Publications by authors named "Francesco Esperto"

58 Publications

Immune checkpoint inhibitors for BCG-resistant NMIBC: the dawn of a new era.

Minerva Urol Nephrol 2021 Mar 29. Epub 2021 Mar 29.

Urology Department, Sant'Andrea Hospital, Università degli Studi di Roma La Sapienza, Rome, Italy.

Introduction: High risk non-muscle invasive bladder cancer (NMIBC) is a recurring and potentially lethal disease. To date, with the exception of radical surgery, there are no validated strategies for patients not responding to intravesical BCG therapy. Immune Checkpoint Inhibitors (ICI) are currently being tested for BCG-resistant NMIBC. We report current available data and ongoing trials exploring the efficacy and safety of ICI in this setting.

Evidence Acquisition: A narrative search was performed including the combination of the following words: ((immunotherapy) AND ((BCG AND resistant) OR (non-muscle AND invasive)) AND (bladder AND cancer)). Three search engines (PubMed, Embase®, and Web of Science) were queried up to November 1, 2020. Congress abstracts reporting results and not only trials' design were also referenced. The US National Library of Medicine was queried via clinicaltrials.gov to explore ongoing trials on the subject.

Evidence Synthesis: Pembrolizumab demonstrated a promising 40.6% (95% CI, 30.7-51.1) complete response within the KEYNOTE-057, with a median duration of response of 16.2 months. Preliminary data in the phase II SWOG S1605 trial with Atezolizumab showed a 41.1% complete response at 3 months. Avelumab is being tested in the PREVERT phase II study exploring ICI with radiotherapy (60-66 Gy) of the whole bladder. CheckMate 9UT analyzes Nivolumab monotherapy versus Nivolumab + BMS-986205 (IDO-1 inhibitor) with or without BCG in patients with BCG-unresponsive, carcinoma in situ with or without papillary component. Finally, Durvalumab is being studied in the BCG resistant space with radiotherapy in the ADAPT-BLADDER study. After proving its safety profile in the phase 1, the trial will randomize patients to Durvalumab + BCG, Durvalumab + radiation therapy (6Gy 3x) or BCG rechallenge.

Conclusions: Pembrolizumab has received FDA approval in the treatment of BCG-resistant NMIBC. All five other ICI molecules are currently being extensively tested within clinical trials. The results of the currently ongoing studies are awaited with impatience by the uro-oncologic community and will probably open a new era in the treatment of BCG-resistant NMIBC.
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http://dx.doi.org/10.23736/S2724-6051.21.04309-5DOI Listing
March 2021

Psychological Health of Surgeons in a Time of COVID-19: A Global Survey.

Ann Surg 2021 Jan 22. Epub 2021 Jan 22.

Department of Urology, National University Hospital, National University Health System, Singapore Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore Department of Psychological Medicine, National University of Singapore Department of Urology, CiptoMangunkusumo Hospital, Jakarta, Indonesia General Surgery and Digestive System Service, Alfredo Espinosa Hospital, Urduliz, Vizcaya, Spain Colorectal Unit, Vall d'Hebron University Hospital, Barcelona, Spain; Department of Advanced Medical and Surgical Sciences, Luigi Vanvitelli University of Campania, Italy Department of Urology, Ng Teng Fong General Hospital, National University Health System, Singapore Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, United Kingdom Hospital Israelita Albert Einstein, Sao Paulo, Brazil; BP-a Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil Department of Urology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, India Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR Eastern Health and Monash University Eastern Health Clinical School, Box Hill, VIC, Australia Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy SH Ho Urology Center, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China Department of Urology, Marmara University Research and Training Hospital, Turkey Conselleria de Sanidad Universal y salud Publica, Spain Hospital Universitario Parc Taulí Sabadell, Spain Escola Paulista de Medicina - Universidade Federal de São Paulo, Brazil Department of Surgery, Faculty of Medicine, Universiti Teknologi MARA, Malaysia Unit of Urological Robotic Surgery and Renal Transplantation, Careggi University Hospital, Florence, Italy Department of Urology, Campus Biomedico University of Rome, Italy Servicio de Urología, Hospital Universitario La Paz, Madrid, Spain Division of Urology, University Health Network, Department of Surgery, University of Toronto, Canada Macquarie University Hospital and Royal North Shore Hospital, Department of Urology, Sydney, New South Wales, Australia Department of Urology- Luzerner Kantonsspital- Luzern, CH, Switzerland Instituto de Investigación Sanitaria San Carlos, Hospital Clinico San Carlos, Madrid, Spain Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS).

Objective: To assess the degree of psychological impact among surgical providers during the COVID-19 pandemic.

Summary Background Data: The COVID-19 pandemic has extensively impacted global healthcare systems. We hypothesized that the degree of psychological impact would be higher for surgical providers deployed for COVID-19 work, certain surgical specialties, and for those who knew of someone diagnosed with, or who died, of COVID-19.

Methods: We conducted a global web-based survey to investigate the psychological impact of COVID-19. The primary outcomes were the Depression Anxiety Stress Scale-21 (DASS-21) and Impact of Event Scale-Revised (IES-R) scores.

Results: 4283 participants from 101 countries responded. 32.8%, 30.8%, 25.9% and 24.0% screened positive for depression, anxiety, stress and Post-Traumatic Stress Disorder (PTSD) respectively. Respondents who knew someone who died of COVID-19 were more likely to screen positive for depression, anxiety, stress and PTSD (OR 1.3, 1,6, 1.4, 1.7 respectively, all p < 0.05). Respondents who knew of someone diagnosed with COVID-19 were more likely to screen positive for depression, stress and PTSD (OR 1.2, 1.2 and 1.3 respectively, all p < 0.05). Surgical specialities that operated in the Head and Neck region had higher psychological distress among its surgeons. Deployment for COVID-19-related work was not associated with increased psychological distress.

Conclusions: The COVID-19 pandemic may have a mental health legacy outlasting its course. The long-term impact of this ongoing traumatic event underscores the importance of longitudinal mental health care for healthcare personnel, with particular attention to those who know of someone diagnosed with, or who died of COVID-19.
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http://dx.doi.org/10.1097/SLA.0000000000004775DOI Listing
January 2021

A Systematic Review of the Use of Social Media for Dissemination of Clinical Practice Guidelines.

Eur Urol Focus 2020 Nov 7. Epub 2020 Nov 7.

Urology Unit, Academic Medical Centre "Santa Maria della Misericordia", Udine, Italy.

