Publications by authors named "Giovanni Cacciamani"

155 Publications

Contemporary Trends of Systemic Neoadjuvant and Adjuvant Intravesical Chemotherapy in Patients With Upper Tract Urothelial Carcinomas Undergoing Minimally Invasive or Open Radical Nephroureterectomy: Analysis of US Claims on Perioperative Outcomes and Health Care Costs.

Clin Genitourin Cancer 2021 Dec 24. Epub 2021 Dec 24.

Department of Urology, Stanford Medical Center, Stanford, CA.

Introduction: New evidence indicates that minimally invasive surgery (MIS) (laparoscopic or robotic-assisted [LNU, RANU]) reaches oncologic equivalence compared with Open Radical Nephroureterectomy (ORNU) for high-risk upper-tract urothelial carcinoma (UTUC). Recently, European Association of Urology (EAU) Guidelines suggested implementing neoadjuvant chemotherapy (NAC) to standard treatment to improve oncologic outcomes of high-risk UTUC. We aimed (1) To explore contemporary trends of MIS for RNU in the United States and to compare perioperative outcomes and costs with that of ORNU. (2) To determine the trends of NAC and postoperative intravesical chemotherapy (PIC) administration for high-risk UTUC and to assess their contribution to perioperative outcomes and costs.

Patients And Methods: The Optum Clinformatics Data Mart de-identified database was queried from 2003 to 2018 to retrospectively examine patients who had undergone LNU/RANU or ORNU with or without NAC and PIC. We evaluated temporal adoption trends, complications, and health care cost analyses. We obtained descriptive statistics and utilized multivariable regression modeling to assess outcomes.

Results: A total of n = 492 ORNU and n = 1618 LNU/RANU procedures were reviewed. The MIS approach was associated with a statistically significant lower risk of intraoperative complications (adjusted Odds Ratio [aOR], 0.48, 95% CI:0.24-0.96), risk of hospitalization costs (aOR: 0.62, 95% CI:0.49-0.78), and shorter hospital stay (aOR: 0.20, 95% CI:0.15-0.26) when compared to ORNU. Overall, adoption of NAC and PIC accounted for only n = 81 and n < 37 cases respectively. The implementation of NAC and higher number of cycles were associated with an increased probability of any complication rate (aOR: 2.06, 95% CI:1.26-3.36) and hospital costs (aOR: 2.12, 95% CI:1.33-3.38).

Conclusion: MIS has become the approach of choice for RNU in the US. Although recommended by guidelines, neither NAC nor postoperative bladder instillation of chemotherapy has been routinely incorporated into the clinical practice of patients with UTUC.
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http://dx.doi.org/10.1016/j.clgc.2021.11.016DOI Listing
December 2021

Robotic vs laparoscopic nephroureterectomy for upper tract urothelial carcinoma: a multicenter propensity-score matched pair "tetrafecta" analysis (ROBUUST collaborative group).

J Endourol 2022 Jan 12. Epub 2022 Jan 12.

Changhai hospital, the second military medical university, the department of Urology, Changhai Road NO. 163, Shanghai, Shanghai, China, 200433;

Purpose: To compare the outcomes of robotic radical nephroureterectomy (RRNU) and laparoscopic radical nephroureterectomy (LRNU) within a large multi-institutional worldwide dataset.

Material And Methods: The ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST) includes data from 17 centers worldwide regarding 877 RRNU and LRNU performed between 2015 and 2019. Baseline features, perioperative and oncological outcomes, were included. A 2:1 nearest-neighbor propensity-score matching with a 0.001 caliper was performed. An univariable and a multivariable logistic regression model were built to evaluate the predictors of a composite "tetrafecta" outcome defined as occurrence of bladder cuff excision + LND + no complications + negative surgical margins.

Results: After matching, 185 RRNU and 91 LRNU were assessed. Patients in the RRNU group were more likely to undergo bladder cuff excision (81.9% vs 63.7%; p<0.001) compared to the LRNU group. A statistically significant difference was found in terms of overall postoperative complications (p=0.003) and length of stay (p<0.001) in favor of RRNU. Multivariable analysis demonstrated that LRNU was an independent predictor negatively associated with achievement of "tetrafecta" (OR: 0.09; p=0.003).

Conclusions: In general, RRNU and LRNU offer comparable outcomes. While the rate of overall complications is higher for LRNU in this study population, this is mostly related to low grade complications, and therefore with more limited clinical relevance. RRNU seems to offer shorter hospital stay but this might also be related to the different geographical location of participating centers. Overall, the implementation of robotics might facilitate achievement of a "tetrafecta" outcome as defined in the present study.
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http://dx.doi.org/10.1089/end.2021.0587DOI Listing
January 2022

Thulium fiber laser in urology: physics made simple.

Curr Opin Urol 2021 Dec 24. Epub 2021 Dec 24.

Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia International School 'Medicine of the Future', Sechenov University, Moscow, Russia USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Keck School of Medicine Artificial Intelligence Center at USC Urology, USC Institute of Urology, University of Southern California, Los Angeles, California, USA.

Purpose Of Review: In this narrative review, we will focus on a novel thulium fiber laser's physical properties in terms of its clinical applicability.

Recent Findings: TFL has successfully moved forward from the preclinical trials into clinical practice and now is being widely used in clinics around the world. The available data suggest that the device effectively operates in soft tissues - benign prostate hyperplasia (BPH) and bladder tumors, as well as in lithotripsy. Also, the first promising results were obtained from laparoscopic surgery showing its possible applicability in the management of renal cell carcinoma. The constructional changes in fiber laser's design, lead to alteration of laser-tissue interactions, which resulted in clinical advantages of the device. Yet, the exact mechanism often is considered complex for understanding. With this work, we are aiming to build a bridge between biophysics and clinical practice and give a simple explanation of how the devices is working and why the knowledge of it is important for a clinician.

Summary: The more effective wavelength (closer to the water absorption peak), favorable beam profile, different modes of action allowing to decrease carbonization on one hand and retropulsion on the other, all this makes TFL an evolution in urologic surgery. Further trials investigating on the possible pros and cons of the device are awaited.
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http://dx.doi.org/10.1097/MOU.0000000000000967DOI Listing
December 2021

Artificial Intelligence Applications in Urology: Reporting Standards to Achieve Fluency for Urologists.

Urol Clin North Am 2022 Feb 23;49(1):65-117. Epub 2021 Oct 23.

USC Institute of Urology, 1441 Eastlake Avenue Suite 7416, Los Angeles, CA 90089, USA. Electronic address:

The growth and adoption of artificial intelligence has led to impressive results in urology. As artificial intelligence grows more ubiquitous, it is important to establish artificial intelligence literacy in the workforce. To this end, we present a narrative review of the literature of artificial intelligence and machine learning in urology and propose a checklist of reporting standards to improve readability and evaluate the current state of the literature. The listed article demonstrated heterogeneous reporting of methodologies and outcomes, limiting generalizability of research. We hope that this review serves as a foundation for future evaluation of medical research in artificial intelligence.
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http://dx.doi.org/10.1016/j.ucl.2021.07.009DOI Listing
February 2022

Future perspective of focal therapy for localized prostate cancer.

Asian J Urol 2021 Oct 3;8(4):354-361. Epub 2021 May 3.

Center for Image-Guided and Focal Therapy for Prostate Cancer, Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Objective: To summarize the recent literature discussing focal therapy for localized prostate cancer.

Methods: A thorough literature review was performed using PubMed to identify recent studies involving focal therapy for the treatment of localized prostate cancer.

Results: In an effort to decrease the morbidity associated with prostate cancer treatment, many urologists are turning to focal therapy as an alternative treatment option. With this approach, the cancer bearing portion of the prostate is targeted while leaving the benign tissue untouched. Multiparametric magnetic resonance imaging remains the gold standard for visualization during focal therapy, but new imaging modalities such as prostate specific membrane antigen/positron emission tomography and contrast enhanced ultrasound are being investigated. Furthermore, several biomarkers, such as prostate cancer antigen 3 and prostate health index, are used in conjunction with imaging to improve risk stratification prior to focal therapy. Lastly, there are several novel technologies such as nanoparticles and transurethral devices that are under investigation for use in focal therapy.

Conclusion: Focal therapy is proving to be a promising option for the treatment of localized prostate cancer. However, further study is needed to determine the true efficacy of these exciting new technologies.
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http://dx.doi.org/10.1016/j.ajur.2021.04.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8566361PMC
October 2021

Focal Therapy for Prostate Cancer: Getting Ready for Prime Time.

Eur Urol 2022 Jan 2;81(1):34-36. Epub 2021 Nov 2.

USC Institute of Urology, Center for Image-Guided Surgery, Focal Therapy and Artificial Intelligence for Prostate Cancer, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

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http://dx.doi.org/10.1016/j.eururo.2021.10.005DOI Listing
January 2022

Can We Avoid a Systematic Biopsy in Men with PI-RADS® 5? Reply.

J Urol 2022 01 19;207(1):241-242. Epub 2021 Oct 19.

USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Center for Image-Guided and Focal Therapy for Prostate Cancer, University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1097/JU.0000000000002299DOI Listing
January 2022

Fighting the 'tobacco epidemic' - A call to action to identify Targeted Intervention Points (TIPs) for better counseling patients with urothelial cancer.

Urol Oncol 2021 Dec 8;39(12):793-796. Epub 2021 Oct 8.

Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

The association between tobacco use and urothelial cancer of the bladder is well known. Given the worsening tobacco epidemic, here we make the case for systematic targeted points of intervention for urologists and other professionals to intervene against bladder cancer. Awareness of contemporary checkpoints where we can intervene for counseling patients may help medical education in a tobacco-pandemic difficult setting.
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http://dx.doi.org/10.1016/j.urolonc.2021.08.025DOI Listing
December 2021

New Ultra-minimally Invasive Surgical Treatment for Benign Prostatic Hyperplasia: A Systematic Review and Analysis of Comparative Outcomes.

Eur Urol Open Sci 2021 Nov 22;33:28-41. Epub 2021 Sep 22.

Department of Oncology, Division of Urology, University of Turin, Turin, Italy.

Context: Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr.

Objective: To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection.

Evidence Acquisition: A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses.

Evidence Synthesis: The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; -9.81 points, 95% confidence interval [CI] -11.37 to -8.25 at 1 mo; -13.13 points, 95% CI -14.98 to -11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8-4.5 to +4.14 ml/s, 95% CI 0.72-7.56 at 12 mo), and postvoid residual volume (-10.10 ml, 95% CI -27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34-2.42 at the start of follow-up; and 1.04, 95% CI 0.28-1.8 after 1 yr), or the IPSS-Quality of Life questionnaire.

Conclusions: Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients' sexual function with respect to baseline, especially regarding preservation of ejaculation.

Patient Summary: We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function.

Take Home  Message: Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient's quality of life.
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http://dx.doi.org/10.1016/j.euros.2021.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8473553PMC
November 2021

Social media and misinformation in urology: what can be done?

BJU Int 2021 10;128(4):397

European Association of Urology - Young Academic Urologist (EAU-YAU), Arnhem, The Netherlands.

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http://dx.doi.org/10.1111/bju.15517DOI Listing
October 2021

Potential Contenders for the Leadership in Robotic Surgery.

J Endourol 2021 Oct 26. Epub 2021 Oct 26.

ORSI Academy, Melle, Belgium.

To summarize the scientific published literature on new robotic surgical platforms with potential use in the urological field, reviewing their evolution from presentation until the present day. Our goal is to describe the current characteristics and possible prospects for these platforms. A nonsystematic search of the PubMed, Cochrane library's Central, EMBASE, MEDLINE, and Scopus databases was conducted to identify scientific literature about new robotic platforms other than the Da Vinci system, reviewing their evolution from inception until December 2020. Only English language publications were included. The following keywords were used: "new robotic platforms," "Revo-I robot," "Versius robot," and "Senhance robot." All relevant English-language original studies were analyzed by one author (R.F.) and summarized after discussion with an independent third party (E.M., S.Y., S.P., and M.A.). Since 1995, Intuitive Surgical, Inc., with the Da Vinci surgical system, is the leading company in the robotic surgical market. However, Revo-I, Versius, and Senhance are the other three platforms that recently appeared on the market with available articles published in peer-reviewed journals. Among these three new surgical systems, the Senhance robot has the most substantial scientific proof of its capacity to perform minimally invasive urological surgery and as such, it might become a contender of the Da Vinci robot. The Da Vinci surgical platform has allowed the diffusion of robotic surgery worldwide and showed the different advantages of this type of technique. However, its use has some drawbacks, especially its price. New robotic platforms characterized by unique features are under development. Of note, they might be less expensive compared with the Da Vinci robotic system. We found that these new platforms are still at the beginning of their technical and scientific validation. However, the Senhance robot is in a more advanced stage, with clinical studies supporting its full implementation.
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http://dx.doi.org/10.1089/end.2021.0321DOI Listing
October 2021

A Radiomic-based Machine Learning Algorithm to Reliably Differentiate Benign Renal Masses from Renal Cell Carcinoma.

Eur Urol Focus 2021 Sep 16. Epub 2021 Sep 16.

USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Artificial Intelligence Center at USC Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA; Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Background: A substantial proportion of patients undergo treatment for renal masses where active surveillance or observation may be more appropriate.

Objective: To determine whether radiomic-based machine learning platforms can distinguish benign from malignant renal masses.

Design, Setting, And Participants: A prospectively maintained single-institutional renal mass registry was queried to identify patients with a computed tomography-proven clinically localized renal mass who underwent partial or radical nephrectomy.

Intervention: Radiomic analysis of preoperative scans was performed. Clinical and radiomic variables of importance were identified through decision tree analysis, which were incorporated into Random Forest and REAL Adaboost predictive models.

Outcome Measurements And Statistical Analysis: The primary outcome was the degree of congruity between the virtual diagnosis and final pathology. Subanalyses were performed for small renal masses and patients who had percutaneous renal mass biopsies as part of their workup. Receiver operating characteristic curves were used to evaluate each model's discriminatory function.

