Enucleation vs vaporization of benign prostatic hyperplasia: a head-to-head comparison of the various outcomes and complications. A systematic review and meta-analysis

INTRODUCTION

Vaporization of the prostate (VP) and endoscopic enucleation of the prostate (EEP) are reliable and frequently used methods for BPO relief. Both surgeries utilize lasers and EAU recommends them in similar patient cohorts. Our objective was to compare intra- and perioperative results of patients who had undergone VP and EEP.

EVIDENCE ACQUISITION

A systematic literature search was performed in three databases (MEDLINE, Web of Science and Scopus). The detailed search strategy is available at Prospero, CRD42020204739. Primary outcomes were functional results (IPSS, QoL, PVR, Qmax), and secondary outcomes were intraoperative results, postoperative PSA and prostate volume, complications, and recurrence rate.

EVIDENCE SYNTHESIS

VP required less operative time compared to EEP, mean difference=-5.51 (95%CI -7.52; -3.50). IPSS and Qmax for VP were worse after 12-month follow-up, mean difference=0.89 (95%CI 0.52; 1.27) and -3.7 (95%CI -4.56; -2.85), respectively, while QoL did not differ significantly. Postoperative PSA level was higher in the VP group, mean difference=2.28 (95%CI 2.00; 2.55). VP was associated with reduced Clavien-Dindo grade I (OR=4.16; 95%CI 2.96; 5.84) and grade II (OR=3.79; 95%CI 2.25; 6.39) complication rate, especially in terms of the percentage of blood transfusion and transient urinary incontinence. The rate of complications grade IIIa and higher was similar (3 - 6%). Reoperation rate was only estimated in one study and was significantly higher in the PVP group at 60 months of follow-up, 2.7% vs 0%, p<0.05.

CONCLUSIONS

EEP and VP share the efficacy and safety in BPH management. Our meta-analysis shows comparable complication rate in Clavien-Dindo III, VP superiority in operation time, and EEP superiority in long-term functional outcomes and PSA reduction.

Ex vivo study of Ho:YAG and thulium fiber lasers for soft tissue surgery: which laser for which case?

The goal of this study was to assess the ablation, coagulation, and carbonization characteristics of the holmium:YAG (Ho:YAG) laser and thulium fiber lasers (TFL). The Ho:YAG laser (100 W av.power), the quasi-continuous (QCW) TFL (120 W av.power), and the SuperPulsed (SP) TFL (50 W av.power) were compared on a non-frozen porcine kidney. To control the cutting speed (2 or 5 mm/s), an XY translation stage was used. The Ho:YAG was tested using E = 1.5 J and P_av = 40 W or P_av = 70 W settings. The TFL was tested using E = 1.5 J and P_av = 30 W or P_av = 60 W settings. After ex vivo incision, histological analysis was performed in order to estimate thermal damage. At 40 W, the Ho:YAG displayed a shallower cutting at 2 and 5 mm/s (1.1 ± 0.2 mm and 0.5 ± 0.2 mm, respectively) with virtually zero coagulation. While at 70 W, the minimal coagulation depth measured 0.1 ± 0.1 mm. The incisions demonstrated zero carbonization. Both the QCW and SP TFL did show effective cutting at all speeds (2.1 ± 0.2 mm and 1.3 ± 0.2 mm, respectively, at 30 W) with prominent coagulation (0.6 ± 0.1 mm and 0.4 ± 0.1 mm, respectively, at 70 W) and carbonization. Our study introduced the TFL as a novel efficient alternative for soft tissue surgery to the Ho:YAG laser. The SP TFL offers a Ho:YAG-like incision, while QCW TFL allows for fast, deep, and precise cutting with increased carbonization.

Information on surgical treatment of benign prostatic hyperplasia on YouTube is highly biased and misleading

OBJECTIVES

To assess the quality of videos on the surgical treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) available on YouTube, given that such video-sharing platforms are frequently used as sources of patient information and the therapeutic landscape of LUTS/BPH has evolved substantially during recent years.

MATERIALS AND METHODS

A systematic search for videos on YouTube addressing treatment options for LUTS/BPH was performed in May 2019. Measures assessed included basic data (e.g. number of views), grade of misinformation and reporting of conflicts of interest. The quality of content was analysed using the validated DISCERN questionnaire. Data were analysed using descriptive statistics.