Context: Clinical practice guideline (CPG) uptake does not occur spontaneously and requires active implementation, especially for long-term implementation. Social media (SoMe) with its power of rapid and global information exchange among physicians, patients, organizations, and stakeholders in the medical field can open up unprecedented opportunities for CPG dissemination.

Objective: The aim of this review was to assess the current use of SoMe in CPG dissemination across different medical specialties.

Evidence Acquisition: A systematic review (SR) of the literature was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Medline, Embase, and Cochrane databases and the general platform Google were searched for all relevant publications (no limitation for publication time and no language restrictions). The search revealed 1881 citations; following title and abstract review, 22 studies were identified; and five studies were finally included after full-text review.

Evidence Synthesis: All included studies were published in the past 5 yr; there was a significant improvement in knowledge, awareness, compliance, and positive behavior toward CPGs with the use of SoMe dissemination compared with traditional methods. A large audience (healthcare professionals and patients) viewed and engaged with the SoMe process of CPG dissemination, and expressed an intent to engage in this method in the future. The studies included in the SR reported variable methods of SoMe use and similarly variable methods of analyzing the outcomes.

Conclusions: Owing to the recent application of SoMe in the context of CPG dissemination, there is no standardized format for its use, and the data available are variable and limited. However, encouraging preliminary results have been reported using SoMe for CPG dissemination in multiple fields, and we have provided a pragmatic method of SoMe usage in CPG dissemination based on the review. It is vital to ensure a uniform method of application and assessment of SoMe use in CPG dissemination and implementation going forward.

Patient Summary: Social media (SoMe) plays an important role in rapid and global information exchange among physicians, patients, organizations, and stakeholders in the medical field, and its power can be harnessed in the dissemination of evidence-based clinical practice guidelines (CPGs) that guide clinicians in practice. Our review reveals that SoMe use for CPG dissemination is a relatively new concept published approximately 5 yr ago, and it has led to significant improvement in knowledge, awareness, compliance, and positive behavior with respect to the CPGs compared with traditional methods. A large audience (healthcare professionals and patients) viewed and engaged with the SoMe process. We have produced a pragmatic method of using SoMe in CPG dissemination. Considering the importance of CPGs in practice and the ever increasing role of SoMe in the medical profession, a new role for SoMe in CPG dissemination could be established.
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http://dx.doi.org/10.1016/j.euf.2020.10.008DOI Listing
November 2020

Prone versus supine percutaneous nephrolithotomy: a systematic review and meta-analysis of current literature.

Minerva Urol Nephrol 2021 Feb 5;73(1):50-58. Epub 2020 Oct 5.

Department of Urology, Campus Bio-Medico University, Rome, Italy.

Introduction: Percutaneous nephrolithotomy (PNL) can be performed either in prone or supine position. This study aimed at gathering together randomized controlled trials (RCTs) comparing efficacy and safety between prone and supine PNL.

Evidence Acquisition: Systematic review of literature was conducted using the Scopus, Medline and Web of Science databases. Study selection, data extraction and quality assessment were independently assessed by two authors. Meta-analysis was performed with Review Manager 5.3. Sensitivity analyses were performed to exclude studies with high risk of bias.

Evidence Synthesis: Pooled data from 12 studies including 1290 patients were available for analysis. Only one study was found to have overall low risk of bias. Significantly shorter operative time was found in favor of supine PNL (mean difference 13 minutes, 95% confidence interval [CI]: 3.4-22.7; P<0.01). Stone-free rate (SFR)≥14 days after surgery was significantly higher in prone PNL (odds ratio [OR]=2.15, 95% CI: 1.07-4.34; P=0.03). Significantly higher fever rate was found in prone PNL (OR=1.60, 95% CI: 1.03-2.47; P=0.04). Overall SFR, hospital stay length, complications rate, transfusions rate and blood loss, as well as non-lower calyx puncture rate, puncture attempts and tubeless intervention rate did not differ between prone and supine PNL (P>0.05).

Conclusions: Efficacy of PNL seems balanced between prone and supine position, with comparable overall SFR and shorter operative time in favor of supine PNL. Safety of PNL appears in favor of supine PNL, with lower fever rate. Because of study heterogeneity and possible risks of outcome bias, results from this study should be interpreted with caution. Altogether, both prone and supine PNL account for appropriate therapy options.
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http://dx.doi.org/10.23736/S0393-2249.20.03960-0DOI Listing
February 2021

Systematic review of neoadjuvant therapy by immune checkpoint inhibitors before radical cystectomy: where do we stand?

Minerva Urol Nefrol 2020 Dec 29;72(6):663-672. Epub 2020 Sep 29.

Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy.

Introduction: After demonstrating their efficacy in metastatic urothelial cancer (UC), immune checkpoint inhibitors (ICI) are currently being tested in the neoadjuvant setting before radical cystectomy. In this systematic review, we analyze current available data and ongoing trials exploring the efficacy and safety of ICI neoadjuvant therapy in UC.

Evidence Acquisition: A systematic search was performed including the combination of the following words: (["neoadjuvant" AND "immunotherapy"] AND ["bladder" AND "cancer"]). Three search engines (PubMed, Embase®, and Web of Science) were queried up to January 1, 2020. Study selection followed the PRISMA guidelines. After screening, 9 articles and abstracts fully compatible with the PICOS were included in the systematic review.

Evidence Synthesis: The PURE-01 trial showed a 37% complete response (pT0) after neoadjuvant pembrolizumab. In the ABACUS trial, atezolizumab determined a complete response in 31% of patients. In both trials, an increased expression of PD-1 or PD-L1 was associated to an improved response to ICI. Moreover, ICI are well tolerated with grade III-IV adverse events in 6% of cases. In the PURE-01 trial, radical cystectomy after neoadjuvant ICI presents a similar complication rate compared to neoadjuvant chemotherapy, with fever (N.= 35, 52%) and ileus (N. = 21, 31%) being the most common postoperative complications. Numerous trials are currently recruiting to test ICI in the neoadjuvant setting, either alone, in combination immunotherapy or with chemotherapy.

Conclusions: Pembrolizumab and atezolizumab single agent demonstrated favorable results for ICI in the neoadjuvant setting. Patients with a higher tumor expression of PD-L1 appear to experience a higher response to ICI, although the adequate biomarker remains to be identified. Radical cystectomy appears to be safe after ICI treatment. The results of the currently ongoing prospective trial are awaited with impatience by the uro-oncologic community.
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http://dx.doi.org/10.23736/S0393-2249.20.03833-3DOI Listing
December 2020

Impact of COVID-19 Pandemic on Health-Related Quality of Life in Uro-oncologic Patients: What Should We Wait For?