Results And Limitations: A total of 684 patients met the selection criteria. Of them, 76% had renal cell carcinoma; 57% had small renal masses, of which 73% were malignant. Predictive modeling differentiated benign pathology from malignant with an area under the curve (AUC) of 0.84 (95% confidence interval [CI] 0.79-0.9). In small renal masses, radiomic analysis yielded a discriminatory AUC of 0.77 (95% CI 0.69-0.85). When negative and nondiagnostic biopsies were supplemented with radiomic analysis, accuracy increased from 83.3% to 93.4%.

Conclusions: Radiomic-based predictive modeling may distinguish benign from malignant renal masses. Clinical factors did not substantially improve the diagnostic accuracy of predictive models. Enhanced diagnostic predictability may improve patient selection before surgery and increase the utilization of active surveillance protocols.

Patient Summary: Not all kidney tumors are cancerous, and some can be watched. We evaluated a new method that uses radiographic features invisible to the naked eye to distinguish benign masses from true cancers and found that it can do so with acceptable accuracy.
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http://dx.doi.org/10.1016/j.euf.2021.09.004DOI Listing
September 2021

Performance of Narrow Band Imaging (NBI) and Photodynamic Diagnosis (PDD) Fluorescence Imaging Compared to White Light Cystoscopy (WLC) in Detecting Non-Muscle Invasive Bladder Cancer: A Systematic Review and Lesion-Level Diagnostic Meta-Analysis.

Cancers (Basel) 2021 Aug 30;13(17). Epub 2021 Aug 30.

Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.

Despite early detection and regular surveillance of non-muscle invasive bladder cancer (NMIBC), recurrence and progression rates remain exceedingly high for this highly prevalent malignancy. Limited visualization of malignant lesions with standard cystoscopy and associated false-negative biopsy rates have been the driving force for investigating alternative and adjunctive technologies for improved cystoscopy. The aim of our systematic review and meta-analysis was to compare the sensitivity, specificity, and oncologic outcomes of photodynamic diagnosis (PDD) fluorescence, narrow band imaging (NBI), and conventional white light cystoscopy (WLC) in detecting NMIBC. Out of 1,087 studies reviewed, 17 prospective non-randomized and randomized controlled trials met inclusion criteria for the study. We demonstrated that tumor resection with either PDD and NBI exhibited lower recurrence rates and greater diagnostic sensitivity compared to WLC alone. NBI demonstrated superior disease sensitivity and specificity as compared to WLC and an overall greater hierarchical summary receiver operative characteristic. Our findings are consistent with emerging guidelines and underscore the value of integrating these enhanced technologies as a part of the standard care for patients with suspected or confirmed NMIBC.
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http://dx.doi.org/10.3390/cancers13174378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8431313PMC
August 2021

A Protocol for the Development of the Intraoperative Complications Assessment and Reporting With Universal Standards Criteria: The ICARUS Project.

Int J Surg Protoc 2021 6;25(1):160-164. Epub 2021 Aug 6.

USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, US.

Introduction: Perioperative complications, especially intraoperative adverse events (iAEs), carry significant potential for long-term sequelae in a patient's postoperative course. These events represent a substantial gap in contemporary surgical literature, with only a fraction of publications reporting intraoperative complications as outcomes of interest. To date, there is no universal standard for comprehensively reporting intraoperative complications in surgical practice and literature beyond the systems developed for grading individual events. We aim to establish a set of best-practice criteria for iAE reporting known as the ntraoperative omplication ssessment and eporting with niversal tandards () Guidelines.

Methods And Analysis: We will generate the ICARUS reporting guidelines using the EQUATOR Network development framework and the SQUIRE Guidelines. The initial step involves an umbrella review and meta-analysis of systemic reviews (SRs) assessing the perioperative adverse events of common surgeries. Measures for assessing, collecting, grading, and reporting the iAEs will be merged into a comprehensive list of criteria. Using a modified Delphi methodology, a team of expert surgeons (≥ 200 inpatient procedures/years) will contribute to and evaluate the proposed reporting guidelines. The panel will evaluate both the clinical usefulness and quality assessment and improvement utility of each criterion using a 5-point Likert. We expect multiple survey rounds until consensus regarding the utility of the guidelines is reached.

Dissemination: We plan to share then validate the newly developed guidelines within each surgical field. Dissemination will involve publicly shared guidelines, simultaneous journal publications, conference presentations, encouragement for journal endorsement, and application for inclusion in the Equator Network database. The study team plans to continue collecting feedback for future extension of the intraoperative reporting guidelines.

Highlights: Intraoperative adverse events are underreported and lack homogeneity in surgical literatureWe aim to use a modified Delphi methodology to develop the consensus-based, intraoperative complications assessment and reporting with universal standards (ICARUS) guidelinesWe will disseminate the ICARUS guidelines through journal publications and presentations at national and international meetings; journals and professional organizations will be encouraged to endorse the ICARUS guidelines.
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http://dx.doi.org/10.29337/ijsp.155DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344953PMC
August 2021

Reply by Authors.

