge, and 1, 2, 3, 4, 6, 8, 12, 16, 20, 24, and 52 weeks after HoLEP. Total IPSS was stratified into mild (score 0–7), moderate (8–19), and severe (20–35) LUTS. Storage symptoms were sub-stratified into storage “negative” and “positive”. IPSS changes served as the main postoperative outcome. Mixed linear models identified risk factors affecting postoperative recovery of LUTS.
Results
Between December 2010 and 2012, 144 consecutive HoLEP patients were prospectively included in the study. Preoperatively 57.6% of the cohort reported severe storage symptoms (mean total IPSS: 22.6 ± 5.0). Total IPSS decreased significantly immediately after surgery (
p
< 0.001). Patients with severe LUTS, storage-positive sub-score, and high maximum urinary flow rate were affected by a rebound of mainly storage symptoms 6–8 weeks after HoLEP and prolonged recovery from LUTS. Of these, about 7.4% presented persisting urge complaints. Finally, 12 weeks following HoLEP, the vast majority of patients were symptom-free. Limitations of this study include missing urodynamic workup and a comparative patient cohort.
Conclusion
Immediately after HoLEP, patients experience a significant decrease of LUTS. Continuous symptom recovery seems to be hampered in patients with severe and storage-positive baseline symptoms. (De-novo) storage symptoms slightly affect postoperative recovery. Quality of life is restored to a stable and significantly improved status 3 months after surgery.
