Archivio Italiano di Urologia e Andrologia - Vol. 95 - n. 4 - 2023 by Edizioni Scripta Manent

ISSN 1124-3562

Vol. 95; n. 4, December 2023 ORIGINAL PAPERS 11723 Endophytic to total tumour volume ratio: An added variable to patients with T1b/T2 renal tumours undergoing partial nephrectomy Asmaa Ismail, Vahid Mehrnoush, Amer Alaref, Radu Rozenberg, Hazem Elmansy, Walid Shahrour, Nishigandha Burute, Anatoly Shuster, Owen Prowse, Ahmed Zakaria, Walid Shabana, Ahmed Kotb

11852 Feasibility study of a novel robotic system for transperitoneal partial nephrectomy: An in vivo experimental animal study Solon Faitatziadis, Vasileios Tatanis, Paraskevi Katsakiori, Angelis Peteinaris, Kristiana Gkeka, Athanasios Vagionis, Theodoros Spinos, Arman Tsaturyan, Theofanis Vrettos, Panagiotis Kallidonis, Jens-Uwe Stolzenburg, Evangelos Liatsikos

12130 Oncological and functional outcomes of patients who underwent open partial nephrectomy for kidney tumor

Efe Bosnali, Enes Abdullah Baynal, Naci Burak Cinar, Enes Malik Akdas, Engin Telli, Bu ̈sra Yaprak Bayrak, Kerem Teke, Hasan Yilmaz, Ozdal Dillioglugil, Onder Kara

11830 Predictors of prostate cancer cetection in MRI PI-RADS 3 lesions – Reality of a terciary center

Débora Araújo, Alexandre Gromicho, Jorge Dias, Samuel Bastos, Rui Miguel Maciel, Ana Sabença, Luís Xambre

12138 The bladder neck preservation in robot assisted radical prostatectomy: Surgical and pathological outcome Michele Zazzara, Marina P. Gardiman, Fabrizio Dal Moro

11897 Salvage cryotherapy for prostate cancer

Duarte Vieira e Brito, Jose Alberto Pereira, Ana Maria Ferreira, Mario Lourenço, Ricardo Godinho, Bruno Pereira, Pedro Peralta, Paulo Conceiçao, Mario Reis, Carlos Rabaça

11514 Immunohistochemical expression of androgen receptors in urothelial carcinoma of urinary bladder. Is it significant? Experience from coastal India Disha Jindal, Pooja K Suresh, Saraswathy Sreeram, Ramesh Holla, Hema Kini, Sridevi HB, Amanda Christina Pinto

12108 Parastomal hernia after radical cystectomy. Incidence, natural history and predictive factors – A single center study

María Alonso Grandes, José Antonio Herranz Yagu ̈e, Rocío Roldán Testillano, Alfonso María Márquez Negro, Casilda Cernuda Pereira, Emilio Andrés Ripalda Ferretti, Álvaro Páez Borda

11642 Treatment results of Para-Testicular Rhabdomyosarcoma (PT-RMS) using radiation as an alternative to retro-peritoneal nodal dissection: A single Institution experience Yasser A. Abdelazim, Monika F. Zaki, Mohsen M. Abdel Mohsen, Reem M. Emad, Heba G. Mohamad, Dalia Abdelfatah, Ehab M. Kalil

11629 Evaluation of bipolar Transurethral Enucleation and Resection of the Prostate in terms of efficiency and patient satisfaction compared to retropubic open prostatectomy in prostates larger than 80 cc. A prospective randomized study Ibrahim Tagreda, Mahmoud Heikal, Adel Elatreisy, Mohamed Fawzy Salman, Ahmed Mohamed Soliman, Ayman Kotb Koritenah, Hesham Abozied, Mohamed Ibrahim Algammal, Ahmed A. Alrefaey, Mohamed Elsalhy, Mohamed Shehab, Mahmoud Mohammed Ali, Aly Gomaa Eid, Abdrabuh M. Abdrabuh, Sayed Eleweedy

12026 Evaluation of Rezum therapy as a minimally invasive modality for management of Benign Prostatic Hyperplasia: A prospective observational study Tamer A. Abouelgreed, Ayman K. Koritenah, Yasser Badran, Ibrahim Tagreda, Mohamed Algammal, Hesham Abozied, Hany A. Eldamanhory, Hossam A. Shouman, Abdelhamid A. Khattab, Munira Ali, Mohammad Thabet Alnajem, Ahmed A. Abdelwahed

11868 The role of irrigation fluid in transurethral resection of the prostate outcomes and surgeon performance Federico Romantini, Daniela Biferi, Guevar Maselli, Federico Narcisi, Maurizio Ranieri, Luca Topazio

12102 Effect of preoperative ureteral stenting on the surgical outcomes of patients with 1-2 cm renal stones managed by retrograde intrarenal surgery using a ureteral access sheath Tamer A. Abouelgreed, Mohamed A. Elhelaly, El-Sayed I. El-Agamy, Rasha Ahmed, Yasser M. Haggag, M. Abdelwadood, Salma F. Abdelkader, Sameh S. Ali, Naglaa M. Aboelsoud, Mosab F. Alassal, Gehad A. Bashir, Tarek Gharib

11691 Study the mRNA level of IL-27/IL-27R pathway molecules in kidney transplant rejection Aftab Karimi, Ramin Yaghobi, Jamshid Roozbeh, Zahra Rahimi, Afsoon Afshari, Zahra Akbarpoor, Mojdeh Heidari continued on page III

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Official Journal of SIEUN, UrOP, SSCU and GUN

EDITORIAL BOARD EDITOR IN CHIEF Alberto Trinchieri (Milan, Italy)

ASSOCIATE EDITORS Emanuele Montanari, Department of Urology, IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Italy – Gianpaolo Perletti, Department of Biotechnology and Life Sciences, Section of Medical and Surgical Sciences, University of Insubria, Varese, Italy; Department of Human Structure and Repair, Ghent University, Ghent, Belgium - Angelo Porreca, Robotic Urology and Mini Invasive Urologic Surgery Unit, Abano Terme Hospital, Abano Terme, Italy EXECUTIVE EDITORIAL BOARD Alessandro Antonelli, Department of Urology, Azienda Ospedaliera Universitaria Integrata (A.O.U.I.), Verona, Italy - Antonio Celia, Department of Urology, San Bassiano Hospital, Bassano del Grappa, Italy - Luca Cindolo, Department of Urology, Villa Stuart Hospital, Rome, Italy - Andrea Minervini, Department of Urology, University of Florence, Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy - Bernardo Rocco, Department of Urology, University of Modena and Reggio Emilia, Modena, Italy - Riccardo Schiavina, Department of Urology, University of Bologna, Bologna, Italy ADVISORY EDITORIAL BOARD Pier Francesco Bassi, Urology Unit, A. Gemelli Hospital, Catholic University of Rome, Italy – Francesca Boccafoschi, Health Sciences Department, University of Piemonte Orientale in Novara, Italy – Alberto Bossi, Department of Radiotherapy, Gustave Roussy Institute, Villejuif, France –Tommaso Cai, S. Chiara Hospital, Trento, Italy – Paolo Caione, Department of Nephrology-Urology, Bambino Gesù Pediatric Hospital, Rome, Italy – Luca Carmignani, Urology Unit, San Donato Hospital, Milan, Italy – Liang Cheng, Department of Urology, Indiana University School of Medicine, Indianapolis, IN; Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN – Giovanni Colpi, Retired Andrologist, Milan, Italy – Giovanni Corona, Department of Urology, University of Florence, Careggi Hospital, Florence, Italy – Antonella Giannantoni, Department of Surgical and Biomedical Sciences, University of Perugia, Italy – Paolo Gontero, Department of Surgical Sciences, Molinette Hospital, Turin, Italy – Steven Joniau, Organ Systems, Department of Development and Regeneration, KU Leuven, Belgium – Frank Keeley, Bristol Urological Institute, Southmead Hospital, Bristol UK – Laurence Klotz, Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada – Börje Ljungberg, Urology and Andrology Unit, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden – Nicola Mondaini, Uro-Andrology Unit, Santa Maria Annunziata Hospital, Florence, Italy – Gordon Muir, Department of Urology, King's College Hospital, London, UK – Giovanni Muto, Urology Unit, Bio-Medical Campus University, Turin, Italy – Anup Patel, Department of Urology, St. Mary's Hospital, Imperial Healthcare NHS Trust, London, UK – Glenn Preminger, Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA – David Ralph, St. Peter's Andrology Centre and Institute of Urology, London, UK – Allen Rodgers, Department of Chemistry, University of Cape Town, Cape Town, South Africa – Francisco Sampaio, Urogenital Research Unit, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil – Kemal Sarica, Department of Urology, Kafkas University Medical School, Kars, Turkey – Luigi Schips, Department of Urology, San Pio da Pietrelcina Hospital, Vasto, Italy – Hartwig Schwaibold, Bristol Urological Institute, Southmead Hospital, Bristol, UK – Alchiede Simonato, Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy – Carlo Terrone, Department of Urology, IRCCS S. Martino University Hospital, Genova, Italy – Anthony Timoney, Bristol Urological Institute, Southmead Hospital, Bristol, UK – Andrea Tubaro, Urology Unit, Sant’Andrea Hospital, “La Sapienza” University, Rome, Italy – Richard Zigeuner, Department of Urology, Medical University of Graz, Graz, Austria BOARD OF REVIEWERS Maida Bada, Department of Urology, S. Pio da Pietrelcina Hospital, ASL 2 Abruzzo, Vasto, Italy - Lorenzo Bianchi, Department of Urology, University of Bologna, Bologna, Italy - Mariangela Cerruto, Department of Urology, Azienda Ospedaliera Universitaria Integrata (A.O.U.I.), Verona, Italy - Francesco Chessa, Department of Urology, University of Bologna, Bologna, Italy - Daniele D’Agostino, Robotic Urology and Mini In-

vasive Urologic Surgery Unit, Abano Terme Hospital, Abano Terme, Italy - Fabrizio Di Maida, Department of Urology, University of Florence, Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy - Antonio Galfano, Urology Unit, Niguarda Hospital, Milan, Italy - Michele Marchioni, Department of Medical, Oral and Biotechnological Sciences, "G. d'Annunzio" University of Chieti, Laboratory of Biostatistics, Chieti, Italy - Andrea Mari, Department of Urology, University of Florence, Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy - Luigi Napolitano, Unit of Urology, Department of Neurosciences, Reproductive Sciences, and Odontostomatology University of Naples “Federico II”, Naples, Italy - Antonio Porcaro, Department of Urology, Azienda Ospedaliera Universitaria Integrata (A.O.U.I.), Verona, Italy - Stefano Puliatti, Department of Urology, University of Modena and Reggio Emilia, Modena, Italy - Daniele Romagnoli, Robotic Urology and Mini Invasive Urologic Surgery Unit, Abano Terme Hospital, Abano Terme, Italy - Chiara Sighinolfi, Department of Urology, University of Modena and Reggio Emilia, Modena, Italy - Tommaso Silvestri, Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy - Petros Sountoulides, Aristotle University of Thessaloniki, Department of Urology, Thessaloniki, Greece - Alessandro Tafuri, Department of Urology, Vito Fazzi Hospital, Lecce, Italy SIEUN EDITOR Pasquale Martino, Department of Emergency and Organ Transplantation-Urology I, University Aldo Moro, Bari, Italy SIEUN EDITORIAL BOARD Emanuele Belgrano, Department of Urology, Trieste University Hospital, Trieste, Italy Francesco Micali, Department of Urology, Tor Vergata University Hospital, Rome, Italy Massimo Porena, Urology Unit, Perugia Hospital, Perugia, Italy – Francesco Paolo Selvaggi, Department of Urology, University of Bari, Italy – Carlo Trombetta, Urology Clinic, Cattinara Hospital, Trieste, Italy – Giuseppe Vespasiani, Department of Urology, Tor Vergata University Hospital, Rome, Italy – Guido Virgili, Department of Urology, Tor Vergata University Hospital, Rome, Italy UrOP EDITOR Carmelo Boccafoschi, Department of Urology, Città di Alessandria Clinic, Alessandria, Italy UrOP EDITORIAL BOARD Renzo Colombo, Department of Urology, San Raffaele Hospital, Milan, Italy – Roberto Giulianelli, Department of Urology, New Villa Claudia, Rome, Italy – Massimo Lazzeri, Department of Urology, Humanitas Research Hospital, Rozzano (Milano), Italy – Angelo Porreca, Department of Urology, Polyclinic Abano Terme, Abano Terme (Padova), Italy – Marcello Scarcia, Department of Urology, "Francesco Miulli" Regional General Hospital, Acquaviva delle Fonti (Bari), Italy – Nazareno Suardi, Department of Urology, San Raffaele Turro, Milano, Italy. GUN EDITOR Arrigo Francesco Giuseppe Cicero, Medical and Surgical Sciences Department, Sant’Orsola-Malpighi University Hospital, Bologna, Italy GUN EDITORIAL BOARD Gianmaria Busetto, Department of Urology, Sapienza University of Rome, Italy – Tommaso Cai, Department of Urology, Santa Chiara Regional Hospital, Trento, Italy – Elisabetta Costantini, Andrology and Urogynecological Clinic, Santa Maria Hospital of Terni, University of Perugia, Terni, Italy – Angelo Antonio Izzo, Department of Pharmacy, University of Naples, Italy – Vittorio Magri, ASST Nord Milano, Milano, Italy – Salvatore Micali, Department of Urology, University of Modena and Reggio Emilia, Modena, Italy – Gianni Paulis, Andrology Center, Villa Benedetta Clinic, Rome, Italy – Francesco Saverio Robustelli della Cuna, University of Pavia, Italy – Giorgio Ivan Russo, Urology Department, University of Catania, Italy – Konstantinos Stamatiou, Urology Department, Tzaneio Hospital, Piraeus, Greece – Annabella Vitalone, Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy

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ORIGINAL PAPERS 11978 Brucella epididymo-orchitis: A single-center experience with a review of the literature Rawa Bapir, Ahmed Mohammed Abdalqadir, Esmaeel Aghaways, Hemn Hussein Bayz, Hiwa O. Abdullah, Shaho F. Ahmed, Berun A. Abdalla, Jihad Ibrahim Hama, Bryar Othman Muhammed, Karokh Fadhil Hamahussein, Farman Mohammed Faraj, Fahmi Hussein Kakamad

11869 Relation between myostatin levels and malnutrition and muscle wasting in hemodialysis patients Amal H. Ibrahim, Sammar A. Kasim, Alshimaa A. Ezzat, Noha E. Ibrahim, Donia A. Hassan, Amira Sh. Ibrahim, Tamer A. Abouelgreed, Ehab M. Abdo, Naglaa M. Aboelsoud, Nermeen M. Abdelmonem, Mohammad Thabet Alnajem, Ahmed A. Aboomar

12128 The effect untreated right subclinical varicocele on the outcomes of contralateral left clinical varicocelectomy in infertile patients Sevgin Yılmaz, Murat Topcuoğlu, Murat Çakan, Ali Akkoç, Murat Uçar

11906 Seminal calbindin 2 level in azoospermia and oligoasthenoteratozoospermia and its correlation with seminal and hormonal parameters Sameh Fayek GamalEl Din, Noha Abdelhafeez Abdelkader, Mohamed Yousry El-Amir, Asmaa Anter Sayed Ahmed, Hesham Fouad Abdel-latif, Mohamed Farag Azmy

11593 Effects of testosterone replacement on lipid profile, hepatotoxicity, oxidative stress, and cognitive performance in castrated wistar rats Oumayma Boukari, Wahid Khemissi, Soumaya Ghodhbane, Aida Lahbib, Olfa Tebourbi, Khemais Ben Rhouma, Mohsen Sakly, Dorsaf Hallegue

11669 Autologous mesenchymal stem cell therapy for diabetic men with erectile dysfunction. Is it promising? A pilot study Mohamed A. Alhefnawy, Emad Salah, Sayed Bakry, Taymour M. Khalifa, Alaa Rafaat, Refaat Hammad, Ali Sobhy, Ahmed Wahsh

12155 The role of the general practictioner in the management of urinary calculi Domenico Prezioso, Gaetano Piccinocchi, Veronica Abate, Michele Ancona, Antonio Celia, Ciro De Luca, Riccardo Ferrari, Pietro Manuel Ferraro, Stefano Mancon, Giorgio Mazzon, Salvatore Micali, Giacomo Puca, Domenico Rendina, Alberto Saita, Salvetti Andrea, Andrea Spasiano, Elisa Tesèe, Alberto Trinchieri

SYSTEMATIC REVIEWS 12049 The prophylactic omentectomy procedure in reducing the complication rate of continuous ambulatory peritoneal dialysis in pediatric: A systematic review and meta-analysis GedeWirya Kusuma Duarsa, Ronald Sugianto, Pande Made Wisnu Tirtayasa, Ni Made Apriliani Saniti, Komang Harsa Abhinaya Duarsa

12018 A systematic review and meta-analysis on the efficacy of preoperative renal artery embolization prior to radical nephrectomy for renal cell carcinoma: Is it necessary? Gullyawan Rooseno, Lukman Hakim, Tarmono Djojodimedjo

LETTERS TO EDITOR 12003 New minimally invasive solutions for Benign Prostatic Obstruction (BPO) management: A position paper from the UrOP (Urologi Ospedalita ̀ Gestione Privata)

Rosario Leonardi, Francesca Ambrosini, Rafaela Malinaric, Angelo Cafarelli, Alessandro Calarco, Renzo Colombo, Ottavio de Cobelli, Ferdinando De Marco, Giovanni Ferrari, Giuseppe Ludovico, Stefano Pecoraro, Domenico Tuzzolo, Carlo Terrone, Guglielmo Mantica

12118 National consensus survey on management approaches for upper urinary tract obstruction: A comparative analysis of retrograde ureteric stent and percutaneous nephrostomy Vasco Quaresma, Francisca Magalhães, Lorenzo Marconi, João Lima, Manuel Lopes, Ana-Marta Ferreira, Pedro Nunes, Arnaldo Figueiredo

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DOI: 10.4081/aiua.2023.11723

ORIGINAL PAPER

Endophytic to total tumour volume ratio: An added variable to patients with T1b/T2 renal tumours undergoing partial nephrectomy Asmaa Ismail 1, Vahid Mehrnoush 1, Amer Alaref 2, Radu Rozenberg 2, Hazem Elmansy 1, Walid Shahrour 1, Nishigandha Burute 2, Anatoly Shuster 2, Owen Prowse 1, Ahmed Zakaria 1, Walid Shabana 1, Ahmed Kotb 1 1 Urology Department, TBRHSC, Northern Ontario School of Medicine University, Thunder Bay, ON, Canada;

2 Radiology Department, TBRHSC, Northern Ontario School of Medicine University, Thunder Bay, ON, Canada.

the last 15 years (7, 8). The scoring system may be beneficial to in patients’ counselling about complexity of surgery and the anticipated success/ failure rate of PN. In daily practice, PN is attempted as the standard of care for small renal masses, regardless of the tumour’s complexity. The aim of this study is to look for the endophytic to total tumour volume ratio as an added variable to study the complexity of partial nephrectomy to patients with T1b/T2 renal tumours.

Summary

Introduction: Partial nephrectomy is the standard of care to patients with small renal masses. It is still encouraged to larger tumours whenever feasible. The aim of this study is to look for the endophytic to total tumour volume ratio as an added variable to study the complexity of partial nephrectomy to patients with T1b/ T2 renal tumours. Methods: Retrospective data collection of patients that had partial nephrectomy for T1b/T2 renal tumours by a single surgeon was done. Radiological re-assessment for the CT images to measure the endophytic to total tumour volume ratio was done. Results: The mean age of the patients was 63 years. The study included 25 males and 11 females. All cases were managed by open surgery using retroperitoneal transverse lateral lumbotomy and warm ischemia was used in all patients. The mean tumour volume was 74 cc, the mean endophytic tumour volume was 29 cc. The mean percentage of endophytic to total tumour volume was 42%. Conclusions: Partial nephrectomy is safe for most of the patients with good performance status, having large renal masses. More complex surgery can be predicted in patients with endophytic to total tumour volume greater than 42%.

METHODS

Retrospective data collection for patients managed by partial nephrectomy, by a single surgeon (AK) for clinically T1b/T2 renal in 2018-2020. Radiologists were provided with the patients’ list for the aim of the study and calculation of the tumour endophytic volume and the percentage of the endophytic volume to the total volume was calculated. The whole tumor volume was calculated by using this equation: Antero-posterior x transverse x craniocaudal dimensions multiplied by 0.52. The area tool was then used to calculate the total tumor as well as to calculate the endophytic tumor component which lies within the kidney. The ratio endophytic to total tumor ratio was calculated by dividing the endophytic component to the whole tumor area. The endophytic component was identified by drawing a line through the tumour to complete the border of the kidney. Figure 1 illustrates the markings. Institutional ethical approval was obtained. Patients’ consent for publishing was obtained as well. Surgery was always started by full mobilization of the kidney and dissection of the renal pedicle regardless of the tumour location. Tumour was identified. Fat covering the tumour was left intact but margins of the tumour at contact with the kidney was cleared of fat. Fat in this region was always sent separately for pathological analysis. After tumour edges are all clearly seen, monopolar cautery was used on the renal capsule 5-10 mm beyond the tumour edge for marking without cutting deeply into the kidney parenchyma. After that, the vascular clamp was used over the artery and vein and deep cutting with the monopolar

KEY WORDS: RCC; Partial nephrectomy; Tumour volume. Submitted 6 September 2023; Accepted 28 September 2023

INTRODUCTION

Partial nephrectomy (PN) is currently accepted as the standard of care for most localized kidney cancer. The American society of clinical oncology defines partial nephrectomy as the standard of care for patients with T1a kidney mass (1). American Urology association guidelines (2021) confirm PN to be the preferred treatment for patients with T1a solid/complex cystic renal tumours (2). Canadian urology association guidelines recommend partial nephrectomy for treatment of tumours 2-4 cm in diameter (3). Most recent European guidelines (2022) (4) recommend PN whenever feasible for T1 tumours, raising the bar to tumours up to 7 cm in diameter. Some studies did show the feasibility of PN for T2 renal tumours (5, 6). Renal scoring systems were emerged and validated over

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11723

A. Ismail, V. Mehrnoush, A. Alaref, et al.

Figure 1. Calculation of the tumour endophytic volume and the percentage of the endophytic volume to the total volume. The endophytic component was identified by drawing a line through the tumour to complete the border of the kidney.

patients. Over a median follow up of 3 years, disease and recurrence free survival was 100%. Figure 2 shows a case with a tumour diameter of 4.2 cm involving the right lower renal pole. The endophytic to total tumour volume was 39%. The case was successfully managed by PN, under warm ischemic time of 10 minutes. Single patient had significant hematuria and drop in Hgb few weeks after surgery. Pseudoaneurysm was identified and clamping by the interventional radiology team was safely done. That patient had endophytic to total tumour volume of 79%. Figure 2. Figure shows a case with a tumour diameter of 4.2 cm involving the right lower renal pole. The endophytic to total tumour volume was 39%.

cautery mixed with mobilizing the wedge having the tumour away with an empty blade handle till tumour with normal parenchymal margin was completely removed. We repair collecting system if encountered. We then use the monopolar cautery spray to cauterize the parenchymal edges before repair. Vicryl 0 was then used to take multiple deep interrupted transverse mattress sutures. Once satisfied, the whole sutures are tied and the vascular clamp is removed. We usually cover the renorrhaphy with a large piece of surgicel leave a drain for 48 hours. The patient was usually discharged on the morning of the third postoperative day.

DISCUSSION

In patients with adequate performance status, PN should be always attempted. All guidelines agree on that for T1a tumours, and some guidelines and many publications extend the recommendation to T1b/ T2 tumours. Scoring systems were introduced and validated to help the decision making and patients’ counselling. Efforts were ongoing to identify adding parameters to predict the success of PN. Sciorio et al. (2020) identified MIC (surgical margin, ischemic time, and complications) as a parameter that could mark the success of the surgery. In their study. Low MIC was correlated to high PADUA score and large tumour diameter (10). Tumour volume and specifically the endophytic tumour volume was not widely studied. Tiwari et al. (11) studied 87 patients that underwent PN for T1a renal mass and found a positive correlation between the endophytic tumour volume and nephrometry score. Mohammadi et al. (12) published a case report for a successful PN to 17 cm renal mass. While they did not measure the tumour volume in their study, the CT images they published clearly showed very low ratio of endophytic to total tumour volume. To our knowledge, this is the first study looking for the percentage of endophytic to total tumour volume in patients that underwent PN for T1b/T2 renal masses. In our hands, PN was safe for such large renal tumours in

RESULTS

Thirty-six patients were identified fulfilling our criteria. The mean age of the patients was 63 years. The study included 25 males and 11 females. All cases were managed by open surgery using retroperitoneal transverse lateral lumbotomy (9). Warm ischemia was applied to all cases, clamping both the renal artery and the vein. The mean ischemic time was 9 minutes. No case required intra or postoperative blood transfusion. No case was changed to radical nephrectomy. Thirty-two cases had solid tumour and 4 had Bosniak 3/4 renal cysts. The mean tumour diameter was 5.5 cm, ranging from 4.2 to 10 cm. The mean tumour volume was 74 cc, the mean endophytic tumour volume was 29 cc. The mean percentage of endophytic to total tumour volume was 42%. Endophytic to total tumour volume of > 42% was found to be associated with longer mean operative time (90 minutes versus 50 minutes. P 0.01) and more mean blood loss (200 versus 50 ml. P 0.02). Renal cell carcinoma (RCC) was the pathological diagnosis of all patients, but one case had angiomyolipoma (AML). Fortunately, positive surgical margin was only seen in the patient having AML. Pathological T3 was identified in 5

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11723

Endophytic to total tumour volume ratio

medically fit patients. We must disclose that this study did not include patients with similar or smaller tumour mass that we elected to do radical nephrectomy because of their poor performance status that we felt PN may be an added risk to them. In our experience, the patients’ performance status and comorbidities were the main factors we consider when offering partial versus radical nephrectomy. While all cases that had PN for large renal masses were successful, cases that had larger endophytic to total tumour volume had significantly longer operative time and blood loss.

12. Mohammadi A, Aghamir SMK. Partial nephrectomy of a huge solid-cystic renal mass with final pathology of renal cell carcinoma. J Surg Case Rep. 2022; 2022:rjab622.

CONCLUSIONS

Partial nephrectomy is a safe treatment option that should be attempted in most of the patients with good performance status regardless of the tumour size. Endophytic to total tumour volume is an added parameter to consider for surgical planning. Endophytic to total tumour volume ratio of greater than 0.42 was associated with longer operative time and more blood loss in patients with T1b/T2 tumours undergoing partial nephrectomy.

REFERENCES

1. Finelli A, Ismaila N, Bro B, et al. Management of Small Renal Masses: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017; 35:668-680. 2. Campbell SC, Clark PE, Chang SS, et al. Renal Mass and Localized Renal Cancer: Evaluation, Management, and Follow-Up: AUA Guideline: Part I. J Urol. 2021; 206:199-208. Correspondence Asmaa Ismail, MD asmaaismail0782@gmail.com Vahid Mehrnoush, MD vahidmehrnoush7@gmail.com Hazem Elmansy, MD hazem.mansy@rocketmail.com Walid Shahrour, MD Walid.shahrour@gmail.com Owen Prowse, MD owen.prowse@tbh.net Ahmed Zakaria, MD aszakaria81@yahoo.com Walid Shabana, MD Waleed.shabana@gmail.com Ahmed Kotb, MD, FRCSC, FRCS Urol, FEBU (Corresponding Author) Associate Professor drahmedfali@gmail.com Urology Department, TBRHSC, Northern Ontario School of Medicine University - 980 Oliver Road, Thunder Bay, ON, Canada. P7B 6V4

3. Richard PO, Violette PD, Bhindi B, et al. Canadian Urological Association guideline: Management of small renal masses - Full-text. Can Urol Assoc J. 2022; 16:E61-E75. 4. Ljungberg B, Albiges L, Abu-Ghanem Y, et al. European Association of Urology Guidelines on Renal Cell Carcinoma: The 2022 Update. Eur Urol. 2022; 82:399-410. 5. Nahar B, Gonzalgo ML. What is the current role of partial nephrectomy for T2 tumors? Can J Urol. 2017; 24:8698-8704. 6. Sharafeldeen M, Sameh W, Mehrnoush V, et al. Partial Nephrectomy for T1b/T2 Renal Mass: An Added Shift from Radical Nephrectomy. J Kidney Cancer VHL. 2022; 9:1-5. 7. Kutikov A, Uzzo RG. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol. 2009; 182:844-53. 8. Kriegmair MC, Mandel P, Moses A, et al. Defining Renal Masses: Comprehensive Comparison of RENAL, PADUA, NePhRO, and CIndex Score. Clin Genitourin Cancer. 2017; 15:248-255.e1.

Amer Alaref, MD Amer.Alaref@tbh.net Radu Rozenberg, MD Radu.Rozenberg@tbh.net Nishigandha Burute, MD nishirad@gmail.com Anatoly Shuster, MD shustera@tbh.net Radiology Department, TBRHSC, Northern Ontario School of Medicine University, Thunder Bay, ON, Canada

9. Ismail A, Oquendo F, Allard-Ihala E, et al. Transverse Lumbotomy for Open Partial/Radical Nephrectomy: How I Do It. Urol Int. 2020; 104:131-134. 10. Sciorio C, Prontera PP, Scuzzarella S, et al. Predictors of surgical outcomes of retroperitoneal laparoscopic partial nephrectomy. Arch Ital Urol Androl. 2020; 92:165. 11. Tiwari RV, Ho CM, Huang HH, et al. Role of computed tomography-calculated intraparenchymal tumor volume in assessment of patients undergoing partial nephrectomy. Int J Urol. 2018; 25:436441.

Conflict of interest: The authors declare no potential conflict of interest.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11723

DOI: 10.4081/aiua.2023.11852

ORIGINAL PAPER

Feasibility study of a novel robotic system for transperitoneal partial nephrectomy: An in vivo experimental animal study Solon Faitatziadis 1, Vasileios Tatanis 1, Paraskevi Katsakiori 1, Angelis Peteinaris 1, Kristiana Gkeka 1, Athanasios Vagionis 1, Theodoros Spinos 1, Arman Tsaturyan 1, 2, Theofanis Vrettos 3, Panagiotis Kallidonis 1, Jens-Uwe Stolzenburg 4, Evangelos Liatsikos 1, 5 1 Department of Urology, University of Patras, Patras, Greece;

2 Department of Urology, Erebouni Medical Center, Yerevan, Armenia;

3 Department of Anesthesiology and ICU, University of Patras, Patras, Greece; 4 Department of Urology, University Hospital of Leipzig, Leipzig, Germany; 5 Department of Urology, Medical University of Vienna, Vienna, Austria.

Summary

Purpose: To evaluate the safety and feasibility of partial nephrectomy with the use of the novel robotic system in an in vivo animal model. Methods: Right partial nephrectomy was performed in female pigs by a surgical team consisting of one surgeon and one bedside assistant. Both were experienced in laparoscopic surgery and trained in the use of the novel robotic system. The partial nephrectomies were performed using four trocars (three trocars for the robotic arms and one as an assistant trocar). The completion of the operations, set-up time, operation time, warm ischemia time (WIT) and complication events were recorded. The decrease in all variables between the first and last operation was calculated. Results: In total, eight partial nephrectomies were performed in eight female pigs. All operations were successfully completed. The median set-up time was 19.5 (range, 15-30) minutes, while the estimated median operative time was 80.5 minutes (range, 59-114). The median WIT was 23.5 minutes (range, 17-32) and intra- or postoperative complications were not observed. All variables decreased in consecutive operations. More precisely, the decrease in the set-up time was calculated to 15 minutes between the first and third attempts. The operative time was reduced by 55 minutes between the first and last operation, while the WIT was decreased by 15 minutes during the consecutive attempts. No complications were noticed in any operation. Conclusions: Using the newly introduced robotic system, all the advantages of robotic surgery are optimized and incorporated, and partial nephrectomies can be performed in a safe and effective manner.

KEY WORDS: Robot-assisted surgery; Avatera system; Partial nephrectomy; Kidney cancer; Animal model. Submitted 20 September 2023; Accepted 23 October 2023

INTRODUCTION

Renal cell carcinoma is the 13th most common malignancy worldwide and the 10th most identified cancer in Europe (1). The gold-standard treatment for small renal masses (< 4 cm) is currently the nephron-sparing surgery (2). By

preserving the affected kidney, this established surgical treatment aims at optimal oncological outcomes while maintaining normal renal function and avoiding chronic kidney disease (3, 4). In recent years, minimally invasive techniques have dominated the surgical field, especially in urology. Consequently, laparoscopic surgery has been widely utilized. However, the steep learning curve and the advanced technical skills, which are associated with laparoscopic surgery, contribute to the underperformance of demanding laparoscopic procedures such as partial nephrectomy (PN) (5). In particular, the restricted motion of laparoscopic instruments can compromise the surgeon’s effort to accomplish tumor resection and hemostatic renorrhaphy in limited warm ischemic time (WIT) (6). Robotic assistance is an established trend in surgery providing high-definition, three-dimensional imaging, along with better articulation of the wristed instruments, there wise, making demanding surgeries like partial nephrectomy more easily feasible (7). The use of robotic surgery in urology is growing exponentially, thus many novel robotic systems have been introduced in the last decade (8). A novel robotic system is a new suggestion and it consists of two main components; the surgical robot with four robotic arms in which the endoscope and the instruments are mounted, and a separate console unit for the surgeon with multiple adjustments for the eyepiece, the seat, and the handling mechanism. As the eyepiece offers a high-resolution image and does not cover the surgeon’s ears and mouth, the cooperation over team members is optimized (9). Four instruments are provided: Bipolar Metzenbaum Scissors for cutting and coagulation, Atraumatic Grasper for holding and grasping tissue, bipolar Maryland Dissector for dissecting and coagulating tissue and Needle Holder for suturing. All instruments are compatible with 5 mm trocars (9). Unlike other robotic systems, the single-use instruments minimize the sterilization costs and eliminate any risk of cross-contamination (9). The aim of the present study is to highlight the feasibility

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S. Faitatziadis, V. Tatanis, P. Katsakiori, et al.

of partial nephrectomy with this novel robotic system in an in vivo animal model.

surgery, if necessary. Prior to the study, both surgeons participated in a training program on the use of this novel robotic system.

MATERIALS AND METHODS

Surgical technique After anesthesia was initiated, the pig was placed in a lateral position. All partial nephrectomies were performed at the right kidney. Three of the four robotic arms were used, and the procedure was performed through four ports. A 10 mm port for the camera was placed in the midclavicular line at the same level as the umbilicus. Two 5 mm ports were placed at approximately 4 mm laterally from the camera trocar, one above and one below the level of the umbilicus. A 12 mm assistant port was placed at the midline, between the umbilicus and the xiphoid, for the assistant’s instruments and the suction. All the currently provided surgical instruments were utilized: the bipolar Metzenbaum Scissors, the Atraumatic Grasper, the bipolar Maryland Dissector, and the Needle Holder. The primary surgeon seated in the console unit and was not scrubbed in, while the assistant surgeon was set at the operating table (Figure 1). After the placement of the trocars and the achievement of pneumoperitoneum, the procedure was initiated. The peritoneum surrounding the right kidney was incised and pulled medially with the use of grasper, exposing the kidney. Holding the grasper on the left arm and the bipolar dissector on the right arm, further mobilization of the kidney was performed, and the renal hilum was identified. A bulldog clamp was placed at the renal artery and the period of warm ischemia was initiated (Figure 2). Afterwards, the excision of a small part of the lower or upper pole of the kidney (the supposed tumor) was performed with the use of bipolar scissors. The specimen was put in a laparoscopic bag and removed from the assistant’s 12 mm port. Renorraphy followed using a running suture and placement of Hem-o-Lok clips to keep tension (Figure 3). When renorraphy was completed, the bulldog clamp was removed from the renal artery and the blood flow to

Compliance with ethical standards Ethics approval was obtained from the corresponding state services and eight female pigs, approximately 30 kg each, were used. The study has been carried out in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The experiments were carefully designed and preapproved by the Veterinary Administration of the Prefecture of Western Greece and conducted according to Directive 2010/63/EU (http: //eurlex.europa.eu/LexUriServ/LexUriServ.do?uri= OJ:L:2010:276:0033:0079:EN: PDF). Preparation of the pigs The pigs were kept unfed 12 hours prior to the procedure. Ketamine, Atropine Sulfate and Xylazine were used for initiating the anesthesia. Following intubation, the pigs were connected to the ventilator and anesthesia was maintained using Propofol 5%. Surgical team Each operation was performed by two surgeons: the primary surgeon (with experience of more than 100 laparoscopic and robotic surgeries) and the bedside assistant surgeon (with experience of more than 100 laparoscopic and robotic surgeries as assistant). The primary surgeon performed the operation via the control console, and the bedside assistant surgeon was standing next to the patient and the robot. The assistant surgeon, familiar with all surgical steps of partial nephrectomy, assisted with dissection and operated the suction, changed the surgical instruments, passed and retrieved sutures and was competent in laparoscopy or capable of converting to open

Figure 1. A) Control console unit B) Surgical robot (the fourth robotic arm is not being used).