Clin Genitourin Cancer 2020 Jul 17. Epub 2020 Jul 17.

Department of Urology, Campus Biomedico, University of Rome, Rome, Italy.

Purpose: To investigate the health-related quality of life of uro-oncologic patients whose surgery was postponed without being rescheduled during the coronavirus disease 2019 (COVID-19) pandemic.

Patients And Methods: From the March 1 to April 26, 2020, major urologic surgeries were drastically reduced at our tertiary-care referral hospital. In order to evaluate health-related quality-of-life outcomes, the SF-36 questionnaire was sent to all patients scheduled for major surgery at our department 3 weeks after the cancellation of the planned surgical procedures because of the COVID-19 emergency.

Results: All patients included in the analysis had been awaiting surgery for a median (interquartile range) time of 52.85 (35-72) days. The SF-36 questionnaire measured 8 domains: physical functioning (PF), role limitations due to physical health (PH), role limitations due to emotional problems (RE), energy/fatigue (EF), emotional well-being (EWB), social functioning (SF), bodily pain (BP), general health perceptions (GHP). When considering physical characteristics as measured by the SF-36 questionnaire, PF was 91.5 (50-100) and PH was 82.75 (50-100) with a BP of 79.56 (45-90). For emotional and social aspects, RE was 36.83 (0-100) with a SF of 37.98 (12.5-90). Most patients reported loss of energy (EF 35.28 [15-55]) and increased anxiety (EWB 47.18 [interquartile range, 20-75]). All patients perceived a reduction of their health conditions, with GHP of 49.47 (15-85). Generally, 86% of patients (n = 43) noted an almost intact physical function but a significant emotional alteration characterized by a prevalence of anxiety and loss of energy.

Conclusion: The lockdown due to the novel coronavirus that has affected most operating rooms in Italy could be responsible for the increased anxiety and decrement in health status of oncologic patients. Without any effective solution, we should expect a new medical catastrophe-one caused by the increased risk of tumor progression and mortality in uro-oncologic patients.
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http://dx.doi.org/10.1016/j.clgc.2020.07.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366083PMC
July 2020

Knowledge gap across continents: the andrology and male infertility exposure among urology residents in the United States and Europe.

Int J Impot Res 2020 Aug 21. Epub 2020 Aug 21.

Department of Urology, University of Illinois at Chicago, Chicago, USA.

It is well established that resident's exposure and training are of primary importance and positively correlated with patient and health quality outcomes. We aimed to compare and contrast urology residents' self-reported perspectives and attitudes toward exposure and education of andrology and male infertility during residency in both the United States and Europe. We performed a cross-sectional design study using a survey that was distributed to a representative sample of American and European urology residents. The survey included questions regarding demographics, and the residents' perception and description of their training in this specific subspecialty. Response data were analyzed using Chi-square tests. Sixty-five percent of European and thirty-five percent American urology residents reported feeling uncomfortable in a new consultation evaluating an infertile patient and interpreting semen analyses. Surprisingly, more than half of responders replied that they would not go to their own training institutions seeking for male fertility care (78% US and 58% Europeans). In the comparative analysis, although no differences were observed in the very low number (18%) of hospitals that offer formal microsurgical training for urology residents between the US and Europe, more US institutions were reported to have an operating microscope for urology (68% vs. 41%), and more US residents replied reported participating in at least one urologic surgery using the microscope (65% vs. 34%). In conclusion, both American and European residents shared the same frustration regarding their education and exposure to andrology and male infertility during residency training. Collaborative efforts between stakeholders are needed to establish a clear and focused curriculum and training objectives to eliminate this educational gap.
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http://dx.doi.org/10.1038/s41443-020-00342-2DOI Listing
August 2020

Simulator Availability Index: a novel easy indicator to track training trends. Is Europe currently at a urological training recession risk?

Cent European J Urol 2020 6;73(2):231-233. Epub 2020 Apr 6.

ESUT-YAU Working Party.

Introduction: To evaluate the European trend regarding the availability of surgical simulators and to propose a novel index to easily track this trend.

Material And Methods: During European Urology Residents Education Program, from 2014 to 2018, residents were asked through an anonymous survey about the availability of specific simulator training boxes at their department. The Simulator Availability Index (SAI) was made by the ratio between the number of departments with at least one box trainer and the total number of departments evaluated.

Results: The SAI decreased in five years from 0.47 to 0.41 for laparoscopic trainers, while the already low initial SAI (0.17) decreased by up to 0.05 in four years for both ureteroscopy (URS) and transurethral resection (TUR) trainers.

Conclusions: A self-analysis may be advisable in order to improve the spread of information and investigate whether any specific reasons may be responsible for this trend. The SAI might be a simple but useful tool to monitor and evaluate this trend in the context of national training plans.
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http://dx.doi.org/10.5173/ceju.2020.0048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7407789PMC
April 2020

Minimally invasive strategies for the treatment of prostate cancer recurrence after radiation therapy: a systematic review.

Minerva Urol Nefrol 2020 Oct 4;72(5):563-578. Epub 2020 Aug 4.

Department of Urology, Campus Bio-Medico University, Rome, Italy.

Introduction: The aim of this review was to conduct a comprehensive analysis of the role of minimally invasive salvage modalities in radio-recurrent prostate cancer and the associated clinical outcomes and toxicity profiles.

Evidence Acquisition: A systematic review of the current literature was conducted through the Medline and NCBI PubMed, Scopus databases in January 2020. All papers published after 2000, concerning studies conducted on humans for radio-recurrent prostate cancer were considered for the review.

Evidence Synthesis: Overall, 545 studies were identified. After duplicate exclusion, initial screening, and eligibility evaluation, a total of 80 studies were included in the qualitative analysis, corresponding to a cohort of 6681 patients. The median age at initial diagnosis ranged from 59 to 75.5. Pre-treatment PSA ranged from 6.2 to 27.4 ng/mL. All patients underwent primary radiotherapy for localized prostate cancer. Cryotherapy, Brachytherapy, EBRT, HIFU were the minimally invasive options mostly used as salvage therapy. They showed to be promising approaches for recurrent prostate cancer (PCa) control, with acceptable toxicities.

Conclusions: Minimally invasive therapeutic options offer promising results in terms of biochemical control in the local recurrence setting. Unfortunately, the absence of high quality and comparative studies makes it difficult to establish which method is the best in terms of oncological and safety outcomes.
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http://dx.doi.org/10.23736/S0393-2249.20.03783-2DOI Listing
October 2020

Management of erectile dysfunction following robot-assisted radical prostatectomy: a systematic review.