J Urol 2021 08 2;206(2):297. Epub 2021 Jul 2.

USC Institute of Urology and Catherine & Joseph Aresty, Department of Urology, Center for Image-Guided and Focal Therapy for Prostate Cancer, University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1097/JU.0000000000001766.02DOI Listing
August 2021

Risks and Benefits of Live Surgical Broadcast: A Systematic Review.

Eur Urol Focus 2021 Jun 17. Epub 2021 Jun 17.

Division of Urology, VCU Health, Richmond, VA, USA. Electronic address:

Context: Live surgical broadcast (LSB), also known as live surgery, has become a popular format for many types of surgical education meetings. However, concerns have been raised in relation to patient safety, ethical issues, and the actual educational value of LSB.

Objective: To summarize current evidence on LSB with a focus on the risks of complications and the educational impact.

Evidence Acquisition: We performed a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies up to December 2020. We identified original articles reporting on patient outcomes, educational value, current use, and development of LSB. We also interrogated surgical society guidelines for position statements on LSB.

Evidence Synthesis: Our literature search identified 46 studies spanning six surgical specialties, with urology being the most frequent. Approximately half of the studies reported on outcomes of surgical procedures during LSB. In urology, the few comparative studies available did not suggest higher complication rates in LSB, whereas data for other surgical fields highlighted evidence of worse outcomes. Four studies assessed the educational value of LSB via survey administration, for which the evidence is limited and of low quality. Thirteen guidelines and position statements on live surgery were identified among major surgical societies, including the European Association of Urology (EAU). Some surgical societies have expressly prohibited the use of LSB at their major meetings. The perspective of surgeons performing and/or attending live surgical sessions was evaluated in six studies, and four studies looked at urologists' perception of LSB compared to semi-LSB. Limitations of this systematic review include the limited number of studies available, the low quality of the evidence, and data heterogeneity.

Conclusions: Evidence regarding outcomes of LSB is limited. Almost all the studies do not show a higher risk of complications or worse outcomes for patients undergoing a procedure during LSB. Only one study on gastrointestinal surgery reported that LSB outcomes were worse. Ongoing concerns have led to specific guidelines by several scientific societies, including the EAU, with the ultimate aim of minimizing surgical risks and maximizing patient safety.

Patient Summary: Live surgery events are often part of surgical conferences. Data in the literature show mixed outcomes for operations performed during live surgery events, but with no increase in complication rates. Safety and ethical concerns remain. Other educational tools, such as prerecorded videos and live surgery transmission from the home institution of the operating surgeon might become preferred options in the future. This review was prospectively registered on the PROSPERO website (www.crd.york.ac.uk/PROSPERO, registration number CRD42020194023).
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http://dx.doi.org/10.1016/j.euf.2021.06.003DOI Listing
June 2021

Risks and Benefits of Live Surgical Broadcast: A Systematic Review.

Eur Urol Focus 2021 Jun 17. Epub 2021 Jun 17.

Division of Urology, VCU Health, Richmond, VA, USA. Electronic address:

Context: Live surgical broadcast (LSB), also known as live surgery, has become a popular format for many types of surgical education meetings. However, concerns have been raised in relation to patient safety, ethical issues, and the actual educational value of LSB.

Objective: To summarize current evidence on LSB with a focus on the risks of complications and the educational impact.

Evidence Acquisition: We performed a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies up to December 2020. We identified original articles reporting on patient outcomes, educational value, current use, and development of LSB. We also interrogated surgical society guidelines for position statements on LSB.

Evidence Synthesis: Our literature search identified 46 studies spanning six surgical specialties, with urology being the most frequent. Approximately half of the studies reported on outcomes of surgical procedures during LSB. In urology, the few comparative studies available did not suggest higher complication rates in LSB, whereas data for other surgical fields highlighted evidence of worse outcomes. Four studies assessed the educational value of LSB via survey administration, for which the evidence is limited and of low quality. Thirteen guidelines and position statements on live surgery were identified among major surgical societies, including the European Association of Urology (EAU). Some surgical societies have expressly prohibited the use of LSB at their major meetings. The perspective of surgeons performing and/or attending live surgical sessions was evaluated in six studies, and four studies looked at urologists' perception of LSB compared to semi-LSB. Limitations of this systematic review include the limited number of studies available, the low quality of the evidence, and data heterogeneity.

Conclusions: Evidence regarding outcomes of LSB is limited. Almost all the studies do not show a higher risk of complications or worse outcomes for patients undergoing a procedure during LSB. Only one study on gastrointestinal surgery reported that LSB outcomes were worse. Ongoing concerns have led to specific guidelines by several scientific societies, including the EAU, with the ultimate aim of minimizing surgical risks and maximizing patient safety.

