Publications by authors named "Giovanni E Cacciamani"

69 Publications

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 2021 Nov 2. 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
November 2021

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

J Urol 2021 Oct 19:101097JU0000000000002299. 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
October 2021

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

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

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

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

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

Eur Urol 2021 Oct 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

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

Techniques and Outcomes of MRI-TRUS Fusion Prostate Biopsy.

Curr Urol Rep 2021 Mar 22;22(4):27. Epub 2021 Mar 22.

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

Purpose Of Review: The goal of this study is to review recent findings and evaluate the utility of MRI transrectal ultrasound fusion biopsy (FBx) techniques and discuss future directions.

Recent Findings: FBx detects significantly higher rates of clinically significant prostate cancer (csPCa) than ultrasound-guided systematic prostate biopsy (SBx), particularly in repeat biopsy settings. FBx has also been shown to detect significantly lower rates of clinically insignificant prostate cancer. In addition, a dedicated prostate MRI can assist in more accurately predicting the Gleason score and provide further information regarding the index cancer location, prostate volume, and clinical stage. The ability to accurately evaluate specific lesions is vital to both focal therapy and active surveillance, for treatment selection, planning, and adequate follow-up. FBx has been demonstrated in multiple high-quality studies to have improved performance in diagnosis of csPCa compared to SBx. The combination of FBx with novel technologies including radiomics, prostate-specific membrane antigen positron emission tomography (PSMA PET), and high-resolution micro-ultrasound may have the potential to further enhance this performance.
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http://dx.doi.org/10.1007/s11934-021-01037-xDOI Listing
March 2021

Impact of Pelvic Lymph Node Dissection and Its Extent on Perioperative Morbidity in Patients Undergoing Radical Prostatectomy for Prostate Cancer: A Comprehensive Systematic Review and Meta-analysis.

Eur Urol Oncol 2021 04 6;4(2):134-149. Epub 2021 Mar 6.

Department of Urology and Division of Experimental Oncology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute, Milan, Italy.

Context: Pelvic lymph node dissection (PLND) yields the most accurate staging in patients undergoing radical prostatectomy (RP) for prostate cancer (PCa), although it can be associated with morbidity.

Objective: To systematically evaluate the impact of PLND extent on perioperative morbidity in patients undergoing RP. A new PLND-related complication assessment tool is proposed.

Evidence Acquisition: A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) was conducted. MEDLINE/PubMed, Scopus, Embase and Web of Science databases were searched to yield studies discussing perioperative complications following RP and PLND. The extent of PLND was classified according to the European Association of Urology PCa guidelines. Studies were categorized according to the extent of PLND. Intra- and postoperative complications were classified as "strongly," "likely," or "unlikely" related to PLND. Anatomical site of perioperative complications was recorded. A cumulative meta-analysis of comparative studies was conducted using Review Manager 5.3 (Cochrane Collaboration, Oxford, UK).

Evidence Synthesis: Our search generated 3645 papers, with 176 studies meeting the inclusion criteria. Details of 77 303 patients were analyzed. Of these studies, 84 (47.7%), combining data on 28 428 patients, described intraoperative complications as an outcome of interest. Overall, 534 (1.8%) patients reported one or more intraoperative complications. Postoperative complications were reported in 151 (85.7%) studies, combining data on 73 629 patients. Overall, 10 401 (14.1%) patients reported one or more postoperative complication. The most reported postoperative complication strongly related to PLND was lymphocele (90.6%). The pooled meta-analysis revealed that RP + limited PLND/standard PLND had a significantly decreased risk of experiencing any intraoperative complication (risk ratio [RR]: 0.55; p =  0.01) and postoperative complication strongly related to PLND (RR: 0.46; p =  <0.00001), particularly for lymphocele formation (RR: 0.52; p =  0.0003) and thromboembolic events (RR: 0.59; p =  0.008), when compared with extended/superextended PLND. The extent of PLND was confirmed to be an independent predictor of lymphocele formation (RR: 1.77; p <  0.00001).

Conclusions: The perioperative morbidity of PLND in patients undergoing RP and PLND for PCa significantly correlates with the extent of PLND. More standardized reporting of intra- and postoperative complications is needed to better estimate the direct impact of PLND extent on perioperative morbidity.