Minerva Urol Nefrol 2020 Oct 4;72(5):543-554. Epub 2020 Aug 4.

European Associations of Urology-European Society of Residents in Urology (EAU-ESRU).

Introduction: We aimed to summarize evidences about the efficacy of available treatments for erectile disfunction after robotic assisted radical prostatectomy (RARP).

Evidence Acquisition: A systematic literature review searching on PubMed (Medline), Scopus, and Web of Science databases was performed in December 2019. PRISMA guidelines were followed. Population consisted of patients with erectile disfunction after RARP (P), conservative and surgical intervention were considered of interest (I). No comparator was considered mandatory (C). Outcomes of interest were the recovery of erectile function after conservative treatments and sexual function after surgical treatments (O).

Evidence Synthesis: Eleven studies were included. Seven studies focused on the use of phosphodiesterase-5 inhibitors (PDE5i) alone (five studies) or associated with other treatments (two studies). All the studies confirmed the efficacy of PDE5i, while the most promising association is with vacuum pump erectile devices. Two studies investigated topical treatments, namely low intensity extracorporeal shock wave therapy and alprostadil. Low intensity extracorporeal shock wave therapy may be a promising option in patients in whom nerve-sparing surgery was performed. The use of alprostadil could be an effective alternative to intracorporeal injection in those who underwent non-nerve-sparing surgery. One study focused and confirmed the efficacy of penile implants. Furthermore, one study reported the efficacy of a multi-modal treatment with preoperative medication, showing the benefits of a multimodal approach.

Conclusions: Penile rehabilitation with PDE5i is effective after nerve sparing RARP. The association of PDE5i with vacuum devices could led to a faster recovery. A multimodal approach with preoperative specific care seems to be effective to fasten erectile function recovery.
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http://dx.doi.org/10.23736/S0393-2249.20.03780-7DOI Listing
October 2020

Triggers for delayed intervention in patients with small renal masses undergoing active surveillance: a systematic review.

Minerva Urol Nefrol 2020 Aug;72(4):389-407

European Society of Residents in Urology (ESRU), Arnhem, the Netherlands.

Introduction: Patients with small renal masses (SRM) can be exposed to overdiagnosis and overtreatment. As such, active surveillance (AS) is recommended by all Guidelines for selected patients. However, it remains underutilized. One key reason is the lack of consensus on the factors prompting delayed intervention (DI). Herein we provide an updated overview of the triggers for DI in patients with SRMs initially undergoing AS.

Evidence Acquisition: A systematic review of the English-language literature was performed according to the PRISMA statement recommendations using the MEDLINE, Cochrane Central Register of Controlled Trials and Web of Science databases.

Evidence Synthesis: Overall, 10 prospective studies including 1870 patients were included. Median patient age ranged between 64 and 75 years, while median tumor size between 1.7 cm to 2.3 cm. The proportion of cystic SRMs ranged from 0% to 30%. Baseline renal tumor biopsy was performed in 7-45.2% of patients. Among these, malignant histology was found in 28.5%-83.3% of cases. Overall, the median growth rate of SRMs ranged between 0.10 and 0.27 cm/year. The proportion of patients undergoing DI ranged between 7% and 44%, after a median AS period of 12-27 months. The most commonly performed type of DI was surgery. Of resected SRMs, 0% to 30% were benign. The actual triggers for DI were either tumor-related (renal mass growth, stage progression, development of local complications/symptoms) or patient-related (patient preference, improved medical conditions, or qualification for other surgical procedures). At a median follow-up of 21.7 - 57-6 months, the proportion of patients experiencing metastatic disease, cancer-specific and other-cause mortality was 0-3.1%, 0-4% and 0-45.6%, respectively.

Conclusions: The available evidence shows that both tumor-related and patient-related factors are ultimate triggers for DI in patients with SRMs undergoing AS. However, the level of evidence is still low and further research is needed to individualize AS strategies according to both tumor biology and patient-related characteristics and values.
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http://dx.doi.org/10.23736/S0393-2249.20.03870-9DOI Listing
August 2020

Implementation and strategies to ensure adequate coordination within a Urology Department during the COVID-19 pandemic.

Int Braz J Urol 2020 07;46(suppl.1):170-180

Department of Urology, Campus Bio-Medico University of Rome, Rome, Italy.

Purpose: to provide an update on the management of a Urology Department during the COVID-19 outbreak, suggesting strategies to optimize assistance to the patients, to implement telemedicine and triage protocols, to define pathways for hospital access, to reduce risk of contagious inside the hospital and to determine the role of residents during the pandemic.

Materials And Methods: In May the 6th 2020 we performed a review of the literature through online search engines (PubMed, Web of Science and Science Direct). We looked at recommendations provided by the EAU and ERUS regarding the management of urological patients during the COVID-19 pandemic. The main aspects of interest were: the definition of deferrable and non-deferrable procedures, Personal Protective Equipment (PPE) and hospital protocols for health care providers, triage, hospitalization and surgery, post-operative care training and residents' activity. A narrative summary of guidelines and current literature for each point of interest was performed.

Conclusion: In the actual Covid-19 scenario, while the number of positive patients globally keep on rising, it is fundamental to embrace a new way to deliver healthcare and to overcome challenges of physical distancing and self-isolation. The use of appropriate PPE, definite pathways to access the hospital, the implementation of telemedicine protocols can represent effective strategies to carry on delivering healthcare.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.S122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719985PMC
July 2020

How Targeted Therapy Influence Renal Surgery for Renal Cell Carcinoma.

Curr Drug Targets 2020 ;21(15):1550-1557

Department of Urology, Campus Biomedico, University of Rome, Rome, Italy

Between the end of 2005 and the beginning of 2006, several new target therapies have been introduced for the treatment of renal cell carcinoma. In this review, we aimed to explore and summarize the main findings of the use of systemic treatment and its effect on surgery in patients with renal cell carcinoma. We identified three different settings: neoadjuvant and adjuvant settings as well as the association of systemic therapy with surgery in the metastatic renal cell carcinoma patients. Neoadjuvant target therapy with tyrosine kinase inhibitor may facilitate the tumor resection and reduce the overall tumor diameter and its complexity. However, most of the evidence is from small phase I or II clinical trials and results are often conflicting without determining a relevant change in the main parameters investigated, such as tumor complexity. In the adjuvant setting, results from pivotal trials investigating the use of tyrosine kinase inhibitors for patients with non-metastatic RCC treated with surgery discourage this practice. Indeed, most of the evidence from single clinical trials and pooled results from meta-analysis failed to find a survival advantage with the use of adjuvant systemic treatment. To date, an improvement of clinical outcomes after systemic targeted therapies could be only found in the setting of cytoreductive nephrectomy. However, the CARMENA and SURTIME trials recently confirmed the evidence against a surgical treatment in patients with mRCC and poor prognosis. In the near future, significant changes may be introduced by the use of immunotherapies.
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http://dx.doi.org/10.2174/1389450121666200704150933DOI Listing
January 2020

Telehealth in Urology: A Systematic Review of the Literature. How Much Can Telemedicine Be Useful During and After the COVID-19 Pandemic?