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Novel robotic system for partial nephrectomy

the kidney was restored. A thorough inspection for bleeding took place. Upon completion of the partial nephrectomy, all the ports were removed, and the abdomen was deflated. Lastly, the fascia and the skin were sutured. Immediately after finalizing the procedure, sedation was discontinued, and all pigs were extubated and monitored postoperatively.

Table 1. The outcomes of the investigated variables in the first and the eighth operation. Median (range) (minutes) 1st Operation 8th Operation Decrease (1st to 8th operation)

Set-up time 19.5 (15-30) 30 min 15 min 15 min

Operative time 80.5 (59-114) 114 min 59 min 55 min

Warm ischemia time 23.5 (17-32) 32 min 17 min 15 min

Complications No No No

Min: minutes.

Figure 2. A) Identification of renal artery and veins (left instrument → bipolar Maryland dissector, right instrument → bipolar Metzenbaum scissors). B) Bulldog clamp on renal artery and initiation of warm ischemia time.

the complications, major or system-related ones were not recorded. The improvement during the consecutive attempts was also evaluated. More precisely, during the first attempt, the set-up, operation and warm ischemia times were 30, 114 and 32 minutes, respectively. On the eighth operation, the set-up and the operation were completed in 15 and 59 minutes, respectively, while the estimated needed WIT was 17 minutes. The decrease in the set-up time was calculated to 15 minutes between the first and third attempt. The operative time was reduced by 55 minutes between the first and last operation, while the WIT was decreased by 15 minutes during consecutive attempts. All the results are summarized in Table 1.

DISCUSSION

Nowadays, minimally invasive techniques are well-established in urology. Robotic assistance is increasingly adopted in the urological field and adjusted in a variety of surgical procedures (10). The idea of robotic surgery is to perform minimally invasive procedures without the technical difficulties of laparoscopy (11). Major benefits of the robotic approach are the high-resolution stereoscopic image and the fully articulating instruments, which allow precise control (6). In the case of partial nephrectomy, precise control helps surgeons to carry out more difficult cases and approach hilar or large endophytic tumors (12-15). Compared to Laparoscopic PN (LPN), the Robotic PN (RPN) offers better outcomes. In particular, recent data suggest that RPN is associated with reduced WIT, fewer complications, lower conversion rates to open surgery, better postsurgery renal function, and reduced hospitalization time (16, 17). Furthermore, a remarkable benefit of robotic surgery is the minimization of the learning curve. It has been shown that RPN’s learning curve is steeper than the learning curve of LPN, having an immediate impact on the operative times, WITs and blood loss (18, 19). In the present study, the feasibility and safety of RPN with the use of a novel robotic system were investigated on a porcine in vivo model. The transperitoneal access was used although the retroperitoneal access has been also utilized in the literature (20). The duration of the surgery was significantly reduced within only eight operations, an indicator of a steep learning curve in the use of this novel robotic system. The set-up time was considerably different between the first and the last surgeries, as it was the first setting and docking of the novel robotic system in our department after initial basic training, and all the new elements had to be assimilated. This important step was easily improved, as mentioned in the Results section. Especially, the simplified controlling mechanisms of the novel robotic system can

Figure 3. A) Suturing and clip placement of renal parenchyma. B) Final look of the kidney with clips after partial nephrectomy.

Data collection The collected intra and postoperative data included the set-up time, the operative time, the WIT, and the presence of complications. The set-up time was defined as the time between the incision for the first trocar and the application of the last robotic arm. The time between the first robotic maneuver and the suture of the trocar incisions was considered as the operative time. WIT was defined as the time between the placement and removal of the bulldog clamp. The recorded complications were stratified into systemrelated or not. The decrease in every variable between the first and last operation was also evaluated.

RESULTS

In total, eight partial nephrectomies were performed in eight female pigs. All operations were successfully completed. The estimated median set-up time was 19.5 minutes (range, 15-30), while the median operative time was calculated to 80.5 minutes (range, 59-114). The median needed WIT was 23.5 minutes (range, 17-32). Regarding

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make any surgeon proficient in setting up the robot easily and in a short time. WIT is of utmost importance in partial nephrectomy and this step was significantly improved during consecutive operations. Prolonged WIT is associated with acute or chronic renal dysfunction, thus it has to be maintained to a minimum (21). The precise time limit is still controversial. More dated studies showed that renal damage may be reversible when WIT is less than 30 minutes (22). Contemporary studies set a goal of 20 minutes (21, 23). In our study, this goal was achieved, as the median WIT was 23.5 minutes. In comparison with laparoscopy, robotic assistance has decreased the technical complexity of tumor excision and intracorporeal suturing by providing articulated instruments and consequently more angles for the surgeon. Therefore, as mentioned above, robotic surgery has better outcomes concerning WIT than laparoscopy (17). This is supported by large comparison studies. Particularly, Wang et al. compared 199 RPN with 176 LPN noticing a significant difference in mean ischemia time between RPN (19.7 min) and LPN (35.2 min) (24). In the study of Benway et al., WIT favored robotic surgery. 129 RPN and 188 LPN were compared and the difference was almost 9 minutes (19.7 min of WIT for robotic and 28.4 min for laparoscopic approach) (25). Besides the superiority of RPN compared to LPN, open PN (OPN) is associated with significantly lower WIT (8.7 vs 15.4 minutes, p = 0.001), as presented by Kowalewski et al. (26). The feasibility of RPN has been evaluated using various novel robotic platforms. Fan et al. investigated the successful completion of RPN using the novel KangDuo Surgical Robot-01 (KD-SR-01) system (SuZhou Kang Duo Robot Co., Ltd., Suzhou, China). One RPN was performed on a 60 kg female porcine. The estimated operative time was 94 minutes, while the set-up time was 4.5 minutes. No complications were reported (27). In our study, the median operative and set-up times were 80.5 and 19.5 minutes, respectively. The feasibility and safety of RPN with KD-SR-01 were also investigated in a clinical study conducted by Xu et al. In total, 17 RPN were performed with a mean operative time of 110.5 ± 37.6 minutes. The median set-up time was calculated to 3.3 minutes (range, 2.2-6.3), while the mean ischemia time was 16.9 ± 9.0 minutes (28). The performance of RPN using the Versius (CMR, Cambridge, UK) robot was investigated in a study conducted by Hussein et al. Six RPN were performed with a median operative time of 170 minutes and without reported malfunctions of the robotic system (29). Hugo RAS system (Medtronic, Minneapolis USA) was also evaluated on both cadaveric and live cases. Three RPN (one on the right and two on the left side) were performed in cadavers. The recorded mean operative and docking times were 98 minutes and 7 minutes, respectively, while no major complications or clashing of the arms occurred (30). Additionally, Gallioli et al. presented their initial experience in 10 cases of RPN using the Hugo RAS system. The median docking time was 9.5 minutes (range, 914) and the median console time was 138 minutes (range, 124-162). The estimated, median WIT was 13 minutes (range, 10-14), whereas one case was completed clampless. One postoperative pseudoaneurysm bleeding was treated by selective embolization (31).

In the present study, this novel robotic system, which gathers all the advantages of a robotic system trying to maximize them and simplify its use, was utilized. Highdefinition 3-D vision and wristed instrumentation are the main elements. Easy handling of the robot and console helps to minimize the set-up time and learning curve. Many safety mechanisms ensure that the operation will be carried out without any risks for the patients. Moreover, all instruments are for single use which neutralizes the possibility of contamination and infections. Unfortunately, this new system has some disadvantages that can be improved. At the time of the study, the singleuse instruments have a life span of one hour of continuous usage which means that during surgery they must be exchanged, most probably more than once. Another disadvantage is the lack of haptic feeling, which, nevertheless, characterizes all robotic systems (9). Despite the encouraging results of the present study, there are some limitations and weaknesses that should be addressed in future studies. Firstly, this is an in vivo experiment, but still, surgical times and difficulties will be different in human operations. Most notably, the intraperitoneal space differs, and the softer tissue of a pig’s renal parenchyma makes it harder to suture. However, the instruments used and the procedure followed were almost identical to clinical practice. Secondly, a small number of partial nephrectomies were performed and strong conclusions with regard to the learning curve cannot be driven. Nevertheless, our institution’s recent experience with this novel robotic system let us anticipate a steep learning curve with this robot as we have already performed several urological procedures. To the best of our knowledge, this is the first time that this novel robotic system has been tested in a complex surgical procedure like partial nephrectomy and we tried to evaluate all its elements.

CONCLUSIONS

Minimally invasive approaches have emerged and been adopted in urology. Robotic assistance has helped surgeons to overcome the technical challenges and disadvantages of laparoscopic surgery and make demanding procedures such as RPN even more feasible. Using this novel robotic system, all the advantages of robotic surgery are optimized and incorporated, and partial nephrectomies can be performed in a safe and effective manner.

REFERENCES

1. Ljungberg B, Campbell SC, Choi HY, et al. The epidemiology of renal cell carcinoma. Eur Urol. 2011; 60:615-21. 2. Van Poppel H, Becker F, Cadeddu JA, et al. Treatment of localised renal cell carcinoma. Eur Urol. 2011; 60:662-72. 3. Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup. J Urol. 2000; 163:442-5. 4. Tan HJ, Norton EC, Ye Z, et al. Long-term survival following partial vs radical nephrectomy among older patients with early-stage kidney cancer. JAMA. 2012; 307:1629-35. 5. Hollenbeck BK, Taub DA, Miller DC, et al. National utilization

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Novel robotic system for partial nephrectomy

trends of partial nephrectomy for renal cell carcinoma: a case of underutilization? Urology. 2006; 67:254-9.

24. Wang L, Lee BR. Robotic partial nephrectomy: current technique and outcomes. IJU. 2013; 20:848-59.

6. Shiroki R, Fukami N, Fukaya K, et al. Robot-assisted partial nephrectomy: Superiority over laparoscopic partial nephrectomy. IJU. 2016; 23:122-31.

25. Benway BM, Bhayani SB, Rogers CG, et al. Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. J Urol. 2009; 182:866-72.

7. Stifelman MD, Caruso RP, Nieder AM, Taneja SS. Robot-assisted laparoscopic partial nephrectomy. JSLS. 2005; 9:83-6.

26. Kowalewski KF, Neuberger M, Sidoti Abate MA, et al. Randomized Controlled Feasibility Trial of Robot-assisted Versus Conventional Open Partial Nephrectomy: The ROBOCOP II Study. Eur Urol Oncol. 2023; S2588-9311(23)00112-8.

8. Salkowski M, Checcucci E, Chow AK, et al. New multiport robotic surgical systems: a comprehensive literature review of clinical outcomes in urology. Ther Adv Urol. 2023; 15:17562872231177781.

27. Fan S, Xu W, Diao Y, et al. Feasibility and Safety of Dual-console Telesurgery with the KangDuo Surgical Robot-01 System Using Fifth-generation and Wired Networks: An Animal Experiment and Clinical Study. Eur Urol Open Sci. 2023; 49:6-9.

9. Avatera. Avatera system. Avatera; 2022 [13/06/2022]; Available from: https://www.avatera.eu/en/avatera-system. 10. Kaouk JH, Khalifeh A, Hillyer S, et al. Robot-assisted laparoscopic partial nephrectomy: step-by-step contemporary technique and surgical outcomes at a single high-volume institution. Eur Urol. 2012; 62:553-61.

28. Xu W, Dong J, Xie Y, et al. Robot-Assisted Partial Nephrectomy with a New Robotic Surgical System: Feasibility and Perioperative Outcomes. J Endourol. 2022; 36:1436-43. 29. Hussein AA, Mohsin R, Qureshi H, et al. Transition from da Vinci to Versius robotic surgical system: initial experience and outcomes of over 100 consecutive procedures. J Robot Surg. 2023; 17:419-26.

11. Aboumarzouk OM, Stein RJ, Eyraud R, et al. Robotic versus laparoscopic partial nephrectomy: a systematic review and metaanalysis. Eur Urol. 2012; 62:1023-33. 12. Dulabon LM, Kaouk JH, Haber GP, et al. Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases. Eur Urol. 2011; 59:325-30.

30. Prata F, Ragusa A, Tempesta C, et al. State of the Art in Robotic Surgery with Hugo RAS System: Feasibility, Safety and Clinical Applications. J Pers Med. 2023; 13:1233.

13. Komninos C, Shin TY, Tuliao P, et al. Robotic partial nephrectomy for completely endophytic renal tumors: complications and functional and oncologic outcomes during a 4-year median period of follow-up. Urology. 2014; 84:1367-73.

31. Gallioli A, Uleri A, Gaya JM, et al. Initial experience of robotassisted partial nephrectomy with Hugo RAS system: implications for surgical setting. World J Urol. 2023; 41:1085-91.

14. Ricciardulli S, Ding Q, Zhang X, et al. Evaluation of laparoscopic vs robotic partial nephrectomy using the margin, ischemia and complications score system: a retrospective single center analysis. Arch Ital Urol Androl. 2015; 87:49-55.

Correspondence Solon Faitatziadis, MD solonasfait@gmail.com Vasileios Tatanis, MD tatanisbas@gmail.com Paraskevi Katsakiori, MD vkatsak@upatras.gr Angelis Peteinaris, MD peteinarisaggelis@gmail.com Kristiana Gkeka, MD kristianagkeka@gmail.com Athanasios Vagionis, MD thanos_vagionis@hotmail.gr Theodoros Spinos, MD thspinos@otenet.gr Arman Tsaturyan, MD tsaturyanarman@yahoo.com Panagiotis Kallidonis, MD pkallidonis@yahoo.com Department of Urology, University of Patras, Patras, Greece

15. Simsek A, Yavuzsan AH, Colakoglu Y, et al. Comparison of robotic and laparoscopic partial nephrectomy for small renal tumours. Arch Ital Urol Androl. 2017; 89:93-6. 16. Choi JE, You JH, Kim DK, et al. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol. 2015; 67:891-901. 17. Lee CU, Alabbasi M, Chung JH, et al. How far has robot-assisted partial nephrectomy reached? Investig Clin Urol. 2023; 64:435-47. 18. Pierorazio PM, Patel HD, Feng T, et al. Robotic-assisted versus traditional laparoscopic partial nephrectomy: comparison of outcomes and evaluation of learning curve. Urology. 2011; 78:813-9. 19. Mottrie A, De Naeyer G, Schatteman P, et al. Impact of the learning curve on perioperative outcomes in patients who underwent robotic partial nephrectomy for parenchymal renal tumours. Eur Urol. 2010; 58:127-32.

Theofanis Vrettos, MD Greece teovret@gmail.com Department of Anesthesiology and ICU, University of Patras, Patras, Greece

20. Bourgi A, Ayoub E, Merhej S, et al. A comparison of perioperative outcomes of transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a systematic review. J Robot Surg. 2023.

Jens-Uwe Stolzenburg, MD jens-uwe.stolzenburg@medizin.uni-leipzig.de Department of Urology, University Hospital of Leipzig, Leipzig, Germany

21. Becker F, Van Poppel H, Hakenberg OW, et al. Assessing the impact of ischaemia time during partial nephrectomy. Eur Urol. 2009; 56:625-34.

Evangelos Liatsikos, MD (Corresponding Author) liatsikos@yahoo.com Department of Urology, University of Patras Medical School, Rio, Patras, 26500, Greece

22. Porpiglia F, Renard J, Billia M, et al. Is renal warm ischemia over 30 minutes during laparoscopic partial nephrectomy possible? Oneyear results of a prospective study. Eur Urol. 2007; 52:1170-8.

Conflict of interest: Jens-Uwe Stolzenburg is co-founder, shareholder and medical advisor of avateramedical GmbH. Evangelos Liatsikos is medical advisor of avateramedical GmbH. The rest of the authors have no relevant financial or non-financial interests to disclose.

23. Thompson RH, Lane BR, Lohse CM, et al. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol. 2010; 58:340-5.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11852

DOI: 10.4081/aiua.2023.12130

ORIGINAL PAPER

Oncological and functional outcomes of patients who underwent open partial nephrectomy for kidney tumor Efe Bosnali 1, Enes Abdullah Baynal 2, Naci Burak Cinar 2, Enes Malik Akdas 2, Engin Telli 2, Büsra Yaprak Bayrak 3, Kerem Teke 2, Hasan Yilmaz 2, Ozdal Dillioglugil 2, Onder Kara 2 1 University of Health Sciences, Derince Training and Research Hospital, Department of Urology, Kocaeli, Turkey; 2 Kocaeli University, School of Medicine, Department of Urology, Kocaeli, Turkey;

3 Kocaeli University, School of Medicine, Department of Pathology, Kocaeli, Turkey.

Summary

Objective: To report long-term functional and oncological outcomes of OPN Methods: We enrolled 182 patients who underwent consecutive OPN with a diagnosis of kidney tumor in our clinic between April 2002 and February 2020 and were selected from our prospective OPN database. Preoperative demographic and clinical characteristics, intraoperative and pathological results, and patients' postoperative functional and oncological follow-up data were retrospectively analyzed. Overall survival (OS) and disease-free survival (DFS) were evaluated using Kaplan-Meier survival analysis. The time-dependent variation between preoperative and postoperative functional results was statistically analyzed and presented in a graph. Results and limitations: The mean age was 54.4 ± 10.8 yr, and the median age-adjusted Charlson comorbidity index (ACCI) was 1 (interquartile range [IQR] 0-1). The mean tumor size was 3.1 ± 1.2 cm, and the median RENAL score was 6 (IQR 5-8). The most common malign histopathological subtype was clear cell carcinoma with 76.6%, and five cases (3.4%) had positive surgical margins (PSMs). The most common surgical techniques were the retroperitoneal approach (98.9%) and cold ischemia (88.5%). Estimated glomerular filtration rate (eGFR) preservation was 92% (80.8-99.3, IQR), which translates to 32% chronic kidney disease (CKD) upstaging. Acute kidney injury (AKI) was detected in 27 (14.8%) patients according to RIFLE criteria. The intraoperative complication rate was 5.5%, and the postoperative overall complication rate (Clavien-Dindo 1-5) was 30.2%. Major complications (Clavien-Dindo 3-5) were observed in 13 (7.1%) patients. The median oncological follow-up was 42 mo (21.384.6, IQR), and the 5- and 10-yr OS were 90.1% and 78.6%, 5 and 10-yr DFS were 99.4% and 92.1%, respectively. No local recurrence was observed in 5 (3.4%) patients with PSMs; only one had distant metastasis in the 8th postoperative month. The retrospective design, the small number of patients who underwent PN based on mandatory indication, and one type of surgical approach may limit the generalizability of our findings. Conclusions: This study confirms excellent long-term oncologic and functional outcomes after OPN in a cohort of patients selected from a single institution. In light of the information provided by the literature and our study, our recommendation is to push the limits of PN under every technically feasible condition in the treatment of kidney tumors to protect the kidney reserve and achieve near-perfect oncological results.

KEY WORDS: Kidney tumor; Open Partial Nephrectomy; Functional outcomes; Oncological outcomes. Submitted 25 November 2023; Accepted 30 November 2023

INTRODUCTION

Renal cell cancer (RCC) incidence is rising in Western countries and accounts for approximately 3% of adult cancers (1). During the last two decades, nephron-sparing surgery (NSS) has become the standard for managing localized renal tumors, achieving excellent oncological outcomes and functional preservation (2). Long-term oncological results of OPN in masses smaller than 4 cm have been well-defined, and it has been reported that similar results are obtained with radical nephrectomy (RN) in local recurrence, disease free survival (DFS), and metastasis-free survival (3, 4). The purpose of PN is to protect the maximum kidney tissue without compromising oncological principles, thereby reducing kidney failure and related cardiac problems that may develop at various levels and extending the OS times compared to RN (5). With the increase in the diagnosis of incidental masses, interest in NSS has increased. In the National Comprehensive Cancer Network (NCCN) and EAU guidelines, PN is recommended to treat early-stage renal tumors under any technically feasible condition (6). We presented our experience of single-center OPN, including long-term functional and oncological outcomes, in describing the complications and rates that developed during and after surgery.

MATERIALS AND METHODS Patient selection A retrospective analysis of the prospective OPN database approved by our institutional review board was performed in May 2020. All consecutive patients undergoing surgery between April 2002 and February 2020 were selected. Five surgeons experienced in OPN performed the surgeries. Due to limited access to the previous hospital patient record system, patients who underwent open PN between 1996 and 2001 were excluded. Overall, 182 patients were included in this study. Variables Preoperative demographic and clinical data of the patients included age, gender, race, body mass index (BMI), age-adjusted Charlson comorbidity index (ACCI), American society of anesthesiologists (ASA) score, history of

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diabetes and hypertension, previous abdominal surgery and smoking status, presence of a solitary kidney, and preoperative eGFR. Tumor complexity was graded as low (RENAL score 4-6, PADUA score 6-7), moderate (RENAL score 6-9, PADUA score 8-9), or high (RENAL score 10-12, PADUA score 10-14). Clinical UICC-TNM stage and nephrometry scores could not be determined in 51 patients whose preoperative cross-sectional imaging could not be accessed. Intraoperative variables included surgical approach and technique (ureteral stenting), operative time, estimated blood loss (EBL), ischemia type, cold ischemia time (CIT), warm ischemia time (WIT), use of a hemostatic agent, transfusion rate, and intraoperative complications. Postoperative variables included length of hospital stay (LoS), 30-day readmission rate, and types of postoperative complications and their incidence. Postoperative complications were graded using the Clavien-Dindo classification, with grade 3a or higher considered major complications. Patients with acute kidney ınjury (AKI) were determined based on the RIFLE criteria for creatinine and eGFR values in the first week postoperatively. Urine leakage was defined as a creatinine value ≥ 2 mg /dl in the drain fluid in addition to postoperative follow-up for at least 4 days or a significant collection around the kidney in postoperative radiological examinations. Tumor histology was performed according to the 2004 World Health Organization criteria, and grade classification followed the Fuhrman/International Society of Urological Pathology (ISUP) scheme. The 2017 yr Union for International Cancer Control (UICC)-TNM classification system was used for pathological staging. PSM was defined as an extension of tumor to the inked surface of the resected specimen on final pathology.

tional imaging in postoperative follow-up. Local recurrence was defined as detecting a new enhancing lesion in the surgical bed or the same renal space. Distant metastasis was defined as disease recurrence in the contralateral kidney or other body organs. Surgical technique We used the previously described standard OPN surgical method in all patients. The most common surgical technique in the study was the retroperitoneal flank approach (98.9%) and cold ischemia (88.5%). Depending on the tumor's location, a subcostal incision was made parallel to the 11th or 12th rib. The kidney was mobilized entirely with the surrounding Gerota fascia, and the renal pedicle was exposed. In order to prevent ischemic kidney damage and reduce intracellular edema, 16 grams of 20% mannitol solution was given intravenously to all patients who underwent cold ischemia a few minutes before arterial clamping. Then, by placing a bulldog clamp on the renal artery, renal hypothermia was induced by intracorporeal ice melting for 15 minutes. Three different (cold, hot, zero) ischemia types were preferred. While mannitol and ice slush application were not applied in the warm ischemia group, a clamp was not placed on the renal artery in the zero ischemia group. Tumor tissue was excised in a wedge shape with a scalpel and cold scissors, leaving approximately 3-5 mm of normal renal parenchyma around it, preserving the overlying fat tissue. 3/0 absorbable polyglactin sutures were used to close the defect that may develop in the collecting system after excision and to provide hemostasis due to bleeding. After achieving hemostasis, the bulldog clamp was removed, and the duration of cold or warm ischemia was recorded. The preserved fatty tissue was wrapped and sutured (with absorbable suture material) in oxidized regenerated cellulose (Surgicel) or polyglactin (Vicryl) mesh and placed into the bed of the defect. The fatty tissue was wrapped in order to provide the appropriate shape for the defect after excision and to help hemostasis with the effect of foreign materials around it. Blunt-tipped non-traumatic 1/0 absorbable polyglactin sutures were passed through the renal parenchyma along the edges of the defect and tied separately, and the wrapped fat tissue was fixed to the resection bed, and renorrhaphy was completed.

Follow up Renal function assessment was based on serum eGFR measurements postoperative days 1 and 3 at regular intervals of 1, 3, 6, and 12 months. The time difference between the preoperative and final eGFR dates of the patients constituted the functional follow-up period. eGFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and CKD staging were assigned according to the eGFR value based on the NKF-KDOQI guideline. eGFR preservation was calculated as the proportion of postoperative eGFR was measured at the last follow-up to preoperative eGFR, and rates of CKD upstaging were evaluated (upstaging from class I-II to III-V, class III to IV-V, or class IV to V). Oncological outcomes were evaluated through routine postoperative follow-up cross-sectional imaging studies, e.g., CT of the chest, abdominal CT and/or MRI. Imaging was carried out at 6, 12 months, then yearly and when clinically indicated. Postoperative cross-sectional imaging and medical records of the patients were examined, and the presence of local recurrence or distant metastasis and the causes of death were included in oncological followup data. Overall survival (OS) was defined as the time between the date of surgery and the date of death (all causes). Disease-free survival (DFS) was defined as the period between the date of surgery and the date of local recurrence or distant metastasis diagnosed by cross-sec-

Statistical analysis The normal distribution of variables was evaluated with the Kolmogorov-Smirnov test. Mean ± standard deviation (SD) was used for parametric variables, and median and interquartile range (IQR) values were used for nonparametric variables. The median eGFR values in the preoperative and postoperative follow-ups were compared in pairs using the nonparametric Friedman test. The time-dependent change of postoperative eGFR was shown with a Box and whisker plot graph. OS and DFS analyses for 5 and 10 years were performed using the Kaplan-Meier method. All statistical analyses were performed using SPSS v24 software (IBM SPSS Statistics, Armonk, NY: IBM Corporation, USA). P < 0.05 was considered statistically significant.

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Table 1. Patient’s Demographics and Preoperative Data. Variables Age years, mean (± SD) Male, n (%) White race, n (%) BMI, mean (± SD) CCI, med (IQR) ASA, med (IQR) Diabetes, n (%) Hypertension, n (%) No Yes Controlled Non controlled Smoker, n (%) No Yes Former Prior Abdominal Surgery, n (%) Pre-op Hb g/dl, mean (± SD) Solitary Kidney, n (%) Pre-op eGFR, med (IQR) Pre-op CKD stages, n (%) I. (eGFR ≥ 90 ml/min/1.73 m2) II. (eGFR 60-89 ml/min/1.73 m2) IIIa. (eGFR 45-59 ml/min/1.73 m2) IIIb. (eGFR 30-44 ml/min/1.73 m2) IV. (eGFR 15-29 ml/min/1.73 m2)

Table 2. Preoperative tumor characteristics and R.E.N.A.L. Score Details.

Total OPN (n = 182) 54.4 (± 10.8) 79 (43.4) 182 (100) 28.3 (± 5.3) 1 (0-1) 2 (2-2) 51 (28)

Tumor size, cm, mean (±SD) Side, right, n (%) Clinical UICC-TNM stage, n (%) T1a T1b T2 T3a Cystic Lesion, n (%) Hilar Location, n (%) Total Number of Arteries, n (%) 1 >1 N/A, n CSA, cm2, med (IQR) R.E.N.A.L score, med (IQR) R.E.N.A.L Complexity, n (%) Simple (4-6) Intermediate (7-9) Complex (10-12) ®adius (max diameter in cm), n (%) ≤4 > 4 but < 7 ≥7 (E)xophytic/Exophytic Properties, n (%) ≥ 50% < 50% Entirely endophytic (N)earness of The Tumor to the Collecting System or Renal Sinus (mm), n (%) ≥7 > 4 but < 7 ≤4 (L)ocation Relative to the Polar Lines (points), n (%) 1 2 3

92 (50.5) 90 (49.5) 81 (44.5) 9 (5) 115 (63.2) 55 (30.2) 12 (6.6) 48 (26.4) 13.7 (± 1.5) 6 (3.3) 96 (82.4-105.9) 113 (62.1) 53(29.1) 7 (3.8) 5 (2.7) 2 (1.1)

ASA, American Society of Anesthesiologists; BMI, Body mass index; CCI, Charlson comorbidity index; CKD, Chronic kidney disease; eGFR, Estimated glomerular filtration rate; Hb, Hemoglobin; IQR, Interquartile range; OPN, Open partial nephrectomy; SD, Standard deviation.

RESULTS

3.1 (± 1.2) 110 (60.4) 108 (82.4) 18 (13.7) 0 5 (3.8) 46 (33.1) 4 (3) 155 (88.1) 21 (11.9) 6 11 (6.7–19.7) 6 (5–8) 81 (61.8) 48 (36.6) 2 (1.5) 146 (81.6) 31 (17.3) 2 (1.1) 67 (51.2) 57 (43.5) 7 (5.3) 59 (45) 41 (31.3) 31 (23.7) 71 (54.2) 35 (26.7) 25 (19.1)

CSA, Contact surface area; IQR, Interquartile range; SD, Standard deviation.

Patients’ characteristics In total, 182 OPNs were performed during this initial time frame for our OPN experience. The mean age at surgery was 54.4 ± 10.8 yr, and 56.6% of patients were women. Six (3.3%) patients underwent PN for a solitary kidney tumor, and 4 (2.1%) patients presented with bilateral renal neoplasms requiring PN. Median preoperative eGFR was 96 ml/min/1.73 m2 CKDEPI (7.6% of patients had preoperative CKD stage ≥ 3). The demographic and preoperative data are presented in Table 1. The mean tumor size on preoperative imaging (CT or MRI) was 3.1±1.2 cm, and 82.4% of neoplasms were classified as clinical stage T1a. Median RENAL and PADUA scores were 6 (IQR 5-8) and 7 (IQR 7-9), respectively. According to the RENAL and PADUA nephrometry scoring systems, 38.1% and 49.6% of tumors were classified as moderately to highly complex, respectively. Seven (5.3%) patients had completely endophytic tumors. The preoperative characteristics of the tumors are presented in Table 2 and Table 3.

cases had zero ischemia; the mean WIT for the remaining patients was 26.1 ± 7.7 minutes. The median operative time was 240 min (IQR 180-240), and the median EBL was 400 ml (IQR 300-600). The intraoperative complication rate was 5.5%, and renal vein injury was the most common (1.7%). The intraoperative transfusion rate was 28.6%. The intraoperative data are summarized in Table 4. Postoperative and pathological outcomes The median postoperative LoS was 5 days (IQR 4-7). The postoperative overall complication rate was 30.2%, and pulmonary complications were the most common (9.3%). Major complications (Clavien-Dindo grade ≥ 3) were observed in 13 (7.1%) patients (Table 5). Urinary leakage occurred in 3.2% of cases and pseudo-aneurysm in 1.1% of the patients. According to the RIFLE criteria, AKI was detected in 27 (14.8%) patients. No patients required postoperative hemodialysis during follow-up. Postoperative complications are detailed in Table 6. Final histopathologic analysis revealed clear cell RCC in 81% of cases. Most tumors (78%) were classified as pT1a and 16.2% were of high Fuhrman/ISUP grade (3 or 4).

Intraoperative outcomes The retroperitoneal approach (98.9%) and cold ischemia (88.5%) were the most common surgical techniques. Six

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Table 5. Postoperative Data of The Patients.

Table 3. Preoperative Tumor Characteristics and PADUA Score Details. PADUA score, med (IQR) PADUA Complexity, n (%) Simple (6-7) Intermediate (8-9) Complex (10-14) Tumor Size (max diameter in cm), n (%) ≤4 > 4 but < 7 ≥7 Exophytic Rate, n (%) ≥ 50% < 50% Entirely endophytic Tumor Relationship with Renal Sinus, n (%) Absent relationship With renal sinus location Tumor Relationship with Urinary Collecting System, n (%) Absent relationship Dislocated/Infiltrated Renal Rim Location, n (%) Not involved Involved Location Relative to the Sinus Lines (points), n (%) 1 2

Variables Length of Stay (LoS), days, med (IQR) Postoperative Transfusion, n (%) ES Units, med (IQR) Overall Postop Complications, n (%) Major (Clavien-Dindo 3-5) Postop Complications Minor (Clavien-Dindo 1-2) Postop Complications Readmission for Urologic Reasons, n (%) < 30 days ≥ 30 days

7 (7–9) 66 (50.4) 42 (32.1) 23 (17.5) 146 (81.6) 31 (17.3) 2 (1.1) 67 (51.2) 57 (43.5) 7 (5.3)

ES, Erythrocyte suspension; IQR, Interquartile range; OPN, Open partial nephrectomy.

114 (87) 17 (13)

Table 6. Postoperative Complication Type of The Patients.

76 (58) 55 (42)

Postoperative Complication Type Cardiac Complications, n (%) 1 Hypertension 2 Cyanosis Pulmonary Complications, n (%) 1 Atelectasis (Need for Antibiotics) 2 Pleural Effusion Genitourinary Complications, n (%) 1 Urine Leakage 2 Perirenal/Psoas Abscess Bleeding Complications, n (%) 1 Postoperative Transfusion 2 Need for Angioembolization Other Infections (Use of Antibiotics), n (%) Ileus/ Small Bowel Obstruction, n (%) Hernia, n (%) Acute Kidney Injury (RIFLE Criteria), n (%) R Risk (Increased Cre x 1,5 or eGFR decrease > %25) I Injury (Increased Cre x 2 or eGFR decrease > %50) F Failure (Increased Cre x 3 or eGFR decrease ≥ %75) L Loss (Complete loss of renal function ≥ 4 weeks) E End stage renal disease

101 (77.1) 30 (22.9) 79 (60.3) 52 (39.7)

IQR, Interquartile range; PADUA, (P)reoperative (A)spects and (D)imensions used for an (A)natomical.

Table 4. Intraoperative Data of The Patients. Variables Surgical Approach, n (%) Retroperitoneal Transperitoneal Operation Time, min, med (IQR) Double J Stent, n (%) Routinely As required (intra-operative) No EBL, ml., med (IQR) Management of Renal Pedicle, n (%) Off clamp Global clamp Technique of Ischemia, n (%) Warm Cold Zero Ischemia Time, min, mean (±SD) Warm Cold Use of Haemostatic Agents, n (%) Tissel Floseal Arista Intraoperative Complications, n (%) 1 cm size injury to the proximal ureter Serosal injury to the colon Injury to the renal vein Pleural injury Laceration of the spleen Vascular injury in the vena cava Injury of the aberrant artery supplying the lower pole Intraoperative Transfusion, n (%) ES Units, med (IQR)

Total OPN (n = 182) 5 (4-7) 14 (7.7) 2 (1-2.2) 55 (30.2) 13 (7.1) 41 (23.1) 11 (6) 7 (3.8) 4 (2.2)

Total OPN (n = 182) 180 (98.9) 2 (1.1) 240 (180-240) 95 (52.2) 14 (7.7) 73 (40.1) 400 (300-600)

Total OPN (n = 182) 3 (1.6) 2 (1.1) 1 (0.5) 17 (9.3) 14 (7.6) 3 (1.6) 16 (8.7) 14 (7.6) 2 (1.1) 16 (8.7) 14 (7.6) 2 (1.1) 4 (2.2) 2 (1.1) 4 (2.2) 27 (14.8) 23 (12.6) 4 (2.2) 0 0 0

6 (3.3) 176 (96.7)

Five (3.4%) patients had PSMs. Among the benign pathologies, oncocytoma was reported most frequently (70.6%). The pathological data of the patients are presented in Table 7.

15 (8.2) 161 (88.5) 6 (3.3) 26.1 (± 7.7) 19.4 (± 3.5) 32.1 (± 4.9) 17 (9.3) 3 (1.6) 12 (6.6) 2 (1.1) 10 (5.5) 1 (0.5) 1 (0.5) 3 (1.6) 1 (0.5) 1 (0.5) 2 (1.1) 1 (0.5) 52 (28.6) 1 (1-2)

Oncological and functional outcomes The median oncological follow-up of the patients was 42 (IQR 21.3-84.6) mo. Local recurrence was observed in three (1.6%) patients at the postoperative 63rd, 73rd and 89th mo. respectively. Distant metastasis developed in 4 (2.2%) patients at 8th, 63rd, 64th, and 96th mo. after surgery secondary to RCC. Seventeen patients died (9.3%), including one from renal cancer (0.5%). No local recurrence was observed in 5 (3.4%) patients with PSMs. Only one (0.5%) patient with PSMs had distant metastasis in the 8th postoperative mo. The 5-and 10-yr OS were determined as 90.1% and 78.6%, 5 and 10-yr DFS rates with the Kaplan-Meier method, respectively, were 99.4% and 92.1% (Figure 1). Oncological data are summarized in Table 8.

EBL, Estimated blood loss; ES, Erythrocyte suspension; IQR, Interquartile range; SD, Standard deviation; OPN, Open partial nephrectomy.

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Table 7. Pathological Data of The Patients. Variables Malignant Disease, n (%) Benign Disease, n (%) N/A, n Pathological UICC-TNM stage, n (%) T1a T1b T2a T3a N/A, n Histological Subtype, n (%) Clear Cell Papillary Chromophobe Malignant mezenchymal Tubulocystic carcinoma Benign Disease, n (%) Histological Subtype, n (%) Oncocytoma Angiomyolipoma Other benign types Positive Surgical Margin, n (%) Fuhrman/ ISUP Grade, n (%) Low FG (1-2) High FG (3-4) N/A, n

Table 8. Oncological Outcomes and Follow-up Data of The Patients. Total OPN (n = 182) 145 (81) 34 (19) 3

Follow-up Times (oncological), mo., med (IQR) Local Recurrence, n (%) Time to Local Recurrence, mo., med (IQR) Distant Metastasis, n (%) Time to Distant Metastasis, mo., med (IQR) Death, n (%) RCC-Related Death, n (%)

120 ( 83.3) 21 (14.5) 0 3 (2.1) 1

42 (21.3-84.6) 3 (1.6) 73 (63-89) 4 (2.2) 63.5 (21.7-88) 5 (3.5) 1 (0.5)

Table 9. Functional Outcomes and Follow-up Data of The Patients.