Patient Summary: Pelvic lymph node dissection (PLND) is the most accurate method for staging in patients undergoing radical prostatectomy for prostate cancer, although it can be associated with complications. This study aims to systematically evaluate the impact of PLND extent on perioperative complications in these patients. We found that intra- and postoperative complications correlate significantly with the extent of PLND. A more rigorous assessment and thorough reporting of perioperative complications are recommended.
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http://dx.doi.org/10.1016/j.euo.2021.02.001DOI Listing
April 2021

Consulting 'Dr. Google' for minimally invasive urological oncological surgeries: A contemporary web-based trend analysis.

Int J Med Robot 2021 Aug 5;17(4):e2250. Epub 2021 Mar 5.

Department of Urology, University of Verona, Verona, Italy.

Purpose: To determine web-based public interest in minimally invasive surgery (MIS) specifically for urological oncological surgical procedures and how interest in robotics and laparoscopy compares over time.

Materials And Methods: Worldwide search-engine trend analysis included electronic Google queries of MIS urologic options from January 2004 to August 2019, worldwide. Join-point regression was performed. Comparison of annual relative search volume (ARSV) and average annual percentage change (AAPC) were analysed to assess loss or gain of interest. Evaluations were made regarding 1) penetrance of interest for MIS in Urology; 2) how MIS urologic procedures compared over time; and 3) which were the top related queries to searches for urologic oncology procedures.

Results: Increased interest was found for all of the MIS procedures evaluated. Mean ARSV for robotic approach was higher for the search term 'prostatectomy" (44.8 vs. 13.5; p < 0.001) and 'partial nephrectomy" (27.1 vs.11.5; p = 0.02). No statistical difference was found for the search terms 'cystectomy" or 'nephrectomy". The analysis of mean (∆-ARSV) of MIS procedures measured between the first and last 12 months of the study period showed an increased interest with a more pronounced ∆-ARSV for robotic procedures. The top related searches for all surgical procedures were examined showing an increasing inquisitiveness with regards of type of urological cancers, treatment options, type of surgery and prognostic outcomes.

Conclusions: People are increasingly searching the web for MIS urological procedures. A growing appeal for robotics is demonstrated, especially for prostatectomy and partial nephrectomy where the robotic approach is gaining traction, suggesting a shift in mind-set amongst people seeking urological healthcare information.
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http://dx.doi.org/10.1002/rcs.2250DOI Listing
August 2021

A systematic review of nerve-sparing surgery for high-risk prostate cancer.

Minerva Urol Nephrol 2021 Jun 13;73(3):283-291. Epub 2021 Jan 13.

Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.

Introduction: We provide a systematic analysis of nerve-sparing surgery (NSS) to assess and summarize the risks and benefits of NSS in high-risk prostate cancer (PCa).

Evidence Acquisition: We have undertaken a systematic search of original articles using 3 databases: Medline/PubMed, Scopus, and Web of Science. Original articles in English containing outcomes of nerve-sparing radical prostatectomy (RP) for high-risk PCa were included. The primary outcomes were oncological results: the rate of positive surgical margins and biochemical relapse. The secondary outcomes were functional results: erectile function (EF) and urinary continence.

Evidence Synthesis: The rate of positive surgical margins differed considerably, from zero to 47%. The majority of authors found no correlation between NSS and a positive surgical margin rate. The rate of biochemical relapse ranged from 9.3% to 61%. Most of the articles lacked data on odds ratio (OR) for positive margin and biochemical relapse. The presented results showed no effect of nerve sparing (NS) on positive margin (OR=0.81, 0.6-1.09) or biochemical relapse (hazard ratio [HR]=0.93, 0.52-1.64). A strong association between NSS and potency rate was observed. Without NSS, between 0% and 42% of patients were potent, with unilateral 79-80%, with bilateral - up to 90-100%. Urinary continence was not strongly associated with NSS and was relatively good in both patients with and without NSS.