Eur Urol 2020 12 18;78(6):786-811. Epub 2020 Jun 18.

Department of Human and Pediatric Pathology "Gaetano Barresi", Urologic Section, University of Messina, Italy.

Context: Coronavirus disease 2019 (COVID-19) pandemic has caused increased interest in the application of telehealth to provide care without exposing patients and physicians to the risk of contagion. The urological literature on the topic is sparse.

Objective: To perform a systematic review of the literature and evaluate all the available studies on urological applications of telehealth.

Evidence Acquisition: After registration on PROSPERO, we searched PubMed and Scopus databases to collect any kind of studies evaluating any telehealth interventions in any urological conditions. The National Toxicology Program/Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies was used to estimate the risk of bias. A narrative synthesis was performed.

Evidence Synthesis: We identified 45 studies (11 concerning prostate cancer [PCa], three hematuria management, six urinary stones, 14 urinary incontinence [UI], five urinary tract infections [UTIs], and six other conditions), including 12 randomized controlled trials. The available literature indicates that telemedicine has been implemented successfully in several common clinical scenarios, including the decision-making process following a diagnosis of nonmetastatic PCa, follow-up care of patients with localized PCa after curative treatments, initial diagnosis of hematuria, management diagnosis and follow-up care of uncomplicated urinary stones and uncomplicated UTIs, and initial evaluation, behavioral therapies, and pelvic floor muscle training in UI patients, as well as follow-up care after surgical treatments of stress urinary incontinence or pelvic organ prolapse. The methodological quality of most of the reports was good.

Conclusions: Telehealth has been implemented successfully in selected patients with PCa, UI, pelvic organ prolapse, uncomplicated urinary stones, and UTIs. Many urological conditions are suitable for telehealth, but more studies are needed on other highly prevalent urological malignant and benign conditions. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine. More robust data on long-term efficacy, safety, and health economics are necessary.

Patient Summary: The diffusion of coronavirus disease 2019 (COVID-19) infections has recently increased the interest in telehealth, which is the adoption of telecommunication to deliver any health care activity. The available literature indicates that telemedicine has been adopted successfully in selected patients with several common clinical urological conditions, including prostate cancer, uncomplicated urinary stones, uncomplicated urinary infections, urinary incontinence, or pelvic organ prolapse. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine, but more robust data on long-term efficacy, safety, and costs are necessary.
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http://dx.doi.org/10.1016/j.eururo.2020.06.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301090PMC
December 2020

Intensive simulation training on urological mini-invasive procedures using Thiel-embalmed cadavers: The IAMSurgery experience.

Arch Ital Urol Androl 2020 Jun 23;92(2). Epub 2020 Jun 23.

IAMSurgery, International Accademy of Miniinvasive Surgery; Department of Urology, Policlinico San Martino Hospital, University of Genova.

Introduction: The objective of the study was to evaluate the benefits perceived by the use of cadaver models by IAMSurgery attendees and to define indications to standardize future similar training camps.

Materials And Methods: A 25-item survey was distributed via e-mail to all the participants of previous training courses named as "Urological Advanced Course on Laparoscopic Cadaver Lab" held at the anatomy department of the University of Malta, for anonymous reply. Participants were asked to rate the training course, the Thiel's cadaveric model, and make comparison with other previously experienced simulation tools.

Results: The survey link was sent to 84 attendees, with a response rate of 47.6% (40 replies). There was improvement in the median self-rating of the laparoscopic skills before and after the training camp with a mean difference of 0.55/5 points in the post-training skills compared to the basal (p < 0.0001). The 72.2% of the urologists interviewed considered Thiel's HCM better than other training methods previously tried, while five urologists (27.8%) considered it equal (p = 0.00077). Globally, 77.5% (31) of attendees found the training course useful, and 82.5% (33) would advise it to colleagues.

Conclusions: Thiel's fixed human cadaveric models seem to be ideal for training purposes, and their use within properly structured training camps could significantly improve the surgical skills of the trainees. An important future step could be standardization of the training courses using cadavers, and their introduction into the standardized European curriculum.
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http://dx.doi.org/10.4081/aiua.2020.2.93DOI Listing
June 2020

What is the role of residents during a pandemic?

Minerva Urol Nefrol 2020 06;72(3):387-388

Department of Urology, Campus Bio-Medico, University of Rome, Rome, Italy.

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http://dx.doi.org/10.23736/S0393-2249.20.03903-XDOI Listing
June 2020

Urologic surgery in a safe hospital during the COVID-19 pandemic scenario.

Minerva Urol Nefrol 2020 Jun 22. Epub 2020 Jun 22.

Department of Urology, Campus Bio-medico, University of Rome, Rome, Italy -

The COVID-19 pandemic induced a global emergency that overwhelmed most hospitals around the world. Access to Hospitals has been restricted to selective oncological and urgent patients to minimize surgeries requiring Intensive Care Unit care. All other kind of non- urgent and benign surgeries have been rescheduled. The burden of oncological and urgent cases on the healthcare system has increased. We have been asked to become the referral center for major oncological and urgent urological surgeries, increasing our surgical volume. Through meticulous hospital protocols on PPE, use of nasopharyngeal swabs, controlled hospital access and the prompt management of suspected/positive cases, we were able to perform 31% more urological surgical procedures during the COVID-19 pandemic compared to the same period in 2019. We observed a 72% increase in oncological surgical procedures and 150% in urgent procedures. Our experience shows how the management of oncological and urgent cases can be maintained during unexpected, global emergencies, such as COVID-19.
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http://dx.doi.org/10.23736/S0393-2249.20.03923-5DOI Listing
June 2020

Endourology (Lithiasis). Management, surgical considerations and follow-up of patients in the COVID-19 era.