RESULTS

A total of 159 videos with a median (range) of 8570 (648-2 384 391) views were included in the analysis. Only 21 videos (13.2%) were rated as containing no misinformation, 26 (16.4%) were free of commercial bias, and two (1.3%) disclosed potential conflicts of interest. According to DISCERN, the median overall quality of the videos was low (2 out of 5 points for question 16). Only four of the 15 assessed categories (bipolar and holmium laser enucleation of the prostate, transurethral resection of the prostate and patient-based search terms) were scored as having moderate median overall quality (3 points).

CONCLUSION

Most videos on the surgical treatment of LUTS/BPH on YouTube had a low quality of content, provided misinformation, were subject to commercial bias and did not report on conflicts of interest. These findings emphasize the importance of thorough doctor-patient communication and active recommendation of unbiased patient education materials.

[C-reactive protein prior to radical cystectomy: preoperative determination of CRP]

BACKGROUND

Numerous studies have shown a positive correlation between elevated C-reactive protein (CRP) and systemic spread of malignancies. The goal of the current study was to assess the predictive significance of preoperative CRP in patients undergoing radical cystectomy (RC).

MATERIAL AND METHODS

Preoperative CRP values were measured in 194 patients undergoing RC because of urothelial carcinoma between 1996 and 2005. Elevated CRP level was defined as ≥ 5 mg/l.

RESULTS

Preoperative increased CRP values were detected in 89 (45.9%) patients and these patients were more likely to have advanced tumor stages (pT3-4), positive resection margins and positive lymph nodes. Advanced urinary diversions were more common in patients with normal CRP values. In multivariate analysis, CRP was identified as an independent prognostic indicator for poor cancer-specific survival.

CONCLUSION

The results confirm previous reports that showed a prognostic significance of preoperative CRP elevation.

Galectin-1 and Galectin-3 mRNA expression in renal cell carcinoma

Background

Galectins are known to regulate cell differentiation and growth as well as cell adhesion and apoptosis. Galectins have been discussed as possible prognosticators for survival in renal cell cancer (RCC) and other urological tumors. They might also play an emerging role as possible new marker-proteins for RCC. In this study, we analyzed the expression of galectin-1 and galectin-3 mRNA in order to further investigate their clinical significance in RCC.

Methods

Tissue samples were obtained from 106 patients undergoing surgery for RCC. The expression of galectin-1 and galectin-3 mRNA in normal kidney and corresponding cancer tissue was analyzed using quantitative real time PCR. Differences in expression levels of paired tissue samples were assessed using paired two-sample tests. Associations of relative mRNA expression levels in tumor tissues with clinical findings were analyzed using univariate logistic regression.

Results

The expression of galectin-1 (p < 0.001) and -3 (p < 0.001) mRNA were significantly higher in RCC when compared to the adjacent normal kidney tissue. For clear cell RCC, an association of male gender with higher galectin-1 and galectin-3 mRNA expression (p = 0.054, p = 0.034) was detected. For all RCCs, galectin-1 mRNA expression failed to show a significant association with advanced disease as well as a higher rate of lymph node metastases (p = 0.058, p = 0.059).

Conclusion

The mRNA expression of galectin-1 and galectin-3 is significantly increased in RCC cancer tissue. The higher mRNA expression in tumor tissue of male patients raises the question of a functional connection between galectins and the higher prevalence of RCC in men. Associations with advanced disease might lead to new ways of identifying patients at higher risk of recurrent disease and might even facilitate early metastasectomy with curative intent.

Neoadjuvant targeted therapy in a primary metastasized renal cell cancer patient leads to down-staging of inferior vena cava thrombus (IVC) enabling a cardiopulmonary bypass-free tumor nephrectomy: a case report

BACKGROUND

We report on a 62-year-old gentleman presenting at our urological department with an advanced renal cell cancer of the right kidney (10 cm in diameter), with an extensive caval vein thrombus (level IV) and bilateral pulmonary metastases. Another suspicious lesion at the left hemithorax was radiologically described.

METHOD

A presurgical, neoadjuvant systemic therapy with sunitinib, a tyrosine kinase inhibitor, was initiated for 4 cycles in total (50 mg/day; 4 weeks on/2 weeks off). The cytoreductive nephrectomy was performed following the fourth cycle of sunitinib and after a 14-day break. Transesophageal echocardiography was used for intraoperative monitoring of the caval vein thrombus. Systemic treatment with sunitinib was continued 4 weeks after surgery.