111 (76.6) 25 (17.2) 7 (4.8) 1 (0.7) 1 (0.7) 34 (19)

Follow-up Times (functional), mo., med (IQR) Preop eGFR, med (IQR) Postop 1st day eGFR, med (IQR) Postop 1st day % eGFR preservation, med (IQR) Postop 3rd day eGFR, med (IQR) Postop 3rd day % eGFR preservation, med (IQR) Postop 1st mo. eGFR, med (IQR) Postop 1st mo. % eGFR preservation, med (IQR) Postop 3rd mo. eGFR, med (IQR) Postop 3rd mo. % eGFR preservation, med (IQR) Postop 6th mo. eGFR, med (IQR) Postop 6th mo. % eGFR preservation, med (IQR) Postop 1st yr. eGFR, med (IQR) Postop 1st yr. % eGFR preservation, med (IQR) Latest eGFR, med (IQR) Latest Follow up % eGFR preservation (IQR) Latest CKD Upstaging, n (%)

24 (70.6) 5 (14.7) 5 (14.7) 5 (3.4) 113 (83.7) 24 (16.2) 10

FG, Fuhrman grade; ISUP, International Society of Urological Pathology; OPN, Open partial nephrectomy.

The median eGFR preservation after OPN was 92.9% (IQR 80.8-99.3%), which translates to a CKD upstaging rate of 32.2%. The median postoperative eGFR was 86.8 ml/min/1.73 m2; data for all patients were available with a median interval of 32.8 mo (IQR 12.3-71) after surgery (Table 9). Time-dependent change between eGFR values in preoperative and postoperative follow-up was statistically analyzed using the Friedman test and demonstrated using a Box and whisker plot graph (Figure 2).

32.8 (12.3-71) 96 (82.4-105.9) 88.1 (70.3-100.3) 94.2 (81.9-100) 91.4 (73.8-101.4) 95 (87.4-100.9) 91.1 (77.3-102) 95.2 (86.3-100.6) 87.2 (70.4-100.2) 92.6 (82-99.2) 87 (70.4-97) 92.2 (83.2-99.2) 87.3 (70.9-99.8) 92.4 (82.2-99.3) 86.8 (70.4-99.1) 92.9 (80.8-99.3) 58 (32.2)

lesions. On the other hand, RN was chosen for high-complexity preoperative cases. It is known that long ischemia times in PN harm kidney function. It was well reported that irrespective of the surgical method, hot and cold ischemia should not take longer than 20 and 30-35 minutes, respectively (10). Thus, cold ischemia was advised to be performed in the literature for cases requiring longer clamping times. In order to benefit from the advantages of cold ischemia, researchers from Cleveland Clinic defined icing techniques that can be utilized during laparoscopic PN (LPN) and robotic-assisted PN (RAPN) for complex cases (11). Yossepowitch et al. (12) demonstrate that while CIT correlated with eGFR decrease immediately after surgery, this correlation was no longer present 1 year after the procedure, highlighting the impact of cold ischemia on preserving long-term kidney function in a study that included 592 cases of cold PN series with a median CIT of 35 minutes. In our study, cold and hot ischemia was performed in 88.5% and 8.2% of our patients, respectively, whereas zero ischemia was performed in 3.3%. The mean cold and hot ischemia times were 32.1 and 19.4 minutes, respectively, within the previously suggested range; therefore, we envision comparable and normal long-term kidney function for both cohorts. A 2020 meta-analysis study, comparing OPN and LPN from 26 different studies with 8095 cases, did not show any differences in intraoperative complication rate and

DISCUSSION

With an increased diagnosis of incidental masses, the interest in NSS has increased and as a result, PN has been suggested to be performed according to the NCCN and EAU guidelines, irrespective of the surgery method, for the treatment of early-stage kidney tumors. In order to obtain good oncological and functional results in PN, all uro-oncologists are required to know the indications, technical details, and complications of PN as well as its management by using the advantages of minimally invasive techniques. Currently, at least 50% of new RCCs are diagnosed incidentally and smaller than 4 cm. This is further supported by previous studies focused on high number OPN series, which show mean tumor sizes of 2.7-3.4 cm (7, 8). Despite this regression, concerning previous years, the more extensive lesions, centrally located and related to the collecting system, were chosen to perform OPN (9). In our study, the mean preoperative tumor size was 3,1 ± 1.2 cm) and RENAL and PADUA scores showed that over half of the tumors are low-complexity

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Figure 1. Kaplan-Meier curves of the survival of patients undergoing open partial nephrectomy. (A) Overall survival. (B) Disease-free survival.

operation time between these two methods. However, it was reported that LPN decreased the EBL, LoS, and blood transfusion requirements (13). In another study comparing OPN, LPN, and RAPN performed for tumors less than 4 cm, it was found that OPN led to increased surgery time (199 ± 56 min) and bleeding (168 ± 266 ml) compared to RAPN (174 ± 64 min, 84 ± 165 ml) (14). In our series, the median operative time of 240 min and bleeding of 400 ml is greater than in previous reports. The routine ureteral stenting (52.2%), 15 minutes application of intracorporal ice slush treatment (88.5%), and additional application of lipocorticoplasty could have contributed to the elongation of the operation time.

The rate of general complications in various PN series varies between 4.1-38.6% in previous studies (4, 7, 15), with urine leakage and bleeding as the most frequent postoperative complications (7, 8). We found a general (major and minor) complication rate of 30.2 %, with pulmonary complications (9.2%), bleeding (8.7%), and urine leakage (7.6%) being the most common. Chang et al. (16) reported a major complication rate of 7.3% in 122 patients that resemble those in our study in terms of tumor characteristics and demographics. Thus, our postoperative major complication rate of 7.1% is in accordance with previous studies. An intraoperative complication rate of 3-5% was detected in the OPN series with a

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Figure 2. Time-dependent change between eGFR values in preoperative and postoperative follow-up (Box and whisker plot graph).

high number of patients, with pleural injuries being the major case (17, 18). In our study, the rate of intraoperative complications was 5.5%, in accordance with the literature. AKI is observed in approximately 20% of all PN, negatively affecting long-term kidney function (19). Our study defined AKI for RIFLE criteria for up to 3 days post-operation (20). In a recent study, 25% of AKI was observed in a cohort of 944 pT1 stage patients operated with three different PN techniques by RIFLE criteria (21). We found an AKI of 14.8% in our study. This lower AKI rate could be attributed to good preoperative kidney function and a small number of solitary kidneys in our cohort. Time-dependent decrease in renal function has been extensively studied, primarily in bilateral kidneys. Kidney function was found to decrease post-PN immediately but reached stable levels 3 weeks to 3 months after surgery upon partial recovery (22). Porpiglia et al. (23) followed the kidney function of patients with bilateral kidneys following LPN via scintigraphy. They found a significant recovery of kidney function 3 months post-operation. In our study, when the postoperative eGFR was compared with the preoperative eGFR in the time-dependent graph, a statistically significant loss of kidney function was found on the postoperative 1st day. The postoperative 3th day, we observed partial recovery of eGFR levels followed by stabilization of kidney function after 1 month, which was in accordance with the results obtained by Porpiglia et al. CKD is defined as a heterogeneous distortion affecting the structure and function of kidneys. NKF-KDOQ1 developed this term in 2002, and the guides demonstrate that these distortions can elevate to life-threatening levels (24). In our cohort, primarily composed of cold ischemia patients, we found 92.9% median preservation of final eGFR levels during 32 months of functional follow-up;

thus, temporary dialysis was deemed unnecessary. When compared with the literature, we think that the normal preoperative renal function of most patients, the low number of patients with high complexity lesions and solitary kidneys, utmost care on the maximum ischemia time, and experience of open surgery in our clinic have contributed to the low incidence of short-term kidney damage post-PN and improved functional recovery in the long-term. A negative surgical margin is required to be left out following tumor excision according to standard surgical principles. PSMs can be observed between 1.3-18% in OPN cohorts. When PN was carried out in large tumors (> 4 cm) or complex tumors with mandatory indications, a higher rate of PSM was observed (23, 25). Even if, minimally invasive strategies involving optical magnification and pedicule clamping with ischemia and tumor's cold scission, are advantageous with increased surgical experience, PSM was higher in large cohorts than in open surgeries (7). PSM rates were found to be 4.9, 8.1 and 8.7% in OPN, LPN, and RAPN, respectively, in a study including more than 11500 cases with comparable numbers for each PN (26). In minimally invasive techniques, the lack of tactile sensations in determining the extension of the masses to the renal parenchyma at different axis angles and difficulty in determining the plan between the renal parenchyma and the tumor border due to the use of energy devices may cause higher rates of PSM compared to open surgery. In our clinic, where all patients were subjected to OPN, PSM rate was 3.4%. In OPN, three-dimensional masses extending into the renal parenchyma at different axis angles can be clearly excised from the kidney and tumor border can be identified by means of tactile senses and use of cold scissors, contributing to the lower detection of PSM observed in our clinic. No local recurrence was observed in the close follow-up

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of 5 (3.4%) patients with PSM. A distant metastasis was detected in one (0.5%) at the postoperative 8th mo. PSM was previously correlated with increased local recurrence risk and distant metastasis progression (27). In another study with a median follow-up of 62 months, PSM was reported as an independent predictor of OS, RFS, and DFS (28). Studies indicate that PSM does not influence survival; however, shorter follow-up and smaller cohort sizes may not had the statistical power to determine PSM's effect (29, 30). The objective of PN is to preserve the kidney tissue while adhering to oncological principles maximally, in order to decrease the prevalence of different levels of kidney failure and related cardiac problems, and ultimately to increase longevity compared to RN (5). Local recurrence rates have been reported in the 1.4-3.3% range in large OPN cohorts with at least 5 yrs of follow-up (3, 31). Lane et al. (32) reported a 10-yr minimum OS of 72 and 78% in 299 patients with OPN and LPN, respectively. Marszalek et al. (33) reported the oncological outcomes of 100 age-, sex-, and tumor size-matched patients treated with OPN and LPN. In this study, the 5-yr OS were 85% and 96%, and 5-yr DFS were 94% and 96.3%, respectively. In our study, local recurrence was observed in 3 (1.6%) patients and a distant metastasis was observed in 4 (2.1%) patients during a median of 42 (21.3-84.6, IQR) months of oncological follow-up. RCC-related death occurred in one (0.5%) patient with distant metastasis. 5 and 10-yr DFS were 99.4 and 99.2%. 5 and 10-yr OS were 90.1 and 78.6%, respectively. Most of the tumors belonging to the pT1a stage (83.3%) and with low Fuhrman/ISUP grade (83.7%) combined with low PSM rates obtained with our open surgical technique play critical roles in this high long-term oncological survival. Our results are consistent with previous studies, and we anticipate that our study will add to the successful oncological outcome of OPN studies. The limitations of our study are retrospective design, a small number of patients subjected to PN upon mandatory indications, and inclusion of a single type of surgical method. In addition, more recent studies demonstrate that the amount of remaining kidney tissue post-operation is the most significant indicator of long-term kidney function. The absence of this parameter is the most significant limitation of our work and will be our field of study in the future.

2. Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup. J Urol. 2000; 163:442-5. 3. Pahernik S, Roos F, Hampel C, et al. Nephron sparing surgery for renal cell carcinoma with normal contralateral kidney: 25 years of experience. J Urol. 2006; 175:2027-31. 4. Patard J-J, Shvarts O, Lam JS, et al. Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience. J Urolo. 2004; 171:2181-5. 5. Thompson RH, Boorjian SA, Lohse CM, et al. Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol. 2008; 179:468-73. 6. Kaouk JH, Autorino R. Laparoendoscopic single-site surgery (LESS) and nephrectomy: current evidence and future perspectives. Eur Urol. 2012; 62:613-5 7. Gill IS, Kavoussi LR, Lane BR, et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol. 2007; 178:41-6. 8. Patard J-J, Pantuck AJ, Crepel M, et al. Morbidity and clinical outcome of nephron-sparing surgery in relation to tumour size and indication. Eur Urol. 2007; 52:148-54. 9. Weight CJ, Fergany AF, Gunn PW, et al. The impact of minimally invasive techniques on open partial nephrectomy: a 10-year single institutional experience. J Urol. 2008; 180:84-8. 10. Becker F, Van Poppel H, Hakenberg OW, et al. Assessing the impact of ischaemia time during partial nephrectomy. Eur Urol. 2009; 56:625-35. 11. Ramirez D, Caputo PA, Krishnan J, et al. Robot-assisted partial nephrectomy with intracorporeal renal hypothermia using ice slush: step-by-step technique and matched comparison with warm ischaemia. BJU Int. 2016; 117:531-6. 12. Yossepowitch O, Eggener SE, Serio A, et al. Temporary renal ischemia during nephron sparing surgery is associated with shortterm but not long-term impairment in renal function. J Urol. 2006; 176:1339-43. 13. You C, Du Y, Wang H, et al. Laparoscopic Versus Open Partial Nephrectomy: A Systemic Review and Meta-Analysis of Surgical, Oncological, and Functional Outcomes. Front Oncol. 2020; 10:2261. 14. Tachibana H, Kondo T, Yoshida K, et al. Lower incidence of postoperative acute kidney injury in robot-assisted partial nephrectomy than in open partial nephrectomy: A propensity score-matched study. J Endourol. 2020; 2020; 34:754-762 15. Lerner SE, Hawkins CA, Blute ML, et al. Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery. J Urol. 1996; 155:1868-73. 16. Chang KD, Abdel Raheem A, Kim KH, et al. Functional and oncological outcomes of open, laparoscopic and robot-assisted partial nephrectomy: a multicentre comparative matched-pair analyses with a median of 5 years’ follow-up. BJU Int. 2018; 122:618-26.

CONCLUSIONS

This study confirms excellent long-term oncologic and functional outcomes after OPN in a cohort of patients selected from a single institution. We contributed to the literature by reporting that our patients who underwent open PN had high oncologic survival, and their kidney functions were well preserved in the long-term follow-up.

17. Minervini A, Mari A, Borghesi M, et al. The occurrence of intraoperative complications during partial nephrectomy and their impact on postoperative outcome: results from the RECORd1 project. Minerva Urol Nefrol 2018; 71:47-54 18. Caraballo ER, Palacios DA, Suk-Ouichai C, et al. Open partial nephrectomy when a non-flank approach is required: indications and outcomes. World J Urol. 2019; 37:515-22.

REFERENCES

1. Ferlay J, Colombet M, Soerjomataram I, et al. Cancer incidence and mortality patterns in Europe: Estimates for 40 countries and 25 major cancers in 2018. Eur J Cancer. 2018; 103:356-87.

19. Capitanio U, Bensalah K, Bex A, et al. Epidemiology of renal cell carcinoma. European urology. 2019; 75:74-84.

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Long-term oncological and functional outcomes of open partial nephrectomy

20. Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure-definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004; 8:R204.

26. Tabayoyong W, Abouassaly R, Kiechle JE, et al. Variation in surgical margin status by surgical approach among patients undergoing partial nephrectomy for small renal masses. J Urol. 2015; 194:1548-53. 27. Yossepowitch O, Thompson RH, Leibovich BC, et al. Positive surgical margins at partial nephrectomy: predictors and oncological outcomes. J Urol. 2008; 179:2158-63.

21. Bravi CA, Mari A, Larcher A, et al. Toward Individualized Approaches to Partial Nephrectomy: Assessing the Correlation Between Ischemia Time and Patient Health Status (RECORD2 Project). Eur Urol Oncol. 2021; 4:645-650.

28. Petros FG, Metcalfe MJ, Yu K-J, et al. Oncologic outcomes of patients with positive surgical margin after partial nephrectomy: a 25year single institution experience. World J Urol. 2018; 36:1093-101.

22. Porpiglia F, Fiori C, Bertolo R, et al. The effects of warm ischaemia time on renal function after laparoscopic partial nephrectomy in patients with normal contralateral kidney. World J Urol. 2012; 30:257-63.

29. Bensalah K, Pantuck AJ, Rioux-Leclercq N, et al. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol. 2010; 57:466-73.

23. Porpiglia F, Fiori C, Bertolo R, et al. Long-term functional evaluation of the treated kidney in a prospective series of patients who underwent laparoscopic partial nephrectomy for small renal tumors. Eur Urol. 2012; 62:130-5.

30. Ani I, Finelli A, Alibhai SM, et al. Prevalence and impact on survival of positive surgical margins in partial nephrectomy for renal cell carcinoma: a population-based study. BJU Int. 2013; 111:E300-E5. 31. Becker F, Siemer S, Humke U, et al. Elective nephron sparing surgery should become standard treatment for small unilateral renal cell carcinoma: long-term survival data of 216 patients. Eur Urol. 2006; 49:308-13.

24. Valente MA, Hillege HL, Navis G, et al. The Chronic Kidney Disease Epidemiology Collaboration equation outperforms the Modification of Diet in Renal Disease equation for estimating glomerular filtration rate in chronic systolic heart failure. Eur J Heart Fail. 2014; 16:86-94..

32. Lane BR, Campbell SC, Gill IS. 10-year oncologic outcomes after laparoscopic and open partial nephrectomy. J Urol. 2013; 190:44-9. 33. Marszalek M, Meixl H, Polajnar M, et al. Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients. Eur Urol. 2009; 55:1171-8.

25. Peycelon M, Hupertan V, Comperat E, et al. Long-term outcomes after nephron sparing surgery for renal cell carcinoma larger than 4 cm. J Urol. 2009; 181:35-41.

Correspondence Efe Bosnali, MD Corresponding Author) efebosnali415@gmail.com Department of Urology, University of Health Sciences, Derince Training and Research Hospital, Turkey, 41380 Enes Abdullah Baynal, MD abdullahbaynal@gmail.com Naci Burak Çınar, MD n.burak.cinar@gmail.com Enes Malik Akdas, MD enesmalikakdas@gmail.com Engin Telli, MD engintelli@gmail.com Kerem Teke, MD drtekekerem@gmail.com Hasan Yılmaz, MD hasanyilmazm.d@gmail.com Özdal Dillioğlugil, MD odillioglugil@gmail.com Önder Kara, MD onerkara@yahoo.com Kocaeli University, School of Medicine, Department of Urology, Kocaeli, Turkey Büşra Yaprak Bayrak, MD busra.yaprakbayrak@kocaeli.edu.tr Kocaeli University, School of Medicine, Department of Pathology, Kocaeli, Turkey Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12130

DOI: 10.4081/aiua.2023.11830

ORIGINAL PAPER

Predictors of prostate cancer cetection in MRI PI-RADS 3 lesions – Reality of a terciary center Débora Araújo 1, Alexandre Gromicho 2, Jorge Dias 1, Samuel Bastos 1, Rui Miguel Maciel 1, Ana Sabença 1, Luís Xambre 1 1 Urology Department, Centro Hospitalar Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal; 2 Urology Department, Centro Hospitalar do Funchal, Madeira, Portugal.

Summary

Introduction and objectives: The Prostate Imaging Reporting and Data System (PI-RADS) score reports the likelihood of a clinically significant prostate cancer (CsPCa) based on various multiparametric prostate magnetic resonance imaging (mpMRI) characteristics. The PI-RADS category 3 is an intermediate status, with an equivocal risk of malignancy. The PSA density (PSAD) has been proposed as a tool to facilitate biopsy decisions on PI-RADS category 3 lesions. The objective of this study is to determine the frequency of CsPCa, assess the diagnostic value of targeted biopsy and identify clinical predictors to improve the CsPCa detection rate in PI-RADS category 3 lesions. Methods: Between 1st January 2017 and 31st December 2022, a total of 1661 men underwent a prostate biopsy at our institution. Clinical and mpMRI data of men with PI-RADS 3 lesions was reviewed. The study population was divided into two groups: target group, including those submitted to systematic plus targeted biopsy versus non-target group when only systematic or saturation biopsy were performed. Patients with PI-RADS 3 lesions were divided into three categories based on pathological biopsy results: benign, clinically insignificant disease (score Gleason = 6 or International Society of Urologic Pathologic (ISUP) 1) and clinically significant cancer (score Gleason ≥ 7 (3+4) or ISUP ≥ 2) according to target and non-target group. Univariate and multivariate analyses were performed to identify clinical predictors to improve the CsPCa detection rate in PI-RADS category 3 lesions. Results: A total of 130 men with PIRADS 3 index lesions were identified. Pathologic results were benign in 77 lesions (59.2%), 19 (14.6%) were clinically insignificant (Gleason score 6) and 34 (26.2%) were clinically significant (Gleason score 7 or higher). Eighty-seven of the patients were included in the target group (66.9%) and 43 in the non-target group (33.1%). The CsPCa detection was higher in the non-target group (32.6%, n = 14 vs 23.0%, n = 20 respectively). When systematic and target biopsies were jointly performed, if the results of systematic biopsies are not considered and only the results of target biopsies are taken into account, a CsPCa diagnosis would be missed on 9 patients. The differences of insignificant cancer and CsPCa rates among the target or non-target group were not statistically significant (p = 0.50 and p = 0.24, respectively). On multivariate analysis, the abnormal DRE and lesions localized in Peripheral zone (PZ) were significantly associated with a presence of CsPCa in PI-RADS 3 lesions (OR = 3.61, 95% CI [1.22,10.72], p = 0.02 and OR = 3.31, 95% CI [1.35, 8.11], p = 0.01, respectively). A higher median PSAD significantly predisposed for

CsPCa on univariate analyses (p = 0.05), however, was not significant in the multivariate analysis (p = 0.76). In our population, using 0.10 ng/ml/ml as a cut-off to perform biopsy, 41 patients would have avoided biopsy (31.5%), but 5 cases of CsPCa would not have been detected (3.4%). We could not identify any statistical significance between other clinical and imagiological variables and CsPCa detection. Conclusions: PI-RADS 3 lesions were associated with a low likelihood of CsPCa detection. A systematic biopsy associated or not with target biopsy is essential in PI-RADS 3 lesions, and targeted biopsy did not demonstrate to be superior in the detection of CsPCa. The presence of abnormal DRE and lesions localized in PZ potentially predict the presence of CsPCa in biopsied PI-RADS 3 lesions.

KEY WORDS: Prostate cancer; PI-RADS category 3 lesions; Prostate multiparametric MRI. Submitted 17 September 2023; Accepted 2 November 2023

INTRODUCTION

The implementation of multiparametric prostate magnetic resonance imaging (mpMRI) prior to prostate biopsy led to an improvement of clinically significant prostate cancer (CsPCa) diagnosis, contributing to the reduction of unnecessary biopsies and over-diagnosis of clinically insignificant prostate cancer and resultant overtreatment (1-4). In the setting of primary diagnosis, mpMRI was interpreted according to the Prostate Imaging Reporting and Data System (PIRADS), created by the European Society of Urogenital Radiology (ESUR) to standardize radiologic reports and improve the diagnostic quality of prostate mpMRI exams (5). In 2021 a new PIRADS version 2.1 replaced the previous 2.0 version published in 2015 (6). The PI-RADS score report the likelihood of a CsPCa based on various mpMRI characteristics. Categories PI-RADS 1 or 2 indicate (very) low likelihood of CsPCa, whereas categories 4 or 5 indicate (very) high likelihood of CsPCa. The European Association of Urology recommends performing a prostate biopsy when mpMRI shows lesions with PI-RADS ≥ 3 (7). However, the PI-RADS category 3 is an intermediate status, with an equivocal risk of malignancy (8). A metanalysis with 17 studies reported a cancer detection rate of 16% (7-27%) in patients with PI-RADS category 3 lesions. (9) The PSA density (PSAD) has been proposed as a tool to facilitate biopsy decisions on PI-RADS categoric 3 lesions. A recent study on biopsy naive patients with PI-RADS 3 lesions and low PSAD (< 0.10 ng/ml/ml) reported a low risk of sig-

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D. Araújo, A. Gromicho, J. Dias, S. Bastos, R. Miguel Maciel, A. Sabença, L. Xambre

nificant disease (4%) suggesting that biopsies could be avoided. Nevertheless, PI-RADS 3 scores in patients with high PSAD (> 0.20 ng/ml/ml) should be offered targeted and systematic biopsies due to the higher risk of significant disease (29%) (10). The objective of this study is to determine the frequency of CsPCa, assess the diagnostic value of targeted biopsy and identify clinical predictors to improve the CsPCa detection rate in PI-RADS category 3 lesions.

lesions, maximum lesion diameter and location (peripheral, transitional, or anterior zone and the base, middle or apex) were examined on mpMRI. PSAD was calculated using pre-biopsy PSA and mpMRI-derived volume. All patients were submitted to a transrectal ultrasound (TRUS)-guided biopsy performed by an urologist (6 urologists, with a median 6.5 years of experience (range, 3-10 years)). Before the prostate biopsy, mpMRI was reviewed and analysed, identifying the presence of any PI-RADS lesion. The mpMRI was performed and reported by different radiologists but every mpMRI protocol included multiplanar T2-weighted imaging, diffusion weighted imaging (DWI), and dynamic contrast-enhanced MRI (DCEMRI). The study population was divided into two groups to assess the diagnostic value of targeted biopsy: target group, including those submitted to systematic plus targeted biopsy versus non-target group when only systematic or saturation biopsy were performed. The patients were distributed according to physician’s preference, and the two groups’ pathological results were compared. The mpMRI-targeted biopsy was performed through cognitive guidance. Three to 5 cores were obtained from each target lesion. The histopathology of the prostate biopsies was reported as a Gleason score and according to the 2014 International Society of Urologic Pathologic (ISUP) guidelines. Patients with PI-RADS 3 lesions were divided into three categories based on pathological biopsy results: benign, clinically insignificant disease (score Gleason = 6 or ISUP 1) and clinically significant cancer (score Gleason ≥ 7 (3+4) or ISUP ≥ 2) according to target and non-target group.

M aterials and methods Between 1st January 2017 and 31st December 2022, a total of 1661 men underwent a prostate biopsy at our center due to altered prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE). The inclusion criteria were: mpMRI with a PI-RADS 3 lesion followed by prostate biopsy. These patients could be biopsy naive, with previous negative biopsies or in active surveillance protocol. The exclusion criteria were absence of mpMRI before prostate biopsy, mpMRI without PI-RADS classification, having a scored lesion other than PI-RADS 3 or only having performed target biopsy. A flowchart with study inclusion criteria is presented in Figure 1. A total of 130 patients with PI-RADS 3 index lesions were retrospectively reviewed. All patients were treatment naive and clinical, mpMRI and pathologic data were collected for each patient. Clinical data included age, total PSA, ratio free to total PSA and DRE results (normal and abnormal findings). Abnormal findings were areas of localized or diffuse firmness, induration, irregularity or nodularity suggestive of a cT2 lesion. Prostate volume, number of target

Figure 1. Flowchart for study inclusion among patients with PI-RADS 3 index lesions with clinical suspicion of prostate cancer.

DRE: Digital rectal examination; mpMRI: multiparametric magnetic resonance imaging; PSA: Prostate-specific antigen. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11830

MRI PI-RADS 3 lesions

Statistical analyses were performed using IBM SPSS Statistics software version 25. Categorical variables are presented as frequencies and percentages, and continuous variables as means and standard deviations, or medians and interquartile ranges for variables with skewed distributions. Pearson's chi-squared or Fisher's Exact test were used to test for associations in categorical variables. Continuous variables were compared with the T-test student and Mann-Whitney U test. Simple and multiple logistic regression were performed to determine clinical predictors of CsPCa. A p-value ≤ 0.05 was considered statistically significant.

nificant (p = 0.32). The CsPCa detection was higher in the non-target group (32.6%, n = 14 vs 23.0%, n = 20 respectively). Regarding the target group, 11 patients with PIRADS 3 lesions had CsPCa in both systematic and target biopsy (55.0%). Nine patients had a positive systematic and negative target biopsy. No case of a positive target biopsy and a negative systematic biopsy was identified. In all patients, the presence of positive pathologic findings in systemic and target biopsy, equivalent histological results for both specimens were found. When systematic and target biopsies were jointly performed, if the results of systematic biopsies are not considered and only the results of target biopsies are taken into account, a CsPCa diagnosis would be missed on 9 patients. The difference of insignificant cancer and CsPCa rates among the target or non-target group was not statistically significant (p = 0.50 and p = 0.24, respectively). PSAD, abnormal DRE and peripheral target lesion location were significantly associated with CsPCa in PI-RADS 3 lesions (p = 0.05, 0.01 and 0.01, respectively). Clinical, mpMRI and pathologic findings on CsPCa lesions are reported in Table 3. On multivariate analysis, the abnormal DRE and lesions localized in Peripheral zone (PZ) were significantly associated with a presence of CsPCa in PIRADS 3 lesions (OR = 3.61, 95% CI [1.22, 10.72], p = 0.02 and OR = 3.31, 95% CI [1.35, 8.11], p= 0.01, respectively). The frequency of abnormal DRE was superior in the group of CsPCa patients (29.0% vs 14.0%, respectively). The median PSAD was similar in CsPCa positive patients and the overall PI-RADS 3 lesions group. A higher median PSAD significantly predisposed for CsPCa on

RESULTS

One thousand six hundred sixty-one men were submitted to prostate biopsy for altered PSA or/and abnormal DRE over the last 6 years. Patients without a pre-biopsy mpMRI (n = 840), without a PI-RADS classification in mpMRI (n = 41) and patients submitted to a target biopsy alone (n = 80) were excluded. One hundred and twenty-two patients with a PI-RADS category 5 lesions (17.4%), 330 with a PI-RADS category 4 lesions (47.1%) and 118 with PI-RADS category 2 lesions (16.9%) were not included in the cohort. The detailed patient inclusion and exclusion flow charts are presented in Figure 1. A total of 130 men (18.5%) with PI-RADS 3 index lesions were biopsied and included in this study. One hundred fifty-three PI-RADS 3 index lesions were observed. General characteristics of the PI-RADS 3 lesions and patients are summarized in Table 1. The mean age was 65.2 ± 6.9 years. Median total PSA was 7.7 ng/dl (IQR 5.43-9.77), with a median of free/total PSA of 14.6% (IQR 11.0-18.9). Seventeen of 121 patients had an abnormal DRE (14.0%). Mean prostate size on mpMRI was 60.1 ± 22.6 ml. When calculated, median PSAD was 0.12 ng/ml/ml (IQR 0.09-0.18). Median maximum lesion diameter was 10.0 mm (IQR 7.0-13.0). The majority of the lesions were located on the peripheral zone (PZ) (64.9%) followed by transitional (TZ) and anterior zone (33.1% and 1.9%, respectively). Regarding prostatic location, most were in the middle of prostate (54.3%). One hundred and eight men had prostates with only one targeted lesion (83.1%) and 22 patients had more than one PI-RADS 3 lesion (16.9%). The number of PI-RADS 3 lesions in the prostate ranged from 1 to 4 lesions. Pathologic results in this cohort were benign in 77 lesions (59.2%), 19 (14.6%) were clinically insignificant (Gleason score 6 or ISUP 1) and 34 (26.2%) were CsPCa (more than Gleason score 7 or above ISUP 2). Of the 34 patients with CsPCa, 30 patients had a Gleason score of 7 (3+4), 3 patients had a Gleason score of 7 (4+3) and one patient had a Gleason score 9 (5+4). Eighty-seven of the patients were included in the target group (66.9%) and 43 in the non-target group (33.1%). The pathologic outcomes of PIRADS 3 lesions, considering the clinical data and target and non-target group, are described in Figure 2. The presence of benign histology was the most common result in both groups. The CsPCa detection in patients with previous negative biopsy was inferior compared to naive or active surveillance patients. The difference in CsPCa rates among the three clinical scenarios was not statistically sig-

Table 1. Clinical and imagiological characteristics of the PI-RADS categoric 3 cohort population. Variables Age (years) [Mean ± SD] Total PSA (ng/dl) [Median (IQR)] Free/total PSA (%) [Median (IQR)] Prostate volume (mL) [Mean ± SD] PSA Density (ng/ml/ml) [Median (IQR)] Abnormal DRE (n, %) Clinical scenario (n, %) – Biopsy naive – Previous negative biopsy – Active surveillance Maximum lesion diameter (ml) [Median (IQR)] Number of PI-RADS 3 index lesions (n, %) – Single – Multiple Target lesion zonal location (n = 154) (n, %) – Peripheral zone – Transition/central zone – Anterior fibromuscular stroma Target lesion quadrantal location (n = 140) (n, %) – Base – Middle – Apex

No. (%) 65.2 ± 6.9 7.7 (5.43-9.77) 14.6 (11.0-18.9) 60.1 ± 22.6 0.12 (0.09-0.18) 17 (14.0) 84 (64.6) 34 (26.2) 12 (9.2) 10.0 (7.0-13.0) 108 (83.1) 22 (16.9) 100 (64.9) 51 (33.1) 3 (1.9) 30 (21.4) 76 (54.3) 34 (24.3)

DRE: Digital rectal examination; IQR: interquartile range; SD: Standard deviation; PSA: Prostate-specific antigen.

