Apostolos P. Labanaris

Introduction: Transperineal prostate (TP) biopsy has emerged as a substantial alternative to the conventional transrectal (TR) approach for prostate sampling by its ability to sample specific areas of the prostate more effectively. The objective of this review is to conduct a comparative analysis of the current literature regarding diagnostic accuracy, complication rate and clinical outcome of transrectal vs. transperineal approaches in prostate biopsy-naïve patients and in repeated biopsy scenarios. Materials and Methods: An extensive search of the literature in PubMed, Scopus, and Web of Science was conducted between September 2010 and September 2024. We utilized a robust and comprehensive retrieval strategy including phrasing the two approaches as follows: (perineal or transperineal) and (rectal or transrectal). Conclusions: The transperineal and transrectal approaches show similar results in the detection of PCa in biopsy-naïve men, similar rates of infection, urinary retention and effectiveness managing biopsy-associated pain. However, in the rebiopsy scenario, the TP approach has demonstrated increased accuracy compared to the TR approach. This has significant implications in decision making and patient counselling.

Penile cancer (PeCa) is a rare urological malignancy characterized by significant geographical variations in both incidence and mortality rates. Due to its rarity and the consequent lack of randomized trials, current management is based on retrospective studies and small prospective trials. In addition, both the diagnostic pathways and treatment strategies exhibit substantial heterogeneity, differing significantly between less-developed and well-developed countries. The prognosis of PeCas is determined by the presence and extent of regional lymph node (LN) involvement. Therefore, the early detection and treatment of LN metastasis is paramount to ensure better outcomes. In recent decades, overall survival of PeCas has increased, mainly due to advancements in imaging techniques and risk stratification. We aim to provide an overview of the current role of PET CT imaging in the management of patients with PeCa.

Penile cancer (PeCa) is a rare urological malignancy characterized by significant geographic variations in both incidence and mortality rates. Due to its rarity and the consequent lack of randomized trials, current management is based on retrospective studies and small prospective trials. In addition, the diagnostic pathways and treatment strategies exhibit substantial heterogeneity, differing significantly between less developed and well-developed countries. The prognosis of PeCa is determined by the presence and extent of regional lymph node (LN) involvement. Therefore, early detection and treatment of LN metastasis is paramount to ensure better outcomes. In recent decades, the overall survival for PeCa has increased, mainly due to advancements in imaging techniques and risk stratification. We aim to provide an overview of the current role of PET CT imaging in the management of patients with PeCa.

Purpose Open ureteral reimplantation is considered the standard surgical approach to treat distal ureteral strictures or injuries. These procedures are increasingly performed in a minimally invasive and robotic-assisted manner. Notably, no series comparing perioperative outcomes and safety of the open vs. robotic approach are available so far. Methods In this retrospective multi-center study, we compared data from 51 robotic ureteral reimplantations (RUR) with 79 open ureteral reimplantations (OUR). Both cohorts were comparatively assessed using different baseline characteristics and perioperative outcomes. Moreover, a multivariate logistic regression for independent predictors was performed. Results Surgery time, length of hospital stay and dwell time of bladder catheter were shorter in the robotic cohort, whereas estimated blood loss, postoperative blood transfusion rate and postoperative complications were lower than in the open cohort. In the multivariate linear regression analysis, robotic approach was an independent predictor for a shorter operation time (coefficient – 0.254, 95% confidence interval [CI] – 0.342 to – 0.166; p < 0.001), a lower estimated blood loss (coefficient – 0.390, 95% CI – 0.549 to – 0.231, p < 0.001) and a shorter length of hospital stay (coefficient – 0.455, 95% CI – 0.552 to – 0.358, p < 0.001). Moreover, robotic surgery was an independent predictor for a shorter dwell time of bladder catheter (coefficient – 0.210, 95% CI – 0.278 to – 0.142, p < 0.001). Conclusion RUR represents a safe alternative to OUR, with a shorter operative time, decreased blood loss and length of hospital stay. Prospective research are needed to further define the extent of the advantages of the robotic approach over open surgery.