Patient Summary: Live surgery events are often part of surgical conferences. Data in the literature show mixed outcomes for operations performed during live surgery events, but with no increase in complication rates. Safety and ethical concerns remain. Other educational tools, such as prerecorded videos and live surgery transmission from the home institution of the operating surgeon might become preferred options in the future. This review was prospectively registered on the PROSPERO website (www.crd.york.ac.uk/PROSPERO, registration number CRD42020194023).
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http://dx.doi.org/10.1016/j.euf.2021.06.003DOI Listing
June 2021

A Quantitative Analysis Investigating the Prevalence of "Manels" in Major Urology Meetings.

Eur Urol 2021 10 4;80(4):442-449. Epub 2021 Jun 4.

Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain.

Background: Female representation in urological meetings is important for gender equity.

Objective: Our objective was to examine the prevalence of "manels" or all-male speaking panels at urological meetings.

Design, Setting, And Participants: Urology meetings organized by major urological associations/societies from December 2019 to November 2020 were reviewed. Meeting information and details of the faculty were retrieved.

Outcome Measurements And Statistical Analysis: Primary outcomes were: (1) the percentage of male faculty in all included sessions and (2) the overall proportion of manels. We made further comparisons between manel and multigender sessions. Male and female faculty were stratified by quartiles of publications, citations, and H-index, and their mean numbers of sessions were compared.

Results And Limitations: Among 285 meeting sessions, 181 (63.5%) were manels. The mean percentage of male faculty was 86.9%. Male representation was very high in urology meetings for most disciplines and urological associations/societies, except for female urology meeting sessions and those organized by the International Continence Society. Nonmanel sessions had higher numbers of chairs/moderators (p = 0.027), speakers (p < 0.001), and faculty (p < 0.001) than manel sessions. A total of 1037 faculty members were included, and 900 of them (86.8%) were male. Male faculty had longer mean years of practice (23.8 vs 17.7 yr, p < 0.001) and was more likely to include professors (43.2% vs 17.5%, p < 0.001) than female faculty. Male faculty within the first quartile (ie, lower quartile) of publications and H-index had a significantly higher number of sessions than female faculty within the same quartile.

Conclusions: Our study showed that manels are prevalent in urology meetings. There is evidence showing that males received more opportunities than females. A huge gender imbalance exists in urology meetings; urological associations and societies should actively strive for greater gender parity.

Patient Summary: Women are under-represented in urology meetings. Urological associations and societies should play an active role to ensure a more balanced gender representation.
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http://dx.doi.org/10.1016/j.eururo.2021.05.031DOI Listing
October 2021

Reply by Authors.

J Urol 2021 08 1;206(2):426. Epub 2021 Jun 1.

USC Institute of Urology and Catherine & Joseph Aresty, Department of Urology, Center for Image-Guided and Focal Therapy for Prostate Cancer, University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1097/JU.0000000000001792.03DOI Listing
August 2021

Digital urologic education during COVID-19: the rise of the "webin-era".

Minerva Urol Nephrol 2021 04;73(2):137-140

Keck School of Medicine, Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA.

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http://dx.doi.org/10.23736/S2724-6051.21.04326-5DOI Listing
April 2021

Impact of the Implementation of the EAU Guidelines Recommendation on Reporting and Grading of Complications in Patients Undergoing Robot-assisted Radical Cystectomy: A Systematic Review.

Eur Urol 2021 08 19;80(2):129-133. Epub 2021 May 19.

University of Southern California Institute of Urology & Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. Electronic address:

In 2012, the European Association of Urology (EAU) Ad Hoc Panel proposed a standardised methodology on reporting and grading complications after urological surgical procedures. The aim of the current study was to assess the impact of this implementation on complications reporting for patients undergoing robot-assisted radical cystectomy (RARC). A systematic review of all English-language original articles published on RARC until March 2020 was performed using PubMed, Scopus, and Web of Science databases. The study selection process followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) criteria. The quality of reporting and grading complication was evaluated according to the EAU recommendations. Our analysis failed to observe a statistically significant improvement in reporting outcomes after the EAU guidelines recommendations except for three of the 14 criteria proposed (ie, follow-up duration, utilisation of a severity grade system, and risk factors included in the analyses). A lower statistically significant adherence to outcome reporting in terms of inclusion of readmissions and causes (p = 0.02), was observed. PATIENT SUMMARY: In this study, we evaluated the impact of the proposed European Association of Urology (EAU) standardised reporting tool for urological complications, in patients treated with robot-assisted radical cystectomy. A low adherence to EAU guidelines recommendations for complications reporting was observed.
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http://dx.doi.org/10.1016/j.eururo.2021.04.030DOI Listing
August 2021

How the use of the artificial intelligence could improve surgical skills in urology: state of the art and future perspectives.