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univariate analyses (p = 0.05) but was not significant in the multivariate analysis (p = 0.76). In our population, using 0.10 ng/ml/ml as a cut-off to perform biopsy, 41 patients would have avoided biopsy (31.5%), but 5 cases of CsPCa would not have been detected (3.4%). We could not identify statistical significance between others clinical and imagiological variables and CsPCa detection.

ly). Nevertheless, a CsPCa diagnosis would be missed in 9 patients if targeted biopsy was performed alone, confirming the importance of not omitting the systematic biopsy in this setting. In our cohort, the value of the systematic biopsy was demonstrated. No case of histological upgrading or only positive pathological results on target biopsies were reported. In our opinion, the target biopsy could be omitted in PI-RADS 3 lesions, however the systematic biopsy should always be performed if CsPCA is suspected. The importance of the systematic biopsies in CsPCa detection in PI-RADS 3 lesions can be explained due to MRI interpretation and mistargeting issues (i.e., the lesion has been correctly identified by mpMRI but missed by mpMRI-targeted biopsy and detected by systematic sampling), especially in non-peripheral zones and smaller lesions. Some authors advocate a saturation targeted approach or increasing the number of cores taken by target to raise the CsPCa detection (15, 16). We believe that in reference centers with large number of patients, experienced teams with dedicated radiologists and urologists, well-defined protocols and newer technologies or softwares, the target biopsy may be crucial in PI-RADS 3 lesions. However, in tertiary centers like ours, there are some disadvantages - smaller number of patients, interpretation of mpMRI by different radiologists and different urologists with different levels of experience. Our targeted biopsies were obtained by cognitive guidance. The current literature does not show superiority or inferiority of the cognitive technique compared with US/MR fusion software or direct in-bore guidance (17). Regarding the pathology analyses, the most common result was benign histology in both groups. The CsPCa detection in patients with previous negative biopsy was lower comparative to naive or active surveillance patients. The difference of CsPCa rates among the three groups was not statistically significant (p = 0.32). Given the high variability of the published studies, it is difficult to decide to perform prostate biopsy in case of PI-RADS 3 lesions independently of clinical scenario (naive patient, or with previous negative biopsy, or active surveillance) (11). Many studies tried to identify clinical and imagiological findings that can help to identify which patients can be selected for surveillance. PSAD is the most frequently investigated clinical predictor. Recently, a risk-adapted biopsy decision was proposed, based on PSAD and mpMRI report. Concerning the PI-RADS 3 lesions, patients with high-risk PSAD (> 0.20 ng/ml/ml) should be offered targeted and systematic biopsies as they have a higher risk for significant disease (29%). On the other hand, patients with low risk PSAD (< 0.10 ng/ml/ml) have a low risk of significant disease (4%) and biopsies could be avoided (10). In our study, the median PSAD was similar in CsPCa positive patients and the general PI-RADS 3 lesions cases. A higher median PSAD significantly predisposed for CsPCa on univariate analyses (p = 0.05) but not significant in the multivariate analysis (p = 0.76). In our population, using 0.10 ng/ml/ml as a cut-off to perform biopsy, 41 patients would have avoided biopsy (31.5%), but 5 cases of CsPCa would not have been detected (3.4%). Venderink et al. demonstrated that biopsying only PI-RADS 3 cases with a PSAD of ≥ 0.15 ng/ml/ml resulted in 42% of cases who would avoid biopsy, thus missing 6%

DISCUSSION

The evaluation of PI-RADS 3 lesions does not represent the primary endpoint in most studies of prostate cancer diagnosis, and, currently, the quality of the studies focusing on this PI-RADS subset remains low. PI-RADS classification was designed to reduce the mpMRI inter-reader reproducibility, however, it does not provide a specific management algorithm for each category (11). Concerning the PI-RADS 3 lesions, there is no agreement on the best clinical management - biopsy or clinical surveillance (12, 13). Prostate biopsy is the standard recommendation, however, in some cases a follow-up strategy could be an acceptable option (10, 11). In our institution, the prevalence of PI-RADS 3 lesions was 18.5%. Maggi et al., in a review of 23 studies, reported a prevalence of PI-RADS 3 cases of 17.3% (range 6.445.7%) (11). Given the incidence of these lesions, choosing the best approach is essential. We demonstrated that PI-RADS 3 lesions were associated with a low risk of prostate cancer (40.8%), especially when considering CsPCa. In our study, most PI-RADS 3 lesions were benign (59.2%) and only 26.2% were CsPCa. The most common Gleason scored diagnosed was score 7 (3+4) or ISUP 2 (30/34). Regarding the diagnosis of ISUP 4 or higher, only one case was identified on PI-RADS 3 lesions. The CsPCa rate was significantly variable between published studies. This can be explained based on the population heterogeneity, MRI protocols, type of mpMRI-targeted biopsy (cognitive guidance, ultrasound or MRI fusion software or direct in-bore guidance) and CsPCa definitions. Oerther et al. reported a cancer detection rate of 16% (7-27%) in patients with PI-RADS 3 lesions (9). Schoots et al. reviewed 3006 biopsy-naive men in five studies and found the percentage of ISUP ≥ 2 detection rate in lesions PIRADS 3 was 16% (10). In a review of thirteen prospective studies of PI-RADS 3 lesions, the overall PCa detection rate was 37%, while for CsPCa it was 21% (14). Magui et al., in a systematic review of 28 studies with a total of 1759 cases of PIRADS 3 lesions, reported a prostate cancer detection rate of 36% (range 10.3-55.8%) and CsPCa rate of 18.5% (range 3.4-46.5%) (11). The best biopsy strategy also remains controversial. The inclusion of the MRI previously to prostate biopsy increased the number of CsPCa detected and reduced the number of insignificant cancer. However, omitting systematic biopsy would miss approximately 16% and 10% of all detected ISUP grade ≥ 2 in biopsy-naive and repeatbiopsy patients, respectively (1-4) In our population, the CsPCa rate was slightly higher in non-target group (32.6 vs. 23%, respectively); and paradoxically, insignificantly cancer rate was slightly higher in the target group (16.1 vs. 11.6%, respectively). However, both results were not statistically significant (p = 0.50 and p = 0.24, respective-

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MRI PI-RADS 3 lesions

of CsPCa cases. Lowering the cut-off value to 0.12 ng/ml/ml resulted in 26% of cases that would have avoided biopsy without missing any CsPCa (18). An abnormal DRE (p = 0.02) and a peripheral target lesion (p = 0.01) significantly predisposed for CsPCa in multivariate logistic regression. The frequency of abnormal DRE was higher in the CsPCa patients group comparatively to general PI-RADS 3 cases (29.0% vs 14.0%, respectively). Sheridan et al. calculated risks factors of CsPCa in PI-RADS 3 lesions in their multivariate analyses and demonstrated that an abnormal DRE was a significant predictor of CsPCa (OR.3.92, p = 0.03), as was advanced age (≥ 70 years) and smaller prostates (≤ 36cc) (19). Radtle et al. showed that a higher PSA level (OR, 2.08), a smaller gland size (OR, 0.81), abnormal DRE findings (cT2 or more lesion, OR, 4.09) and advanced age (OR, 1.09) were independently associated with CsPCa in PIRADS 3 lesions. (20) Abnormal DRE is a strong predictor of advanced PCa that is associated with an increasing risk of higher ISUP and, despite being a subjective test, is an important tool in our population to decide who should underwent biopsy. Most of the PI-RADs 3 lesions in our cohort were located in the peripheral zone, independently of CsPCa results. Liddell et al. showed that PI-RADS 3 lesions within the PZ were more likely to be associated with malignant disease compared with lesions identified within TZ (10.8% vs. 3.8%) (21). Yang et al. demonstrated in his study that PIRADS 3 lesions were most frequent in TZ than PZ (n = 67 and n = 54, respectively), however the CsPCa rate was superior in PZ (18.5% vs. 6.0%, respectively) (22). Galosi et al. defended a low risk of cancer in PI-RADS 3 lesions located in TZ; they concluded that biopsy could be omitted in same patients considering a nomogram with PCa risk, PSAD, and lesion location (23). A systematic review and meta-analyses of a total of 17 articles showed no systematic difference of cancer detection rate between PZ lesions and TZ lesions in different PI-RADS classifications (24). Schoots et al. explain that mpMRI interpretation of TZ is more challenging comparative to PZ because the TZ shows heterogeneous signal intensities due to presence of nodules of benign prostatic hyperplasia while a normal PZ is brightly hyperintense on T2 images and hypointense abnormalities can be easily identified. In case of PI-RADS 3 lesions, the overlapping with benign situations often interpreted as false-positive mpMRI findings (benign prostate hyperplasia, inflammation or fibrosis) are more common (25). This can explain the higher frequency of PI-RADS 3 lesions on TZ, however, it was not observed in our cohort. Our study has several limitations. It is a retrospective study, from a single institution and with limited PI-RADS 3 lesions enrolled which may have resulted in possible risk of selection bias. It included patients from 2017 to 2022 and some lesions were classified as intermediate probability using criteria from version 2 and others with version 2.1. Therefore, the possibility of a bias of interpretation is higher given that the mpMRI reports are reviewed by multiple readers, with an interobserver variability of identification and classification of the lesions. Biopsies were also performed by different urologists with different experience and biopsy specimens were evaluat-

ed by multiple pathologists. It was not possible to compare the results with other approaches, namely transperineal biopsy or fusion guided software, to analyse differences in CsPCa detection. Our definition of CsPCa considered only the Gleason/ISUP score without any interpretation on basis in lesion volume. Larger studies, prospective and randomized, are required to evaluate the reproducibility of our results.

CONCLUSIONS

We have demonstrated in our cohort that prostate lesions characterized as PI-RADS 3 lesions, according to the current prevalent scoring systems, were associated with a low likelihood of the CsPCa detection. A systematic biopsy associated or not with a target biopsy is essential in PIRADS 3 lesions, and targeted biopsy did not demonstrate to be superior in the detection of CsPCa. The presence of abnormal DRE and lesions localized in PZ potentially predict the presence of CsPCa in biopsied PI-RADS 3 lesions.

REFERENCES

1. Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. The Lancet. 2017; 389:815-22. 2. Rouvière O, Puech P, Renard-Penna R, et al. Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): a prospective, multicentre, paired diagnostic study. Lancet Oncol. 2019; 20:100-9. 3. van der Leest M, Cornel E, Israël B, et al. Head-to-head Comparison of Transrectal Ultrasound-guided Prostate Biopsy Versus Multiparametric Prostate Resonance Imaging with Subsequent Magnetic Resonance-guided Biopsy in Biopsy-naïve Men with Elevated Prostate-specific Antigen: A Large Prospective Multicenter Clinical Study. Eur Urol. 2019; 75:570-8. 4. Drost FJH, Osses DF, Nieboer D, et al. Prostate MRI, with or without MRI-targeted biopsy, and systematic biopsy for detecting prostate cancer. Cochrane Database Syst Rev. 2019; 4:CD012663. 5. Barentsz JO, Richenberg J, Clements R, et al. ESUR prostate MR guidelines 2012. Eur Radiol. 2012; 22:746-57. 6. Turkbey B, Rosenkrantz AB, Haider MA, et al. Prostate Imaging Reporting and Data System Version 2.1: 2019 Update of Prostate Imaging Reporting and Data System Version 2. Eur Urol. 2019; 76:340-51. 7. EAU Guidelines. Edn. presented at the EAU Annual Congress Milan 2023. ISBN 978-94-92671-19-6. 8. Weinreb JC, Barentsz JO, Choyke PL, et al. PI-RADS Prostate Imaging - Reporting and Data System: 2015, Version 2. Eur Urol. 2016; 69:16-40. 9. Oerther B, Engel H, Bamberg F, Sigle A, Gratzke C, Benndorf M. Cancer detection rates of the PI-RADSv2.1 assessment categories: systematic review and meta-analysis on lesion level and patient level. Prostate Cancer Prostatic Dis. 2022; 25:256-63. 10. Schoots IG, Padhani AR. Risk-adapted biopsy decision based on prostate magnetic resonance imaging and prostate-specific antigen density for enhanced biopsy avoidance in first prostate cancer diagnostic evaluation. BJU Int. 2021; 127:175-8. 11. Maggi M, Panebianco V, Mosca A, et al. Prostate Imaging

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11830

D. Araújo, A. Gromicho, J. Dias, S. Bastos, R. Miguel Maciel, A. Sabença, L. Xambre

Reporting and Data System 3 Category Cases at Multiparametric Magnetic Resonance for Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus. 2020; 6:463-78.

Classified Equivocal, Likely or Highly Likely to Be Clinically Significant Prostate Cancer. Eur Urol. 2018; 73:353-60. 19. Sheridan AD, Nath SK, Syed JS, et al. Risk of Clinically Significant Prostate Cancer Associated With Prostate Imaging Reporting and Data System Category 3 (Equivocal) Lesions Identified on Multiparametric Prostate MRI. AJR Am J Roentgenol. 2018; 210:347-57.

12. Maggi M, Panebianco V, Mosca A, et al. Prostate Imaging Reporting and Data System 3 Category Cases at Multiparametric Magnetic Resonance for Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Focus. 2020; 6:463-78.

20. Radtke JP, Wiesenfarth M, Kesch C, et al. Combined Clinical Parameters and Multiparametric Magnetic Resonance Imaging for Advanced Risk Modeling of Prostate Cancer—Patient-tailored Risk Stratification Can Reduce Unnecessary Biopsies. Eur Urol. 2017; 72:888-96.

13. Ullrich T, Quentin M, Arsov C, et al. Risk Stratification of Equivocal Lesions on Multiparametric Magnetic Resonance Imaging of the Prostate. J Urol. 2018; 199:691-8. 14. Park KJ, Choi SH, Lee JS, et al. Risk Stratification of Prostate Cancer According to PI-RADS® Version 2 Categories: Meta-Analysis for Prospective Studies. J Urol. 2020; 204:1141-9.

21. Liddell H, Jyoti R, Haxhimolla HZ. mp-MRI Prostate Characterised PIRADS 3 Lesions are Associated with a Low Risk of Clinically Significant Prostate Cancer - A Retrospective Review of 92 Biopsied PIRADS 3 Lesions. Curr Urol. 2015; 8:96-100.

15. Hansen NL, Barrett T, Lloyd T, et al. Optimising the number of cores for <scp>magnetic resonance imaging</scp> - guided targeted and systematic transperineal prostate biopsy. BJU Int. 2020; 125:260-9.

22. Yang S, Zhao W, Tan S, et al. Combining clinical and MRI data to manage PI-RADS 3 lesions and reduce excessive biopsy. Transl Androl Urol. 2020; 9:1252-61.

16. Cash H, Günzel K, Maxeiner A, et al. Prostate cancer detection on transrectal ultrasonography-guided random biopsy despite negative real-time magnetic resonance imaging/ultrasonography fusionguided targeted biopsy: reasons for targeted biopsy failure. BJU Int. 2016; 118:35-43.

23. Galosi AB, Palagonia E, Scarcella S, et al. Detection limits of significant prostate cancer using multiparametric MR and digital rectal examination in men with low serum PSA: Up-date of the Italian Society of Integrated Diagnostic in Urology. Arch Ital Urol Androl. 2021; 93:92-100.

17. Wegelin O, Exterkate L, van der Leest M, et al. The FUTURE Trial: A Multicenter Randomised Controlled Trial on Target Biopsy Techniques Based on Magnetic Resonance Imaging in the Diagnosis of Prostate Cancer in Patients with Prior Negative Biopsies. Eur Urol. 2019; 75:582-90.

24. Oerther B, Engel H, Bamberg F, et al. Cancer detection rates of the PI-RADSv2.1 assessment categories: systematic review and metaanalysis on lesion level and patient level. Prostate Cancer Prostatic Dis. 2022; 25:256-63. 25. Schoots IG. MRI in early prostate cancer detection: how to manage indeterminate or equivocal PI-RADS 3 lesions? Transl Androl Urol. 2018; 7:70-82.

18. Venderink W, van Luijtelaar A, Bomers JGR, et al. Results of Targeted Biopsy in Men with Magnetic Resonance Imaging Lesions

Correspondence Débora Araújo, MD deboracerqueiraaraujo@gmail.com Jorge Dias, MD josh_dias@hotmail.com Samuel Bastos, MD samuel.sbastos@hotmail.com Rui Miguel Maciel, MD rui.painhas.maciel@chvng.min-saude.pt Ana Sabença, MD anasofiassg@gmail.com Luís Xambre, MD xambreluis@gmail.com Urology Department, Centro Hospitalar Vila Nova de Gaia/Espinho EPE, Vila Nova de Gaia, Portugal Alexandre Gromicho, MD alexandrepgromicho@gmail.com Urology Department, Centro Hospitalar do Funchal, Madeira, Portugal

Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11830

DOI: 10.4081/aiua.2023.12138

ORIGINAL PAPER

The bladder neck preservation in robot assisted radical prostatectomy: Surgical and pathological outcome Michele Zazzara 1, Marina P. Gardiman 2, Fabrizio Dal Moro 1 1 Urology Clinic, Department of Surgical Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy; 2 Surgical Pathology and Cytopathology Unit, Department of Medicine, University of Padua, Padua, Italy.

Summary

Introduction: The post-prostatectomy incontinence is influenced by multiple elements, anatomic components and biological factors. The bladder neck preservation, more accurate during robot assisted radical prostatectomy, works on two anatomic components responsible for post-prostatectomy continence. The bladder neck preservation spares the internal sphincter, which is responsible for passive continence, and results in earlier return to continence and lower rates of post-prostatectomy incontinence. Moreover, this surgical technique spares the zone of urothelium coaptation and provides primary resistance to the urine to maintain postprostatectomy continence. The potential risk of bladder neck positive surgical margins (PSM) may prevent the usage of the bladder neck preservation. Aim: The purpose of this study is to evaluate the surgical and pathological outcome in prostate cancer patients underwent robot assisted radical prostatectomy with bladder neck preservation. Materials and methods: Prospectively, we have collected demographic, clinical, surgical and pathological data of prostate cancer patients underwent robot assisted radical prostatectomy with bladder neck preservation, from January 2014 to December 2016, in Urological Clinic of the University of Padua. Moreover, it was valued the presence of alterations or continuous solutions of specimen external capsule, attributable to the surgical technique of bladder neck preservation, by microscopic and macroscopic pathological analysis. Results: According to D'Amico risk classification, 40 patients (45.4%) had a low risk neoplasia, 35 patients (39.8%) had an intermediate risk neoplasia, 13 patients (14.8%) had an high risk neoplasia. The median prostatic volume, valued on specimen, was 30.84 cc (21.5-44.75 cc). The median prostatic weight, valued on specimen, was 51 gr (36-67 gr). The pathological stage of disease was pT2a in 11 cases (12.5%), pT2b in 37 cases (42.1%), pT3a in 28 cases (31.8%), pT3b in 12 cases (13.6%). The pathological stage of lymph node involvement was pNx in 17 cases (19.3%), pN0 in 66 cases (75%), pN1 in 5 cases (5.7%). The prostate cancers diagnosed had a Gleason score at specimen of 6 in 10 cases (10.4%), 7 (3+4) in 30 cases (34.1%), 7 (4+3) in 20 cases (22.7%), 8 in 19 cases (21.6%) and 9 in 9 cases (10.2%). The prostatic base was involved by neoplasia in 14 patients (15.9%); of these, 5 patients (35.7%) had bladder neck PSM. The patients with bladder neck PSM had: a pathological stage of disease as pT3a in 2 cases (40%) and pT3b in 3 cases (60%); a pathological stage of lymph node involvement as pN0 in 2 cases (40%) and pN1 in 3 cases (60%); a Gleason score at specimen of 8 in 3 cases (60%) and 9 in 2 cases (40%);

multiple PSM. Nobody had alterations or continuous solutions of specimen external capsule, attributable to surgical technique of bladder neck preservation. Conclusions: The bladder neck preservation, during robot assisted radical prostatectomy, is a safe oncological procedure resulting in a good functional outcome, about post-prostatectomy continence, working on two anatomic components responsible for post-prostatectomy continence. The bladder neck PSM are linked to neoplasia with adverse pathological features, rather than the bladder neck preservation.

KEY WORDS: RARP; Bladder Neck Sparing Surgery; Prostate cancer. Submitted 27 November 2023; Accepted 30 November 2023

INTRODUCTION

Persistent urinary incontinence (UI) after radical prostatectomy (RP), commonly referred to as post-prostatectomy incontinence (PPI), is an adverse event that leads to significant distress. Ficarra et al. (1) found that for a "no pad" definition of UI, rates ranged from 4% to 31%, with a mean of 16%. The PPI is influenced by muliple elements, anatomic components and biological factors (2). The anatomic components that influence on urinary continence, after RP, are the urethral sphincter complex, the supporting structures of the membranous urethra (3), the fibrosis after surgery (4), the neural components (5-8), the zone of urothelium coaptation. The biological factors contributing to PPI are the age (9), the functional bladder changes (10), the body mass index (11), pre-existing low urinary tract symptoms (12), TURP before RP (13), the prostate size (14) and the membranous urethral length (15). The urethral sphincter complex consists of two functionally independent components, an internal or lissosphincter of smooth muscle and an outer or external rhabdosphincter of skeletal muscle, that are thought to be responsible for passive and active continence, respectively (16). The internal sphincter maintains continence during normal activity when there is little stress on the bladder outlet. Its smooth muscle maintains tone for long periods with minimal exertion. The external urethral sphincter is a muscle that is very strong but becomes fatigued very quickly. The urothelium is surrounded by elastic tissue and fibers

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M. Zazzara, M.P. Gardiman, F. Dal Moro

RESULTS

of smooth and striated muscle. At the junction of the inferior bladder and the proximal urethra, the urothelium becomes a key component of sphincter function. The elastic components of the proximal urethral wall are responsible for coaptation of the urothelium (zone of coaptation). This proper adhesion of the urethral wall provides primary resistance to the urine to maintain continence (17). Little is known about the optimal length of the zone of coaptation. It is hypothesized that it should be at least 5-10 mm to ensure continence (18). The bladder neck preservation (BNP), more accurate during robot assisted radical prostatectomy (RARP), works on these two anatomic components responsible for post-prostatectomy continence influencing PPI. The potential risk of bladder neck PSM may prevent the usage of the BNP. The current study investigates the surgical and pathological outcome of BNP in prostate cancer patients treated with RARP.

Table 1 summarizes patient demographic and clinical data. The mean patient age was 64.77 ± 6.75 years and the mean body-mass index was 26.73 ± 3.04 kg/m2. The median IPSS score was 9 (4,5-14) and the median IIEF-5 score was 17 (11-23). The median prostate-specific antigen value was 6.09 ng/ml (4.92-8.01 ng/ml). The median prostatic volume was 40 cc (38.75-50 cc). Clinical staging was cT1c in 51 patients (58%), cT2a in 26 patients (29.5%), cT2b in 8 patients (9.1%), cT2c in 2 patients (2.3%) and cT3a in 1 patient (1.1%). The bioptic Gleason score was 6 in 48 patients (54.6%), 7 [3 + 4] in 27 patients (30.7%), 7 [4 + 3] in 3 patients (3.4%), 8 in 9 patients (10.2%), 9 in 1 patient (1.1%). As per the D'Amico risk classification, 40 patients (45.4%) had lowrisk prostate cancer, 35 patients (39.8%) had intermediate-risk prostate cancer, and 13 patients (14.8%) had high-risk prostate cancer. Table 2 summarizes pathological data. The median prostatic volume, valued on specimen, was 30.84 cc (21.5-44.75 cc). The median prostatic weight, valued on specimen, was 51 gr (36-67 gr). Pathological stage was pT2a in 11 cases (12.5%), pT2b in 37 cases (42.1%), pT3a in 28 cases (31.8%), pT3b in 12 cases (13,6%). The pathological stage of lymph node involvement was pNx in 17 cases (19.3%), pN0 in 66 cases (75%), pN1 in 5 cases (5.7%). The prostate cancers diagnosed had a Gleason score at specimen of 6 in 10 cases (10.4%), 7 (3+4) in 30 cases (34.1%), 7 (4+3) in 20 cases (22.7%), 8 in 19 cases (21.6%) and 9 in 9 cases (10.2%). The prostatic base was involved by neoplasia in 14 patients (15.9%); of these, 5 patients (35.7%) had bladder neck PSM. The patients with bladder neck PSM had: a pathological stage of disease as pT3a in 2 cases (40%) and pT3b in 3 cases (60%); a pathological

MATERIALS AND METHODS

Between January 2014 and December 2016, 88 patients with prostate cancer underwent daVinci® RARP with BNP at the Urology Department of the University of Padua. We prospectively collected demographic data including age, body mass index, comorbidities, previous surgery, erectile function as per the International Index of Erectile Function 5 (IIEF-5) questionnaire (19), and lower urinary tract symptoms as per the International Prostate Symptom Score (IPSS) questionnaire (20), as well as clinical data including prostate-specific antigen status, clinic stage according to tumor, node, and metastasis staging (21), bioptic Gleason Score (22) and D’Amico risk classification (23) for each patient. Surgical data including total operative duration, blood loss, whether a transfusion was performed, time to drain removal, time to cystography and time to catheter removal were also recorded. The BNP was considered reached when the diameter of the BN was adequate to the diameter of the urethra, not requiring BN neck reconstruction before anastomosis. All surgical procedures were performed by the same expert surgeon. The prostate specimen was formalin fixed in the standard manner; the paraffin-embedded specimen was examined histologically in the form of 4-mm, whole mount, haematoxylin and eosin stained sections. Therefore, the specimen was examined in its entirety in every case. A positive surgical margin was defined as the presence of tumour at the inked margin (24). Therefore, for each patient we evaluated the following pathological parameters: site and side of the tumour, definitive Gleason Score, pathological extension of the primary tumour and the lymph node involvement. Moreover, it was valued the presence of alterations or continuous solutions of specimen external capsule, attributable to the surgical technique of bladder neck preservation, by microscopic and macroscopic pathological analysis. A single expert uro-pathologist reviewed all RP specimens. This study did not receive any funding. All patients provided written informed consent for the procedures described herein. Descriptive data are presented as the mean ± standard deviation or median (interquartile range).

Table 1. Patient demographic and clinical data. Parameter Age (years) BMI (kg/m2) IPSS score IIEF-5 score Prostatic volume (cc) PSA (ng/ml) Bioptical Gleason score -6 - 7 (3+4) - 7 (4+3) -8 -9 cT - cT1c - cT2a - cT2b - cT2c - cT3a D'Amico risk classification - Low risk - Intermediate risk - High risk

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12138

Value (64.77 ± 6.75) (26.73 ± 3.04) (9; 4.5-14) (17; 11-23) (40; 38.75-50) (6.09; 4.92-8.01) 48 (54.6%) 27 (30.7%) 3 (3.4%) 9 (10.2%) 1 (1.1%) 51 (58%) 26 (29.5%) 8 (9.1%) 2 (2.3%) 1 (1.1%) 40 (45.4%) 35 (39.8%) 13 (14.8%)

Bladder neck preservation in robot assisted radical prostatectomy

Table 2. Patient pathological data. Parameter Prostatic volume (cc) Prostatic weight (gr) pT - pT2a - pT2b - pT3a - pT3b pN - pNx - pN0 - pN1 Gleason score -6 - 7 (3+4) - 7 (4+3) -8 -9 Tumor site - Base - Other sites Basal PSM - Present - Absent pT in patients with basal PSM - pT3a - pT3b pN in patients with basal PSM - pN0 - pN1 Gleason score in patients with basal PSM -8 -9 Multiple PSM in patients with basal PSM - Present - Absent Continuous solutions of specimen external capsule due to surgery - Present - Absent

ing on two anatomic components influencing PPI. The other anatomic components are the targets of several surgical procedure, as supporting structures of the membranous urethra are the targets of anterior fixation or posterior reconstruction, as the neural components are the targets of nerve-sparing surgery. Therefore, the continence recovery after RP is multifactorial and its achievement is due to several surgical approaches and not exclusively to a single surgical procedure. For this reason, in our study, it was not investigated the continence outcome. The current study investigates the surgical and pathological outcome of BNP during RARP. In fact, the potential risk of bladder neck PSM may prevent the usage of the BNP. Nowadays, this topic is controversial; some authors support that BNP may raise the bladder neck PSM (8, 29), contrarily, a meta-analysis (30) and other studies (31-36), support that the BNP would not compromise the oncological control of disease and that the mini-invasive approach, in particular RARP, and the best imaging diagnostic tools may allow a more safe procedure. To address this controversy, we have evaluated in our study the presence of alterations or continuous solutions of specimen external capsule, attributable to the surgical technique of BNP, by microscopic and macroscopic pathological analysis. In our series, no specimen exhibited alterations or continuous solutions of specimen external capsule, referring to the surgical technique of BNP. However, in 5 of the 14 cases (35.7%) with basal tumor, there were bladder neck PSM. Evaluating the pathological features of these cases, it was shown an extraprostatic extension of disease (pT3a-3b), a low grade of disease differentiation (G.S. 8-9), a lymph node involvement in more part of them, multiple PSM and not exclusive of BN; therefore, all patients with bladder neck PSM showed unfavorable pathological features. According to Golabeck (34), the potential risk of bladder neck PSM would be linked to neoplasia with extraprostatic extension and a low grade of disease differentiation. Our study shows that BNP during RARP doesn't cause alterations or continuous solutions of specimen external capsule, attributable to the surgical technique of bladder neck preservation, by microscopic and macroscopic pathological analysis, and that the bladder neck PSM are linked to neoplasia with adverse pathological features, rather than the BNP. Moreover, all case with bladder neck PSM showed multiple PSM, and, therefore, the PSM would be present regardless of BNP. There are several limitations to this study. Although the data on our patients are collected prospectively, there isn't a control group, the patients are not randomized, and the number of patients is weak. Moreover, the BN approach was decided intraoperatively. Thus, it is possible that patients were selected according to individual features and technical considerations encountered intraoperatively. Cases of large prostate, prominent middle lobe or more difficult dissection would likely be spared the BNP approach.

Value (30.84; 21, 5-44, 75) 51; 36-67) 11 (12.5%) 37 (42.1%) 28 (31.8%) 12 (13.6%) 17 (19.3%) 66 (75%) 5 (5.7%) 10 (10.4%) 30 (34.1%) 20 (22.7%) 19 (21.6%) 9 (10.2%) 14 (15.9%) 74 (84.1%) 5 (35.7%) 9 (64.3%) 2 (40%) 3 (60%) 2 (40%) 3 (60%) 3 (60%) 2 (40%) 88 (100%) 0 (0%) 0 (0%) 88 (100%)

stage of lymph node involvement as pN0 in 2 cases (40%) and pN1 in 3 cases (60%); a Gleason score at specimen of 8 in 3 cases (60%) and 9 in 2 cases (40%); multiple PSM. Nobody had alterations or continuous solutions of specimen external capsule, attributable to surgical technique of bladder neck preservation. The median time to cystography was 6 days (4.5-14). In one case, there was anastomosis urinary leakage at cystography (1.13%).

DISCUSSION

The bladder neck preservation spares the internal sphincter, which is responsible for passive continence, and results in earlier return to continence and lower rates of post-prostatectomy incontinence (25-27). Moreover, this surgical technique spares the zone of urothelium coaptation and provides primary resistance to the urine to maintain post-prostatectomy continence (17). Thus, the BNP is a surgical factor contributing to PPI, act-

CONCLUSIONS

The BNP during RARP is a safe oncological procedure resulting in a good functional outcome, about post-prosta-

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12138

M. Zazzara, M.P. Gardiman, F. Dal Moro

tectomy continence, working on two anatomic components responsible for post-prostatectomy continence. The bladder neck PSM are linked to neoplasia with adverse pathological features, rather than the BNP.

anatomical concept and its physiological correlate. J Urol. 2008; 179:1683-9. 17. Sacco E, Prayer-Galetti T, Pinto F, et al. Urinary incontinence after radical prostatectomy: incidence by definition, risk factors and temporal trend in a large series with a long-term follow-up. BJU Int. 2006; 97:1234-41.

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21. Sobin LH, Compton CC. TNM seventh edition: what's new, what's changed: communication from the International Union Against Cancer and the American Joint Committee on Cancer. Cancer. 2010; 116:5336.

5. Catarin MV, Manzano GM, Nóbrega JA, et al. The role of membranous urethral afferent autonomic innervation in the continence mechanism after nerve sparing radical prostatectomy: a clinical and prospective study. J Urol. 2008; 180:2527-31.

22. Epstein JI, Egevad L, Amin MB, et al. The 2014 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma: Definition of Grading Patterns and Proposal for a New Grading System. Am J Surg Pathol. 2016; 40:244.

6. Ozdemir MB, Eskicorapci SY, Baydar DE, et al. A cadaveric histological investigation of the prostate with three-dimensional reconstruction for better results in continence and erectile function after radical prostatectomy. Prostate Cancer Prostatic Dis. 2007; 10:7781.

23. D’Amico AV, Whittington R, Malkowicz SB, et al, Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA1998; 280:969.

7. Kaye DR, Hyndman ME, Segal RL, et al. Urinary outcomes are significantly affected by nerve sparing quality during radical prostatectomy. Urology. 2013; 82:1348-53.

24.Ficarra V, Novara G, Secco S, et al. Predictors of positive surgical margins after laparoscopic robot assisted radical prostatectomy. J Urol. 2009; 182:2682-8.

8. Burkhard FC, Kessler TM, Fleischmann A, et al. Nerve sparing open radical retropubic prostatectomy--does it have an impact on urinary continence? J Urol. 2006; 176:189-95.

25. Stolzenburg JU, Kallidonis P, Hicks J, et al. Effect of bladder neck preservation during endoscopic extraperitoneal radical prostatectomy on urinary continence. Urol Int. 2010; 85:135-8.

9. Matsushita K, Kent MT, Vickers AJ, et al. Preoperative predictive model of recovery of urinary continence after radical prostatectomy. BJU Int. 2015; 116:577-83.

26. Soljanik I, Bauer RM, Becker AJ, et al. Is a wider angle of the membranous urethra associated with incontinence after radical prostatectomy? World J Urol. 2014; 32:1375-83.

10. Song C, Lee J, Hong JH, et al. Urodynamic interpretation of changing bladder function and voiding pattern after radical prostatectomy: a long-term follow-up. BJU Int. 2010; 106:681-6.

27. Selli C, De Antoni P, Moro U, et al. Role of bladder neck preservation in urinary continence following radical retropubic prostatectomy. Scand J Urol Nephrol. 2004; 38:32-7.

11. Wolin KY, Luly J, Sutcliffe S, et al. Risk of urinary incontinence following prostatectomy: the role of physical activity and obesity. J Urol. 2010; 183:629-33.

28. Srougi M, Nesrallah LJ, Kauffmann JR, et al. Urinary continence and pathological outcome after bladder neck preservation during radical retropubic prostatectomy: a randomized prospective trial. J Urol. 2001; 165:815-8.

12.Wei JT, Dunn RL, Marcovich R, et al. Prospective assessment of patient reported urinary continence after radical prostatectomy. J Urol. 2000; 164:744-8.

29. Zakri RH, Vedanayagam M, John B, et al. Bladder neck sparing (BNS) robot assisted laparoscopic prostatectomy (RALP): Does it improve continence? Eur Urol. Suppl. 2016; 15:eV20.

13.Elder JS, Gibbons RP, Correa RJ Jr, Brannen GE. Morbidity of radical perineal prostatectomy following transurethral resection of the prostate. J Urol. 1984; 132:55-7.

30. Ma X, Tang K, Yang C, et al. Bladder neck preservation improves time to continence after radical prostatectomy: a systematic review and meta-analysis. Oncotarget. 2016; 7:67463-67475.

14. Konety BR1, Sadetsky N, Carroll PR; CaPSURE Investigators. Recovery of urinary continence following radical prostatectomy: the impact of prostate volume--analysis of data from the CaPSURE Database. J Urol. 2007; 177:1423-5.

31. Nyarangi-Dix JN, Radtke JP, Hadaschik B, et al. Impact of complete bladder neck preservation on urinary continence, quality of life and surgical margins after radical prostatectomy: a randomized, controlled, single blind trial. J Urol. 2013; 189:891-8.

15. Paparel P, Akin O, Sandhu JS, et al. Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral fibrosis measured by preoperative and postoperative endorectal magnetic resonance imaging. Eur Urol. 2009; 55:629-37.

32. Friedlander DF, Alemozaffar M, Hevelone ND, et al. Stepwise description and outcomes of bladder neck sparing during robot-assisted laparoscopic radical prostatectomy. J Urol. 2012; 188:1754-60.

16. Koraitim MM. The male urethral sphincter complex revisited: an

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Bladder neck preservation in robot assisted radical prostatectomy

33. Golabek T, Jaskulski J, Jarecki P, et al. Laparoscopic radical prostatectomy with bladder neck preservation: positive surgical margin and urinary continence status. Wideochir Inne Tech Maloinwazyjne. 2014; 9:362-70.

35. Bianco FJ, Grignon DJ, Sakr WA, et al. Radical prostatectomy with bladder neck preservation: impact of a positive margin. Eur Urol. 2003; 43:461-6.

34. Gomez CA, Soloway MS, Civantos F, Hachiya T. Bladder neck preservation and its impact on positive surgical margins during radical prostatectomy. Urology. 1993; 42:689-93.

36. Gawlas W, Golabek T, Hessel T, et al. Bladder neck preservation and the risk of positive surgical margins after laparoscopic radical prostatectomy. Eur Urol, Suppl. 2014; 13:e1275.

Correspondence Michele Zazzara, MD michele.zazzara@gmail.com Fabrizio Dal Moro, MD Urology Clinic, Department of Surgical Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy Marina P. Gardiman, MD Surgical Pathology and Cytopathology Unit, Department of Medicine, University of Padua, Padua, Italy Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12138

DOI: 10.4081/aiua.2023.11897

ORIGINAL PAPER

Salvage cryotherapy for prostate cancer Duarte Vieira e Brito, Jose Alberto Pereira, Ana Maria Ferreira, Mario Lourenço, Ricardo Godinho, Bruno Pereira, Pedro Peralta, Paulo Conceiçao, Mario Reis, Carlos Rabaça Urology Department Portuguese Institute of Oncology Coimbra, Portugal.

this reason, treatments that prevent or delay ADT may be beneficial. Salvage radical prostatectomy for recurrence after radiotherapy is an accepted alternative although it is a demanding surgical procedure involving serious morbidity and risk of surgical complications (14) . Optimal local treatment of recurrence is controversial, with alternative treatments depending on availability of instrumentation and risk, age and comorbidities of the patient (2, 15). New treatment modalities with minimally invasive techniques such as percutaneous cryotherapy and thermal ablation, have gained popularity for treatment of men with prostate cancer (2). Use of cryotherapy for treatment of prostate cancer (PCa) dates back to 1960, although at the time it was associated with multiple and drastic complications (16). With technical advances, cryotherapy has resurfaced as a safe and interesting technique in treating prostate cancer in the recurrence and primary setting, with little toxicity (16, 17). Cryoablation implies the freezing of tissue to promote tissue destruction with direct and indirect mechanisms of action, with a fast freeze phase, followed by slow heating and a repeat cycle (18-20). Optimal duration of freezing and temperature are debatable with various protocols existing, but most studies report critical cellular damage at temperatures below -20ºC (20). Prostate cryosurgery has been increasingly used for focal treatment of primary and recurrent for prostate cancer, utilizing the same thermal and biological principles for different settings (6, 21, 22). In our centre cryosurgery has been utilized mostly in the context of recurrence, therefore our study aims to evaluate recurrence free survival and time to further treatments associated with cryotherapy.

Summary

Background: Most men diagnosed with prostate cancer will be candidates for active treatment and 20 to 50% of patients treated with organ preserving strategies recur within the prostate. Optimal treatment of recurrence is controversial. Prostate cryosurgery has been increasingly used as primary, recurrence and focal treatment for prostate cancer. Methods: We analysed 55 patients submitted to cryotherapy as salvage treatment after recurrence. Results: Study population presented with a mean age of 70.9 ± 6.2 years, mean initial PSA of 7.6 ng/ml and average prostate volume by ultrasound of 43.2 ± 14.7 grams. Mean follow-up was of 18.0 months. Biochemical free survival at one year of follow-up was of 85%. Conclusions: Cryotherapy can be an effective and safe treatment for recurrence after primary curative treatment failure.