Introduction: Uretero–arterial fistula (UAF) represents a rare condition that manifests as massive or intermittent hematuria and requires collaboration between a urologist, vascular surgeon and interventional radiologist. In this article, we present our experience with UAF diagnosis, treatment pathways and the results of a nonsystematic review of the literature published in the last decade regarding modern diagnostic procedures. Material and method: We analyzed the clinical data of nine consecutive patients from our institution diagnosed with UAF in the interval of 2012–2022 who underwent open or endovascular surgical treatment. We reviewed patient characteristics, diagnoses and treatment pathways. The literature search resulted in 14 case series, published from 2012 to 2022, describing a total of 670 cases of UAF. Results: The mean age of patients in our cohort was 65.3 years (IQR: 51–79). UAFs were more common in women (77.7%). All patients presented a history of surgical intervention and ir-radiation for pelvic malignancy with permanent ureteric stenting. Overall, 88.8% of patients had urinary diversion, either via ileal conduit or cutaneous ureterostomy. The most common clinical manifestation of UAF was gross hematuria with or without clots accompanied by flank pain due to stent obstruction, while three patients presented with hypovolemic shock. Angiography represents the best option for diagnosis, followed by angioCT, with a sensitivity of 59.83% and 47.01%, respectively. There is no definitive imaging modality associated with high accuracy in detecting UAF and negative findings do not exclude the disease. In emergency cases with massive bleeding, surgical exploration remains the most appropriate management option for both diagnosis and treatment. Endovascular stent graft placement is preferred over open surgery in stable hemodynamic patients. Conclusions: Uretero–arterial fistulas represent a life-threatening complication and must be treated with great awareness. Angiography represents the best modality for diagnosis, followed by computed tomography. However, there is no definitive imaging modality and, in some cases, open approach remains the only option for diagnosis and treatment.

To examine whether an extended prostate biopsy (PB) scheme is associated with an improvement in the accuracy between the PB Gleason score (GS) and radical prostatectomy (RP) pathology and to identify probable preoperative variables that stratified patients likely to harbor significant upgrading (SU). A retrospective review of 538 patients' records diagnosed with prostate cancer (PCa) who underwent RP and exhibited a SU, at two tertiary medical centers, was conducted. The patients were divided into 3 groups: 194 who underwent a 6-core PB (36%), 156 who underwent a 12-core PB (28.9%) and 188 (34.9%) who underwent an 18-core PB. A multivariate analysis was conducted, including prostate-specific antigen (PSA) level, clinical stage, prostate size and duration from PB to RP. The 6-core group exhibited a 42.7% SU, the 12-core group exhibited a 38.8% SU and the 18-core group exhibited a 14.1% SU. There was a highly significant lower rate of SU in the 18-core than that in the 6-core (p35 g significantly elevated the probability of SU in the 6-core (p35 g in patients who undergo a 6- or 12-core PB is the only preoperative variable that stratifies patients likely to harbor SU.

The diagnosis of anterior prostate cancer (APC) is troublesome due to its anatomical location. Patients with an APC often require multiple sets of biopsies until diagnosis is made. The objective of this study is to examine if endorectal magnetic resonance imaging (e-MRI) of the prostate could improve the detection of APC. A retrospective review of 412 patients records with a clinical suspicion of prostate cancer (PCa) (prostate-specific antigen (PSA) levels >4 ng/ml or a suspicious finding on digital rectal examination (DRE)) who underwent conventional e-MRI (e-cMRI) and functional e-MRI (e-fMRI) of the prostate and subsequent prostate biopsy from April 2004 to July 2010 was conducted. All patients had a history of at least one prior negative set of prostate biopsy. Sixty-five percent (N=268) of patients' images were considered suspicious for PCa of which 53 (12.8%) cases were considered to be suspicious for APC (defined as the presence of PCa anterior to the urethra). All patients underwent an 18-core transrectal ultrasonography (TRUS)-guided biopsy of the peripheral zone and an additional 3-core TRUS-targeted biopsy anterior to the urethra. The median age and median PSA levels of the patients was 68.9 (range=56-72) years and 12.7 ng/ml (range=6.4-21.3), respectively. DRE was only positive in 6 patients (11.4%). The overall PCa detection rate was 90.5%. APC was detected through the targeted cores in 48 patients (90.5%). Seven patients (13.2%) exhibited a PCa of the peripheral zone as well. e-MRI-positive predictive value was 90.5%. e-MRI of the prostate has a high predictive value in detecting APC. Patients with a constant increase of PSA levels, negative DRE findings and prior negative sets of prostate biopsy are ideal candidates for e-MRI of the prostate and subsequent TRUS-targeted biopsies of possible suspicious anterior gland sites.