RESULTS

A significant reduction in tumor size, metastatic sites and down-staging of IVC from level IV to level III according to Novick classification was achieved.

CONCLUSION

Significant down-staging of the tumor caval vein thrombus which initially reached the right atrium enabled us to perform surgery limited to the abdominal cavity without extracorporeal circulation nor hypothermia.

[Ewing's sarcoma of the kidneys with simultaneous seminoma]

Extraosseous Ewing's sarcoma (EOE) is rarely observed in the urinogenital tract, which results in only sporadic descriptions of primary EOE of the kidneys in the literature with cytologic analyses. A timely diagnosis and differentiated therapy of this aggressive disease are compromised by its infrequent appearance and scarce available data. With a simultaneously diagnosed seminoma our case report supports and extends further the data collected so far.

Oncological and functional results of open, robot-assisted and laparoscopic radical prostatectomy: does surgical approach and surgical experience matter?

The treatment of prostate cancer has undergone a fundamental change in the last decade. New surgical and nonsurgical minimal invasive methods have evolved. As the methodology of the different treatments is commonly known to urologists, this article focuses on oncological and functional outcome of open retropubic (ORP), trans- or extraperitoneal endoscopical (LRP), and robot-assisted radical prostatectomy (RALP), based on personal experience and review of the literature. A MEDLINE search was performed to review the literature on LRP and RALP between 1982 and 2007 with special emphasis on oncological and functional results, technical considerations, comparison of LRP and RALP to ORP, laparoscopic training, historical aspects, and cost-efficiency of the techniques. Based on diligent training and proctoring programs, a continuous dissemination of laparoscopic techniques takes place. There is a trend towards the extraperitoneal access in most of the minimal invasive programs at least in the European community. Mid-term outcomes of LRP and short-term outcomes of RALP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower transfusion rates, shorter convalescence, and better cosmetics. In contrast to RALP, LRP reaches cost-equivalence with open surgery in selected centers. LRP and RALP reproduce the short-term results of open surgery while providing the advantages of a minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow, but the discussion about the longer learning curve for laparoscopy handling remains. The future will show if European centers adopt the use of robots comparable to the United States.

Estimation of inter-binding-site distances in sarcoplasmic reticulum (Ca2+ + Mg2+)-ATPase under occluded and non-occluded conditions

Distances between binding sites in skeletal sarcoplasmic reticulum (Ca2+ + Mg2+)-ATPase were estimated by measuring energy transfer between a luminescent lanthanide probe for the calcium sites (Eu3+) and suitable acceptors. A distance measurement between the two calcium binding sites of the enzyme was made with and without MgATP, corresponding to two different states in the hydrolytic cycle. We found that without ATP, the inter-calcium-site distance is about 0.9 nm, while in the presence of MgATP these sites are 0.05 nm to 0.1 nm closer. We also estimated the distance from the calcium sites to the hydrolytic site using CrATP as an acceptor; this distance is approximately 1.8 nm. These measurements provide the start for a description of intramolecular movement during the transport cycle, and should be of use in mapping out the three-dimensional structure of the Ca2+ pump.

Interaction of europium(III) with phospholipid vesicles as monitored by laser-excited europium(III) luminescence

The technique of laser-excited Eu(III) luminescence was applied to monitor Eu(III) binding to a variety of phospholipids. Eu(III) excitation spectra were similar with and without the presence of neutral phospholipids, while acidic phospholipids changed the spectrum in a concentration-dependent manner. Eu(III) appears to bind to the phosphate moiety with at least a 2:1 phospholipid:metal ion stoichiometry. Analysis of luminescence lifetimes reveals that only one or two waters of hydration are removed from Eu(III) by addition of neutral phospholipids, whereas acidic phospholipids and inorganic phosphate strip off all but one or two waters. Implications with regard to fusion and use of lanthanides as probes in membrane preparations are discussed.

Estimation of inter-binding-site distances in sarcoplasmic reticulum (Ca2+ + Mg2+)-ATPase using Eu(III) luminescence energy transfer

We have used several trivalent lanthanides as probes for the high-affinity Ca(II)-binding site of the Ca(II) + Mg(II)-ATPase of skeletal muscle sarcoplasmic reticulum. The luminescent probes Eu(III) and Tb(III) were excited directly with pulsed laser light and the energy transfer efficiencies to several lanthanide acceptors were measured, under conditions in which most donor-acceptor pair occupied high-affinity Ca(II) sites. We obtain an inter-ionic site distance of about 0.8-0.9 nm. Energy transfer measurements were also done with Eu(III) in at least one Ca(II) site and bidentate Cr-ATP complex at the ATP hydrolytic site. Quenching of Eu(III) luminescence by Cr-ATP was total under these conditions. We calculate an upper limit of 1.0 nm for the distance from the Ca(II) site(s) to the complexed Cr(III) ion at the hydrolytic site.