KEY WORDS: Prostate cancer; Recurrence; Cryotherapy. Submitted 1 October 2023; Accepted 23 October 2023

INTRODUCTION

Most men diagnosed with prostate cancer will be candidates for active treatment, being, in most cases, treated with radiotherapy with external beams or brachytherapy or radical surgery (1, 2). Depending on risk factors, about 20 to 50% of patients treated with organ preserving strategies recur within the prostate with some of them benefiting from additional treatments(2-4). Most patients receive androgen deprivation treatment (ADT) for recurrence although they still are candidates for curative treatment with local salvage treatment (3, 5, 6). Recurrence after radical surgery (two PSA values superior to 0.2 ng/mL after previous undetectable PSA) involves different treatment options when compared to recurrence after radiotherapy (PSA values higher than 2 ng/mL plus nadir) (7). Treatment options for recurrence after surgery include observation, salvage radiotherapy (ideally when the PSA is lower than 2 ng/mL) and ADT while most patients treated with previous radiotherapy cannot be irradiated again (7). Progression of prostate cancer is highly dependent on testosterone and this represents the rationale for treatment with ADT (8, 9). Hormonal therapies are associated with side effects derived from hypogonadism, such as increased cardiovascular risk, cognitive deterioration, sarcopenia among other important effects (8, 10-13). For

MATERIAL AND METHODS Patient selection and variables All male patients submitted to cryotherapy as salvage treatment during follow-up for prostate cancer in our institution between January 2014 and December 2022 were evaluated. Patients with localized recurrence submitted to hormone treatment were excluded. All patients were submitted to conventional staging with CT to the chest, abdomen and pelvis and a bone scintigraphy previously to treatment

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Figure 1. Patients survival.

rent usage of androgen deprivation treatment. Patients were then divided in two groups for comparison: patients with biochemical failure (group 1) and patients with no failure of treatment (group 2). As a whole, study population presented with a mean age of 70.9 ± 6.2 years, a mean initial PSA of 7.6 ng/ml and average prostate volume by ultrasound of 43.2 ± 14.7 grams. Mean follow-up was of 18.0 (± 13.4) months. Regarding previous treatments, 36 (65,4%) patients were submitted to radiotherapy, 16 (29.1%) to brachytherapy and 3 (5.5%) to previous cryotherapy. A total of 19 (34.5%) patients presented with recurrence at a mean of 23.2 ± 16.7 months. Biochemical free survival at one year of follow-up was of 85%, with 43 patients achieving this length of follow up and 2 patients with recurrence at six months. Minimum follow-up was of 6 months, achieved by all 55 patients (date of first patients treatment failure), and maximum of 60 months. In regards of immediate post-operative complications (first week) the most frequent was perineal hematoma in 6 (10.9%) patients, followed by urinary retention in 2 (3.6%) patients. Long term complications are described in Table 1. Mean PSA values in group 1 and group 2 are described in Table 2. When comparing between ISUP

in order to exclude extra prostatic disease and in case of doubt with PET-PSMA. Biopsy to the prostate was not performed in most patients. Patients were evaluated at baseline and at 3,6,12,18,24 and after every 6 months until change of treatment due to biochemical failure under Phoenix criteria. Continence was evaluated at every evaluation and a basal reference was obtained. Surgical technique Patients were submitted to whole gland prostate cryotherapy utilizing CryoCare CS™ (third generation cryoablation system). Cryoprobes were introduced transperineally, using a hands-free, under real-time bi-plane transrectal ultrasonography guidance. The procedure was conducted utilizing argon gas. A rectal thermal sensor was introduced as well as a sensor placed at the external sphincter and a urethral warmer was introduced. Two freeze cycles are performed (10-min freezing per cycle), with active warming in the first cycle and passive after the second cycle; the formed ice-ball and the temperatures are monitored up to 5 min after the second freezing cycle is completed; the cryoprobe, sensors and warming catheter device are removed after the second cycle, and a Foley catheter is placed to be removed after one week. Patients are discharged on the same day.

Table 1. Long term side effects of treatment. Complication None reported Light urinary incontinence Severe urinary incontinence Haematuria Fistula Urge incontinence Ureteral stenosis

Statistical analysis Pearson chi-square, Mann-Whitney and Kolmogorov Smirnov tests were used to compare quantitative and categorical variables. Unconditional binary logistic regression was used to evaluate the independent association between possible predictors of recurrence. Statistical significance in this study was set as p < 0.05. Statistical analysis was performed using IBM SPSS®, version 27.0 for Windows.

Number 34 7 3 1 1 7 2

Percentage 61.8 12.7 5.5 1.8 1.8 12.7 3.6

Table 2. Average PSA values between groups.

RESULTS

Of a total of 70 patients submitted to cryotherapy were considered; 55 were evaluated after exclusion of 15 to cur-

PSA PSA at 3 months PSA at 6months PSA at 12 months

Group 1 8.6 3.2 3.9 4.3

Group 2 7.8 1.6 1.4 1.5

P 0.4 0.03 0.001 0.000

Prostate Volume Mean follow-up Age

44 cc 29.5 months 69.5

43cc 23.8 months 71.0

0.27 0.20 0.53

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Salvage cryotherapy for prostate cancer

In our study, 34 patients 61.8% did not report any significant side effects, a rate higher than average. The most common side effects were both urge incontinence and mild urinary incontinence reported in 7 patients, less severe when compared to side effects reported after salvage prostatectomy where severe continence is present in 25% of patients (7, 26, 29). Only one patient presented with a fistula; he was a 72-year-old patient submitted to prior brachytherapy with combined radiotherapy for ISUP 5 disease. On the contrary, many patients submitted to radical surgery suffer from bladder neck contracture, anastomotic leakage with one third of patients presenting with Clavien 3 or higher complications (26). Our study shows that, with the currently improved equipment and technique, cryosurgery should be considered as a valid and important option for patients after failure of primary treatment with little toxicity. Although patients were not biopsied previously to treatment previous histology reported 5 patients with ISUP 4 and 3 with ISUP 5: only 2 patients of the ISUP 4 group presented with failure and none in the other group at an average follow-up of 21.6 and 18.6 months respectively, indicating a possibly important role in high grade disease. When PSA values between the two groups were considered, initial PSA was non-significantly different, as all other variables considered for direct comparison. Differences of values at 3,6 and 12 months were statistically significant with p values of 0.03,0.001 and 0.000 respectively. Accordingly, lower PSA values at these intervals predicts treatment success and longer recurrence free survival, similarly to what was reported (25). Limitations of our study include utilization of the Phoenix criteria to determine biochemical failure, designed initially for radiotherapy, as no current guidelines exist to define failure after cryotherapy, the retrospective nature of our study, relative short average follow-up time and lack of confirmatory biopsy of assumed failure.

Table 3. Population characteristics. ISUP 1 ISUP 2 ISUP 3 ISUP 4 ISUP 5 No Prostate MRI Prostate MRI No PET-PSMA PET PSMA

Number 11 23 13 5 3 25 30 42 13

Percentage 20.0 41.8 23.6 9.1 5.5 45.5 54.5 76.4 23.6

grades, volume and age between groups a non-significant p value were obtained. Other population characteristics are summarized in Table 3. Over half of patients were submitted to an MRI and 23.6% to PET PSMA previous to treatment allowing for the exclusion of extra prostatic disease and better treatment planning, that can explain our low rates of incontinence, due to better patient selection.

DISCUSSION

Patients with localized recurrence present with an opportunity for salvage therapies with a curative intent, although with the current widespread usage of ADT, most patients receive hormonal therapies for biochemical failure after curative treatment (23). Androgen deprivation treatment can be responsible for considerable side effects and worse quality of life (24). In our cohort of patients treatment failure, defined by the Phoenix criteria (as currently no validated definition exists for cryotherapy) occurred in 19 (34.5%), with an average time to recurrence of 23.2 months, signifying that patients were spared the side effects of testosterone deprivation therapy for almost two years, with little morbidity associated. A recent study analysing biochemical failure after treatment found rates of recurrence at 12 months of 15% and 19% at two years. Our data in terms of recurrence are similar to these studies although longer follow-up is needed (25). Most surgical options are associated with considerable morbidity for the patient, with great impact on quality of life and very high degrees of incontinence and fistula (7, 26). Salvage radical surgery presents with a biochemical recurrence free rate of 34-83% at five years, depending on the study considered, that is similar to the rates for minimal invasive procedures (14, 27). Functional outcomes differ significantly between treatment options although most patients present already with a low erection capacity after previous treatment with radiotherapy. After surgery (salvage radical prostatectomy), almost no patient retains erectile function and 25% of patients presents with severe incontinence and significantly lower rates of continence compared to other salvage treatments or surgery as primary treatment (28, 29). High intensity focused ultrasound (HIFU) is also available for treatment for localized prostate cancer with continence rates superior to 50% but inferior to what has been reported for cryotherapy (26).

CONCLUSIONS

Cryotherapy can be an effective and safe treatment for recurrence after primary curative treatment failure, allowing for delay or even eliminate the need for ADT, sparing patients the unnecessary toxicity and complications from salvage radical prostatectomy with little and in most cases manageable side effects.

REFERENCES

1. Finley DS and Belldegrun AS. Salvage cryotherapy for radiationrecurrent prostate cancer: outcomes and complications. Curr Urol Rep. 2011; 12:209-15. 2. Autran-Gomez AM, Scarpa RM, Chin J. High-intensity focused ultrasound and cryotherapy as salvage treatment in local radiorecurrent prostate cancer. Urol Int. 2012; 89:373-9. 3. Duijzentkunst DA, et al. Focal salvage therapy for local prostate cancer recurrences after primary radiotherapy: a comprehensive review. World J Urol. 2016; 34:1521-1531. 4. Golbari NM and Katz AE. Salvage Therapy Options for Local Prostate Cancer Recurrence After Primary Radiotherapy: a Literature Review. Curr Urol Rep. 2017; 18:63.

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5. Lomas DJ, Woodrum DA, Mynderse LA. Salvage ablation for locally recurrent prostate cancer. Curr Opin Urol. 2021; 31:188-193.

androgen deprivation therapy in cryotherapy and radiation recurrent prostate cancer patients. Int J Hyperthermia. 2017; 33:810-813.

6. Bauman G, et al. Cryosurgery Versus Primary Androgen Deprivation Therapy for Locally Recurrent Prostate Cancer After Primary Radiotherapy: A Propensity-Matched Survival Analysis. Cureus. 2020; 12:e7983.

25. Tan WP, et al., Oncological and Functional Outcomes for Men Undergoing Salvage Whole-gland Cryoablation for Radiation-resistant Prostate Cancer. Eur Urol Oncol. 2023; 6:289-294. 26. Abufaraj M, Siyam A, Ali MR, et al. Functional Outcomes after Local Salvage Therapies for Radiation-Recurrent Prostate Cancer Patients: A Systematic Review. Cancers (Basel). 2021; 13:244.

7. Artibani W, et al. Management of Biochemical Recurrence after Primary Curative Treatment for Prostate Cancer: A Review. Urol Int. 2018; 100:251-262.

27. Gontero P, et al. Salvage Radical Prostatectomy for Recurrent Prostate Cancer: Morbidity and Functional Outcomes from a Large Multicenter Series of Open versus Robotic Approaches. J Urol. 2019; 202:725-731.

8. Gheorghe GS et al. Androgen Deprivation Therapy, Hypogonadism and Cardiovascular Toxicity in Men with Advanced Prostate Cancer. Curr Oncol. 2021; 28:3331-3346. 9. Desai K, McManus JM, Sharifi N. Hormonal Therapy for Prostate Cancer. Endocr Rev. 2021; 42:354-373.

28. Marquis A, et al. Nightmares in Salvage Robot-assisted Radical Prostatectomy After Primary Radiation Therapy for Prostate Cancer: A Step by Step Tutorial. Eur Urol Open Sci. 2022; 43:62-67.

10. Ferreira VV, et al. Cardiovascular complications of treatment for prostate cancer. Br J Hosp Med (Lond). 2022; 83:1-12.

29. Pfister D, et al. Salvage radical prostatectomy after local radiotherapy in prostate cancer. Curr Opin Urol. 2021; 31: 194-198.

11. Afferi L, Longoni M, Moschini M, et al. Health-related quality of life in patients with metastatic hormone-sensitive prostate cancer treated with androgen receptor signaling inhibitors: the role of combination treatment therapy. Prostate Cancer Prostatic Dis. 2023. 12. DE Nunzio C, et al. Androgen deprivation therapy and cardiovascular risk in prostate cancer. Minerva Urol Nephrol. 2022; 74:508-517. 13. Korczak J, Mardas M, Litwiniuk M, et al. Androgen Deprivation Therapy for Prostate Cancer Influences Body Composition Increasing Risk of Sarcopenia. Nutrients. 2023; 15:1631. 14. Grubmüller B, et al. Salvage Radical Prostatectomy for RadioRecurrent Prostate Cancer: An Updated Systematic Review of Oncologic, Histopathologic and Functional Outcomes and Predictors of Good Response. Curr Oncol. 2021; 28:2881-2892. 15. Ingrosso G, et al. Nonsurgical Salvage Local Therapies for Radiorecurrent Prostate Cancer: A Systematic Review and Metaanalysis. Eur Urol Oncol. 2020; 3:183-197. 16. Siomos VJ, Barqawi A. The current status of cryotherapy and high-intensity focused ultrasound in the treatment of low-grade prostate cancer. Rev Recent Clin Trials. 2011; 6:171-6.

Correspondence Duarte Vieira e Brito, MD (Corresponding Author) duartevbrito@hotmail.com Casa da Aveleira, Pencelo, Guimaraes 4800-110 Jose Alberto Pereira, MD joseaclpereira@gmail.com Ana Maria Ferreira, MD anaferreira6842@gmail.com Mario Lourenço, MD mariolourenco88@gmail.com Ricardo Godinho, MD ricardogodinhoandrade@gmail.com Bruno Pereira, MD brunoalexpereira@gmail.com Pedro Peralta, MD joaopedroperalta@gmail.com Paulo Conceiçao, MD 3605@ipocoimbra.min-saude.pt Mario Reis, MD reismario58@gmail.com Carlos Rabaça, MD carlosrabaca@gmail.com Urology Department Portuguese Institute of Oncology Coimbra, Portugal

17. Cho S, Kang SH. Current status of cryotherapy for prostate and kidney cancer. Korean J Urol. 2014; 55:780-8. 18. Erinjeri JP, Clark TW. Cryoablation: mechanism of action and devices. J Vasc Interv Radiol. 2010; 21(8 Suppl):S187-91. 19. Korpan NN, Hochwarter G, Sellner F. Cryoscience and cryomedicine: new mechanisms of biological tissue injury following low temperature exposure. Experimental study. Klin Khir. 2009; (78):80-5. 20. Gage AA and Baust J. Mechanisms of tissue injury in cryosurgery. Cryobiology. 1998; 37:171-86. 21. Becher E, Lepor H. Oncological control following partial gland ablation for intermediate-risk prostate cancer. Urol Oncol. 2020; 38:671-677. 22. Shah TT, et al. Early-Medium-Term Outcomes of Primary Focal Cryotherapy to Treat Nonmetastatic Clinically Significant Prostate Cancer from a Prospective Multicentre Registry. Eur Urol. 2019; 76:98-105. 23. Bruce JY, et al. Current controversies in the management of biochemical failure in prostate cancer. Clin Adv Hematol Oncol. 2012; 10:716-22. 24. Kongnyuy M, et al. Salvage focal cryosurgery may delay use of

Conflict of interest: The authors declare no potential conflict of interest.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11897

DOI: 10.4081/aiua.2023.11514

ORIGINAL PAPER

Immunohistochemical expression of androgen receptors in urothelial carcinoma of urinary bladder. Is it significant? Experience from coastal India Disha Jindal 1, Pooja K Suresh 2, Saraswathy Sreeram 2, Ramesh Holla 3, Hema Kini 2, Sridevi HB 2, Amanda Christina Pinto 2 1 Kasturba Medical College, Mangalore, Manipal Academy of Higher education, Manipal, Karnataka, India;

2 Department of Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India; 3 Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal,

Karnataka, India.

ovary. AR gene in humans is present on the X chromosome (2). There is a significant role of androgens and their receptors in male bladder development and functioning. AR has also been shown in urothelium and bladder submucosa. It also regulates the storage of urine and other functions of the urinary tract. Activation of AR correlates with progression of growth of urothelial cancer (UC) (2). Hence we aimed to study AR expression in bladder urothelial carcinomas and assess its association with stage and grade of the disease.

Summary

Background: Bladder carcinoma (BC) ranks second among the genitourinary cancers worldwide. Influence of androgens and expression of androgen receptors in neoplasms are recent findings which were implicated in the development of BC. We aimed to study androgen receptor (AR) expression in bladder urothelial neoplasms and correlate its expression with grade and stage of the tumor. Methods: Immunohistochemistry (IHC) was done on samples collected in a tertiary care hospital over one year consisting of 71 urothelial BC and 20 non-neoplastic urothelial conditions. Two pathologists graded the IHC and nuclear staining was considered as positive expression. Results: AR was expressed in 23.9% (17/71) of bladder urothelial neoplasms. AR was expressed in 25.7% and 22.3% of high and low-grade tumors and 25% and 22.3% of non-muscle-invasive and muscle-invasive BC. AR expression had no significant correlation with gender, age (> 50 years), muscle invasion or grade. AR expression was significantly absent in non-neoplastic conditions (p = 0.018). Conclusions: AR has varied expression in BC and it is relatively lower in this study population.

METHODS

The Institutional Ethics Committee approved the study. This retrospective study included UCs from the urinary bladder received in the Pathology department of a tertiary care center of coastal south India between January 2013 and December 2018. UC were classified as per the World Health Organization classification 2016 (9). The urothelium in bladder biopsies of non-neoplastic conditions served as controls. Cases in which paraffin blocks were not available or had inadequate tissue for immunohistochemistry (IHC) were excluded. The samples underwent routine processing with formalin fixation and were embedded in paraffin. Three microns thickness sections were used for IHC. IHC was performed using anti-AR [Ready-to-use mouse monoclonal primary antibody kit (BioGenex)] on the appropriate tumor blocks following the manufacturer’s instructions. The secondary antibody used was Dako REAL EnVision/HRP (Labeled polymer, Code K5007) against rabbit and mouse primary antibodies. The AR expression was considered positive based on the German immunoreactive score as shown in Table 1 (11). A descriptive analysis of data was done using the software package SPSS version 21.0. Cross tables were generated to compare the neoplastic and non-neoplastic groups and associations between the groups were analyzed using the Chi-square test and Student t-test. Odds ratio (OR) was calculated to establish the association between AR and urothelial carcinomas. A p-value < 0.05 was considered statistically significant.

KEY WORDS: Bladder cancer; Urothelial neoplasms; Androgen receptor expression. Submitted 9 June 2023; Accepted 14 July 2023

INTRODUCTION

Bladder cancer (BC) ranks second among the genitourinary cancers worldwide with over 12 million cases annually (1, 2). About 95% of bladder tumors are of epithelial type and the diagnosis is mainly dependent on cellular dysplasia and muscle invasion. Metastasis is a late phenomenon in BC (3). The occurrence of BC is higher in men than in women because men are more exposed to industrial chemicals and cigarette smoke, which contain amines. However, even in the absence of these carcinogens, men are more prone to BC. In this context, androgen receptor (AR) could be proposed as another potential reason for the difference (4). Androgens were discovered in 1936 and are steroidal hormones that are secreted by adrenal cortex, testes, and

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D. Jindal, P.K. Suresh, S. Sreeram, R. Holla, H. Kini, H.B. Sridevi, A.C. Pinto

Table 1. AR expression calculated by German immunoreactive score.

Immunohistochemical AR nuclear expression was seen in 23.9% of the cases (n = 17) Percentage Proportion Intensity Intensity Final score = Proportion score Final Figure 2. of immunoreactive cells score of staining score x intensity score interpretation AR expression was not asso0% 0 Negative 0 0-1 Negative (0) ciated with age of the 1-10% 1 Weak 1 2-4 Weakly positive (1+) patients, gender, grade and 11-50% 2 Moderate 2 6-8 Moderately positive (2+) stage of the tumor (Table 3). 51-80% 3 Strong 3 9-12 Strongly positive (3+) Positive AR expression was 81-100% 4 seen in 23.9% of neoplastic samples (Figure 1d-e) while AR expression was completely absent in non-neoplastic lesions. This was statistically RESULTS significant (p = 0.018) (Table 4). During the study period, we received 220 bladder biopsies or specimens from transurethral bladder resections. Figure 2. Out of them 71 specimens of UCs were included in the Distribution of androgen receptor expression in UC. study based on the inclusion and exclusion criteria. The mean age at presentation of UC cases was 62 years (age range: 36-91 years) with a male predominance (63 men and 8 women). High grade tumor was seen in 50.7% (35/71) of cases and muscle invasive UC in 38% (19/71) of tumors (Table 2, Figure 1a-c).

Table 2. Clinical-pathological features of UC cases (n = 71). Variables Gender Male Female Age in years < 50 > 50 Muscle invasiveness Absent Present Histologic grade High Low

Cases (n)

Percentage (%)

63 8

88.7% 11.2%

7 64

90.1% 9.9%

44 19

62% 38%

35 36

Table 3. Association of AR expression with age, gender, grade and stage.

50.7% 49.3%

Age (years) < 50 > 50 Gender Men Women Grade Low High Muscle invasion Non invasive Invasive

Figure 1. AR expression in urothelial carcinoma. a. Urothelial carcinoma showing papillary pattern (HE stain, 10x); b. Urothelial carcinoma – low grade (HE stain, 40x); c. Urothelial carcinoma – high grade (HE stain, 40x); d-e. Immunohistochmical expression of AR receptors in urothelial carcinomas (AR IHC stain, 10x).

Negative 0

AR Expression Positive Positive 1+ 2+

Positive 3+

P-value

5 (71.4%) 49 (66.2%)

2 (28.6%) 3 (4.1%)

0 (0%) 9 (12.2%)

0 (0%) 13 (17.5%)

0.09

48 (76.2%) 6 (75%)

4 (6.3%) 1 (12.5%)

8 ( 12.6%) 1 ( 12.5%)

3 (4.7%) 0 (0%)

0.85

28 (77.8%) 26 (74.2%)

2 (5.5%) 3 (8.5%)

6 ( 16.7%) 3 (8.5%)

0 (0%) 3 (8.5%)

0.2

33 (75%) 21 (77.8%)

3 (6.8%) 2 (7.4%)

7 ( 15.9%) 2 (7.4%)

1 (2.3%) 2 (7.4%)

0.5

Table 4. AR in neoplastic and non-neoplastic urothelial lesions. AR expression Neoplastic Non-neoplastic Total

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Negative

Positive

Total

54 19 73 (100%)

17 0 17(100%)

71 (78%) 19 (22.0%) 90 (100%)

AR expression in bladder urothelial neoplasms

DISCUSSION

CONCLUSIONS

Androgens are considered to have a pivotal role in urothelial carcinogenesis. AR expression had a significant impact on modern oncological breast cancer treatment. In this study, immunohistochemical expression of AR was analyzed in the urothelial neoplasms. Expression of AR was seen in 23.9% of the cases of urothelial neoplasms. A study conducted by Mir et al. (13) showed AR expression in 12.9% of bladder tumors, Miyamoto et al. (11) in 42% of tumors and Boorjiana et al. (14) in 53.1%. The rate observed in this study is within a similar range with differences in the expression in urothelial neoplasm that could be attributed to ethnicity, sample sizes, antibody clones, IHC techniques and scoring methodologies. An interesting, subtle yet significant observation in this study was the variation in AR expression between nonneoplastic and neoplastic urothelial lesions. AR expression was completely absent in non-neoplastic lesions whereas it was positive in 23.9% of neoplastic lesions. Mashhadi et al. had previously reported 22% of AR-positivity in cases with no expression in the controls (10). A meta-analysis with five studies conducted by Chen et al. (15) showed negative correlation between expression of AR and BC predisposition. Data from studies by Izumi et al. suggested a low expression of AR (p = 0.02) in BC as compared to non-neoplastic urothelial tissues (16). AR expression was noted in 25.7% of high grade BC and 22.3% of low-grade BC. Tumor grade was not associated statistically with AR expression. Ide et al. showed significant androgen loss in BC with higher grade compared with lower grades (p < 0.001) (17). Data from a study conducted by Miyamoto et al. showed lower expression of AR in high-grade BC (36%) compared to the low grade tumours (55%; p = 0.0232) (11). This brings forward a potential utility of AR IHC of bladder lesions as a marker to exclude benign nature if expressed. AR IHC could be helpful in the differential diagnoses between basal cell hyperplasia or transitional metaplasia versus a low-grade urothelial carcinoma. The validation of these results is an area for further research. Furthermore, AR expression in other malignancies like lymphoma or other varieties of carcinoma versus urothelial carcinoma could be evaluated. In the present study there was a downregulation of AR expression with muscle invasion. AR expression was seen in 22.3% of MIBC and 38.9% of NMIBC. Mir et al. showed expression of AR in 9% of NMIBC as compared with 15.1% of MIBC (p = 0.059) (13). Miyamoto et al. also reported lower expression of AR in MIBC (33%) compared to NMIBC (51%; p = 0.018) (11). Wagih et al. and Szabados et al. also showed similar results (18, 19). A therapeutic implication of AR expression in urothelial carcinomas could be the use of AR inhibitors to prevent UC growth in presence of androgens and to prevent chemotherapy resistance (20). Limitations of our study are absence of data on treatment and follow-up and incomplete data on progression and recurrence. Few of our cases were excluded due to nonavailability of the tissue in the block for IHC. This also reduced the sample size of our study.

AR has varied expression in BC and it is relatively lower in this study population. The expression of AR in bladder cancer had no significant correlation with gender, age (50 years), muscle invasion or grade of the tumor. AR expression was downregulated in MIBC albeit without any statistical significance, thereby precluding its role in targeted therapy.

REFERENCES

1. Ploeg M, Aben KK, Kiemeney LA. The present and future burden of urinary bladder cancer in the world. World J Urol. 2009; 27:289-93. 2. Li P, Chen J, Miyamoto H. Androgen receptor signaling in bladder cancer. Cancers. 2017; 9:20. 3. Humphrey PA, Moch H, Cubilla AL, et al. The 2016 WHO Classification of Tumours of the Urinary System and Male Genital Organs-Part B: Prostate and Bladder Tumours. Eur Urol. 2016; 1-14. 4. Miyamoto H, Yang Z, Chen YT, et al. Promotion of bladder cancer development and progression by androgen receptor signals. J National Cancer Institute. 2007; 99:558-68. 5. Izumi K, Ito Y, Miyamoto H, et al. Expression of androgen receptor in non-muscle-invasive bladder cancer predicts the preventive effect of androgen deprivation therapy on tumor recurrence. Oncotarget. 2016; 7:14153. 6. Kawahara T, Inoue S, Kashiwagi E, et al. Enzalutamide as an androgen receptor inhibitor prevents urothelial tumorigenesis. Am J Cancer Res. 2017; 7:2041. 7. Zhuang YH, Bläuer M, Tammela T, Tuohimaa P. Immunodetection of androgen receptor in human urinary bladder cancer. Histopathology. 1997; 30:556-62. 8. Necchi A, Vullo SL, Giannatempo P, et al. Association of Androgen Receptor Expression on Tumor Cells and PD-L1 Expression in Muscle-Invasive and Metastatic Urothelial Carcinoma: Insights for Clinical Research. Clinical Genitourinary Cancer. 2018; 16:e403-10. 9. Hata S, Ise K, Azmahani A,et al. Expression of AR, 5αR1 and 5αR2 in bladder urothelial carcinoma and relationship to clinicopathological factors. Life sciences. 2017; 190:15-20. 10. Mashhadi R, Pourmand G, Kosari F, et al. Role of steroid hormone receptors in formation and progression of bladder carcinoma: a case-control study. Urology Journal. 2014; 11:1968-73. 11. Miyamoto H, Yao JL, Chaux A, et al. Expression of androgen and oestrogen receptors and its prognostic significance in urothelial neoplasm of the urinary bladder. BJU international. 2012; 109:1716-26. 12. Nam JK, Park SW, Lee SD, Chung MK. Prognostic Value of SexHormone Receptor Expression in Non-Muscle-Invasive Bladder Cancer. Yonsei Med J. 2014; 55:1214-21. 13. Mir C, Shariat SF, Van Der Kwast TH, et al. Loss of androgen receptor expression is not associated with pathological stage, grade, gender or outcome in bladder cancer: a large multi-institutional study. BJU international. 2011; 108:24-30. 14. Boorjian S, Ugras S, Mongan NP, et al. Androgen receptor expression is inversely correlated with pathologic tumor stage in bladder cancer. Urology. 2004; 64:383-8. 15. Chen J, Cui Y, Li P, et al. Expression and clinical significance of androgen receptor in bladder cancer: A meta-analysis. Molecular and clinical oncology. 2017; 7:919-27. 16. Izumi K, Ito Y, Miyamoto H, et al. Expression of androgen recep-

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11514

D. Jindal, P.K. Suresh, S. Sreeram, R. Holla, H. Kini, H.B. Sridevi, A.C. Pinto

tor in non-muscle-invasive bladder cancer predicts the preventive effect of androgen deprivation therapy on tumor recurrence. Oncotarget. 2016; 7:14153.

urothelial carcinoma of the urinary bladder in Egyptian patients: An immunohistochemical study. Afr J Urol. 2020; 26:1. 19. Szabados B, Duncan S, Choy J, et al. Androgen Receptor Expression Is a Predictor of Poor Outcome in Urothelial Carcinoma. Front. Urol. 2022; 2:863784.

17. Ide H, Inoue S, Miyamoto H. Histopathological and prognostic significance of the expression of sex hormone receptors in bladder cancer: A meta-analysis of immunohistochemical studies. PloS One. 2017; 12:e0174746.

20. Tripathi A, Gupta S. Androgen receptor in bladder cancer: A promising therapeutic target. Asian J Urol. 2020; 7:284-90.

18. Wagih M, Kamel M. Evaluation of androgen receptor status in

Correspondence Disha Jindal, MBBS student Kasturba Medical College, Mangalore, Manipal Academy of Higher education, Manipal, Karnataka, India Pooja K Suresh, Additional Professor (Corresponding Author) puja4444@gmail.com Saraswathy Sreeram, Associate Professor Hema Kini, Professor Sridevi HB, Additional Professor Amanda Christina Pinto, Assistant Professor Department of Pathology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India Ramesh Holla, Associate Professor Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11514

DOI: 10.4081/aiua.2023.12108

ORIGINAL PAPER

Parastomal hernia after radical cystectomy. Incidence, natural history and predictive factors – A single center study María Alonso Grandes, José Antonio Herranz Yagüe, Rocío Roldán Testillano, Alfonso María Márquez Negro, Casilda Cernuda Pereira, Emilio Andrés Ripalda Ferretti, Álvaro Páez Borda University Hospital of Fuenlabrada, Department of Urology, Fuenlabrada, Madrid, Spain.

erogeneity of the definitions applied, the follow-up time and the way it is diagnosed. Clinical parastomal hernia (cPH) is defined as peristomal protrusion through a wall defect detected by physical examination, with the patient in the supine or standing position. One of the most frequently used classifications to define radiological PH (rHP) is the one proposed by Moreno-Matías and Serra-Aracil et al. in 2009 (Figure 1), creating three different categories according to the relationship between the hernia sac and the bowel forming the stoma. Although most patients remain asymptomatic, up to one third may require surgical repair (4), in most cases due to pain, skin irritation, leakage and, in a small percentage, bowel obstruction. Most of the information dedicated to PH research comes from the colorectal literature, and there is little data about the natural history and risk factors associated with the development of PH in Bricker-type urinary diversions. The aim of our study was to analyze the incidence of PH after radical cystectomy with ileal conduit and to describe the evolution and predictive factors.

Summary

Purpose: Parastomal hernia (PH) is one of the most frequent complications after stoma creation. Our objective was to analyze the incidence, evolution and predictive factors of PH in Bricker-type urinary diversion. Patients and methods: Case series analysis of 125 patients submitted to radical cystectomy and ileal conduit diversion for cancer in a single center during 2006-2021. Patient’s record and imaging tests were reviewed to identify those suffering PH. Moreno-Matías classification was used to define radiological PH (rPH). Demographic and preoperative characteristics of the patients, surgical details and postoperative complications were recorded. Univariate and multivariate analyses were conducted to determine the effect of each predictive variable on the development and progression of PH. Results: 21.6% of patients developed PH (median follow-up 37 months). Incidence increased with follow-up time (15.2% at 1 year, 20.8% at 2 years). BMI ≥ 25 (Expβ 8.31, 95% CI 1.0665.18, p = 0.04), previous midline laparotomy (Expβ 6.74, 95% CI 1.14-39.66, p = 0.04) and wound infection (Expβ 3.87, 95% CI 1.21-12.33, p = 0.02) were significantly associated with PH. Half of the patients with hernia had symptoms, 25.9% requiring surgical correction. 46% of type 1 hernias and 40% of type 2 hernias progressed to grade 3 with a median of 11 months. No variable was associated with radiological progression. Conclusions: This study proved 3 independent factors (overweight, laparotomy and wound infection) that increase the risk of developing PH.

PATIENTS AND METHODS Patients The files of 125 consecutive patients undergoing open or lap radical cystectomy and Bricker urinary diversion at our institution (January 2006-January 2021) were retrospectively reviewed. Patient records were reviewed to gather any information suggesting the development of PH. Time since the cystectomy, presence of symptoms, and the requirement for surgery and surgical outcome were also gathered. Demographic data were collected, including age, gender, BMI, HT, DM, COPD, chronic kidney disease, smoking, preoperative hemoglobin and albumin, and history of previous pelvic radiotherapy, abdominal surgery and neoadjuvant chemotherapy. We also documented the approach (open or laparoscopic), stoma fixation to the rectus aponeurosis, surgical time, days of hospitalization and the application of Fasttrack protocol.

KEY WORDS: Parastomal hernia; Radical cystectomy; Ileal conduit; Risk factors; Natural history. Submitted 19 November 2023; Accepted 28 November 2023

INTRODUCTION

Bricker ileal conduit is one of the most commonly used urinary diversions in radical cystectomy. Stoma-related complications, with a reported incidence of up to 60% (1), are a major problem because of their negative impact on patients' quality of life (2). Parastomal hernia (PH), defined as an incisional hernia associated with a stoma in the abdominal wall, is one of the most frequent complications following Bricker urinary diversion (3). Its incidence varies widely depending on the series (4-65%) (4, 5), as a consequence of the het-

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Figure 1. Radiological classification of PH. A) Type 1: hernia sac contains prolapsed bowel forming the stoma. B) Type 2: PH contains abdominal fat or omentum herniating through the abdominal wall defect created by the stoma. C) Type 3: hernial sac contains bowel loops. A.

RESULTS

Additionally, we analyzed the effect of the following complications on the development of PH: evisceration, paralytic ileus, wound infection, transfusion, intestinal and urinary fistula, pelvic abscess and intensive care unit (ICU) admission.

Patient characteristics 125 patients undergoing radical cystectomy and Bricker urinary diversion were included in the study. Average age (84.8% male) was 66.2 years (SD 9.4). Table 1 shows the main patients characteristics and univariate and multivariate analyses. Multivariate analysis detected a significant association between PH and BMI ≥ 25 (Expβ 8.31, 95% CI 1.065.18, p = 0.04) and previous abdominal surgery with previous midline laparotomy (Expβ 6.74, 95% CI 1.1439.66, p = 0.04).

Statistical analysis Uni- and multivariate logistic regression analyses were performed to determine the effect of each predictive variable on the development and progression of PH. Patients with radiological follow-up shorter than 12 months and those with incomplete clinical data were excluded. Statistical analysis was performed using the IBM SPSS Statistics version 20.

Variable Age, years Gender, n (%) Male Female BMI, n (%) Normal (BMI < 25) Overweight and obesity (BMI ≥ 25) Diabetes, n (%) Hypertension, n (%) Smoking, n (%) COPD, n (%) Chronic kidney disease, n (%) Previous midline laparotomy, n (%) Previous hernioplasty, n (%) Pelvic radiotherapy, n (%) Anemia (Female Hb < 12. Male Hb < 13.8), n (%) Hypoalbuminemia (< 3.5 g/dL), n (%) Pathological stage, n (%) ≤ T2. N0 > T2. N0 Any T, N+

Overall (n = 125) 66.2 (DE 9.4)

Univariate analysis HR (95% CI) p 0.97 (0.95-1.05) 0.34

106 (84.8) 19 (15.2)

Reference 0.72 (0.21-2.99)

0.78

32 (25.6) 93 (74.4) 29 (23.2) 72 (57.6) 53 (42.4) 27 (21.6) 23 (18.4) 8 (6.4) 17 (13.6) 8 (6.4) 70 (56) 27 (21.6)

Reference 10.18 (1.31-78.98) 1.18 (0.42-3.41) 1.14 (0.46-2.83) 1.59 (0.66-3.86) 0.45 (0.12-1.72) 0.58 (016-2.15) 9.30 (1.60-54.34) 2.10 (0.65-6.92) 0.75 (0.10-6.71) 0.59 (0.24-1.44) 0.65 (0.19-2.15)

0.026 0.75 0.77 0.30 0.23 0.42 0.023 0.21 0.97 0.25 0.48

Multivariate analysis HR (95% CI) p

8.31 (1.06-65.18)

0.04

6.74 (1.14-39.66)

0.04

50 (40) 50 (40) 25 (20)

BMI Body mass index, COPD Chronic obstructive pulmonary disease. Values in bold indicate a p-value < 0.05.

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Table 1. Univariate and multivariate Cox regression analyses of the predictive factors for the development of PH (patient characteristics).