Curr Opin Urol 2021 07;31(4):378-384

USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Keck School of Medicine.

Purpose Of Review: As technology advances, surgical training has evolved in parallel over the previous decade. Training is commonly seen as a way to prepare surgeons for their day-to-day work; however, more importantly, it allows for certification of skills to ensure maximum patient safety. This article reviews advances in the use of machine learning and artificial intelligence for improvements of surgical skills in urology.

Recent Findings: Six studies have been published, which met the inclusion criteria. All articles assessed the application of artificial intelligence in improving surgical training. Different approaches were taken, such as using machine learning to identify and classify suturing gestures, creating automated objective evaluation reports, and determining surgical technical skill levels to predict clinical outcomes. The articles illustrated the continuously growing role of artificial intelligence to address the difficulties currently present in evaluating urological surgical skills.

Summary: Artificial intelligence allows us to efficiently analyze the surmounting data related to surgical training and use it to come to conclusions that normally would require human intelligence. Although these metrics have been shown to predict surgeon expertise and surgical outcomes, evidence is still scarce regarding their ability to directly improve patient outcomes. Considering this, current active research is growing on the topic of deep learning-based computer vision to provide automated metrics needed for real-time surgeon feedback.
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http://dx.doi.org/10.1097/MOU.0000000000000890DOI Listing
July 2021

Focal Therapy for Low-Risk Prostate Cancer Opinion: No.

J Endourol 2021 Sep;35(9):1284-1287

USC Institute of Urology and Catherine and Joseph Aresty Department of Urology, and University of Southern California, Los Angeles, California, USA.

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http://dx.doi.org/10.1089/end.2021.0226DOI Listing
September 2021

Systematic Biopsy of the Prostate can Be Omitted in Men with PI-RADS™ 5 and Prostate Specific Antigen Density Greater than 15.

J Urol 2021 08 5;206(2):289-297. Epub 2021 Apr 5.

USC Institute of Urology and Catherine & Joseph Aresty, Department of Urology, Center for Image-Guided and Focal Therapy for Prostate Cancer, University of Southern California, Los Angeles, California.

Purpose: We evaluated the prostate cancer and clinically significant prostate cancer detection on systematic biopsy (SB), target biopsy (TB) alone and combined SB and TB in men with Prostate Imaging Reporting and Data System™ (PI-RADS™) 5 lesion.

Materials And Methods: From a prospectively maintained prostate biopsy database, we identified consecutive patients with PI-RADS 5 lesion on multiparametric magnetic resonance imaging. The patients underwent multiparametric magnetic resonance imaging followed by transrectal TB of PI-RADS 5 lesion and 12-core SB. The prostate cancer and clinically significant prostate cancer (Grade Group, GG ≥2) detection on SB, TB and SB+TB were determined for all men and accordingly to prostate specific antigen density. Statistic significant was set a p <0.05.

Results: Overall, 112 patients met inclusion criteria. The detection rate of prostate cancer for SB, TB and SB+TB was 89%, 93% and 95%, respectively, and for clinically significant prostate cancer it was 72%, 81% and 85%, respectively. SB added 2% prostate cancer and 4% clinically significant prostate cancer detection to TB. A total of 78 patients had prostate specific antigen density >0.15 ng/ml, and the detection rate of PCa for SB, TB and SB+TB was 92%, 97% and 97%, respectively, and for clinically significant prostate cancer it was 79%, 91% and 95%, respectively. In this population, if SB was omitted, 0 prostate cancer and only 4% (3) of clinically significant prostate cancer would be missed. The clinically significant prostate cancer detection rate improved with increased prostate specific antigen density for SB (p=0.01), TB (p <0.0001) and combined SB+TB (p=0.002).

Conclusions: In patients with PI-RADS 5 on multiparametric magnetic resonance imaging and prostate specific antigen density >0.15 ng/ml, SB marginally increases clinically significant prostate cancer detection, but not overall prostate cancer detection in comparison to TB alone. Systematic biopsy did not affect patients' management and can be omitted on this population.
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http://dx.doi.org/10.1097/JU.0000000000001766DOI Listing
August 2021

Comparative Effectiveness of Techniques in Targeted Prostate Biopsy.

Cancers (Basel) 2021 Mar 22;13(6). Epub 2021 Mar 22.

USC Institute of Urology and Catherine & Joseph Aresty Department of Urology, Center for Image-Guided and Focal Therapy for Prostate Cancer, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA.