Conclusions: NSS may provide benefits for patients with urinary continence and significantly improves EF in high-risk patients. Moreover, it is not associated with an increased risk of relapse in short- and middle-term follow-up. However, the advantages of using such a surgical technique are unclear.
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http://dx.doi.org/10.23736/S0393-2249.20.04178-8DOI Listing
June 2021

A systematic review of nerve-sparing surgery for high-risk prostate cancer.

Minerva Urol Nephrol 2021 Jun 13;73(3):283-291. Epub 2021 Jan 13.

Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.

Introduction: We provide a systematic analysis of nerve-sparing surgery (NSS) to assess and summarize the risks and benefits of NSS in high-risk prostate cancer (PCa).

Evidence Acquisition: We have undertaken a systematic search of original articles using 3 databases: Medline/PubMed, Scopus, and Web of Science. Original articles in English containing outcomes of nerve-sparing radical prostatectomy (RP) for high-risk PCa were included. The primary outcomes were oncological results: the rate of positive surgical margins and biochemical relapse. The secondary outcomes were functional results: erectile function (EF) and urinary continence.

Evidence Synthesis: The rate of positive surgical margins differed considerably, from zero to 47%. The majority of authors found no correlation between NSS and a positive surgical margin rate. The rate of biochemical relapse ranged from 9.3% to 61%. Most of the articles lacked data on odds ratio (OR) for positive margin and biochemical relapse. The presented results showed no effect of nerve sparing (NS) on positive margin (OR=0.81, 0.6-1.09) or biochemical relapse (hazard ratio [HR]=0.93, 0.52-1.64). A strong association between NSS and potency rate was observed. Without NSS, between 0% and 42% of patients were potent, with unilateral 79-80%, with bilateral - up to 90-100%. Urinary continence was not strongly associated with NSS and was relatively good in both patients with and without NSS.

Conclusions: NSS may provide benefits for patients with urinary continence and significantly improves EF in high-risk patients. Moreover, it is not associated with an increased risk of relapse in short- and middle-term follow-up. However, the advantages of using such a surgical technique are unclear.
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http://dx.doi.org/10.23736/S0393-2249.20.04178-8DOI Listing
June 2021

Renal cancer with extensive level IV intracardiac tumour thrombus removed by robot.

Lancet 2020 11;396(10262):e88

Department of Cardiovascular Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

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http://dx.doi.org/10.1016/S0140-6736(20)32291-1DOI Listing
November 2020

Multiparametric magnetic resonance imaging facilitates reclassification during active surveillance for prostate cancer.

BJU Int 2021 06 10;127(6):712-721. Epub 2020 Dec 10.

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

Objective: To investigate the utility of multiparametric magnetic resonance imaging (mpMRI) in the reassessment and monitoring of patients on active surveillance (AS) for Grade Group (GG) 1 prostate cancer (PCa).

Patients And Methods: We identified, from our prospectively maintained institutional review board-approved database, 181 consecutive men enrolled on AS for GG 1 PCa who underwent at least one surveillance mpMRI followed by MRI/prostate biopsy (PBx). A subset analysis was performed among 68 patients who underwent serial (at least two) mpMRI/PBx during AS. Pathological progression (PP) was defined as upgrade to GG ≥2 on follow up biopsy.

Results: Baseline MRI was performed in 34 patients (19%). At a median follow-up of 2.2 years for the overall cohort, the PP was 12% (6/49) for Prostate Imaging Reporting and Data System (PI-RADS) 1-2 lesions and 37% (48/129) for the PI-RADS ≥3 lesions. The 2-year PP-free survival rate was 84%. Surveillance prostate-specific antigen density (P < 0.001) and surveillance PI-RADS ≥3 (P = 0.002) were independent predictors of PP on reassessment MRI/PBx. In the serial MRI cohort, the 2-year PP-free survival was 95% for the No-MRI-progression group vs 85% for the MRI-progression group (P = 0.02). MRI progression was significantly higher in the PP (62%) than in the No-PP (31%) group (P = 0.04). If serial MRI were used for PCa surveillance and biopsy were triggered based only on MRI progression, 63% of PBx might be postponed at the cost of missing 12% of GG ≥2 PCa in those with stable MRI. Conversely, this strategy would miss 38% of those with upgrading to GG ≥2 PCa on biopsy. Stable serial mpMRI correlates with no reclassification to GG ≥3 PCa during AS.