Parastomal hernia after radical cystectomy

Variable Neoadjuvant chemotherapy, n (%) Fast-track protocol, n (%) Approach, n (%) Open Laparoscopy Aponeurosis attachment, n (%) Operating time (> 6h), n (%) Long length of stay (> 15 days), n (%) Postoperative complications (first 90 days) Evisceration, n (%) Paralytic ileus, n (%) Wound infection, n (%) Intestinal fistula, n (%) Urinary fistula, n (%) Pelvic abscess, n (%) ICU admission, n (%) Polytransfusión (> 5 RBC Concentrates), n (%) Parenteral nutrition, n (%) Clavien complication ≥ 3, n (%)

Overall (n = 125) 49 (39.2) 48 (38.4)

Univariate analysis HR (95% CI) p 0.67 (0.26-1.72) 0.41 1.41 (0.57-3.44) 0.45

103 (82.4) 22 (17.6) 97 (77.6) 36 (28.8) 43 (34.4)

Reference 1.33 (0.43-4.11) 0.63 (0.15-3.52) 2.57 (1.02-6.47) 1.26 (0.49-3.18)

0.61 0.60 0.04 0.62

26 (20.8) 58 (46.4) 18 (14.4) 11 (8.8) 22 (17.6) 34 (27.2) 30 (24) 23 (18.4) 62 (49.6) 54 (43.2)

1.92 (0.68-5.35) 0.48 (0.19-1.22) 3.72 (1.22-11.28) 2.00 (0.46-8.63) 0.94 (0.28-3.11) 1.15 (0.43-3.09) 0.56 (0.18-1.81) 0.77 (0.23-2.55) 0.41 (0.16-1.03) 1.62 (0.67-3.93)

0.21 0.12 0.02 0.35 0.92 0.78 0.33 0.67 0.06 0.28

Multivariate analysis HR (95% CI) p

2.38 (0.92-6.17)

0.07

3.87 (1.21-12.33)

0.02

Table 2. Univariate and multivariate Cox regression analyses of the predictive factors for the development of PH (surgery-related characteristics).

ICU Intensive care unit, RBC red blood cells. Values in bold indicate a p-value < 0.05.

Surgery-related characteristics and postoperative complications Open approach was the technique of choice (82.4% of the patients). Mean operative time was 322 min (SD 60). Mean hospital stay was 15.9 days [SD 16.7, R (5-122)]. 43.2% (54/125) of the patients presented severe postoperative complications (score 3 or higher on the ClavienDindo scale), the most frequent being paralytic ileus. The main postoperative complications and their effect on the development of PH are described in Table 2. Univariate analysis showed a significant association between PH and two different variables: prolonged surgical time and surgical wound infection, but only wound infection was confirmed in the multivariate analysis (Expβ 3.87, 95% CI 1.21-12.33, p = 0.02).

Table 3. Reported symptoms in 27 patients with clinical or radiological PH. Patients with PH Asymptomatic patients Symptomatic patients Pain Device-related problems (leak, poor adjustment) Skin irritation Aesthetic problems Bowel obstruction

n = 27 (%) 14 (51.8) 13 (48.2) 10 (37) 4 (14.8) 3 (11.1) 4 (14.8) 1 (3.7)

early recurrence at 2 months. One patient required stoma relocation. Regarding natural history, 46% (5/11) of type 1 hernias and 40% of type 2 (4/10) progressed to type 3 at a median time of 11 months (SD 9.4) (Figure 3). None of the previously described variables were significantly associated with PH progression.

PH: diagnosis, symptoms and natural history 21.6 % (27/125) of patients developed PH, with a median follow-up of 37 months (SD 37). Median time to diagnosis was 7 months (SD 6.4). The incidence increased with follow-up time, with an incidence of 15.2% one year after surgery, and 20.8% at two years. Radiological detection rate was more frequent than the detection after clinical examination (21.6% vs. 11.2%, respectively) (Figure 2). Approximately half of the patients with PH (48.2%, 13/27) presented symptoms (Table 3). 76.8% (10/13) of these symptomatic patients, corresponded to grade 2 and 3 hernias, while only 23.2% (3/13) of grade 1 hernias caused symptoms. 7 patients (25.9%) underwent PH correction, surgical repair being significantly higher in patients with grade 3 rPH (HR 4.4, 95% CI 1.06-18.33, p = 0.04). Pain was the main indication for surgery, except in one patient who required emergent surgical intervention due to bowel obstruction. Open approaches were the rule. In 85.7% (6/7) of the patients, a mesh was placed during the repair, while in one case primary closure was performed, with

DISCUSSION

The European Hernia Society (EHS) defines PH as an abnormal protrusion of the contents of the abdominal cavity through an abdominal wall defect created during placement of a colostomy, ileostomy, or ileal conduit stoma (6). This term does not include protrusions caused by atony or paresis of the abdominal wall muscles, but rather true peritoneal sac hernias (3). PH is the most frequent complication after stoma placement, to the point that many authors consider it an evolutionary consequence and part of the natural history of the stoma (3). Its incidence is difficult to estimate and varies widely in the series [incidence described as 4-65% (4, 5)], due to the heterogeneity in the definition used, the

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Figure 2. PH detected by physical examination.

Figure 3. PH type 2 with radiological progression to type 3 during follow-up.

Cingi et al. (11) described a radiographic PH rate (rPH) of 78% and a clinical PH rate (cPH) of 52% in a series of 23 patients evaluated by computed tomography (CT) and physical examination, supporting the hypothesis that imaging is superior to clinical examination in detecting PH. Dechao Feng et al. (12) performed a meta-analysis involving a total of 1878 patients with PH. In this case, the radiological incidence of PH was 23%, while the incidence of clinical PH was 15%. These data agree with those obtained in our series, where radiological detection of PH with CT was higher than those obtained by physical examination (21.6% vs. 11.2% respectively). A frequent concern arising from the increased use of imaging tests is the detection of a higher number of clinically insignificant hernias. Although data are limited, there appears to be good correlation between radiologic diagnosis and symptoms resulting from PH (4). Seo et al. (13) described the rates of cPH and rPH in 83 patients with terminal colostomy. All patients with type 3 PH had PH on clinical examination and all of them were symptomatic; 80% of type 2 PH were clinically detectable and 75% were symptomatic; and 60% of type 1 PH were detectable on physical examination, with 63% showing symptoms.

follow-up time and the way of diagnosis. The type of ostomy also has an important impact on the incidence of PH. Thus, terminal colostomy is the one with the highest rates of hernia, while bowel-dependent ostomies, whether terminal ileostomies, loop ostomies or Bricker-type urinary diversions, are those with the lowest incidence of PH (7). Most of them develop in the first two years following surgery (4, 8-9), but presentation can be delayed up to 20 or 30 years (10). Diagnosis of PH can be clinical or radiological. Most clinical definitions are based on the finding of a protrusion close to the stoma, but studies differ considerably as how the clinical examination is performed: supine vs. standing, and with or without Valsalva maneuvers. The use of physical examination as a diagnostic tool, especially in retrospective studies underestimates the number of PH, mainly at the expense of low-grade hernia. Radiological evaluation of the stoma aids the clinical examination improving the detection rate of PH. Radiographic criteria have the advantage of being more objective and less influenced by the patient's body habitus (4). In addition, imaging allows measurement of the size of stoma and hernia sac over time, which is essential in the study of the natural history of PH.

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Parastomal hernia after radical cystectomy

In our experience, more than one third (76.8%) of the 13 patients developing symptoms corresponded to grade 2-3 hernias, while only 23.2% of grade 1 hernias were symptomatic. Also, surgical repair, motivated in most cases by pain, was significantly higher in patients with radiological grade 3 PH (HR 4.4, 95% CI 1.06-18.33, p = 0.04). The etiology of PH is multifactorial, and determined by factors related to the patient and the surgical technique (4-7, 14-15). Donahue et al. performed a retrospective study of 386 patients undergoing radical cystectomy and ileal diversion (15), with female gender (HR 2.25), BMI (1.08) and preoperative hypoalbuminemia (HR 0.4) accounting for a significant association with the development of PH. In another study involving 58 patients with PH after cystectomy, previous median laparotomy (HR 1.98) and severe obesity BMI > 40 (HR 4) were identified as independent risk factors for PH (5). DM (HR 1.81), Chronic Obstructive Pulmonary Disease (HR 1.78) (16) and long operative time (17) have also been shown to predispose to the development of this complication. The most important modifiable risk factor for PH is obesity, contributing to the weakening of the abdominal wall and thus to the formation of hernias through several mechanisms such as increased intra-abdominal pressure, seroma development, necrosis and wound infection (5, 16). Regarding technical factors, size and location of the stoma and preoperative stoma site marking by certified ostomy nurse, have been described in the literature as factors that may influence the development of PH after stoma creation (3-5, 15). The size of the cutaneous and aponeurotic orifice should be wide enough to allow passage of the bowel, but not too large, to avoid the risk of herniation. Several studies have described the correlation between larger stoma diameter and the risk of developing symptomatic PH. For instance, Seo et al. (13) reported significant differences in the diameter of the stoma fascial defect in symptomatic versus asymptomatic patients (76.45 mm vs. 49.41 mm, p = 0.00) and, furthermore, they observed a significant correlation between the size of the opening and the type of rHP (rHP type 2, 62.69 mm, rHP type 3, 81.01; p = 0.003). Despite this, there is insufficient evidence to define an ideal size preventing the development of hernias. Traditionally, it is estimated that the orifice should not exceed 3 cm in colostomies and 2.5 cm in ileostomies (18), since fascial defects larger than this size can multiply the risk of developing a PH by up to five times (17). The use of fascial support sutures is a procedure routinely performed in clinical practice despite the lack of evidence of any effect in reducing PH rates. Pisters et al. (19) described the impact of anterior fascial fixation sutures in 496 patients undergoing radical cystectomy with ileal conduit at the MD Anderson Cancer Center, with a median follow-up of 16 months. Sixty-one patients (12.2%) developed PH. The rate of cPH was significantly higher in patients who had anterior fascial sutures placed compared to those who did not (15.3% vs. 7.3%, p = 0.02). Furthermore, they observed that the use of these sutures was an independent risk factor in multivariate analysis for the development of PH (OR 2.3 CI95%, 1.03-5.14; p = 0.04), so they discouraged their use in radical cystectomy

with ileal diversion. Moreover, multiple studies in the colorectal literature also advise against facial support sutures, since they have not been shown to reduce PH rates in this type of stoma (15, 20, 21). Our series confirmed the association between PH and obesity, and previous midline laparotomy, two factors that contribute to weakening the abdominal wall and promote herniation. The other factors previously mentioned as predisposing the development of PH (female sex, DM, hypoalbuminemia, prolonged surgical time, etc. [4-7, 14-17)] did not show a significant association in our series, probably as a consequence of the limited number of cases. We also observed that PH was significantly more frequent in patients with postoperative surgical wound infection. Although studies in the colorectal literature have previously described this association (20, 21), to our knowledge, this is the first study in the field of urology to link surgical wound infection with PH. This could be explained by the tissue damage and necrosis produced by the infection, which contributes to the weakening of the abdominal wall and therefore to the development of PH. The pathophysiology and natural history of PH is a poorly studied subject, and most of the available data is derived from the colorectal literature. Radiographic classifications are indispensable, as they provide insight into its evolution, especially regarding changes in size and time to progression to a higher grade in the classification. In our series, radiological progression occurred in 46% of type 1 and 40% of type 2 hernias, with a median time of 11 months (SD 9.4). As in other previously reported studies (16), we found no predictive factors for progression, although the small number of events could also affect the results. Despite this, only 25.9% of our patients with PH required surgical repair, and only one patient underwent emergency surgery due to intestinal obstruction, a figure similar to the previously reported (9-30%) (4, 5, 15-17). In general, PH surgical correction tends to be postponed due to its extreme complexity and high recurrence rate. Primary repair and stoma relocation have traditionally been associated with unacceptably high hernia recurrence rates (up to 76%) (10, 20, 21). This figure drops to 10% (21) when a mesh is placed during the surgery, making this procedure the preferred choice. The two main techniques described so far are the Sugarbaker technique (reduction of the contents of the hernial sac and placement of intraperitoneal mesh covering the aponeurotic orifice and the bowel forming the stoma) and the Keyhole technique (creation of a hole in the mesh through which the stoma passes). In the colorectal literature, the first one has shown lower recurrence rates (18), although data are limited in patients with ileal diversion. The high prevalence of PH along with the negative impact on patients' quality of life, morbidity of surgical repair, and high recurrence rates have encouraged urologists to attempt to prevent its development by prophylactic mesh placement at the time of stoma creation. Recently, three prospective randomized trials have demonstrated a significant reduction in the rate of PH by more than 50% with no differences in postoperative complications or mesh-related complications (infection) (22-24). The only difference between the two groups lies in surgical time (median 50

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M. Alonso Grandes, J.A. Herranz Yagüe, R. Roldán Testillano, et al.

min more in patients with mesh placement). Prospective trials with longer follow-up time are needed, as well as cost-effectiveness studies to evaluate the role of prophylactic mesh in cystectomy and to determine if it should be placed systematically in all patients or only in those with a higher risk of PH (obese patients, female sex, COPD...). The main limitation of our study lies in its retrospective nature, which may lead to underdiagnosis of clinical PH, mainly low-grade PH (I and II).

13. Seo SH, Kim HJ, Oh SY, et al. Computed tomography classification for parastomal hernia. J Korean Surg Soc 2011; 81:111-4. 14. Aquina CT, Iannuzzi JC, Probst CP, et al. Parastomal hernia: a growing problem with new solutions. DigSurg. 2014; 31:366-76. 15. Donahue TF, Bochner BH. Parastomal hernias after radical cystectomy and ileal conduit diversion. Investig Clin Urol. 2016; 57:240-8. 16. Ghoreifi A, Allgood E, Whang G, et al. Risk factors and natural history of parastomal hernia after radical cystectomy and ileal conduit. BJU Int. 2022; 130:381-388. 17. Hussein AA, Ahmed YE, May P, et al. Natural History and Predictors of Parastomal Hernia after Robot-Assisted Radical Cystectomy and Ileal Conduit Urinary Diversion. J Urol. 2017; 199:766-773.

CONCLUSIONS

Parastomal hernia is a common complication following radical cystectomy and Bricker-type urinary diversion, and can be considered as part of natural evolution after stoma creation. Consideration of the predictive factors can help for patient preoperative optimization and in the planning of surgery. Obesity, wound infection and a history of midline laparotomy represent independent risk factors.

18. Pallisera A, Serra X, Mora L, et al. Actualización de las hernias paraestomales: diagnóstico, tratamiento y prevención Parastomal. Rev Hispanoam Hernia. 2017; 5:3-12. 19. Pisters AL, Kamat AM, Wei W, et al. Anterior fascial fixation does not reduce the parastomal hernia rate after radical cystectomy and ileal conduit. Urology 2014; 83:1427-31. 20. Israelsson LA. Parastomal hernias. Surg Clin North Am 2008; 88:113-25.

REFERENCES

21. Carne PW, Frye JN, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg. 2003; 90:784-93.

1. Caricato M, Ausania F, Ripetti V, et al. Retrospective analysis of long-term defunctioning stoma complications after colorectal surgery. Colorectal Dis. 2007; 9:559-61.

22. Janes A, Cengiz Y, Israelsson LA. Randomized clinical trial of the use of a prosthetic mesh to prevent parastomal hernia. Br J Surg 2004; 91:280.

2. Gerharz EW, Mansson A, Hunt S, Skinner EC, Månsson W. Quality of life after cystectomy and urinary diversion: an evidencebased analysis. J Urol 2005; 174:1729-36.

23. Liedberg F, Kollberg P, Allerbo M, et al. Preventing parastomal hernia after ileal conduit by the use of a prophylactic mesh: a randomised study. Eur Urol. 2020; 78:757-63.

3. Uriarte Vergara B, Gutiérrez Ferreras AI, Pérez de Villarreal Amilburu P, et al. Guía para el manejo actualizado de la hernia paraestomal. Rev Hispanoam Hernia 2021; 9:126-130.

24. Hammond TM, Huang A, Prosser K, et al. Parastomal hernia prevention using a novel collagen implant: a randomised controlled phase 1 study. Hernia. 2008; 12:475.

4. Donahue TF, Bochner BH, Sfakianos JP, et al. Risk factors for the development of parastomal hernia after radical cystectomy. J Urol 2014; 191:1708-13. 5. Liu NW, Hackney JT, Gellhaus PT, et al. Incidence and risk factors of parastomal hernia in patients undergoing radical cystectomy and ileal conduit diversion. J Urol 2014; 191:1313-8. 6. Muysoms F, Campanelli G, Champault GG. EuraHS: the development of an international online platform for registration and outcome measurement of ventral abdominal wall hernia repair. Hernia. 2012; 16:239-250.

Correspondence

7. Martínez Lahoz Y, Casas Sicilia E, Castán Villanueva N, et al. Hernias paraestomales. Revisión de la literatura. Revista Sanitaria de Investigación 2022; 3 (8).

María Alonso Grandes, MD (Corresponding Author) marialonsograndes@gmail.com University Hospital of Fuenlabrada, Department of Urology, Camino del Molino 2, 28942, Fuenlabrada, Madrid, Spain

8. Martin L, Foster G. Parastomal hernia. Ann R Coll Surg Engl 1996; 78:81-4.

José Antonio Herranz Yagüe, MD jherranz@salud.madrid.org

9. Marimuthu K, Vijayasekar C, Ghosh D, Mathew G. Prevention of parastomal hernia using preperitoneal mesh: a prospective observational study. Colorectal Dis 2006; 8:672-5.

Rocío Roldán Testillano, MD rocio.roldan@salud.madrid.org

10. Ripoche J, Basurko C, Fabbro-Perray P, Prudhomme M. Parastomal hernia. A study of the French federation of ostomy patients. J Visc Surg 2011; 148:e435-41.

Alfonso María Márquez Negro, MD alfonsomaria.marquez@salud.madrid.org Casilda Cernuda Pereira, MD casilda.cernuda@salud.madrid.org

11. Cingi A, Cakir T, Sever A, Aktan AO. Enterostomy site hernias: a clinical and computerized tomographic evaluation. DisColon Rectum 2006; 49:1559-63.

Emilio Andrés Ripalda Ferretti, MD emilio.ripalda@salud.madrid.org

12. Feng D, Wang Z, Yang Y, et al. Incidence and risk factors of parastomal hernia after radical cystectomy and ileal conduit diversion: a systematic review and meta-analysis. Transl Cancer Res. 2021; 10:1389-1398.

Álvaro Páez Borda, MD alvaro.paez@salud.madrid.org Conflict of interest: The authors declare no potential conflict of interest.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12108

DOI: 10.4081/aiua.2023.11642

ORIGINAL PAPER

Treatment results of Para-Testicular Rhabdomyosarcoma (PT-RMS) using radiation as an alternative to retro-peritoneal nodal dissection: A single Institution experience Yasser A. Abdelazim 1, Monika F. Zaki 1, Mohsen M. Abdel Mohsen 2, Reem M. Emad 1, Heba G. Mohamad 3, Dalia Abdelfatah 4, Ehab M. Kalil 1 1 Department of Radiation Oncology, National Cancer Institute, Cairo University, Egypt; 2 Department of Clinical Oncology, Faculty of medicine, Cairo University, Egypt;

3 Department of Surgical Oncology, National Cancer Institute, Cairo University, Egypt;

4 Department of Cancer epidemiology & biostatistics. National Cancer Institute, Cairo University, Egypt.

Summary

Background: Para-testicular Rhabdomyosarcoma (PT-RMS) has a favorable treatment outcome adopting multidisciplinary management; resection, namely high inguinal orchiectomy ± retro-peritoneal lymph node dissection (RPLND) followed by standard or intensive chemotherapy ± adjuvant radiation therapy. Patients and methods: This is a retrospective study including all patients with pathologically proven PT-RMS, presented to the National Cancer Institute, Cairo University, during the period from 2005 to 2020. Endpoints included overall survival, disease free survival and patterns of failure of different treatment modalities. Results: Forty one patients were identified. Median age in our cohort was 15 years (range: 2-54 years). After a median follow up of 26 months (range, 3-75 months) ,two and five years OS were 100% and 91.7% respectively and median survival was not reached. Patients who underwent retro-peritoneal nodal dissection had a 5-year DFS rate of 100% versus 73% for those who received radiation to para-aortic nodes (p = 0.185). Limitations include retrospective nature and deviation from COG protocol. Conclusions: This study shows promising results suggesting that less aggressive local treatment modalities including radiation to para-aortic chain could be an option in PT-RMS, given the excellent results of this subtype. However further validation in a prospective study is warranted.

KEY WORDS: Para-testicular rhabdomyosarcoma; Retro-peritoneal dissection; Radiation therapy. Submitted 5 August 2023; Accepted 31 August 2023

INTRODUCTION

Paratesticular rhabdomyosarcoma (PT-RMS) is a special entity of rhabdomyosarcoma with an estimated incidence around 7% of all patients with RMS (1). The prognosis for patients with localized disease is excellent, owing to early detection of the tumor given its special location and a predominance of paired box gene (PAX)-fusion negative RMS (2, 3). This allows for using less aggressive local treatment modalities especially with

the recent multiagent chemotherapy protocols and high sensitivity of imaging techniques. Management strategy includes high inguinal orchiectomy with or without retro-peritoneal nodal dissection and multiagent chemotherapy depending on the stage and group of disease (4). Patients with no sampling of para-aortic nodes are managed as stage III disease. In our institute, retro-peritoneal nodal sampling is not widely adopted and radiation therapy to para-aortic chain is used as an alternative. Herein, we review our experience and clinico-epidemiological factors were studied as well as treatment strategies potentially influencing disease-free survival (DFS) in addition to overall survival (OS) and loco regional recurrence (LRR).we aim to explore treatment outcomes with radiation therapy instead of retro-peritoneal nodal dissection.

PATIENTS AND METHODS

This is a retrospective study involving all patients with para-testicular RMS presented to NCI, Cairo University in the period from 2005 till 2020. IRB approval was obtained before data collection from ethical committee of Faculty of Medicine, Cairo University. No consents were required given the retrospective nature of the study. Patients' records were reviewed to extract clinico-epidemiological data including age, pathological subtype, tumor size , risk stratification, staging and treatment data including type of surgery (biopsy or resection, para-aortic lymph node dissection), chemotherapy regimen and radiotherapy details (dose, overall period of treatment, radiation technique and timing of radiation),and patterns of failure. Patients with incomplete treatment records were excluded from data analysis. All patients were diagnosed by initial biopsy (high inguinal orchiectomy or trans-scrotal). Patients who underwent complete surgical staging were staged according to IRSG Postsurgical Grouping Classification (5) (Table 1), while those who underwent orchiectomy only without nodal assessment or those with clinical positive nodes were managed as

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Y.A. Abdelazim, M.F. Zaki, M.M. Abdel Mohsen, et al.

Table 1. IRSG Postsurgical Grouping Classification. Group 1 A B Group 2 A B C Group 3 Group 4

Figure 1. Diagrammatic scheme of IRS-IV protocol.

Localized disease, completely resected, no microscopic residual Confined to site of origin, completely resected Extends beyond site of origin, completely resected Gross total resection Residual microscopic disease ( positive margins) Involved regional nodes, completely resected Microscopic local and/or regional residual disease Incomplete resection or biopsy with gross residual Distant metastasis

group III. Pretreatment clinical staging was per IRSG presurgical staging (5) (Table 2). Work up included scrotal U/S, MRI of the pelvis, CT of chest and abdomen with contrast and bone scan. PET-CT was done for 5 patients for initial staging and/or post chemotherapy to assess the treatment response in last two years (2019-2020). Lymph node evaluation was done using staging CT of the abdomen and pelvis in all cases. Surgical nodal staging was done in only 4 cases. Treatment details All patients underwent surgery for the primary testicular tumor (most of them were by inguinal approach); only 4 patients underwent therapeutic retroperitoneal lymph node dissection (RPLND) for grossly enlarged nodes on CT. Postoperative chemotherapy was used according to the Intergroup Rhabdomyosarcoma Study IRS- IV chemotherapy protocol (vincristine, dactinomycin, and cyclophosphamide) (6) for 42 weeks. A flow chart of the protocol is provided in Figure 1. Hemi-scrotum irradiation was used in cases of scrotal violation (trans-scrotal approach). Iliac and inguinal nodal radiation was used with para-aortic nodal radiation in cases of presence of clinically involved nodes in these stations. Regarding radiation therapy planning, patients were fixed with a mattress during CT simulation. CT cuts were taken with a slice thickness of 3 mm from level of suprasternal notch down to mid-thighs. A three-dimensional conformal radiotherapy technique was commonly used for treatment. Table 2. IRSG Pre-surgical Staging Classification. Stage I

III

Sites Orbit, head and neck (excluding PM), GU: non-bladder/non-prostate Bladder/prostate, extremity, cranial, PM other (includes trunk, retroperitoneum, and so on) Bladder/prostate, extremity, cranial, PM, other (includes trunk, retroperitoneum, and so on) All

Tumor (T) T1 or T2 T1 or T2

Size a or b

Metastases (M) M0

Node (N) N0, N1 or Nx N0 or Nx

T1 or T2

a b

N1 N0, N1 or Nx

Any

Tumor: T1, confined to anatomic site of origin, (a) < 5 cm in diameter, (b) > 5 cm in diameter; T2, extension and/or fixative to surrounding tissue, (a) < 5 cm in diameter, (b) > 5 cm in diameter; regional nodes: N0, regional nodes clinically negative; N1, regional nodes clinicallypositive; Nx, clinical status is unknown; metastasis: M0, no distant metastasis; M1, metastasis present. GU, genitourinary; PM, para-meningeal.

Starting from year 2020, IntensityModulated Radiation Therapy (IMRT) technique was used for better sparing of organs at risk. Radiotherapy doses were dependent on the completeness of surgical resection of the primary tumor (Clinical Group) and presence or absence of involved regional lymph nodes. After resection, patients with complete resection and stage I alveolar histology were treated to 36 Gy, those with stage II and uninvolved nodes received 41.4 Gy, those with pathologically involved nodes received 41.4 Gy and patients with positive gross nodes in planning CT received 50.4

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11642

Radiation role in in PT-RMS

Table 3. Demographic and pathological characteristics of patients in this study.

Gy. The gross tumor volume (GTV) was defined as any gross nodal disease on planning CT or post-chemotherapy PETCT. The clinical target volume (CTV) was defined as 1.5 cm expansion on aorta and inferior vena cava (IVC) from level of 11th dorsal vertebra (DV11) down to bifurcation, excluding bowel, bone and muscles. The planning target volume (PTV) was defined as an additional 1 cm margin to CTV. Kidneys, bowel and spinal cord were delineated as organs at risk. PTV coverage of minimum 95% of dose to 95% of volume was required for plan acceptance. Dmax of cord was limited to < 45 Gy and bilateral kidney V24 was limited to < 50%. Radiation therapy was started at week 13 in patients with Low Risk (14 patients) whereas in other cases it was usually given at week 20 as per protocol.

N = 41 (%) Age Median (range) ≤ 10 > 10 Histological type Alveolar Embryonal Pleomorphic Staging Stage 1 Stage 2 Stage 3 Stage 4 Grouping Group 1 Group 2 Group 3 Risk stratification Low risk Intermediate risk High risk

Statistical analysis Data was analyzed using IBM SPSS advanced statistics (Statistical Package for Social Sciences), version 21 (SPSS Inc., Chicago, IL). Numerical data was described as mean and standard deviation or median and range as appropriate, while qualitative data were described as number and percentage. Endpoints were the disease-free survival, metastasis-free survival, loco-regional control and overall survival. Overall survival was defined as the time from primary diagnosis date to death (all-cause). Time to loco-regional recurrence was defined as time from primary treatment to recurrence at the primary tumor site or regional lymph nodes, whichever comes first; distant recurrences and deaths that occur before local events were ignored. Distant recurrence was defined as recurrences outside these loco-regional sites; deaths and loco-regional recurrences that occur before distant events were ignored. Disease-free survival (DFS) was defined as the time from primary treatment to loco-regional recurrence, distant recurrence, whichever comes first. Comparisons between the two groups were made using either Chi- square test or Fishers exact test for categorical data. For quantitative data comparison between 2 groups was done using either parametric or non-parametric t-test as appropriate. Survival analysis was done using Kaplan-Meier method and comparison between survival curves was done using Log rank test. A p-value less than 0.05 was considered statistically significant. All tests were two tailed.

15 (2-54) 10 (24) 31 (76) 2 (4.9) 37 (90.2) 2 (4.9) 23 (56.1) 4 (9.8) 4 (9.8) 10 (24.4) 8 (19.5) 13 (31.7) 20 (48.8) 14 (34.1) 14 (34.1) 13 (31.7)

Treatment related characteristics Thirty-nine (95%) patients were surgically excised completely by high inguinal orchiectomy and high cord ligation at the internal ring prior to tumor mobilization as per international guidelines; only 2 patients (5%) were managed by trans-scrotal approach. Thirty seven (90%) patients did not undergo retroperitoneal lymph node dissection (RPLND), while four (10%) patients underwent inguinal orchiectomy with RPLND (all were > 10 years), Patients were treated according to Intergroup Rhabdomyosarcoma Study IRS-IV protocol. All patients were treated by systemic chemotherapy (VAC based regimens) for 42 weeks. Radiotherapy was adopted for local control in thirty one (75%) patients, while 8 patients did not receive radiotherapy as they were low risk group (stage I, group I, embryonal histology). One patient did not receive radiation due to his guardian’s refusal and one patient did not receive local treatment due to progression during chemotherapy and he was shifted to second line chemotherapy Ifosfamide/Carboplatin/Etoposide (ICE), with good response. Patients who received radiation to scrotum were due to scrotal violation during surgery and those who received radiation to inguinal and ipsilateral iliac nodes was due to presence of gross disease at these sites at presentation. The timing of radiotherapy in COG Protocol was in week 13 in all risk groups. Patients in low risk group received radiotherapy at week 12 and some patients were delayed to week 20. The median radiotherapy dose was 36Gy

RESULTS

Forty one patients with pathologically proven PT RMS were identified in the period from January 2005 till December 2020. The Median age in our cohort was 15 years (range: 2-54 years). Children below 10 years constituted 24% of the total population. Thirty seven (90%) patients had embryonal histology. Retroperitoneal lymph node involvement was present in twelve (29%) patients by CT evaluation (four patients < 10 years and eight patients > 10 years). Ten patients presented with initially metastatic disease (eight patients to lungs and two patients to supra-clavicular lymph nodes). Demographic and pathological characteristics of the patients are summarized in Table 3.

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Y.A. Abdelazim, M.F. Zaki, M.M. Abdel Mohsen, et al.

Table 4. Treatment related characteristics in this study. Surgical approach n = 41 (%) Inguinal Scrotal PALN dissection Yes No PALN status Positive Negative Type of CTH VAC VAC-ICE VAC-ICE-IE VCR

Patterns of failure One patient had distant failure in lung, one patient had distant failure in bones and seven patients had nodal failure, three of them in ilio-inguinal nodes and 4 patients had para-aortic failure. In patients who underwent RPLND, one patient had para-aortic failure.

39 (95) 2 (5) 4 (10) 37 (90)

Survival analysis Overall survival (OS) After a median follow up of 26 months (range, 3-75 months), two and five years OS were 100% and 91.7% respectively and median survival was not reached (Figure 2). Five year survival rate for patients < 10 years were 100% versus 86% for patients above 10 years of age (p = 0.390).

12 (29) 29 (71) 32 (78) 6 (15) 1 (2.4) 2 (5)

(range, 19.5- 50.4 Gy). Treatment related characteristics are summarized in Table 4. Figure 2. KM curve representing overall survival for the whole study group.

Disease Free Survival (DFS) Five years disease free survival for the whole group was 77 percent (Figure 3). Patients who underwent retro-peritoneal nodal dissection had a 5-year DFS rate of 100% versus 73% for those who received radiation to para-aortic nodes (p = 0.185). Five years DFS was 100% for patients < 10 years versus 71% for those > 10 years (p = 0.106). No difference in DFS between patients who had positive para-aortic nodes at presentation (n = 12) and those with negative para-aortic nodes (n = 29), with a 5-year DFS rate 90 percent vs. 72 percent, respectively (p = 0.287). Local control (LC) The one-year LC is 85% for whole study group while the five-year LC is 71.2%. No difference in LC between patients with positive para-aortic nodes at presentation and those with negative nodes at 5 years (89 percent vs. 60 percent, respectively, p = 0.158).

DISCUSSION

This retrospective study included 41 patients with para-testicular Rhabdomyosarcoma (PT RMS) who presented to NCI - Cairo University in the period from 2005 to 2020. The median age of the study patients group was 15 years which is comparable to other studies showing a median age of 16.5 years (7). The embryonal pathological subtype constituted 90% of the study group. Similar results were reported in the literature with predominance of the embryonal histology representing 70% (7). Regarding the surgical and clinical group, the majority of the studied patients were categorized as Group 3 (50%) which is consistent with the analysis of PT RMS patients treated in IRS II through IV in which surgical group 3 was reported in (40%) of cases (7). Regarding the IRSG stage, 56% of studied patients presented in stage I while 25% of

Figure 3. Kaplan Meier curve representing DFS for the whole study group.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11642

Radiation role in in PT-RMS

patients had stage IV disease. Findings are in agreement with other studies which reported stage I and IV diseases in 40% and 40% of cases respectively (7). Approximately 29% of patients with PT-RMS presented with retroperitoneal lymph node disease which is comparable to another study in which approximately 25% of patients with PT-RMS had Positive retroperitoneal lymph node disease (6). The treatment of the patients in this study followed the international guidelines regarding the surgical approach for the primary tumor (high inguinal orchiectomy) which was followed by standard chemotherapy protocol. As for the nodal regional control in positive retroperitoneal lymph nodes, radiotherapy was used in most of the patients (90%) instead of RPLND which was only done in four patients (10%). This policy adapted by our institute is contradictory to the current protocol for Children's Oncology Group (COG) adapting ipsilateral staging RPLND for all boys aged 10 years or more and for those with enlarged lymph nodes suspicious for metastatic disease on CT scan, or patients with alveolar histology irrespective of the age (8). Retro-peritoneal nodal dissection carries a high post-operative morbidity rates between 520% at high-volume centers. The most common complications being small bowel obstruction, retrograde ejaculation, lower extremity lymphedema, hydronephrosis and chylous ascites (9-11). These complications are considered more significant compared for nodal irradiation complications which include radiation dermatitis, gastroenteritis, and myelosuppresion (12). Despite these low rates of para-aortic nodal dissection in our study, median OS was not reached and the calculated one and five year OS rates were 100% and 91.7% respectively, reflecting the excellent prognosis of the disease regardless of the nodal regional treatment modality used. These results are comparable to similar studies which reported overall survival rates ranging between 81 and 95 percent (6, 13, 14). The retroperitoneal lymph node positivity at presentation (whether clinical or pathological) did not influence the outcome as there was no difference in treatment related outcomes between patients with positive and negative para-aortic nodes at presentation, reflecting the excellent outcome despite less intensive treatment in our study. In terms of DFS, 5-year DFS rate was 73% in patients who received radiotherapy to para-aortic chain versus 100% for those who underwent retro-peritoneal nodal dissection with no significant difference between both groups statistically (p = 0.185). Only one patient (2.7%) out of 37 patients in our study experienced isolated regional failure in para-aortic chain. This is comparable to another study which was held by SIOP 2016 which reported 5-year DFS 83% in patients who underwent Radical inguinal orchiectomy without RPLND (15). In summary, our study shows a favorable outcome in PTRMS patients managed with radiation to para-aortic chain instead of surgery. This might be attributed to the indolent nature of the disease itself or the efficacy of radiation. However, a prospective study may be warranted. To our knowledge, this is the first work addressing radiation as an alternative to surgery in PT-RMS.

Limitations of this study include its retrospective nature which makes it subjected to selection bias, small sample size, lack of toxicity scoring and quality of life (QoL) assessment of the patients, lack of PET-CT staging which might have underestimated the real incidence of clinically positive retro-peritoneal nodes and deviation from the current COG protocol. However in such rare diagnosis where prospective trials are difficult to conduct, institutional series remain instructive.

REFERENCES

1. Stewart LH, Lioe TF, Johnston SR. Thirty-year review of intrascrotal rhabdomyosarcoma. Br J Urol. 1991; 68:418-20. 2. Raney RB Jr, Tefft M, Lawrence W Jr, et al. Paratesticular sarcoma in childhood and adolescence. A report from the Intergroup Rhabdomyosarcoma Studies I and II, 1973-1983. Cancer. 1987; 60:2337-43. 3. Raney RB, Walterhouse DO, Meza JL, et al. Results of the Intergroup Rhabdomyosarcoma Study Group D9602 protocol, using vincristine and dactinomycin with or without cyclophosphamide and radiation therapy, for newly diagnosed patients with low-risk embryonal rhabdomyosarcoma: a report from the Soft Tissue Sarcoma Committee of the Children’s Oncology Group. J Clin Oncol. 2011; 29:1312-1318. 4. Rogers TN, Seitz G, Fuchs J, et al. Surgical management of paratesticular rhabdomyosarcoma: A consensus opinion from the Children's Oncology Group, European pediatric Soft tissue sarcoma Study Group, and the Cooperative Weichteilsarkom Studiengruppe. Pediatr Blood Cancer. 2021; 68:e28938. 5. Crane JN, Xue W, Qumseya A, et al. Clinical group and modified TNM stage for rhabdomyosarcoma: A review from the Children's Oncology Group. Pediatr Blood Cancer. 2022; 69:e29644. 6. Crist WM, Anderson JR, Meza JL, et al. Intergroup rhabdomyosarcoma study-IV: Results for patients with nonmetastatic disease. J Clin Oncol. 2001; 19:3091-3102. 7. Kumar R, Kapoor R, Khosla D, et al. Paratesticular rhabdomyosarcoma in young adults: A tertiary care institute experience. Indian J Urol. 2013; 29:110-3. 8. Rogers TN, De Corti F, Burrieza GG, et al. Paratesticular rhabdomyosarcoma—impact of locoregional approach on patient outcome: a report from the European paediatric Soft tissue sarcoma Study Group (EpSSG). Pediatr Blood Cancer. 2020; 67:e28479. 9. Heidenreich A, Albers P, Hartmann M, et al. Complications of primary nerve sparing retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors of the testis: experience of the German Testicular Cancer Study Group. J Urol. 2003; 169:1710-1714. 10. Beck SD, Bey AL, Bihrle R, Foster RS. Ejaculatory status and fertility rates after primary retroperitoneal lymph node dissection. J Urol. 2010; 184:2078-2080. 11. Steiner H, Zangerl F, Stöhr B, et al. Results of bilateral nerve sparing laparoscopic retroperitoneal lymph node dissection for testicular cancer. J Urol. 2008; 180:1348-1353. 12. Gupta AA, Anderson JR, Pappo AS, et al. Patterns of chemotherapy-induced toxicities in younger children and adolescents with rhabdomyosarcoma: a report from the children's oncology group soft tissue sarcoma committee. Cancer. 2012;118:1130-1137. 13. LaQuaglia MP, Ghavimi F, Heller G, et al. Mortality in pediatric paratesticular rhabdomyosarcoma: a multivariate analysis. J Urol. 1989; 142:473-478.