Int Braz J Urol 2020 07;46(suppl.1):39-49

Department of Urology, Campus Biomédico, University of Rome, Rome, Italy.

Purpose: To provide recommendations on the endourological management of lithiasis in the scenario of the COVID-19 pandemic.

Materials And Methods: A non-systematic review in PubMed and the grey literature, as well as recommendations by a panel of stakeholders was made, regarding management, surgical considerations and follow-up of patients affected by lithiasis in the COVID-19 era.

Results: Under the current outbreak and COVID-19 pandemic scenario, patients affected by lithiasis should be prioritized into low, intermediate and high risk categories, to decide their delay and save resources, healthcare personnel, beds and ventilators. However, patients with potentially serious septic complications need emergency interventions. The possibility of performing or restarting elective activity depends on local conditions, the availability of beds and ventilators, and the implementation of screening protocols in the context of the COVID-19 pandemic. Delaying lithiasis surgery and increasing waiting lists will have consequences and will require considerable additional effort. Teleconsultation may be useful in guiding these patients, reducing visits and unnecessary exposure.

Conclusions: categorization and prioritization of patients affected by lithiasis is crucial for management, surgical selection and follow-up. Protocols, measures and additional efforts should be carried out in the current situation of the COVID-19 pandemic.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.S105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719981PMC
July 2020

COVID-19's Impact on Italian Urology.

Int Braz J Urol 2020 07;46(suppl.1):26-33

Department of Urology, Campus Biomédico, University of Rome, Rome, Italy.

The COVID-19 pandemic has impacted our lives, our habits and our healthcare system. Italy is one of the countries affected first and more aggressively from the outbreak. Our rapidity has been guide for other healthcare systems from around the World. We describe the impact of COVID-19 on Urology, how the Urological scientific community responded to the emergency and our experience in a high-volume Roman University hospital. The aim of our work is to share our experience providing suggestions for other global hospitals on how to manage the COVID-19 emergency.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.S103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719978PMC
July 2020

Metastasis-directed therapy and prostate-targeted therapy in oligometastatic prostate cancer: a systematic review.

Minerva Urol Nefrol 2020 Oct 16;72(5):531-542. Epub 2020 Jun 16.

EAU Young Urologist Office (YOU), Arnhem, the Netherlands.

Introduction: The aim of this review was to summarize the available evidence on the role of metastasis-directed therapy (MDT) and/or prostate-targeted therapy (PTT) in the setting of oligometastatic prostate cancer (PCa).

Evidence Acquisition: We searched PubMed, the Web of Science, and the Cochrane Library databases. The following keywords were used: ("prostate cancer" OR "prostate carcinoma" OR "prostate neoplasm" OR "prostate tumor") AND ("oligometastatic" OR "oligometastasis" OR "PSMA") AND ("surgery" OR "prostatectomy" OR "radical prostatectomy" OR "cytoreductive" OR "local treatment" OR "radiotherapy" OR "stereotactic" OR "stereotaxic") AND ("survival" OR "mortality").

Evidence Synthesis: After evaluating the selection criteria, 81 studies were evaluated for our endpoints. We included 22 studies for PTT of synchronous mPCa. There have been no randomized studies on cytoreductive prostatectomy (cRP). Four prospective studies showed that cRP was feasible but did not contribute to a positive effect on overall survival (OS). Regarding PTT-radiotherapy, two randomized controlled phase 3 trials showed that OS was improved in men with a low metastatic burden. Regarding MDT of metachronous lymph node recurrence, we included 29 retrospective studies. For MDT of oligometastases, we included 30 studies. One randomized phase 2 trial showed that androgen deprivation therapy-free survival improved with stereotactic body radiation therapy compared to that with surveillance; however, benefits on OS remain unclear.

Conclusions: We performed a comprehensive overview of the current literature on MDT and PTT. The feasibility of MDT and PTT is supported by several retrospective studies. Nevertheless, there remains a lack of high-quality trials to prove its survival benefits. Results from ongoing prospective trials data are awaited.
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http://dx.doi.org/10.23736/S0393-2249.20.03779-0DOI Listing
October 2020

Bladder Cancer at the time of COVID-19 Outbreak.

Int Braz J Urol 2020 07;46(suppl.1):62-68

Department of Urology, Campus Bio-Medico University of Rome, Rome, Italy.

The COVID-19 outbreak has led to the deferral of a great number of surgeries in an attempt to reduce transmission of infection, free up hospital beds, intensive care and anaesthetists, and limit aerosol-generating procedures. Guidelines and suggestions have been provided to categorize Urological diseases into risk groups and recommendations are available on procedures that can be or cannot be deferred. We aim to summarise updates on diagnosis, treatment and follow up of bladder cancer during the COVID-19 outbreaks.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.S107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719998PMC
July 2020

[Implementation of Remote Clinics in urology practice during the COVID-19 era: What have we learned?]

Arch Esp Urol 2020 Jun;73(5):345-352

Servicio de Urología. Hospital Universitario La Paz. Madrid. España.

The COVID-19 pandemic has requiredd rastic measures for an attempt in controlling its spread. Health resources and facilities are being destined for the treatment of critically ill infected patients. During the past weeks, we, as urologists have faced increasingly difficult changes in practice, as out patient activity and elective surgeries must be postponed in order to save resources and limit the mobilization of patients and faculty. During this conflictive situation, telehealth medicine can provide adequate support using technological tools and trying to simulate face-to-face consults with the use of video or telephone calls. However, many out patient clinics and facilities are not ready yet for telehealth as their experience in this area is low. The benefits for telemedicine in urology are continuing urologic outpatient follow-up, providing recommendations and prescriptions, and the triage of patients who will need urgent procedures. Urology residency training has suffered an abrupt disruption nowadays as outpatient, surgical and academic meetings are cancelled. In this scenario, virtual strategies and "smart learning" activities are being used to continue education. We provide a review of the latest published literature regarding the use of telehealth medicine or telemedicine for the modern urology practice, along side our recommendations and conclusions.
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June 2020

Risk of Virus Contamination Through Surgical Smoke During Minimally Invasive Surgery: A Systematic Review of the Literature on a Neglected Issue Revived in the COVID-19 Pandemic Era.

Eur Urol Focus 2020 09 5;6(5):1058-1069. Epub 2020 Jun 5.

Department Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padova, Padova, Italy. Electronic address:

Context: The coronavirus disease 2019 (COVID-19) pandemic raised concerns about the safety of laparoscopy due to the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diffusion in surgical smoke. Although no case of SARS-CoV-2 contagion related to surgical smoke has been reported, several international surgical societies recommended caution or even discouraged the use of a laparoscopic approach.