Characterization of calciphorin by laser-excited europium luminescence

There is some question whether the calcium binding characteristics of calciphorin are due to contaminating phospholipids. To differentiate protein ion binding by phospholipids or contaminating detergent, we describe here the use of Eu(III) as a metal-binding-site probe, and characterize the interaction of Eu(III) with calciphorin, cardiolipin, deoxycholate, and digitonin. The luminescence excitation pattern of Eu(III) bound to the calciphorin preparation clearly differentiates it from Eu(III) interactions with the possible contaminants. In addition, the effect of the luminescence decay constant of Eu(III) bound to calciphorin on the mole fraction of H2O in a mixture of H2O/2H2O indicates that all except approximately 0.8 of the 9 to 10 water molecules coordinating Eu(III) in solution are stripped off upon binding to calciphorin. This also contrasts with the data for the possible contaminants.

Ionophorous properties of the 13 000-Da fragment from sarcoplasmic reticulum (Ca2+ + Mg2+)-ATPase

The 25 000-Da tryptic fragment from rabbit muscle sarcoplasmic reticulum (Ca2+ + Mg2+)-ATPase was subjected to cyanogen bromide digestion, and the four fragments isolated. Only the 13 000-Da fragment induced ionophorous activity in planar thin lipid membranes made with 5:1 (w/w) phosphatidylcholine/cholesterol in decane. The membranes became cation selective, with a selectivity sequence among divalent of Mn2+ greater than Ca2+ greater than Ba2+ greater than Sr2+ greater than Mg2+. This is different from that of the 25 000-Da fragment (A.E. Shamoo, 1978, J. Memb. Biol. 43, 227-242), it's 'parent' 55 000-Da fragment, and the intact enzyme, all of which have the same selectivity sequence. The inhibitory effects of Hg2+, Cd2+ and Zn2+ were also examined. All were inhibitory, with Zn2+ being the most effective of these. The heavy-metal-induced inhibition of Ca2+ conductance could be reversed by selective chelation of the heavy metals by EDTA. From changes in the selectivity as well as changes in heavy-metal-induced inhibition behavior, we conclude that the ion transport site of the 13 000-Da fragment may not be the same site as that of the parent fragment. It is either a different site altogether or has been physically modified by peptide cleavage.

Ion pathways in proteins of the sarcoplasmic reticulum

In summary, we have begun to characterize three different ion pathways in the sarcoplasmic reticulum. Ca2+-ionophoric activity has been traced to a 13,000-dalton CNBr fragment localized at the amino terminus of the ATPase molecule... The pathway involved in Ca2+ release can be distinguished from the pathway involved in Ca2+ uptake by its insensitivity to quercetin. An anion pathway is sensitive to DIDS and appears to be localized in the ATPase molecule

The electrical response to light of bacteriorhodopsin in planar membranes

We have measured the light-induced short-circuit current generated by a planar membrane containing bacteriorhodopsin incorporated by vesicle fusion. The experimental results are consistent with an equivalent electrical circuit analogue that assumes that the vesicles remain intact after fusion and that the current generator equivalent of the light-driven proton pump is linearly dependent on bias voltage. The transient response to light of the planar membrane has also been examined. Slow response times are seen to be associated with the capacitive charging and discharging of the fused vesicles. A study of the leading edge of the light response curve of the planar membrane yields information about the transient response of the light-driven proton pump. We propose that the translocation of protons across the membrane is associated with a first-order process characterized by a rate constant lambda.

A measurement of the proton pump current generated by bacteriorhodopsin in black lipid membranes

The light-induced electrical current generated by black lipid membranes containing bacteriorhodopsin from Halobacterium halobium has been measured directly. It is shown that a measurement of membrane potential can also be used to obtain the proton pump current developed during illumination. Evidence is presented that the charge movement across the membrane is associated with the release of protons in the photoreaction cycle of bacteriorhodopsin. The time variation of the pump current when the light is turned on suggests the rapid depopulation of some initially occupied state.