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Risultati funzionali a lungo termine della cistectomia radicale robot-assistita (RARC) con diversione urinaria totalmente intracorporea (ICUD)
Full text linkIntroduzione: La cistectomia radicale a cielo aperto (ORC) rappresenta tuttora il trattamento standard per il tumore della vescica muscolo invasivo e per quello non-muscolo invasivo ricorrente di alto grado. Tuttavia nell’ultima decade la cistectomia radicale robot-assistita (RARC) ha gradualmente acquisito popolarità come possibilità terapeutica alternativa. Recenti studi in letteratura hanno, infatti, dimostrato per la RARC un più basso tasso di complicanze intra- e peri- operatorie seppur con risultati oncologici equiparabili all’ORC. Obiettivo dello studio: Analizzare, per la prima volta in letteratura, le complicanze tardive e i risultati funzionali a lungo termine in una numerosa coorte di pazienti sottoposti a RARC con ICUD (intracorporeal urinary diversion) Materiali e Metodi: Sono stati prospettivamente arruolati pazienti trattati con RARC e ICUD tra Agosto 2012 e Giugno 2019. Sono stati inclusi pazienti con carcinoma uroteliale della vescica muscoloinvasivo o di alto grado ricorrente refrattario all’immunoterapia intravescicale ed esclusi pazienti con malattie cardiovascolari (FE < 36%), vasculopatie retiniche, shunt ventricoloperitoneali e quelli trattati senza fini curativi. Il follow-up è stato condotto in accordo alle linee guida della Società Europea di Urologia. Risultati: Sono stati inclusi 210 pazienti totali, di cui il 76% uomini, con età media di 62 anni. Le derivazioni urinarie impiegate sono state la “Vescica ileale padovana” (VIP) nell’80% dei casi, e l’ “ureteroileocutaneostomia” (Bricker) nel 20% dei pazienti (in media più anziani e con più comorbidità). Il follow up medio è stato di 30±22 mesi. Il 4% dei pazienti ha presentato una stenosi dell’anastomosi uretero-ileale, mentre più rilevante è stata la riduzione ≥10% dell’eGFR (in più del 50% dei casi). Le IVU si sono verificate nel 37% dei pazienti, soprattutto nei primi 12 mesi. Solo il 2% ha presentato occlusioni intestinali, mentre il 20% laparocele, il 10% linfocele e l’1% eventi sistemici (acidosi metabolica ed episodi cardiovascolari). La continenza urinaria diurna, nelle VIP, si è ottenuta nell’85% dei casi, quella notturna nel 50%. Conclusioni: Questo è il primo grande studio a singolo centro a riportare i risultati funzionali e le complicanze a medio termine in un gruppo di pazienti sottoposti a RARC con ICUD. Questi dati appaiono incoraggianti e in linea con i dati registrati in serie storiche di ORC. Pertanto questo studio è un ulteriore tassello nel supportare la RARC come un’opzione chirurgica sicura ed efficace per il trattamento del carcinoma vescicale muscolo-infiltrante in centri terziari di riferimento
Editorial Comment from Dr Presicce et al. to Emerging links between non-neurogenic lower urinary tract symptoms secondary to benign prostatic obstruction, metabolic syndrome and its components. a systematic review
No full textIn 1998, Hammarsten et al. first proposed a possible causal association between metabolic abnormalities and the development of benign prostatic hyperplasia (BPH).1 Since then, an increasing number of studies have investigated this relationship with controversial conclusions. The discordant classifications used to define the presence of metabolic syndrome (MetS), the different prevalence of MetS and the ethnic disparities among the enrolled populations make comparisons difficult, and could explain the conflicting results of the available evidence. Notwithstanding all these limitations, a positive association between MetS and lower urinary tract symptoms (LUTS), particularly storage LUTS,2 seems to emerge as confirmed by the present review.3 The authors evaluated the current and higher‐quality evidence of the relationship between MetS and LUTS. Furthermore, Russo et al. have the merit of exploring the possible connection between LUTS/bladder outlet obstruction (BPO) and each single component of MetS. They found a positive association between MetS, the number of components and LUTS/BPO, and in particular the main endocrine metabolic abnormalities involved seem to be central obesity and hypertriglyceridemia.3 However, this is only the tip of the iceberg, and several questions about this promising topic remain unanswered
Clinical Implications for the Early Treatment of Benign Prostatic Enlargement (BPE). a Systematic Review
No full textPurpose of review: Therapeutic options for the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE) have considerably increased in recent years. However, the ideal timing to initiate medical treatment of LUTS/BPE has not been fully established. The aim of this review was to systematically collect available evidence on the influence of early treatment on the natural history of LUTS/BPE patients. Recent Findings: A systematic literature search from January 1996 until April 2018 was performed by combining the following MESH terms: Lower Urinary Tract Symptoms, Benign Prostatic Enlargement, male, medical treatment, surgical treatment, early treatment/intervention, and early intervention/treatment. The Medline, PubMed, and Scopus databases were searched. Each article title and abstract was reviewed for relevance and appropriateness with regard to the topic of this review. In recent years, the medical armamentarium for the management of LUTS secondary to BPE has been extensively implemented, significantly improving treatment outcomes and markedly reducing the need for BPE surgery. Early intervention in patients at risk for disease progression may offer better clinical outcomes compared to a deferred approach. However, evidences supporting early treatment are scarce, and criteria to discriminate patients that could mostly benefit from immediate treatment remain poorly defined. Moreover, as a result of delayed surgery after prolonged medical treatment, patients undergoing surgical relief show larger prostates, older age, and comorbidities. Nevertheless, technological advancements in surgical techniques have largely counterweighed this critical scenario, and commonly, a non-pejorative trend has been reported in perioperative complications. Summary: The timeliest moment to start a medical treatment in LUTS/BPE patients is still undefined, and unexpectedly, peer-reviewed evidence remains scarce. Further studies are awaited to better discriminate patients who mostly benefit from early treatment of LUTS/BPE