Objective: To evaluate the risk of virus spread due to surgical smoke during surgical procedures.

Evidence Acquisition: We searched PubMed and Scopus for eligible studies, including clinical and preclinical studies assessing the presence of any virus in the surgical smoke from any surgical procedure or experimental model.

Evidence Synthesis: We identified 24 studies. No study was found investigating SARS-CoV-2 or any other coronavirus. About other viruses, hepatitis B virus was identified in the surgical smoke collected during different laparoscopic surgeries (colorectal resections, gastrectomies, and hepatic wedge resections). Other clinical studies suggested a consistent risk of transmission for human papillomavirus (HPV) in the surgical treatments of HPV-related disease (mainly genital warts, laryngeal papillomas, or cutaneous lesions). Preclinical studies showed conflicting results, but HPV was shown to have a high risk of transmission.

Conclusions: Although all the available data come from different viruses, considering that the SARS-CoV-2 virus has been shown in blood and stools, the theoretical risk of virus diffusion through surgical smoke cannot be excluded. Specific clinical studies are needed to understand the effective presence of the virus in the surgical smoke of different surgical procedures and its concentration. Meanwhile, adoption of all the required protective strategies, including preoperative patient nasopharyngeal swab for COVID-19, seems mandatory.

Patient Summary: In this systematic review, we looked at the risk of virus spread from surgical smoke exposure during surgery. Although no study was found investigating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or any other coronavirus, we found that the theoretical risk of virus diffusion through surgical smoke cannot be excluded.
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http://dx.doi.org/10.1016/j.euf.2020.05.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274598PMC
September 2020

A Global Survey on the Impact of COVID-19 on Urological Services.

Eur Urol 2020 Aug 26;78(2):265-275. Epub 2020 May 26.

Department of Urology, New York University, New York, NY, USA; Department of Population Health, New York University, New York, NY, USA; Manhattan VA Medical Center, New York, NY, USA.

Background: The World Health Organization (WHO) declared coronavirus disease-19 (COVID-19) as a pandemic on March 11, 2020. The impact of COVID-19 on urological services in different geographical areas is unknown.

Objective: To investigate the global impact of COVID-19 on urological providers and the provision of urological patient care.

Design, Setting, And Participants: A cross-sectional, web-based survey was conducted from March 30, 2020 to April 7, 2020. A 55-item questionnaire was developed to investigate the impact of COVID-19 on various aspects of urological services. Target respondents were practising urologists, urology trainees, and urology nurses/advanced practice providers.

Outcome Measurements And Statistical Analysis: The primary outcome was the degree of reduction in urological services, which was further stratified by the geographical location, degree of outbreak, and nature and urgency of urological conditions. The secondary outcome was the duration of delay in urological services.

Results And Limitations: A total of 1004 participants responded to our survey, and they were mostly based in Asia, Europe, North America, and South America. Worldwide, 41% of the respondents reported that their hospital staff members had been diagnosed with COVID-19 infection, 27% reported personnel shortage, and 26% had to be deployed to take care of COVID-19 patients. Globally, only 33% of the respondents felt that they were given adequate personal protective equipment, and many providers expressed fear of going to work (47%). It was of concerning that 13% of the respondents were advised not to wear a surgical face mask for the fear of scaring their patients, and 21% of the respondents were advised not to discuss COVID-19 issues or concerns on media. COVID-19 had a global impact on the cut-down of urological services, including outpatient clinic appointments, outpatient investigations and procedures, and urological surgeries. The degree of cut-down of urological services increased with the degree of COVID-19 outbreak. On average, 28% of outpatient clinics, 30% of outpatient investigations and procedures, and 31% of urological surgeries had a delay of >8 wk. Urological services for benign conditions were more affected than those for malignant conditions. Finally, 47% of the respondents believed that the accumulated workload could be dealt with in a timely manner after the COVID-19 outbreak, but 50% thought the postponement of urological services would affect the treatment and survival outcomes of their patients. One of the limitations of this study is that Africa, Australia, and New Zealand were under-represented.

Conclusions: COVID-19 had a profound global impact on urological care and urology providers. The degree of cut-down of urological services increased with the degree of COVID-19 outbreak and was greater for benign than for malignant conditions. One-fourth of urological providers were deployed to assist with COVID-19 care. Many providers reported insufficient personal protective equipment and support from hospital administration.

Patient Summary: Coronavirus disease-19 (COVID-19) has led to significant delay in outpatient care and surgery in urology, particularly in regions with the most COVID-19 cases. A considerable proportion of urology health care professionals have been deployed to assist in COVID-19 care, despite the perception of insufficient training and protective equipment.
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http://dx.doi.org/10.1016/j.eururo.2020.05.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7248000PMC
August 2020

Conservative management of urinary incontinence following robot-assisted radical prostatectomy.

Minerva Urol Nefrol 2020 Oct 20;72(5):555-562. Epub 2020 May 20.

European Association of Urology - European Society of Residents in Urology (EAU-ESRU).

Introduction: Robotic assisted radical prostatectomy (RARP) is getting more and more popular becoming the most common radical prostatectomy technique. Unfortunately, a not negligible proportion of patients in whom RARP is performed experience urinary incontinence. We aimed to systematically review the current literature evidence on urinary incontinence conservative treatment after RARP.

Edidence Aquisition: A systematic literature review search using PubMed (Medline), Scopus, and Web of Science databases was performed in December 2019. PRISMA guidelines have been adopted. Population consisted of patients with urinary incontinence after RARP (P), conservative intervention was considered of interest (I). No comparator was considered mandatory (C). Outcomes of interest were the recovery of continence and quality of life (O).

Evidedence Synthesis: Six studies were included. Four of them investigated the use of pelvic floor muscle training (PFMT). PFMT improved pelvic muscle strength. Continence recovery was faster when guided PFMT was adopted. Moreover, two studies tested the effect of solifenacin on urinary incontinence. One of them, a randomized clinical trial, failed to show shorter time to continence in solifenacin group compared to placebo.

Conclusions: The use of pads is associated with a detrimental effect on quality of life thus active treatments for UI post-RARP are warranted. PFMT has the main advantage to shorten the time for recovery. The use of solifenacin seems to not offer striking advantages in UI following RARP. Future studies should focus on testing the efficacy of these treatments when used after robotic vs. open radical prostatectomy.
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http://dx.doi.org/10.23736/S0393-2249.20.03782-0DOI Listing
October 2020

A systematic review and meta-analysis of prognostic impact of different Gleason patterns in ISUP grade group 4.