Conclusion: On surveillance mpMRI, PI-RADS ≥3 was associated with increased risk of PCa reclassification. Surveillance biopsy based only on MRI progression may avoid a large number of biopsies at the cost of missing many PCa reclassifications.
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http://dx.doi.org/10.1111/bju.15272DOI Listing
June 2021

Timing, Patterns and Predictors of 90-Day Readmission Rate after Robotic Radical Cystectomy.

J Urol 2021 02 9;205(2):491-499. Epub 2020 Oct 9.

USC Institute of Urology, Keck Medicine of USC, University of Southern California, Los Angeles, California.

Purpose: We examine the timing, patterns and predictors of 90-day readmission after robotic radical cystectomy.

Materials And Methods: From September 2009 to March 2017, 271 consecutive patients undergoing robotic radical cystectomy with intent to cure bladder cancer (intracorporeal diversion 253, 93%) were identified from our prospectively collated institutional database. Readmission was defined as any subsequent inpatient admission or unplanned visit occurring within 90 days from discharge after the index hospitalization. Multiple readmissions were defined as 2 or more readmissions within a 90-day period. Logistic regression analysis was used to identify independent factors related to single and multiple 90-day readmissions.

Results: A total of 78 (28.8%) patients were readmitted at least once within 90 days after discharge, of whom 20 (25.6%) reported multiple readmissions. The cumulative duration of readmission was 6.2 (6.17) days with 6 (7.6%) patients having less than 24 hours readmission. Metabolic, infectious, genitourinary and gastrointestinal complications were identified as the primary cause of readmission in 39.5%, 23.5%, 22.3% and 17%, respectively. Fifty percent of readmissions occurred in the first 2 weeks after hospital discharge. On multivariable logistic regression analysis in-hospital infections (OR 2.85, p=0.001) were independent predictors for overall readmission. Male gender (OR 3.5, p=0.02) and in-hospital infections (OR 4.35, p=0.002) were independent predictors for multiple readmissions.

Conclusions: The 90-day readmission rate following robotic radical cystectomy is significant. In-hospital infections and male gender were independent factors for readmission. Most readmissions occurred in the first 2 weeks following discharge, with metabolic derangements and infections being the most common causes.
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http://dx.doi.org/10.1097/JU.0000000000001387DOI Listing
February 2021

Web search queries and prostate cancer.

Lancet Oncol 2020 04 30;21(4):494-496. Epub 2020 Mar 30.

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 90089-2211, USA. Electronic address:

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http://dx.doi.org/10.1016/S1470-2045(20)30138-8DOI Listing
April 2020

Impact of radiomics on prostate cancer detection: a systematic review of clinical applications.

Curr Opin Urol 2020 11;30(6):754-781

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

Purpose Of Review: To systematically review the current literature to assess the role of radiomics in the detection and evaluation of prostate cancer (PCa).

Recent Findings: Radiomics involves the high-throughput extraction of radiologic features from clinical imaging, using a panel of sophisticated data-characterization algorithms to make an objective and quantitative determination of diagnoses and clinical characteristics. Radiomics evaluation of existing clinical images would increase their clinical value in many cancer management pathways, including PCa. However, a consensus on the implementation of radiomics has not been established across different sites, delaying its implementation in clinical practice. There are many potential advantages to radiomics. The ability to extract features from existing clinical imaging is one such advantage. A second is the empiric nature of the analysis. The third lies in the application of new technologies, such as machine learning, to be able to evaluate large quantities of data to make clinical conclusions. In this systematic review, we identify publications regarding the role of radiomics in PCa detection and evaluation. Many of these studies noted that radiomics, when incorporated into predictive models, had an advantageous impact on detection of PCa, clinically significant PCa, and extracapsular extension. This may assist in individualized decision making not only for diagnosis of PCa, but also for surveillance and surgical planning. With additional validation in large sample sizes, and randomized, multicenter studies using a consensus driven methodology, radiomics has the potential to alter the landscape of PCa detection and management, necessitating further prospective randomized investigation.