Introduction: The objective of this study is to evaluate the surgical, oncological and short-term functional outcomes in patients with a pathologic prostate specimen weight ≥100 g versus patients with a pathologic prostate specimen weight ≤50 g undergoing robot-assisted radical prostatectomy (RARP). Patients and Methods: The records of 4,000 men who underwent RARP from February 2006 to April 2012 were reviewed retrospectively. A total of 185 men had a pathologic prostate specimen weight ≥100 g (group A). A matched pairs analysis was performed using our database to identify men with a pathologic prostate specimen weight ≤50 g but with equivalent clinicopathologic characteristics to serve as the control group (group B). Results: Our results indicated that although the intraoperative results were more than satisfying in patients with large glands, there is a significant increase in blood loss, operative time needed, increased need for bladder neck reconstruction as well as an increase in intraoperative complications. Nevertheless, patients with large glands exhibit less aggressive tumors, less positive surgical margins and a lower incidence of biochemical recurrence. Regarding functional outcomes, patients with larger glands had no difference regarding continence rates when compared to patients with smaller glands but exhibited significantly lower potency rates. Conclusions: Although RARP in patients with a pathologic prostate specimen weight ≥100 g is technically challenging, in experienced hands it can be considered a safe procedure with excellent surgical, oncological and functional outcomes. Nevertheless, this conclusion is limited, in that it is from a single institution with a large case volume and may not be reflective of outcomes at centers with smaller volumes and less experience.

Peritoneal dissemination of prostate cancer (PCa) with the absence of other metastases is extremely rare. Atypical sites of metastatic disease, for example the peritoneum, are only a recognized finding at autopsy. Herein, we report a case of peritoneal dissemination of a PCa, with the absence of lymph node, skeletal, or visceral metastases in a patient scheduled to undergo robot-assisted laparoscopic prostatectomy.

Prune-Belly syndrome is a disorder characterized by the following triad of symptoms: deficiency of the abdominal muscles, malformations of the urinary tract and bilateral cryptorchidism. This study included a total of 16 patients. The findings included clinical characteristics, diagnostics, therapy and long-term clinical outcomes. All patients were asked to complete a questionnaire and, in some cases, were given further examination. All patients were diagnosed with congenital aplasia of the abdominal wall and a variety of urogenital malformations. Cryptorchidism was present in 11 patients (68.8%), malformations of the prostate in 3 (18.8%), urethral malformations in 8 (50%) and mega-ureter in 14 patients (87.5%). A mega-bladder was observed in 13 patients (81.3%). Distinctive renal malformations, such as renal dysplasia, in 3 patients (18.8%) and hydronephrosis in 9 patients (56.3%), respectively. Abdominoplasty was performed on 4 patients (25%). Urethral surgery was performed in 10 patients (62.5%). Seven patients (43.8%) required ureter surgery, most of which involved re-implantation of the ureter and, in some cases, additional ureter modeling. Renal surgery was performed on 5 patients. Four patients with non-functioning kidneys with hydronephrosis underwent a nephrectomy and one patient pyeloplasty. We demonstrate that successful treatment is possible even in cases of serious and complex malformations, such as those of the Prune-Belly syndrome. Treatment must be tailored to the individual patient. The severity of the renal dysplasia is the main prognostic factor.