Minerva Urol Nephrol 2021 Feb 20;73(1):42-49. Epub 2020 May 20.

Department of Urology, Medical University of Vienna, Vienna, Austria.

Introduction: This systematic review and meta-analysis was conducted to assess the prognostic differences between different Gleason patterns in patients with prostate cancer (PC) within Internal Society of Urological Pathology (ISUP) grade group 4 (GG 4).

Evidence Acquisition: PUBMED and Scopus databases were searched for articles published prior to December 2019 according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Studies were deemed eligible if they compared overall survival (OS), cancer-specific survival (CSS), and surgical pathological outcomes in PC patients categorized as ISUP GG 4 (Gleason Score [GS] 4+4 vs. GS 3+5 or GS 5+3). Formal meta-analyses were performed for these outcomes.

Evidence Synthesis: Ten studies with 42,041 patients were eligible for the systematic review and eight studies with 36,250 patients for meta-analysis. The treatment type of included study was three surgery and three radiotherapy. The other four studies included many kinds of treatments such as surgery, radiotherapy, androgen deprivation therapy, and chemotherapy. GS 4+4 was significantly associated with better OS (pooled hazard ratio (HR): 0.52, 95% confidential interval (CI): 0.29-0.91) than GS 3+5 or GS 5+3. Positive surgical margin rates were significantly lower with GS 4+4 than GS 3+5 and GS 5+3 (odds ratio [OR] 0.70/95% CI 0.64-0.77 and OR 0.70/95% CI 0.56-0.87, respectively). In contrast, different Gleason patterns in ISUP GG 4 were not significantly associated with CSS (pooled HR: 0.77, 95% CI: 0.56-1.06).

Conclusions: GS 4+4 in patients with PC was associated with better OS and positive surgical margin rates. It seems likely that there is heterogeneity within ISUP GG 4. However, caution should be exercised in interpreting the conclusions drawn from this study, given the limitations of the study, which include the heterogeneity of the population of interest and the retrospective nature of the primary data evaluated.
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http://dx.doi.org/10.23736/S0393-2249.20.03778-9DOI Listing
February 2021

The Impact of COVID-19 on European Health Care and Urology Trainees.

Eur Urol 2020 Jul 27;78(1):6-8. Epub 2020 Apr 27.

Department of Urology, Campus Biomedico, University of Rome, Rome, Italy.

The COVID-19 pandemic has had rapid and inevitable effects on health care systems and the training and work plans of urology residents. Smart learning is a valuable strategy for maintaining the learning curve of residents.
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http://dx.doi.org/10.1016/j.eururo.2020.04.042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183959PMC
July 2020

Biomarkers predicting oncological outcomes of high-risk non-muscle-invasive bladder cancer.

Minerva Urol Nefrol 2020 Jun 16;72(3):265-278. Epub 2020 Apr 16.

Department of Urology, Campus Bio-Medico University, Rome, Italy.

Introduction: The European Organization for Research and Treatment of Cancer (EORTC) and the Spanish Urological Club for Oncological Treatment (CUETO) scoring systems show limited accuracy for the prediction of disease recurrence and progression of non-muscle-invasive bladder cancer (NMIBC). This aspect is even more relevant in the category of HR NMIBC. Biomarkers might potentially help to further categorize the outcomes of these patients. Therefore, we sought to review the evidence available on tissue-based, urinary, and serum biomarkers for the prediction of recurrence, progression, and survival in HR NMIBC.

Evidence Acquisition: A systematic literature review without time restrictions was performed using PubMed/EMBASE, Web of Science, SCOPUS, and the Cochrane Libraries. The search was filtered for articles in the English, Italian, German, French, and Spanish languages, involving patients with more than 18 years of age. Relevant papers on tissue-based, serum and urinary biomarkers related to the prediction of oncological outcomes for high-risk bladder cancer patients were included in the analyses.

Evidence Synthesis: Overall, 71 studies were eligible for inclusion in this review. The majority of the investigations performed so far focused on immunohistochemical analyses on tumoral tissue. Overall, p53 was the most studied biomarker, but results regarding its prognostic and predictive role were contradictory. Ki67 seems to be a promising biomarker in the prediction of recurrence. Recently, PD-L1 has been associated with the prediction of recurrence free survival and of treatment-refractory disease. Markers developed un urine samples are focused on commercially available kits, which currently do not unequivocally show strongly superior levels of accuracy to cytology. However, they have demonstrated to be potentially helpful in the prediction of recurrence. Blood-based biomarkers represent an emerging reality with promising future applications.

Conclusions: Despite a long history of attempts to discover accurate biomarkers predicting oncological outcomes for HR NMIBC, contradictory or uncertain findings render the adoption of this ancillary techniques in clinical practice still unlikely. Future attempts should be directed to the development of prospective trials and the definition of standardized cut-off levels to render findings worthy of comparison.
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http://dx.doi.org/10.23736/S0393-2249.20.03786-8DOI Listing
June 2020

Impact of the COVID-19 pandemic on urology residency training in Italy.

Minerva Urol Nefrol 2020 Aug 7;72(4):505-509. Epub 2020 Apr 7.

European Society of Residents in Urology (ESRU), Arnhem, the Netherlands.

In the global emergency scenario caused by COVID-19 pandemic, the Urology residents' training might be critically affected. To provide insights on this issue, a 25-item online Survey was sent to all Italian residents one month after the first case of COVID-19 in Italy, to evaluate their routine involvement in "clinical" (on-call duty, outpatient visits, diagnostic procedures) and "surgical" (endoscopic, open and minimally invasive surgery) training activities before and during the COVID-19 period. Overall, 351 of 577 (60.8%) residents completed the Survey. Before the COVID-19 pandemic, the proportion of residents routinely involved in "clinical" and "surgical" activities ranged from 79.8% to 87.2% and from 49.3% to 73.5%, respectively. In the COVID-19 period, the proportion of residents experiencing a severe reduction (>40%) or complete suppression (>80%) of training exposure ranged between 41.1% and 81.2% for "clinical" activities while between 44.2% and 62.1% for "surgical" activities. This reduction was even more pronounced for residents attending the final year of training. Our study is the first to provide real-life data on how Urology residency training can be impaired during an emergency period. To address this challenge, strategies aiming to increase the use of telemedicine, "smart learning" programs and tele-mentoring of surgical procedures, are warranted.
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http://dx.doi.org/10.23736/S0393-2249.20.03868-0DOI Listing
August 2020