Summary: Radiomics is a promising new field, allowing for high-throughput analysis of imaging features for PCa detection and evaluation. These features can be extracted from existing data; therefore, the potential for future study is immense.
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http://dx.doi.org/10.1097/MOU.0000000000000822DOI Listing
November 2020

High Intensity Focused Ultrasound Hemigland Ablation for Prostate Cancer: Initial Outcomes of a United States Series.

J Urol 2020 10 8;204(4):741-747. Epub 2020 Sep 8.

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

Purpose: We report outcomes of hemigland high intensity focused ultrasound ablation as primary treatment for localized prostate cancer in the United States.

Materials And Methods: A total of 100 consecutive men underwent hemigland high intensity focused ultrasound (December 2015 to December 2019). Primary end point was treatment failure, defined as Grade Group 2 or greater on followup prostate biopsy, radical treatment, systemic therapy, metastases or prostate cancer specific mortality. IIEF (International Index of Erectile Function), I-PSS (International Prostate Symptom Score) and 90-day complications were reported.

Results: At study entry patients had very low (8%), low (20%), intermediate favorable (50%), intermediate unfavorable (17%) and high (5%) risk prostate cancer. Median followup was 20 months. The 2-year survival free from treatment failure, Grade Group 2 or greater recurrence, repeat focal high intensity focused ultrasound and radical treatment was 73%, 76%, 90% and 91%, respectively. Bilateral prostate cancer at diagnosis was the sole predictor for Grade Group 2 or greater recurrence (p=0.03). Of men who underwent posttreatment biopsy (58), 10 had in-field and 8 out-of-field Grade Group 2 or greater positive biopsy. Continence (zero pad) was maintained in 100% of patients. Median IIEF-5 and I-PSS scores before vs after hemigland high intensity focused ultrasound were 22 vs 21 (p=0.99) and 9 vs 6 (p=0.005), respectively. Minor and major complications occurred in 13% and 0% of patients. No patient had rectal fistula or died.

Conclusions: Short-term results of focal high intensity focused ultrasound indicate safety, excellent potency and continence preservation, and adequate short-term prostate cancer control. Radical treatment was avoided in 91% of men at 2 years. Men with bilateral prostate cancer at diagnosis have increased risk for Grade Group 2 or greater recurrence. To our knowledge, this is the initial and largest United States series of focal high intensity focused ultrasound as primary treatment for prostate cancer.
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http://dx.doi.org/10.1097/JU.0000000000001126DOI Listing
October 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

Quality Assessment of Intraoperative Adverse Event Reporting During 29 227 Robotic Partial Nephrectomies: A Systematic Review and Cumulative Analysis.

Eur Urol Oncol 2020 12 27;3(6):780-783. Epub 2020 May 27.

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

The definition of intraoperative adverse events (IAEs) still lacks standardization, hampering the assessment of surgical performance in this regard. Over the years, efforts to address this issue have been carried out to improve the reporting of outcomes. In 2019, the European Association of Urology (EAU) proposed a standardized reporting tool for IAEs in urology. The objective of the present study is to distill systematically published data on IAEs in patients undergoing robotic partial nephrectomy (RPN) for renal masses to answer three key questions (KQs). (KQ1) Which system is used to report the IAEs? (KQ2) What is the frequency of IAEs? (KQ3) What types of IAEs are reported? A comprehensive systematic review of all English-language publications on RPN was carried out. We followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines to evaluate PubMed, Scopus, and Web of Science databases (from January 1, 2000 to January 1, 2019). Quality of reporting and grading complications were assessed according to the EAU recommendations. Globally, 59 (35.3%) and 108 (64.7%) studies reported zero and one or more IAEs, respectively. Overall, 761 (2.6%) patients reported at least one IAE. Intraoperative bleeding is reported as the most common IAE (58%). Our analysis showed no improvement in reporting and grading of IAEs over time. PATIENT SUMMARY: Up to now, an agreement regarding the definition and reporting of intraoperative adverse events (IAEs) in the literature has not been achieved. The aim of this study is to evaluate the reporting of IAEs in patients undergoing robotic partial nephrectomy (RPN) after a systematic review of the literature. More rigorous reporting of IAEs during RPN is needed to measure their impact on patients' perioperative care.
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http://dx.doi.org/10.1016/j.euo.2020.04.003DOI Listing
December 2020
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