In this review, we evaluated literature regarding different modalities for multiparametric magnetic resonance imaging (mpMRI) and mpMRI-targeted biopsy (TB) for the detection of prostate cancer (PCa). We identified studies evaluating systematic biopsy (SB) and TB in the same patient, thereby allowing each patient to serve as their own control. Although the evidence supports the accuracy of TB, there is still a proportion of clinically significant PCa (csPCa) that is detected only in SB, indicating the importance of maintaining SB in the diagnostic pathway, albeit with additional cost and morbidity. There is a growing subset of data which supports the role of TB alone, which may allow for increased efficiency and decreased complications. We also compared the literature on transrectal (TR) vs. transperineal (TP) TB. Although further high-level evidence is necessary, current evidence supports similar csPCa detection rate for both approaches. We also evaluated various TB techniques such as cognitive fusion biopsy (COG-TB) and in-bore biopsy (IB-TB). COG-TB has comparable detection rates to software fusion, but is operator-dependent and may have reduced accuracy for smaller lesions. IB-TB may allow for greater precision as lesions are directly targeted; however, this is costly and time-consuming, and does not account for MRI-invisible lesions.
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http://dx.doi.org/10.3390/cancers13061449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8004898PMC
March 2021

Single stage Xi® robotic radical nephroureterectomy for upper tract urothelial carcinoma: surgical technique and outcomes.

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

Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.

Background: Radical nephroureterectomy (RNU) represents the standard of care for high grade upper tract urothelial carcinoma (UTUC). Open and laparoscopic approaches are well-established treatments, but evidence regarding robotic RANU is growing. The introduction of the Xi® system facilitates the implementation of this multi-quadrant procedure. The aim of this video-article is to describe the surgical steps and the outcomes of Xi® robotic RNU.

Methods: Single stage Xi® robotic RNU without patients repositioning and robot re-docking were done between 2015 and 2019 and collected in a large worldwide multi-institutional study, the ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST). Institutional review board approval and data share agreement were obtained at each center. Surgical technique is described in detail in the accompanying video. Descriptive statistics of baseline characteristics and surgical, pathological, and oncological outcomes were analyzed. RESULTSː Overall, 148 patients were included in the analysis; 14% had an ECOG >1 and 68.2% ASA ≥3. Median tumor dimension was 3.0 (IQR:2.0-4.2) cm and 34.5% showed hydronephrosis at diagnosis. Forty-eight% were cT1 tumors. Bladder cuff excision and lymph node dissection were performed in 96% and 38.1% of the procedures, respectively. Median operative time and estimated blood loss were 215.5 (IQR:160.5-290.0) minutes and 100.0 (IQR: 50.0-150.0) mL, respectively. Approximately 56% of patients took opioids during hospital stay for a total morphine equivalent dose of 22.9 (IQR:16.0-60.0) milligrams equivalent. Postoperative complications were 26 (17.7%), with 4 major (15.4%). Seven patients underwent adjuvant chemotherapy, with median number of cycles of 4.0 (IQR:3.0-6.0).

Conclusions: Single stage Xi® RNU is a reproducible and safe minimally invasive procedure for treatment of UTUC. Additional potential advantages of the robot might be a wider implementation of LND with a minimally invasive approach.
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http://dx.doi.org/10.23736/S2724-6051.21.04247-8DOI Listing
March 2021

Artificial Intelligence Will (MAY) Make Doctors Expendable (IN GOOD WAYS): Pro.

Eur Urol Focus 2021 Jul 24;7(4):683-684. Epub 2021 Mar 24.

AI Center at USC Urology, USC Institute of Urology, University of Southern California, Los Angeles, CA, USA.

The field of artificial intelligence continues to advance rapidly. Improvements in both patient outcomes and the patient-doctor relationship may occur if physicians embrace this technology.
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http://dx.doi.org/10.1016/j.euf.2021.03.011DOI Listing
July 2021

Penile length and circumference dimensions: A large study in young Italian men.

Andrologia 2021 Jul 21;53(6):e14053. Epub 2021 Mar 21.

Centro Integrato di Sessuologia Il Ponte, Florence, Italy.

The aim of the present study was to evaluate the size of the penis in flaccidity and in erection of Italian men. A total of 4,685 men living in Italy and who have been visited at the Italian urology operating units were involved in the study between January 2019 and January 2020. Each patient was given details on how to measure their penis (erect length and circumference) in flaccidity and in erection, from the lower base to the distal penile tip. Mean (standard deviation [SD]) flaccid penis length was 9.47 (2.69), mean (SD) flaccid penis circumference was 9.59 (3.08), mean (SD) erect penis length was 16.78 (2.55) and mean (SD) erect penis circumference was 12.03 (3.82). At the linear regression analysis, height was associated with flaccid penis length (β = 0.04; p-value = .01), and erect penis length was (β = 0.05; p-value < .01) and erect penis circumference was (β = 0.06; p-value < .01). Height is proportional to the length of the penis in flaccidity and in erection, and to the circumference in erection. The increase in BMI leads to a reduction in the length of the erect penis, as well as weight gain reduces the length of the flaccid penis.
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http://dx.doi.org/10.1111/and.14053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243978PMC
July 2021
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