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Y.A. Abdelazim, M.F. Zaki, M.M. Abdel Mohsen, et al.

14. Lawrence W Jr, Gehan EA, Hays DM, et al. Prognostic significance of staging factors of the UICC staging system in childhood rhabdomyosarcoma: a report from the Intergroup Rhabdomyosarcoma Study (IRS II). J Clin Oncol. 1987; 5:46.

15. Stevens MC, Rey A, Bouvet N, et al. Treatment of nonmetastatic rhabdomyosarcoma in childhood and adolescence: third study of the International Society of Paediatric Oncology–SIOP Malignant Mesenchymal Tumor 89. J Clin Oncol. 2005; 23:2618-2628.

Correspondence Yasser A. Abdelazim, MD (Corresponding Author) Yasser.anwar@nci.cu.edu.eg National Cancer Institute 1 Kasr EL Ainy Street, Cairo, Egypt, 11796 Monika Foad Zaki, MD monikafouad@icloud.com Reem Mohamad Emad, MD reem.emad@nci.cu.edu.eg Ehab Mohamad Khalil, MD ehab.khalil@nci.cu.edu.eg Department of Radiation Oncology, National Cancer Institute, Cairo University, Egypt Mohsen Mokhtar Abdel Mohsen, MD mohsenonc@hotmail.com Department of Clinical Oncology, Faculty of Medicine, Cairo University, Egypt Heba Gamal Mohamad, MD hebasurg@yahoo.com Department of Surgical Oncology, National Cancer Institute, Cairo University, Egypt Dalia Abdelfatah Mohammed, MD dalia.abdelfatah@nci.cu.edu.eg Department of Cancer Epidemiology & Biostatistics. National Cancer Institute, Cairo University, Egypt

Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11642

DOI: 10.4081/aiua.2023.11629

ORIGINAL PAPER

Evaluation of bipolar Transurethral Enucleation and Resection of the Prostate in terms of efficiency and patient satisfaction compared to retropubic open prostatectomy in prostates larger than 80 cc. A prospective randomized study Ibrahim Tagreda, Mahmoud Heikal, Adel Elatreisy, Mohamed Fawzy Salman, Ahmed Mohamed Soliman, Ayman Kotb Koritenah, Hesham Abozied, Mohamed Ibrahim Algammal, Ahmed A. Alrefaey, Mohamed Elsalhy, Mohamed Shehab, Mahmoud Mohammed Ali, Aly Gomaa Eid, Abdrabuh M. Abdrabuh, Sayed Eleweedy Urology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.

Summary

Objectives: To compare the outcomes of bipolar Transurethral Enucleation Resection of the Prostate (TUERP) and simple retropubic prostatectomy in patients with prostate volumes larger than 80 cc. Patients and methods: A prospective randomized study included all patients amenable to surgeries for benign prostate hyperplasia (BPH) with prostate size over 80 cc at a tertiary care hospital between January 2020 to February 2022. Bipolar TUERP and Retropubic open prostatectomy techniques were compared regarding patients' demographics, intraoperative parameters, outcomes, and peri-operative complications. Results: Ninety patients were included in our study and randomly assigned to bipolar TUERP (Group 1 = 45 patients) and retropubic open prostatectomy (Group 2 = 45 patients). The TUERP group demonstrated significantly lower operative time (77 ± 11 minutes vs. 99 ± 14 minutes, p < 0.001), hemoglobin drop (median = 1.1 vs. 2.5, p < 0.001), and resected tissue weight (71 ± 6.6 cc vs. 84.5 ± 10.6 cc, p < 0.001). Postoperatively, the TUERP group demonstrated significantly lower catheter time (median = 2 vs. 7 days, p < 0.001) and less hospital stay. IPSS, Qmax, and patient satisfaction were better in the TUERP group within six months of surgery. We reported 90-day complications after TUERP in 13.3% of patients compared to 17.8% after retropubic prostatectomy, with a statistically insignificant difference. Urethral stricture predominated after TUERP, while blood transfusion dominated in retropubic prostatectomy. Conclusions: The present study found that TUERP had equivalent efficacy and safety to open retropubic prostatectomy for patients with BPH and prostate volumes > 80 ml.

KEY WORDS: TUERP; Simple retropubic prostatectomy; Complications. Submitted 1 August 2023; Accepted 31 August 2023

INTRODUCTION

Open prostatectomy is considered the most durable surgical option for large (> 80 gm) prostates. Meanwhile, it

is the most invasive and associated with high operative morbidity (1). The rate of open prostatectomy surgeries has been progressively decreasing with the advent of minimally invasive techniques, including monopolar and bipolar TURP and diferent laser therapies (2). Holmium laser enucleation of the prostate (HoLEP) has shown a comparable functional outcome to open prostatectomy in treating prostates larger than 80 cc (3). However, due to its steep learning curve and higher cost, HoLEP gained little popularity, especially in developing countries (4). Transurethral enucleation resection of the prostate (TUERP) incorporated the enucleation technique with standard transurethral resection of the prostate (TURP). It is available in all urology theaters, is cost-effective, and could be considered a treatment option resembling LASER enucleation, specifically bipolar TUERP (5). In the present study, we aimed to assess the efficacy and safety of bipolar TUERP compared to retropubic prostatectomy in patients with LUTS secondary to benign prostatic hyperplasia with prostate volumes larger than 80 cc.

PATIENTS AND METHODS

A prospective randomized study included all patients amenable to benign prostate hyperplasia (BPH) surgeries to control lower urinary tract symptoms with prostate size over 80 cc at the Urology Department of Al-Azhar University Hospitals between January 2020 to February 2022. We excluded patients with neurogenic bladder dysfunction, previous prostatic or urethral surgeries, urethral stricture or bladder neck contracture, renal impairment, and comorbidities that render them at high anesthetic risk. The local ethical committee approved our research, and all participants signed informed consent. Patients were randomly allocated into one of the two groups; Group 1 included patients who underwent bipolar TUERP, and Group 2 had retropubic open prostatectomy. A stratified block randomization method (1:1 ratio) was used for patient allocation.

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All recruited patients were assessed through the following regimen: full medical history including International Prostate Symptom Score (IPSS) assessment and international index of erectile function (IIEF); complete clinical examination, including digital rectal examination (DRE) and focused neurological examination; urine analysis, urine culture and sensitivity, serum creatinine, coagulation profile, CBC, serum Na and potassium, blood sugar, and prostate specific antigen (PSA). Objective evaluation of LUTS carried out through uroflowmetry with post-void residual urine, transrectal ultrasound for estimation of prostate volume, and pelvic-abdominal ultrasound in cases with recurrent hematuria, infection, loin pain, or high post-void residual urine. TUERP procedure was performed using a Plasma kinetic resection using a KLS Martin maximum with Storz Fr 26 resectoscope with plasma kinetic electrode using the bipolar current and normal saline irrigation. The procedure involved the creation of the plane of the surgical capsule at a level closely proximal to the verumontanum with vaporization; the adenoma was dissected from the capsule plane by unclenching it using the beak of the resectoscope sheath from one side to the other. The blood vessels to the adenoma were coagulated at the time of dissection. When the whole adenoma was almost dissected from the capsule, a small proportion of adenoma was allowed to anchor the capsule at the bladder neck, which helped the surgeon to harvest the whole adenoma in pieces with resection. The adenoma slices were evacuated manually. The retropubic open prostatectomy procedure was performed following the standard operative technique (6). Intraoperative adverse events, operative time, and enucleated prostatic weight were recorded. Similarly, postoperative reporting of hemoglobin, hematocrit, serum sodium and potassium (K), hospital stay, catheterization period, and 90-day complications were recorded. Patients were booked for clinic visits after one, three, and six months from surgery for clinical evaluation, including IPSS questionnaire, physical assessment, uroflowmetry, and PVR. The study groups were compared in terms of patient demographics, intraoperative parameters, outcomes, and peri-operative complications.

Table 1. Baseline general and clinical characteristics of the study groups.

Age (years), mean ± SD Co-morbidities, N (%) IPSS, median(range) Quality of life, N (%) Mostly dissatisfied Unhappy Terrible IEEF, median(range) Prostate size (cc), mean ± SD Residual urine (ml), median(range) TRUS (TV) (cc), mean ± SD TZ (cc), mean ± SD Qmax (ml/sec), mean ± SD

Group 1 (n = 45) 66 ± 6 31(68.9) 25 (18-32)

Group 2 (n = 45) 66 ± 7 28 (62.2) 24 (16-35)

8 (17.8) 14 (31.1) 23 (51.1) 7 (5-14) 110 ± 8 cc 195 (90 - 590) 104 ± 12 cc 89 ± 8.7 cc 9.4 ± 14

5 (11.1) 11 (24.4) 29 (64.4) 7 (5-13%) 112 ± 7 cc 190 (107-240) 108 ± 10 91.4 ± 7.9 8.9 ± 1.5

P-value 0.7 0.506 0.209 0.418

0.239 0.211 0.721 0.085 0.169 0.819

IPSS: International Prostate Symptom Score; IEEF: International index of erectile function; TV: total volume of prostate; TZ: transition zone of prostate.

Table 2. Baseline laboratory findings of the study groups.

Pyuria, N (%) Positive urine culture, N (%) Serum creatinine (mg/dl), mean ± SD Hemoglobin (gm/dl), mean ± SD Hematocrit (%), mean ± SD Serum Na (mEq/l), mean ± SD K (mEq/l), mean ± SD PSA-total (ng/ml), median (range) PSA-free (ng/ml), median (range) INR, mean ± SD Random blood sugar (mg/dl), mean ± SD

Group 1 (n = 45) 23 (51.1) 23 (51.1) 1.12 ± 0.34 13.2 ± 1.8 40.3 ± 4.7 136.9 ± 4.2 4.12 ± 0.66 4 (1.1-20) 1 (0.3-2.3) 0.99 ± 0.03 107 ± 16

Group 2 (n = 45) 28 (62.2) 28 (62.2) 1.03 ± 0.18 13.6 ± 1 41.3 ± 2.9 135.8 ± 1.5 4.05 ± 0.36 3.8 (1.9-10.9) 0.8 (0.4-1.9) 0.97 ± 0.04 104 ± 15

P-value 0.288 0.288 0.114 0.235 0.199 0.081 0.509 0.707 0.084 0.129 0.361

K: potassium; PSA; prostate specific antigen; INR; international normalized ratio.

Statistical analysis Statistical analysis was done utilizing the SPSS version 28 (IBM, Armonk, New York, United States). Quantitative data were assessed for normality using the Shapiro-Wilk test and direct data visualization methods. According to normality, quantitative data were summarized as means and standard deviations or medians and ranges. Categorical data were expressed as numbers and percentages. Quantitative data were compared between the studied groups using the independent t-test or Mann-Whitney U test for normally and non-normally distributed quantitative variables. Categorical data were compared using the Chisquare or Fisher’s exact test. All statistical tests were twosided. P values less than 0.05 were considered significant.

retropubic open prostatectomy (Group 2 = 45 patients). The study groups were comparable regarding the patients’ demographics and preoperative laboratory investigations, as shown in Tables 1 and 2. The TUERP group demonstrated significantly lower operative time (77 ± 11 minutes vs. 99 ±14 minutes, p < 0.001), hemoglobin drop (median = 1.1 vs. 2.5, p < 0.001), resected tissue weight (71 ± 6.6 cc vs. 84.5 ± 10.6 cc, p < 0.001), serum potassium (3.9 ± 0.4 vs. 4.1 ± 0.3, p = 0.002), hematocrit (vs. 29 ± 2 vs. 31 ± 2, p < 0.001), and bleeding (22.2% vs. 57.8%, p < 0.001). No significant difference was observed regarding serum Na (p = 0.948) (Table 3). Postoperatively, the TUERP group demonstrated significantly lower catheter time (median = 2 vs. 7 days, p < 0.001) and lower serum potassium level (2.9 ±0.3 vs. 4.1 ± 0.3, p < 0.001). Additionally, hospital stay significantly differed between the studied groups (p < 0.001), with 57.8% and 42.2% of the TUERP patients having a hospi-

RESULTS

Ninety patients were included in our study and randomly assigned to bipolar TUERP (Group 1 = 45 patients) and

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Table 6. Three-month follow-up in the studied groups.

Table 3. Intraoperative findings in the studied groups.

Operative time (min), mean ± SD Hemoglobin drop (gm/dl), median(range) Resected tissue weight (gm), mean ± SD Na (mEq/l), mean ± SD K (mEq/l), mean ± SD Hematocrit (%), mean ± SD Bleeding, N (%)

Group 1 (n = 45) 77 ± 11 1.1 (0.2-3.7) 71 ± 6.6 132 ± 4 3.9 ± 0.4 29 ± 2 10 (22.2)

Group 2 (n = 45) 99 ± 14 2.5 (0.9-6.5) 84.5 ± 10.6 132 ± 2 4.1 ± 0.3 31 ± 2 26 (57.8)

P-value IPSS, median(range) Quality of life, N (%) Mostly satisfied Equivocal IIEF, median(range) Dysuria, N (%) Pyuria, N (%) Uroflow (ml/sec), mean ± SD Residual urine (ml), median (range)

< 0.001 < 0.001 < 0.001 0.948 0.002 < 0.001 < 0.001

K: potassium.

Group 1 (n = 45) 4 (2-6)

Group 2 (n = 45) 5 (3-18)

43 (95.5) 2 (4.4) 7 (5-13) 0 (0) 0 (0) 19.7 ± 2.6 16 (5-50)

40 (88.8) 5 (11.1) 7 (5-13) 7 (15.6) 3 (6.7) 18.5 ± 2.5 10 (0-140)

P-value 0.049

0.588 0.012 0.242 0.022 0.014

IPSS: International Prostate Symptom Score; IEEF: International index of erectile function.

Table 4. Postoperative findings in the studied groups.

Catheter time (days) Hospital stays (days), N (%) Two days Three days Seven days Na (mEq/l), mean ± SD K (mEq/l), mean ± SD Hemoglobin (gm/dl), mean ± SD Hematocrit (%), mean ± SD

Group 1 (n = 45) 2 (2-3)

Group 2 (n = 45) 7 (7-7)

26 (57.8) 19 (42.2) 0 134.7 ± 4.2 3.9 ± 0.3 10.8 ± 1.3 30 ± 1.8

0 0 45 (100) 133.9 ± 2.6 4.1 ± 0.3 11.1 ± 0.9 29.6 ± 3.3

Table 7. Six-month follow-up in the study groups.

P-value < 0.001 < 0.001

IPSS, median(range) Quality of life, N (%) Pleased Mostly satisfied Equivocal Mostly dissatisfied IIEF, median(range) Dysuria, N (%) Pyuria, N (%) Uroflow (ml/sec), mean ± SD Residual urine (ml), median(range)

0.265 < 0.001 0.243 0.495

K: potassium.

Table 5. One-month follow-up in the studied groups.

IPSS, median(range) Quality of life, N (%) Mostly satisfied Equivocal Mostly dissatisfied IIEF, median(range) Dysuria, N (%) Pyuria, N (%) Uroflow (ml/sec), mean ± SD Residual urine (ml), median (range)

Group 1 (n = 45) 6 (5-8)

Group 2 (n = 45) 7 (6-17)

34 (75.5) 11 (24.4) 0 7 (5-13) 11 (24.4) 0 (0) 20.1 ± 3.1 20 (10-70)

30 (66.6) 11 (24.4) 4 (8.9) 6 (5-12) 7 (15.6) 11 (24.4) 17.1 ± 1.9 25 (0-120)

Group 1 (n = 45) 3 (2-5)

Group 2 (n = 45) 3 (2-18)

37 (82.2) 8 (17.8) 0 (0) 0 (0) 7 (5-13) 0 (0) 0 (0) 19.3 ± 2.7 15 (4-40)

34 (75.6) 8 (17.8) 1 (2.2) 2 (4.4) 7 (5-13) 3 (6.7) 3 (6.7) 17.7 ± 2.4 0 (0-160)

P-value 0.189 0.523

0.361 0.242 0.242 0.005 < 0.001

IPSS: International Prostate Symptom Score; IEEF: International index of erectile function.

P-value < 0.001

most TUERP patients being mostly satisfied (75.5%) compared to the open group (66.6%). No significant differences were observed regarding IIEF (p = 0.065), dysuria (p = 0.292), and residual urine (p = 0.868) (Table 5). After three months, the TUERP group demonstrated significantly lower IPSS (median = 4 vs. 5, p = 0.049) and dysuria (0% vs. 15.6%, p = 0.012). In contrast, it showed a significantly higher urinary flow (19.7 ± 2.6 ml/sec vs. 18.5 ± 2.5 ml/sec, p = 0.022) and residual urine (median = 16 ml vs. 10 ml, p = 0.014). Additionally, the quality of life differed between the studied groups, with most TUERP patients being mostly satisfied (95.5%) compared to the open group (88.8%). No significant differences were observed regarding IIEF (p = 0.588) and pyuria (p = 0.242) (Table 6). After six months, the TUERP group demonstrated significantly higher urinary flow (19.3 ± 2.7 ml/sec vs. 17.7 ± 2.4 ml/sec, p = 0.005) and residual urine (median = 15 ml vs. 0, p < 0.001) compared to the open group. No significant differences were observed regarding IPSS (p = 0.189), QOL (p = 0.523), IIEF (p = 0.361), dysuria (p = 0.242), and pyuria (p = 0.242) (Table 7). As regards the complications in the bipolar TUERP

0.065 0.292 < 0.001 < 0.001 0.868

IPSS: International Prostate Symptom Score; IEEF: International index of erectile function.

tal stay of two and three days compared to seven days in patients in the open group. No significant differences were observed regarding serum Na (p = 0.265), hemoglobin (p = 0.243), and hematocrit (p = 0.495) levels (Table 4). After one month from surgery, the TUERP group demonstrated significantly lower IPSS (median = 6 vs. 7, p < 0.001) and pyuria (0% vs. 24.4%, p < 0.001). In contrast, it showed a significantly higher urinary flow (20.1 ± 3.1 ml/sec vs. 17.1 ± 1.9 ml/sec, p < 0.001). Additionally, the quality of life differed between the studied groups, with

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Table 8. Postoperative complications in the study groups.

Secondary hemorrhage, N (%) Retention, N (%) Blood transfusion, N (%) LUTS, N (%) Bladder neck contracture, N (%) Urethral stenosis, N (%)

Group 1 (n = 45) 1 (2.2) 1 (2.2) 0 (0) 2 (4.4) 0 (0) 2 (4.4)

Group 2 (n = 45) 2 (4.4) 0 (0) 2 (4.4) 3 (6.7) 1 (2.2) 0 (0)

drop in hematocrit concentration, and lower incidence of bleeding. In line with our results, a study by Wei et al. found that TUERP had a better outcome regarding operative time and less tissue removal, which may indicate a more precise and targeted approach to prostate surgery (9). Rao et al. found that TUERP generated a smaller serum hemoglobin level drop than trans-vesical prostatectomy (2). In contrast, Ou et al. found no significant difference in operative time between the two procedures (p = 0.107) (10). The resected adenoma weight harvested in the trans-vesical prostatectomy group was more than that in the TUERP group, but the difference between the groups was insignificant (p = 0.062). Similarly, Wang and Wang found no statistically significant differences in operative time between both techniques (13). Some authors reported no significant differences regarding the volume of tissue retrieved and postoperative Hb in both groups (p > 0.05) (13, 14). However, some authors reported shorter operative time in open prostatectomy procedures compared to TUERP (2, 14). These findings may be due to variations in the study populations, prostate size, surgical techniques, and outcome measures used in each study. As supported by several authors (9, 10, 13, 14), we have found that TUERP has advantages over simple prostatectomy in terms of shorter postoperative catheter time and hospital stay. The current study shows the superiority of the urinary functional outcome of TUERP compared to retropubic prostatectomy. IPSS, Qmax, and patient satisfaction were better in the TUERP group within six months of surgery. However, IPSS and patient satisfaction were similar for both techniques six months after surgery. A study by Wei et al. (9) supports our findings that TUERP is better regarding functional outcomes such as IPSS and Qmax. Conversely, other authors reported no superiority for TUERP regarding postoperative urinary functional outcomes compared to simple open prostatectomy. Giulianelli et al. found no significant differences in the Qmax score, QoL score, PSA, and Post-void residual urine between both techniques (14). The smaller prostate size may explain it compared to the populations in our study. Additionally, differences in the follow-up period can contribute to differences in study results. Patients were followed up for 12 months, whereas our study followed up patients for a shorter period. There were no significant differences in Qmax between TUERP and open prostatectomy during the postoperative 1, 3, 6, 12 months, and two years when followed by Chen et al. (3). Analysis by Geavlete et al. showed no significant differences in QoL or PSA between TUERP and open prostatectomy at each follow-up time point (11). The lack of significant differences in Qmax, QoL, and PSA between TUERP and open prostatectomy at multiple follow-up time points in these studies suggests that the two procedures may have similar long-term outcomes in terms of these measures. However, the findings could be affected by patient characteristics, surgical technique, and followup period.

P-value 1.0 1.0 0.494 1.0 1.0 0.494

group, two patients developed persistent LUTS postoperatively and were treated with anticholinergics for one month. One patient was catheterized due to urine retention and needed a re-cystoscopy with resection of remnant prostatic tissue. Another patient was hospitalized due to secondary hemorrhage and received IV fluids, antibiotics, and hemostatic drugs for three days without re-catheterization or need for blood transfusion. Two patients developed urethral stenosis, which was treated by visual internal urethrotomy (VIU). In the open group, two patients needed blood transfusion postoperatively. Three patients developed persistent LUTS and were treated with anticholinergics for six weeks. Two patients were hospitalized due to secondary hemorrhage and received IV fluids, antibiotics, and hemostatic drugs for two days without re-catheterization or need for blood transfusion. At the same time, one patient developed bladder neck contracture and was treated by bladder neck incision (BNI). The study groups had no statistically significant difference (Table 8).

DISCUSSION

BPH is a prevalent condition with substantial costs, leading to increased interest in its management (7). Surgical treatments include resection, enucleation, vaporization, alternative ablative techniques (Aquablation- Prostatic artery embolization- The Rezum System), and non-ablative techniques (Prostatic urethral Lift, Intra-prostatic injections) (8). TUERP is a recently developed procedure in which the prostate is transurethrally enucleated and resected using a bipolar plasma kinetic resectoscope. Many studies suggested that TUERP is a safe and feasible treatment for BPH with few complications (9-11). Although several studies have demonstrated better clinical benefits for TUERP than other treatments, this procedure has yet to be widely accepted for prostates larger than 60 g (12). Therefore, the current study aimed to compare the safety and efficacy of transurethral enucleation resection of the prostate (TUERP) versus open retropubic prostatectomy in patients with LUTS secondary to benign prostatic hyperplasia with prostate volumes larger than 80 cc. In the current study, the TUERP group demonstrated significantly lower operative time, smaller drop in serum hemoglobin level, less resected tissue weight, smaller

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Other measures, such as operative time, blood loss, and length of hospital stay, may still favor TUERP over open prostatectomy. Therefore, the choice of procedure may depend on various factors, including patient preference and surgeon experience. Similarly, Ou et al. found no significant difference between the groups regarding IPSS and PVR at 3 and 12 months postoperatively. However, the patients in the open prostatectomy group appeared to have a better Qmax at three months, but the difference was insignificant (p = 0.081). Each group's mean postoperative PSA reductions were similar (p = 0.12) (10). In contrast, Giulianelli et al. observed significantly lower IPSS and PVR scores at 12, 24, and 36 months in the TUERP group when compared with the open prostatectomy group (p < 0.05) (14). We reported 90-day complications after TUERP in 13.3% of patients compared to 17.8% after retropubic prostatectomy with a statistically insignificant difference; urethral stricture predominated after TUERP while blood transfusion dominated in retropubic prostatectomy. Giulianelli et al. found that dysuria was the most common Grade I complication in the TUERP group (p < 0.05) and urinary urge incontinence up to 30 days in the open prostatectomy group (p < 0.05). In the Grade II complications, the results favored the TUERP group (postoperative acute urinary retention, p < 0.05 and blood transfusion requirement, p < 0.05) than the open prostatectomy group. The study favored the TUERP group (capsular perforation and reintervention, p < 0.05) over the open prostatectomy group for Grade III complications (14). Also, Gratzke et al. reported a higher incidence of blood transfusion, stress incontinence, and urethral stricture in a large series of open prostatectomies for large prostates (15). UTI and re-catheterization rates were slightly lower in a study by Tubaro et al. (16). Serretta et al. detected a higher incidence of bleeding, blood transfusions, and sepsis in open prostatectomies. Reinterventions were also higher, mainly due to bladder neck stenosis (17). Also, Wang and Wang (13) and Wei et al. (9) found that the incidence of complications in the TUERP group was statistically lower (p < 0.05). Geavlete et al. found no statistical differences between TUERP and open prostatectomy concerning transient incontinence, bladder neck contracture, or urethral stricture (11).

ty to open retropubic prostatectomy for patients with BPH and prostate volumes > 80 ml.

REFERENCES

1. Gravas, SCJN, Cornu JN, Gacci M, et al. Management of nonneurogenic male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO). European Association of Urology, 2019. (European Association of Urology. Guidelines). 2. Rao JM, Yang JR, Ren YX, et al. Plasmakinetic enucleation of the prostate versus transvesical open prostatectomy for benign prostatic hyperplasia > 80 mL: 12-month follow-up results of a randomized clinical trial. Urology. 2013; 82:176-81. 3. Chen S, Zhu L, Cai J, et al. Plasmakinetic enucleation of the prostate compared with open prostatectomy for prostates larger than 100 grams: a randomized noninferiority controlled trial with longterm results at 6 years. Eur Urol. 2014; 66:284-291. 4. Elzayat EA, Elhilali MM. Holmium laser enucleation of the prostate (HoLEP): long-term results, reoperation rate, and possible impact of the learning curve. Eur Urol. 2007; 52:1465-1472. 5. Lourenco T, Armstrong N, N’dow J, et al. Systematic review and economic modelling of effectiveness and cost utility of surgical treatments for men with benign prostatic enlargement. Health Technol Assess. 2008; 12: 1-146. 6. Millin T. The surgery of prostatic obstructions. Irish Journal of Medical Science (1926-1967). 1947; 22:185-189. 7. Miernik A, Gratzke C. Current treatment for benign prostatic hyperplasia. Deutsches Ärzteblatt International. 2020; 117:843. 8. Hwang EC, Jung JH, Borofsky M, et al. Aquablation of the prostate for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database of Systematic Reviews. 2019; 2. 9. Wei Y, Xu N, Chen SH, et al. Bipolar transurethral enucleation and resection of the prostate versus bipolar resection of the prostate for prostates larger than 60gr: a retrospective study at a single academic tertiary care center. International Braz J Urol. 2016; 42:747756. 10. Ou R, Deng X, Yang W, et al. Transurethral enucleation and resection of the prostate vs transvesical prostatectomy for prostate volumes > 80 mL: a prospective randomized study. BJU international. 2013; 112:239-245.

Limitations of the study Despite being a prospective randomized trial, the current study has some limitations. Firstly, it has a small sample size. Secondly, the follow-up period is short. Additionally, it is essential to note that the study only included patients with prostate volumes larger than 80cc, which may not represent patients with smaller prostate volumes.

11. Geavlete B, Bulai C, Ene C, et al. Bipolar vaporization, resection, and enucleation versus open prostatectomy: optimal treatment alternatives in large prostate cases. J Endourol. 2015; 29:323-331. 12. Xu P, Xu A, Chen B, et al. Bipolar transurethral enucleation and resection of the prostate: Whether it is ready to supersede TURP? Asian J Urol. 2018; 5:48-54. 13. Wang Y, Wang X. Comparison of effects of transurethral enucleation of prostate and suprapubic prostatectomy in the treatment of massive prostatic hyperplasia. Chinese Journal of Primary Medicine and Pharmacy. 2019; 2467-2470.

CONCLUSIONS

The number of patients with large prostate volumes undergoing surgical therapy is increasing, and the trend is likely to continue as the population ages. The present study found that TUERP had equivalent efficacy and safe-

14. Giulianelli R, Gentile BC, Mirabile G, et al. Bipolar plasma enucleation of the prostate vs. open prostatectomy in large benign prostatic hyperplasia: a single centre 3-year comparison. Prostate Cancer and Prostatic Dis. 2019; 22:110-116.

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15. Gratzke C, Schlenker B, Seitz M, et al. Complications and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: results of a prospective multicenter study. J Urol. 2007; 177:1419-1422.

ty and efficacy of suprapubic transvesical prostatectomy in patients with benign prostatic hyperplasia. J Urol. 2001; 166:172-176. 17. Serretta V, Morgia G, Fondacaro L, et al. Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions. Urology. 2002; 60:623-627.

16. Tubaro A, Carter S, Hind A, et al. A prospective study of the safe-

Correspondence Ibrahim Tagreda, MD itagreda@yahoo.com Mahmoud Heikal, MD mahheikal1187@gmail.com Adel Elatreisy, MD (Corresponding Author) dr_adelelatreisy@yahoo.com; adel.elatreisy@azhar.edu.eg Mohamed Fawzy Salman, MD prof_mohamed_fawzy@yahoo.com Ahmed Mohamed Soliman, MD a_soliman_1@hotmail.com Ayman Kotb Koritenah, MD dr.ayman.kotb@gmail.com Hesham Abozied, MD aboziedhesham@gmail.com Mohamed Ibrahim Algammal, MD gemykarter2020@gmail.com Ahmed A. Alrefaey, MD a7medrefa3y.ash@gmail.com Mohamed Elsalhy, MD drsalhy2020@gmail.com Mohamed Shehab, MD shehab810@gmail.com Mahmoud Mohammed Ali, MD dr_mahmoud72@hotmail.com Aly Gomaa Eid, MD alygomaa68@yahoo.com Abdrabboh Abdrabboh, MD abdo197871@yahoo.com Sayed Eleweedy, MD seleweedy2002@yahoo.com Urology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11629

DOI: 10.4081/aiua.2023.12026

ORIGINAL PAPER

Evaluation of Rezum therapy as a minimally invasive modality for management of Benign Prostatic Hyperplasia: A prospective observational study Tamer A. Abouelgreed 1, 2, Ayman K. Koritenah 1, Yasser Badran 1, Ibrahim Tagreda 1, Mohamed Algammal 1, Hesham Abozied 1, Hany A. Eldamanhory 1, Hossam A. Shouman 1, Abdelhamid A. Khattab 3, Munira Ali 4, Mohammad Thabet Alnajem 5, Ahmed A. Abdelwahed 6 1 Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt; 2 Gulf Medical University, Ajman, UAE;

3 Department of Urology, Damanhur Teaching Hospital, Albuheira Government, Egypt; 4 Department of Radiology, Thumbay University Hospital, Ajman, UAE; 5 Department of Radiology, Tawam Hospital, Alain, UAE;

6 Department of Radiology, Ain shams University, Cairo, Egypt.

INTRODUCTION

Summary

Objective: To evaluate safety and efficacy of Rezum therapy as a minimally invasive modality for management of benign prostatic hyperplasia in patients with prostate volume < 80cc and those with prostate volume > 80cc. Methods: Between June 2020 and February 2023, A total of 98 patients diagnosed with BPH and managed by Rezum were included in this study. Patients were divided based on their prostate volume of either less than 80 cc or greater than 80 cc. We evaluated several parameters related to their condition, including prostate volume, post-voiding residual (PVR) before and after surgery, number of treatments received, maximum urine flow rate (Qmax) before and after surgery and mean follow-up periods. Results: The mean age was 68 years (SD 11.2). The median prostatic volume was 62 cc (IQR 41, 17). A maximum of 9 treatments were administered. Six months was determined to be the average post-operative follow-up period (IQR: 3.5-7.2). The mean preoperative total PSA was 2.7 (IQR 1, 2), preoperative mean PVR was 79.8 cm3, preoperative mean Qmax was 8.2 ml/s (IQR 4.7-10.5), and median post-operative days until catheter removal was four days (IQR 3,1). Post-operative PVR was 24.7 cm3 (IQR 18.2, 29.4) and the mean post-operative Qmax was 18.3 ml/s (SD 6.3). Qmax levels significantly increased, by an average of 8.2 ml/s (SD 7.13) (p < 0.001). Similarly, a decrease of average PVR of 97.28 cm3 (SD 95.85) (p < 0.001) was detected, which is a substantial reduction. Between prostates less 80cc and those over 80cc, there were no appreciable differences in Qmax or PVR (p-values: 0.435 and 0.431, respectively). Conclusions: From our study, we conclude that Rezum water vapor thermal therapy, as a minimally invasive modality, is an effective and safe surgical option for management of benign prostatic hyperplasia of men with moderate to severe lower urinary tract symptoms (LUTS). This procedure has been shown to be effective in patients with varying larger prostate volumes.

Benign prostatic hyperplasia (BPH) is a disease of high prevalence and its natural history shows that 25% of men are affected by bothersome lower urinary tract symptoms (LUTS) caused by bladder outflow obstruction during their lifetime (1, 2). There are many devised treatment options to treat BPH. Initial medical therapy may be effective for mild to moderate symptoms. Patients with moderate or severe symptoms may still require surgical intervention in presence of objective measurements that indicate greater obstruction. In the past, transurethral resection of the prostate (TURP) was considered the gold standard procedure for BPH treatment. TURP was associated with high rates of morbidity, including bleeding, sexual dysfunction, stress incontinence, urethral strictures, and longer length of stay (3, 4). Recently, many innovative surgical procedures using thermal energy steam, or prostate artery embolization or mechanical dilation with UroLift have been introduced (5, 6). The aim of all of them is to maintain a strategic distance from the complications associated with TURP whereas keeping comparable results. Rezum is recommended for men ≥ 50 year of age with BPH and prostate volumes extending from 30 cm3 to 80 cm3. Its use is suggested for the treatment of enlargement of the central zone and/or a middle lobe. In general, the prostate is ablated through convective warm water vapor, produced through radiofrequency (7, 8). This procedure has been detailed within the literature to result in a significant reduction in LUTS in patients with BPH, with high safety profile (9). Rezum has too illustrated advancement in symptoms scores compared to medical therapy (10, 11). Another recognized key advantage of Rezum treatment is the low rate of sexual affection post-operatively, which may be a watched key complication of other treatments for BPH, such as TURP (10). The aim of this study is to evaluate safety and efficacy of Rezum therapy as a minimally invasive modality for management of benign prostatic hyperplasia in patients with prostate volume < 80cc and those with prostate volume > 80cc.

KEY WORDS: Hyperplasia; Prostate; Rezum. Submitted 24 October 2023; Accepted 11 November 2023

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T.A. Abouelgreed, A.K. Koritenah, Y. Badran, et al.

MATERIALS AND METHODS

Table 1. General demographical data.

Between June 2020 and February 2023, a total of 98 patients diagnosed with BPH and managed by Rezum on the urology department of the institution of the Authors were included in this prospective observational study. All procedures performed in this study complied with institutional and/or national research council ethical standards as well as the 1964 Declaration of Helsinki and its subsequent amendments or similar ethical standards. Protocols and written informed consent for all participants were approved by the Research Ethics Committee of Thumbay University Hospital (affiliated with Gulf Medical University, REC #: 432/2020). Written informed consent was obtained from the patients for their anonymized information to be published in this article. The Rezum procedure utilizes the flow of water vapor to deliver heat to the prostate tissue in short bursts of 9 seconds. At our hospital, patients underwent Rezum therapy in the operating room under general anesthesia. Following the procedure, all patients had catheters of varying sizes inserted. The data collected included basic demographic information such as age and ethnicity, as well as preoperative and postoperative values. Additionally, we recorded the number of treatments administered, the time taken for catheter removal (TWOC), the average follow-up time, and any complications that arose. Due to non-compliance from some patients, it was not feasible to utilize standardized symptom questionnaires for assessment purposes. Furthermore, we categorized patients into two groups based on their prostate volume of either less than 80 cc or greater than 80 cc.