Clinical significance of intravesical prostatic protrusion in the management of benign prostatic enlargement: A systematic review and critical analysis of current evidence
No full textINTRODUCTION: Filling cystometry and pressure flow studies (PFS) are the most widespread used invasive urodynamic techniques in the assessment of male LUTS. However, these techniques are time- and cost-intensive. Intravesical prostatic protrusion (IPP) has been proposed as non-invasive method used to diagnose bladder outlet obstruction (BOO) in men with male lower urinary tract symptoms (LUTS). The purpose of the present review is to analyze the diagnostic and therapeutic relevance of IPP. EVIDENCE ACQUISITION: A comprehensive systematic MEDLINE search was performed for English language reports published before June 2016 using the term "intravesical prostatic protrusion." EVIDENCE SYNTHESIS: We identified 28 eligible original articles. Determination of IPP seems as useful method to predict BOO. The area under the curve of IPP for the prediction of BOO was found to range from 0.708 (95% CI: 0.615- 0.791) to 0.858 (95% CI : 0.809-0.908). IPP seems to have a predictive role in a successful trial without catheter following acute urinary retention. The percentage of successful TWOC in patients with IPP>10 mm was reported at 13% and 18%, respectively, compared to a approximately 80% chance of successful trial in patients with IPP10 mm should be counseled regarding the high chance of need for surgical treatment following acute urinary retention
Inflammatory mediators in the development and progression of benign prostatic hyperplasia
No full textBenign prostatic hyperplasia (BPH) is the most common urological disease in elderly men. Epidemiological data suggest a causal link between this condition and prostatic inflammation. The prostate is an immune-competent organ characterized by the presence of a complex immune system. Several stimuli, including infectious agents, urinary reflux, metabolic syndrome, the ageing process, and autoimmune response, have been described as triggers for the dysregulation of the prostatic immune system via different molecular pathways involving the development of inflammatory infiltrates. From a pathophysiological standpoint, subsequent tissue damage and chronic tissue healing could result in the development of BPH nodules
Is early benign prostatic hyperplasia (BPH) treatment worthwhile?
No full textThe medical armamentaria for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) have been extensively implemented over the past decade. Nevertheless, the timeliest moment for a possible treatment has not been fully established
Can Long-term LUTS/BPH Pharmacological Treatment Alter the Outcomes of Surgical Intervention?
No full textDetrusor overactivity increases bladder wall thickness in male patients: a urodynamic multicenter cohort study
No full textAbstract
AIMS:
To evaluate the role of Bladder wall thickness (BWT) as a predictor of Detrusor overactivity (DO) in patients with Lower urinary tract symptoms (LUTS)/Benign prostatic enlargement without Bladder Outlet Obstruction.
METHODS:
From January 1996 to December 2000, each new patient, aged 45 years or older with LUTS, underwent standard diagnostic assessment, urodynamic studies (cystometry and pressure flow studies), and ultrasound measurements of the bladder wall thickness (BWT) in two centers. In order to exclude the possible effect of benign prostatic obstruction (BPO) on detrusor thickness, patients with a Schaefer class was ≥2 were excluded from the study. The area under the receiver operating characteristics curve (AUC) quantified the predictive accuracy (PA) of BWT for the diagnosis of DO.
RESULTS:
Overall 195 patients were enrolled. DO was observed in 98/195 patients (50%). The BWT presented an AUC of 0.70; 95% CI: 0.62-0.77 for the diagnosis of DO. At the best cut-off value of 3.85 mm sensitivity was 73%; specificity was 59%; positive predictive value (64%, PPV). Negative predictive value (69%, NPV).
CONCLUSIONS:
Our study firstly showed, how BWT in male patients may be a consequence of DO other than BPO. Our finding, if confirmed in further studies, could limit the accuracy of BWT in patients with DO and BPO.
© 2016 Wiley Periodicals, Inc
Moderate-to-high cardiovascular risk is associated with increased lower urinary tract storage symptoms in patients with benign prostatic enlargement
No full textTo assess the association between cardiovascular risk (CVR) and lower urinary tract symptoms (LUTS) in men with benign prostatic enlargement (BPE)
Castration resistance prostate cancer. what is in the pipeline?
No full textINTRODUCTION: To evaluate the available evidence on the standard diagnosis and management of men with metastatic castration resistant prostate cancer (mCRPC), and providing the timely update on new pharmacological treatments. EVIDENCEACQUISITION: Asystematic literature search from from January 2000 until March 2017 was performed by combining the following MESH terms: castrate resistant prostate cancer, abiraterone, enzalutamide, 223radium, sipuleucel-T, docetaxel, cabazitaxel, resistance mechanisms, resistance to androgen deprivation, androgen receptor (AR) mutations, amplifications, splice variants, and AR alterations. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). EVIDENCESYNTHESIS: In the few last years the introduction of new treatment modalities as abiraterone or enzalutamide have significantly change our prospective in mCRPC management increasing patients survival and quality of life. The standard imaging modalities to define the presence of regional or distant metastasis or the different resistant mechanisms to the available treatments are still an issue of debate, however several studies are ongoing to define the standard of care and to reduce treatments' resistance. Data from ongoing phase IIItrials are awaited to introduce in clinical new effective treatments that can be used in patients resistant to abiraterone/enzalutamide or more probably in a different phase of the disease. CONCLUSIONS: Castration resistant prostate cancer is now the key issue in prostate cancer management and research. Our challenge in the near future will be to identify the right treatment or better the right combination and sequencing of treatments that should be used in patients with mCRPCor even with advanced prostate cancer
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