Mean/median 68 62 2.7 8.2 79.8 4 18.3 24.7

Age Prostate volume Preoperative PSA total Preoperative Qmax Preoperative PVR TWOC Post-Op Qmax Post-Op PVR

Qmax: peak urinary flow; PSA: prostate-specific antigen; PVR: post-void residual; TWOC: time to removal of catheter.

of 4.2 treatments into the median lobe. Six months was determined to be the average post-operative follow-up period (IQR: 3.5-7.2). The mean preoperative total PSA in our sample was 2.7 (IQR 1,2), mean preoperative PVR was 79.8 cm3, mean preoperative Qmax was 8.2 ml/s (IQR 4.7-10.5), and the median post-operative days until catheter removal was four days (IQR 3.1). Mean postoperative PVR was 24.7 cm3 (IQR 18.2, 29.4) and mean post-operative Qmax was 18.3 ml/s (SD 6.3) (Table 1). Qmax levels significantly increased, by an average of 8.2 ml/s (SD 7.13) (p < 0.001). Similarly a decrease of average PVR by 97.28 cm3 (SD 95.85) (p < 0.001) was detected, which is a substantial reduction (Table 2). Between prostates less 80cc and those over 80cc, there were no appreciable differences in Qmax or PVR (p-values: 0.435 and 0.431, respectively) (Table 3). Our study's complications included two occurrences of urinary tract infections (UTI), which were treated with oral antibiotics, and five instances of hematuria, which resolved on its own. Due to the catheter's temporary post-operative presence, several patients experienced slight discomfort. None of the patients who underwent this treatment reported any sexual difficulties. Regarding the use of post-operative med-

Statistical methods The IBM Statistical Package for the Social Sciences (SPSS) software, version 25.0 (IBM Corp., Armonk, NY), was used to enter and analyze the data. Pre- and postoperative values of parameters as PSA, Qmax, and PVR were compared. The Wilcoxon signed-rank test was applied since the change was negatively skewed and the data were paired. Statistics were judged significant at a 0.05 p-value. Additionally, we used a non- Table 2. Mean changes in Qmax and PVR. parametric Mann-Whitney U test to examine if the preoperative prostatic volume was connectMean SD Median ed to the change in Qmax and PVR. Change in Q 8.2 7.13 5.60 max

Change in PVR

RESULTS

SD/IQR 11.2 41, 17 1,2 4.7, 10.5 42.4, 115.0 3,1 6.3 18.2, 29.4

-97.28

95.58

-71.50

Percentile 25 3.42 -142.00

Percentile 75 11.90 -31.10

p-value < 0.001 < 0.001

Qmax: peak urinary flow; PVR: post-void residual.

This prospective observational study comprised 98 patients with benign prostatic hyperplasia who underwent Rezum surgery at Thumbay University Hospital (affiliated to Gulf Medical University) between June 2020 and February 2023. The mean age was 68 years (SD 11.2) (Table 1). Overall, 54.2% (51/96) of the patients had prostate gland volumes that were less than 80 cc and 45.8% (45/96) of the patients had prostate gland volumes that were more than 80 cc. The mean prostatic volume was 69 cc (SD 34.19), while the median prostatic volume was 62 cc (IQR 41,17). A maximum of 9 treatments were administered, with a mean

Table 3. Mean changes in measures of Qmax and PVR in relation to prostate volume between the studied groups. Change in Qmax Prostate volume Change in PVR Prostate volume

Mean

Median

Percentile 25

Percentile 75

p-value

<=80 >80

7.65 12.88

5.66 13.10

6.62 6.10

2.80 3.20

12.30 28.10

0.435

<=80 >80

29.3 31.2

25.8 21.7

22.2 27.6

15.8 17.8

28.4 46.7

0.431

Qmax: peak urinary flow; PVR: post-void residual.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12026

Therapy for management of Benign Prostatic Hyperplasia

ications, patients stopped using their medications within three months of the procedure.

whom were on medical treatment (30.2%). Within 90 days’ post-operatively, our patients had discontinued their previous medications, this results going in line with the single office experience of Mollengarden et al. (18). Our study focused on postoperative changes in PVR and Qmax as objective measures of improvement in postoperative outcomes. At three months follow up, we observed a significant average increase in Qmax and a significant decrease in PVR, in line with other internationally published papers (17, 19). We also looked at the relationship between preoperative prostatic volume and changes in Qmax and PVR. In our sample, there was no statistically significant relationship. This was in contrast to Garden et al., who found that men with larger (> 80cc) prostates showed more profound Qmax and PVR changes than men with smaller prostates (< 80cc) (19). Medication sideeffects can lead to patients not adhering to treatment for BPH; for example, Cindolo et al. (20), showed that adherence was 29% after one year of treatment with at least 6 months of therapy in a population based cohort study of 1,5 million men. In our experience, patients have only needed medical treatment temporarily after surgery, while no medications were needed for symptom control after 90 days from the procedure. This alone may increase the acceptance of the procedure and increase the adoption rate. In addition to reducing the need for medication and improving quality of life, Rezum is also a well-tolerated procedure (21). One of the main drawbacks of temporary catheterization after surgery is that it can take an average of 4 days to heal, and our patients have reported discomfort during this time. In our study, complications have included UTI that was managed with antibiotics only, as well as four cases of spontaneous resolving hematuria. No patients needed to be readmitted for any reason, and no patients reported sexual dysfunction up to the most recent follow-up. This is consistent with published data, as Dixon et al. found no clinically relevant changes in sex function over 2 years. McVary et al. reported a single treatment of water vapor therapy with no adverse effects on sex function over a 3-year period, which is in contrast to medical treatment that results in worsening erectile dysfunction and libido (9, 10). Lastly, the population that requires surgery for BPH includes an older group of men, many of whom may be on anti-coagulants and have multiple underlying conditions. Rezum is an excellent choice as it does not require the interruption of anticoagulants and does not require general anesthesia.

DISCUSSION

Benign prostatic obstruction (BPO) is one of the most frequently diagnosed conditions of the male genitourinary tract. Globally, BPO results in 1,2 million surgical procedures annually. The range of interventions available to treat BPH has broadened in recent years. Quality of life (QOL) and healthcare spending may be impacted in ageing men because of LUTS due to enlargement of the Prostate (LUTS) (12). Rezum presented itself as a new surgical innovation, providing satisfactory clinical results while offering a safe and low-risk side effect profile (3). Its recommended by the the American Urological Association (AUA) and the European Urological Association (EUA). In addition to the existing interventions of prudent waiting and lifestyle modifications, pharmacotherapy, and surgical management for LUTS, it has historically been difficult for patients with BPH to remain compliant with the medical treatments offered (e.g. 5-alpha reductase, phosphodiesterase, etc.). These treatments provide symptomatic relief but at the expense of side-effects that threaten compliance (3). In this study, we have highlighted the effectiveness of Rezum therapy through comparing the preoperative and post-operative outcomes in our institution among different patients with enlarged prostate including volumes greater than 80cc. Our study showed no significant difference in Qmax or PVR among prostate volumes of less than 80cc versus greater than 80cc. Historically, TURP has been the gold standard of BPH treatment. TURP provided patients with clinically meaningful improvements in LUTS. However, TURP’s major disadvantage is its complications, particularly bleeding and sexual dysfunctions (12). Rezum has several advantages over TURP. First, it improves clinical outcomes while maintaining sexual function. Second, it has minimal bleeding. Third, it can be performed without general anesthesia. This may be beneficial for some elderly patients. Fourth, it has been studied for cost-effectiveness in the USA compared to TURP long term follow-up, demonstrating that Rezum is comparable in health and cost-effectiveness (13, 14). While clinical improvement with TURP was increased, the literature has shown an overall cost reduction with Rezum due to the lower adverse effects (14, 15). Randomized control trials have also shown a reduction in symptomatic LUTS at four years with an average IPSS improvement with Rezum therapy of 47% (10). Lastly, due to COVID-19 and the benefit of reducing operative time, Rezum has proven to be a good choice with each procedure being reported to take about 17.5 minutes compared with 60-90 minutes for TURP (16). The efficacy of Rezum in the Arab population has not been extensively studied since the introduction of this novel therapy. However, in the UK it has been reported on the preoperative experience of Rezum, as described in the study of Maximilian et al. (17). Our study has demonstrated the benefit of Rezum therapy amongst the Arab population, based on improvements in Qmax, PVR, and patient symptom reporting. Our population did not have any patient with catheter dependency, 29 of

Limitations. In our study median lobe size was not sufficiently measured to adequately evaluate the effect of this measurement on outcome and response to Rezum. Our small sample size of patients with prostate size > 80cc emphasizes the need for larger, more robust prospective studies to elucidate Rezum outcomes in patients with larger prostates.

CONCLUSIONS

From our study, we conclude that Rezum water vapor thermal therapy as a minimally invasive modality is effective and safe surgical option for management of benign prostatic hyperplasia of men with moderate to severe

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12026

T.A. Abouelgreed, A.K. Koritenah, Y. Badran, et al.

LUTS. This procedure has been shown to be effective in patients with varying larger prostate volumes.

sive convective radiofrequency thermal therapy with Rezum system for treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Res Rep Urol. 2017; 9:159-68.

ACKNOWLEDGMENTS

Thanks to Prof. Dr. Hossam Hamdy, President of Gulf Medical University for his suggestion.

16. Johnston M, Shah T, Emara A, et al. Rezum water vapour ablation therapy for benign prostatic hyperplasia: Preoperative results from the United Kingdom. J Urol. 2019; 201: e1-e2.

REFERENCES

17. Johnston MJ, Noureldin M, Abdelmotagly Y, et al. Rezum water vapour therapy: promising early outcomes from the first UK series. BJU Int. 2020; 126:557-8. 10.1111/bju.15203.

1. Speakman M, Kirby R, Doyle S, Ioannou C. Burden of male lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) - focus on the UK. BJU Int. 2015; 115:508-519.

18. Mollengarden D, Goldberg K, Wong D, Roehrborn C. Convective radiofrequency water vapor thermal therapy for benign prostatic hyperplasia: a single office experience. Prostate Cancer Prostatic Dis. 2018; 21:379-85.

2. Lee SWH, Chan EMC, Lai YK. The global burden of lower urinary tract symptoms suggestive of benign prostatic hyperplasia: a systematic review and meta-analysis. Sci Rep. 2017; 7:7984.

19. Garden EB, Shukla D, Ravivarapu KT, et al. Rezum therapy for patients with large prostates (≥ 80 g): Preoperative clinical experience and postoperative outcomes. World J Urol. 2021; 39:3041-8.

3. Foster HE, Dahm P, Kohler TS, et al. Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA Guideline Amendment 2019. J Urol. 2019; 202:592-8.

20. Cindolo L, Pirozzi L, Fanizza C, et al. Drug adherence and clinical outcomes for patients under pharmacological therapy for lower urinary tract symptoms related to benign prostatic hyperplasia: population-based cohort study. Eur Urol. 2015; 68:418-25.

4. Guo RQ, Yu W, Meng YS, et al. Correlation of benign prostatic obstruction-related complications with clinical outcomes in patients after transurethral resection of the prostate. Kaohsiung J Med Sci. 2017; 33:144-51.

21. McVary KT, Holland B, Beahrs JR. Water vapor thermal therapy to alleviate catheter-dependent urinary retention secondary to benign prostatic hyperplasia. Prostate Cancer Prostatic Dis. 2020; 23:303-308.

5. Jones P, Rai BP, Nair R, Somani BK. Current status of prostate artery embolization for lower urinary tract symptoms: review of world literature. Urology. 2015; 86:676-81. 6. Jones P, Rajkumar GN, Rai BP, et al. Medium-term outcomes of urolift (minimum 12 months follow-up): evidence from a systematic review. Urology. 2016; 97:20-4.

Correspondence Tamer A. Abouelgreed, MD (Corresponding Author) dr_tamer_ali@yahoo.com; tamerali.8@azhar.edu.eg Department of Urology, Faculty of medicine, Al-Azhar University, Cairo, Egypt & Gulf medical university, Ajman, UAE

7. Green Z, Westwood J, Somani BK. What's new in rezum: a transurethral water vapour therapy for BPH. Curr Urol Rep. 2019; 20:39. 8. Mynderse LA, Hanson D, Robb RA, et al. Rezum System Water Vapor Treatment for Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia: Validation of Convective Thermal Energy Transfer and Characterization with Magnetic Resonance Imaging and 3-Dimensional Renderings. Urology. 2015; 86:122-7.

Ayman K. Koritenah, MD dr_ayman.kotb@gmail.com Yasser Badran, MD dryasserbadran@gmail.com Ibrahim Tagreda, MD itagreda@yahoo.com Mohamed Algammal, MD gemykarter2020@gmail.com Hesham Abozied, MD aboziedhesham@gmail.com Hany A. Eldamanhory, MD drhanyeldamanhory@gmail.com Hossam A. Shouman, MD drhossamshouman@gmail.com Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

9. Dixon CM, Cedano ER, Pacik D, et al. Two-year results after convective radiofrequency water vapor thermal therapy of symptomatic benign prostatic hyperplasia. Res Rep Urol. 2016; 8:207-16. 10. McVary KT, Rogers T, Roehrborn CG: Rezum water vapor thermal therapy for lower urinary tract symptoms associated with benign prostatic hyperplasia: 4-year results from randomized controlled study. Urology. 2019; 126:171-9. 11. Gupta N, Rogers T, Holland B, et al. Three-year treatment outcomes of water vapor thermal therapy compared to doxazosin, finasteride and combination drug therapy in men with benign prostatic hyperplasia: cohort data from the MTOPS trial. J Urol. 2018; 200:405-13.

Abdelhamid A. Khattab, MD abdelhamed1123ufw@gmail.com Department of Urology, Damanhur teaching hospital, Albuheira Government, Egypt

12. Aboutaleb H, Ali TA, Zaghloul A, Amin MM. Efficacy of bipolar ‘button’ plasma vaporisation of the prostate compared to green laser vaporisation for benign prostatic obstruction. Journal of Clinical Urology. 2018; 11: 350-356.

Munira Ali, MD muniraali1@gmail.com Department of Radiology, Thumbay University Hospital, Ajman, UAE

13. Arezki A, Sadri I, Couture F, et al.: Reasons to go for Rezum steam therapy: an effective and durable outpatient minimally invasive procedure. World J Urol. 2021; 39:2307-13.

Mohammad Thabet Alnajem, MD mtnajem@gmail.com Department of Radiology, Tawam Hospital, Alain, UAE

14. Ulchaker JC, Martinson MS. Cost-effectiveness analysis of six therapies for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Clinicoecon Outcomes Res. 2018; 10:29-43.

Ahmed A. Abdelwahed, MD ahmed_abdelwahed@yahoo.com Department of Radiology, Ain shams University, Cairo, Egypt

15. Darson MF, Alexander EE, Schiffman ZJ, et al. Procedural techniques and multicenter postmarket experience using minimally inva-

Conflict of interest: The authors declare no potential conflict of interest.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12026

DOI: 10.4081/aiua.2023.11868

ORIGINAL PAPER

The role of irrigation fluid in transurethral resection of the prostate outcomes and surgeon performance Federico Romantini, Daniela Biferi, Guevar Maselli, Federico Narcisi, Maurizio Ranieri, Luca Topazio Mazzini Hospital, Department of Urology, ASL Teramo, Teramo, Italy.

tion time, expressed in minutes (g/m) (2). Efficiency is defined as “the ability to produce something with a minimum amount of effort” (in this context, the best outcome for the patient vs. the minimum operating time) (3). To calculate the resection rate as an efficiency parameter, the surgeon must weight all the resected tissue chips after the operation, or wait for the histopathological findings, when usually the weight of the tissue is recorded (typically, many days later); after that, it is then necessary to calculate the ratio between the amount of resected tissue and the duration of the operation. At present there is not unanimous consensus about the starting point in time of a TURP: from the introduction of the cutting device in the urethra or from the first cut chip, and this could lead to variable results in the resection-rate recorded in different centres.

Summary

Introduction: Transurethral resection of the prostate (TURP) is the gold-standard for the treatment of benign prostate enlargement (BPE) associated with lower urinary tract symptoms (LUTS), after failure of conservative therapy. At present, only resection-rate (grams of prostate resected over time) is regarded as an efficiency parameter to evaluate the skill of the operator and to assess the outcome of the procedure. Materials and methods: Five surgeons performed TURP using a Gyrus-type bipolar system in 123 patients with BPE/LUTS who came to our observation from June 2016 to December 2019. The amount of irrigation fluid used during the procedure was registered and correlated to the operating time, resection-rate, prostate adenoma weight, post-operative bladder irrigation time, intraoperative bleeding and days of catheterization. Results: We found an inverse correlation between the amount of irrigation fluid used during TURP and the resection-rate recorded for all operators, according to Spearman's Correlation (r = -0.78, p = 0.002); a direct correlation was also found between the amount of irrigation fluid and the adenoma weight. Finally, we also found a direct correlation with intraoperative bleeding and the duration and amount of bladder irrigation during and after TURP. Conclusions: The amount of irrigation fluid used is proposed as a reliable parameter to estimate the efficiency of the endoscopic procedure as well to assess the skill of the operator and shortterm results. The observed data encourage the possibility of applying this new efficiency indicator to all endoscopic maneuvers.

MATERIALS AND METHODS

We enrolled 123 patients with BPE/LUTS who came to our observation from June 2016 to December 2019. Patients were evaluated preoperatively with medical history, symptom questionnaires (IPSS and Bother Score), digital rectal exploration, PSA assay, blood tests, serum electrolytes, complete urodynamic examination and transrectal, renal, bladder and prostate ultrasound. All patients underwent TURP. Patients with bladder stones and/or diverticula, stenosis of the urethra and patients with alterations in coagulation or platelet aggregation were excluded from our study. All patients taking antiplatelet or anticoagulant drugs discontinued therapy according to the guidelines. The procedures were performed under spinal anesthesia, in the lithotomy position, by 5 different operators. TURP was performed, in all patients, using a bipolar type resectoscope with a 27 Ch diameter liner, continuous flow, and a 'U' shaped cutting loop. The plasmakinetic device had a maximum power of 200 watts, a radiofrequency range of 320 to 450 kHz, and a voltage range of 350 to 450 volts. Once connected, the generator was programmed for a power of 160 W for shear and 80 W for hemostasis. The bipolar resectoscope used were from two different manufacturers. The main difference between the two types of resectoscopes, as far as the study is concerned, is the different caliber of the irrigation channels of the operating sheaths, which, however, although probably providing different flow rates, do not affect the final recording of the amount of fluid used during the interventions (Figure 1). The irri-

KEY WORDS: Prostate; Benign Prostatic Hyperplasia; Obstruction. Submitted 23 September 2023; Accepted 13 October 2023

INTRODUCTION

Transurethral resection of the prostate (TURP) is the goldstandard for the treatment of benign prostate enlargement (BPE) associated with lower urinary tract symptoms LUTS after failure of conservative therapy (1). The choice for the most appropriate surgical therapy depends on the size of the prostate gland and the skills of the operator. The evolution of endoscopic surgical treatments has led to the introduction of bipolar plasma-kinetic energy for trans-urethral resection. In clinical practice, the only parameter used to evaluate the efficiency of a TURP is the “resection-rate”, i.e., the ratio between the amount of prostatic tissue resected, expressed in grams, and the resec-

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11868

F. Romantini, D. Biferi, G. Maselli, F. Narcisi, M. Ranieri, L. Topazio

Table 2. intraoperative variables recorded during TURP.

Figure 1. Details of the different irrigation system of the two bipolar endoscopic resectoscopes used.

Operating time (minutes) Irrigation fluid (litres) Resection-rate (g/m)

Mean + SD 71.01 ± 31.52 16.63 ± 5.52 0.548 ± 0.18

Intraoperative variables such as operation time, volume of irrigation fluid used and resection rate are shown in Table 2, with means and their standard deviations. Figure 2 shows the inverse correlation between the amount of irrigation fluid used during TURP and the resection rate recorded for all operators, according to Spearman's correlation (r= -0.78, p = 0.002).

gation fluid used was 0.9% NaCl saline, in three-liter bags connected to a 6-mm-diameter outflow tube attached to the bipolar device. The solution was at room temperature (20°-22°) and placed at a height of 60 cm from the patient's pubic symphysis, at a continuous and constant washing rate. The drained washing fluid flowed into an aspirator (S.HO.W) equipped with a system that allows automatic digital measurement of drained fluid volumes. We measured the amount of irrigation fluid used, the amount of irrigation fluid in the aspirator at the end of the procedure, the surgical time (from insertion of the device into the urethra), and registered the operator. The amount of prostate tissue excised was weighed with a scale at the end of resection; a Dufour 20Ch catheter was placed in all patients, with continuous and constant irrigation with 9% NaCl saline. Once clear urine was obtained, bladder irrigation was stopped. In the postoperative period, we evaluated the difference in hemoglobin levels (preoperative vs postoperative), duration of bladder irrigation, and catheter dwell times.

Figure 2. Inverse correlation between the amount of fluid used and resection-rate according to Spearman's Correlation; (r = - 0.78, p = 0.002).

Statistical analysis All collected data was evaluated as mean (M) ± standard deviation (SD). The correlation between the parameters was calculated using Spearman's correlation coefficient. Values of p < 0.05 were considered statistically significant.

Figure 3 shows Spearman correlation between the amount of irrigation fluid (in liters) and adenoma weight (in grams), stratified by operator. The results for the cumulative data is statistically significant (p = 0.005) (r = 0.61575).

RESULTS

Figure 3. Correlation between the amount of irrigation fluid and adenoma weight, stratified by operator.

The median age of the patients was 70.13 years (SD ± 8.74), and the means and relative standard deviations of the preoperative characteristics of the study population are shown in Table 1. Table 1. Preoperative characteristics of the study population. Patients characteristics Age IPSS BS Qmax (ml|/s) Voided volume (ml)

Mean + SD 70.13 ± 8.74 17.63 ± 4.58 4.63 ± 1.03 7.66 ± 3.38 231.67 ± 101.09

Post-void Residual Volume (PVR) Prostate adenoma (g) Prostate volume (g)

98.03 ± 113.22 38.96 ± 13.56 52.20 ± 16.81

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11868

Measuring irrigation fluids used during TURP

DISCUSSION

Figure 4 shows a direct, statistically significant correlation (p = 0.004) between the amount of irrigation fluid used and the duration of bladder irrigation after TURP (r = 0.2498).

The main purpose of this study was to propose monitoring the amount of irrigation fluid used during a TURP procedure as a new parameter of resection efficiency. The efficacy and safety of TURP are often discussed in current literature, but there is a lack of quantitatively relevant data on efficiency (4). In clinical practice, resection-rate is described as the only parameter that can evaluate the efficiency of a trans-urethral prostate resection and is often used to compare the skills of different operators or as a benchmark parameter when new techniques or instrument are to be tested. The average resection-rate value during bipolar TURP reported in the literature is 0.65 (5). Our experience shows an average of 0.55 ± 0.18. Higher resection-rate values correspond to a more efficient resection, in terms of time and, most importantly, intraoperative bleeding. The cornerstone of all endoscopic procedures is vision, and an efficient and safe TURP requires a clear, blood-free surgical field; the medium through which we look is water, or rather different irrigation fluids containing H2O. During TURP, bleeding hampers the procedure and forces the surgeon to use more irrigation fluid, both because resection is slowed and because the operator will increase flow to allow better vision, having to drain more blood from the visual field (6). It is reported in the literature how this type of issue is particularly important during resections with a monopolar instrument, and is less pronounced during resections with a bipolar instrument (6). Poorly controlled bleeding not only makes the procedure take longer, but also makes it less accurate, and ultimately, less efficient. Our data show a direct correlation between the amount of irrigation fluid used and intraoperative bleeding, which can be quantified as grams of hemoglobin lost during the procedure (difference between pre- and post-operative values). The correlation was statistically significant. Longer operative times are not only related to short-term complications, such as TUR syndrome, clot retention, and the need for blood transfusions (7, 8); longer operative time has also been linked to longterm complications, particularly urethral strictures (9). We hypothesized that the amount of irrigation fluid used during bipolar TURP could be a valid parameter for estimating the efficiency of resection and predicting the likelihood of short- and long-term complications. Indeed, our data show a statistically significant inverse correlation between the resection rate and the amount of irrigation fluid; the correspondence was observed in all operators. A statistically significant direct correlation was observed between the amount of fluid used during surgery and the duration of postoperative bladder irrigation, which in turn is directly dependent on postoperative period hematuria. A smaller amount of irrigation fluid used during TURP could be a direct indicator of the likelihood of less hematuria in the postoperative period and the possibility of using slow-flow bladder irrigation after surgery to control bleeding. An inverse correlation was found between irrigation fluid and duration of catheterization after TURP; this could allow more accurate prediction of early patient mobilization and shorter hospital stay. Follow-up at 40 days showed significant improvement in symptom scores and uroflowmetric parameters, regardless of resection efficiency estimated by resection rate and amount of irriga-

Figure 4. Correlation between the amount of irrigation fluid used and the duration of bladder irrigation after TURP, with r: 0.2498 and p = 0.004.

A change in hemoglobin concentration was observed within 48 hours after surgery (p < 0.0001), which was statistically significant, although this was clinically irrelevant in most patients, with no signs or symptoms of severe anemia. The postoperative blood transfusion rate was 0.81%. A direct link was observed between change in hemoglobin concentration and resected tissue weight (p < 0.0001) as well as the amount of irrigation fluid used (Figure 5). Only one patient was given a blood transfusion on the third postoperative day for anemia. The mean preoperative hemoglobin was 12.4 g/dl and the mean postoperative hemoglobin was 11.5 g/dl. The mean hemoglobin loss was 0.9 g/dl. This result proved not to be clinically relevant. Figure 5. Direct correlation between intraoperative blood loss (difference in pre and post operative hemoglobin concentration) and amount of irrigation fluid used.

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F. Romantini, D. Biferi, G. Maselli, F. Narcisi, M. Ranieri, L. Topazio

tion fluid. Aa mid- and long-term evaluation of patients at 6 and 12 months is needed to better understand the correlation between TURP efficiency (expressed by resection rate and irrigation fluid used) and surgery outcomes expressed in IPSS questionnaire score.

2. Cury J, Coelho RF, Bruschini H, Srougi M. Is the ability to perform transurethral resection of the prostate influenced by the surgeon’s previous experience? Clinics. 2008; 63:315-20. 3. The Oxford English Dictionary, Oxford University Press, 2019. 4. Skolarikos A, Rassweiler J, de la Rosette JJ, et al. Safety and Efficacy of Bipolar Versus Monopolar Transurethral Resection of the Prostate in Patients with Large Prostates or Severe Lower Urinary Tract Symptoms: Post Hoc Analysis of a European Multicenter Randomized Controlled Trial. J Urol. 2016; 195:677-84.

CONCLUSIONS

The present study shows that less irrigation fluid used during transurethral prostatic resection correlates significantly with less intra- and postoperative bleeding. Thus, a lower amount of fluid used correlates with a better visual field during surgery, which translates into better operating conditions for the operator. Postoperatively, this correlation is reflected in shorter catheterization time and hospital stay. The amount of irrigation fluid used is proposed as a reliable parameter for estimating the efficiency of the endoscopic procedure and the skill of the operator; its application may be particularly useful in the evaluation of physicians-in-training, measuring over time any improvement in the operational efficiency of surgeons in their professional training. Monitoring and measurement of irrigation fluids could also be used as predictive parameters of the clinical situation in the immediate postoperative period.

5. Kallstrom R, Hjertberg H, Kjolhede H, et al. Use of a virtual reality,real-time, simulation model for the training of urologists in transurethral resection of the prostate. Scand J Urol Nephrol. 2005; 39:313-20. 6. Huang X, Wang L, Wang XH, et al. Bipolar transurethral resection of the prostate causes deeper coagulation depth and less bleeding than monopolar transurethral prostatectomy. Urology. 2012; 80:1116-1120. 7. Mamoulakis C, Ubbink DT, de la Rosette JJ. Bipolar versus monopolar transurethral resection of the prostate: a systematic review and meta-analysis of randomized controlled trials. Eur Urol. 2009; 56:798-809. 8. Huang X, Wang XH, Wang HP, et al. Comparison of the microvessel diameter of hyperplastic prostate and the coagulation depth achieved with mono- and bipolar transurethral resection of the prostate. A pilot study on hemostatic capability. Scand J Urol Nephrol. 2008; 42:265-268.

REFERENCES

9. Tan GH, Shah SA, Ali NM, et al. Urethral strictures after bipolar transurethral resection of prostate may be linked to slow resection rate. Investig Clin Urol. 2017; 58:186-191.

1. EAU Guidelines. Edn. presented at the EAU Annual Congress Amsterdam 2022. ISBN 978-94-92671-16-5.

Correspondence Romantini Federico, MD (Corresponding author) federomantini@gmail.com Biferi Daniela, MD daniela.biferi@aslteramo.it Maselli Guevar, MD gue.maselli@gmail.com Narcisi Federico, MD federico.narcisi@aslteramo.it Ranieri Maurizio, MD maurizio.ranieri@aslteramo.it Topazio Luca, MD luca.topazio@aslteramo.it Mazzini Hospital, Department of Urology, ASL Teramo; Teramo, Italy Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11868

DOI: 10.4081/aiua.2023.12102

ORIGINAL PAPER

Effect of preoperative ureteral stenting on the surgical outcomes of patients with 1-2 cm renal stones managed by retrograde intrarenal surgery using a ureteral access sheath Tamer A. Abouelgreed 1, 2, Mohamed A. Elhelaly 1, El-Sayed I. El-Agamy 1, Rasha Ahmed 1, Yasser M. Haggag 3, M. Abdelwadood 4, Salma F. Abdelkader 5, Sameh S. Ali 6, Naglaa M. Aboelsoud 7, Mosab F. Alassal 8, Gehad A. Bashir 9, Tarek Gharib 10 1 Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt; 2 Gulf medical university, Ajman;

3 Department of Urology, Faculty of Medicine, Al-Azhar University, Asyut., Egypt;

4 Department of Urology, Faculty of Medicine, Ain Shams University, Cairo, Egypt;

5 Department of Radiology, Faculty of Medicine Ain Shams University, Cairo, Egypt; 6 Department of Radiology, Sheikh Khalifa general Hospital, UAQ, UAE;

7 Department of Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt; 8 Department of Vascular Surgery, Saudi German Hospital, Ajman, UAE;

9 Department of Urology, Sheikh Khalifa Medical City, Abu Dhabi, UAE;

10 Department of Urology, Faculty of medicine, Benha University, Benha, Egypt.

INTRODUCTION

Summary

Objective: To assess the surgical results of patients who underwent retrograde intrarenal surgery (RIRS) using a ureteral access sheath (UAS) for management of renal stones sized 1-2 cm compared between patients who did and did not undergo preoperative ureteral stenting. Materials and methods: This prospective study included 83 patients (aged ≥ 20 years) who underwent RIRS from July 2021 to January 2023. All patients had renal calculi (stone size: 1-2 cm) located within the pelvicalyceal system. 43 and 40 patients were allocated to the non-prestent (group A) and prestent (group B), respectively. Patient baseline characteristics, renal stone details, operative data, stone-free rate (SFR) at 4 weeks and 6 months, and perioperative complications were compared between groups. Results: The baseline characteristics of all patients were comparable across the groups. Four weeks after surgery, the overall stone-free rate (SFR) stood at 62.65%. In the non-prestent and prestent groups, the SFRs were 58.12% and 67.5%, respectively (p = 0.89). By the sixth month post-surgery, the overall SFR rose to 80.72%. In the non-prestent and prestent groups, the SFRs were 76.74% and 85%, respectively (p = 0.081). No notable differences emerged in other variables, including perioperative complications, between the two groups. Conclusions: The SFR showed no significant difference between the prestenting and non-prestenting groups at the 4-week and 6-month postoperative marks. Additionally, there were no substantial differences in complications during surgery and recovery between the groups. Notably, the SFR increased from 4 weeks to 6 months without any additional procedures in either group.

Using a ureteral access sheath (UAS) in retrograde intrarenal surgery (RIRS) offers several advantages. These include a reduction in operative time, simplified entry and reentry into the ureter, facilitation of active extraction of stone fragments, lower intrapelvic pressure during the procedure, and the elimination of the need for periodic bladder emptying (1, 2). The UAS enables repeated access to the renal pelvis without causing trauma to the ureter, enhances visibility, safeguards the ureteroscope, improves drainage, and allows swift extraction of stone fragments (3). However, it is important to note that the use of a UAS may elevate the risk of ureteral injury and is linked to increased postoperative pain after RIRS, especially when a postoperative ureteral stent is not inserted (1). Preoperative ureteric stenting is primarily employed for internal urinary drainage in patients with obstructive renal stones, hydronephrosis, urinary tract infections, and those requiring passive dilatation of the ureter. Nevertheless, the use of ureteral stents is associated with complications such as infection, encrustation, hematuria, and discomfort caused by tissue irritation. Previous studies have reported conflicting views on the impact of preoperative ureteral stenting on the stone-free rate (SFR) after ureteroscopic lithotripsy (4, 5). Consequently, the objective of this study was to examine the surgical outcomes of patients undergoing RIRS with a UAS for the management of kidney stones measuring 1-2 cm, comparing those who underwent preoperative ureteral stenting with those who did not.

KEY WORDS: Access sheath; Ureteral stenting; Renal stones.

MATERIALS AND METHODS

Submitted 16 November 2023; Accepted 28 November 2023

Between July 2021 and January 2023, we enrolled 83

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T.A. Abouelgreed, M.A. Elhelaly, El-Sayed I. El-Agamy, et al.

patients who underwent RIRS in this prospective comparative study. All procedures performed in this study complied with institutional and/or national research council ethical standards as well as the 1964 Declaration of Helsinki and its subsequent amendments or similar ethical standards. Protocols and written informed consent for all participants were approved by the Research Ethics Committee of Thumbay University Hospital (affiliated with Gulf Medical University, REC #: 487/2021). Among participants, 43 patients were assigned to the non-prestent group (Group A), while 40 patients belonged to the preoperative ureteral stenting (group B). All participants met our study's inclusion criteria, which included being 18 years or older, having renal calculi within the pelvicalyceal system, and stone sizes ranging from 1 to 2 cm. The same experienced surgeon consistently performed the procedures. Preoperative ureteral stents were placed for reasons such as the inability to pass UAS or a flexible ureterorenoscope, a history of renal or ureteral calculi operation, upper urinary tract infection, or hydronephrosis. Stone size was determined using plain kidney, ureter, bladder (KUB) radiography or non-contrastenhanced computed tomography (CT). The largest diameter of a single renal calculus or the sum of the largest diameters of multiple stones was recorded as the overall stone size. SYNAPSE 5 (Fujifilm Corporation, Tokyo, Japan) was the radiographic program employed for assessing stone size. Before initiating the RIRS procedure, antibiotic prophylaxis, typically third-generation cephalosporins or fluoroquinolones for patients with penicillin allergy was administered intravenously. Patients were positioned in the lithotomy position. Following cystoscopy, a Sensor™ PTFE-Nitinol Guidewire with Hydrophilic Tip (Boston Scientific Corporation, Marlborough, MA, USA) was passed through the ureter toward the renal pelvis to serve as a safety guidewire. Under fluoroscopy, a dual-lumen catheter was inserted into the ureter using the guidewire as a guide. An Amplatz Super Stiff® Guidewire (Boston Scientific) was then introduced into the ureter via the second lumen of the dual-lumen catheter. The dual-lumen catheter was subsequently removed, leaving the Sensor™ PTFE-Nitinol Guidewire and the Super Stiff® Guidewire in the ureter. A UAS (11/13 French size (Fr) or 12/14 Fr) was placed over the Amplatz Super Stiff® Guidewire and advanced through the ureter up to the proximal ureter to facilitate kidney access. The Amplatz Super Stiff® Guidewire was then removed. Flexible ureteroscopy (fURS) with a holmium: yttrium-aluminum-garnet (Ho: YAG) laser lithotripsy device featuring a 272-μm laser fiber was employed to fragment the stone(s). The choice of laser lithotripsy technique (fragment and basketing, dusting, or popcorn) depended on the stone's appearance. Dusting or popcorn was used for soft stones, while fragment and basketing were employed for hard stones. A 1.9 Fr tipless stone basket was used to extract as many residual stone fragments as possible. The final step involved removing the UAS and carefully inspecting the ureter for potential injuries as the fURS was withdrawn. In the majority of cases, a ureteral stent (6 or 7 Fr) was left indwelling after successful RIRS. Plain KUB radiography was the primary imaging modality post-procedure, although non-contrast-enhanced CT-KUB was conducted

in cases involving non-opaque or semi-opaque stones. Stone-free rates (SFRs) were assessed at 4 weeks and 6 months post-RIRS, representing early and late follow-ups, respectively. Stone-free was defined as the absence of stone fragments or the presence of fragments less than 2 mm in diameter. Complications were classified as intraoperative or postoperativePostoperative complications, as observed in this study, included fever (defined as a febrile state with hemoculture showing no growth) and urosepsis (defined as hemoculture showing positive growth for a bacterial organism). Bleeding requiring blood transfusion was not observed in any patient. Statistical analysis was conducted using PASW Statistics 18.0.0 software (SPSS, Inc., Chicago, IL, USA). Categorical data were compared using the chi-square test or Fisher’s exact test, with results presented as numbers and percentages. For normally distributed data, the unpaired ttest was employed, while the Mann-Whitney U test was used for non-normally distributed data. Mean plus/minus standard deviation and median and range were used to present normally and non-normally distributed data, respectively. A p-value less than 0.05 was considered statistically significant for all tests.

RESULTS

Patients included in the prestenting group underwent preoperative stenting for various reasons: 32.5% due to the inability to pass UAS or flexible ureterorenoscope, 22.5% following a previous operation for renal calculi, 20% following a previous operation for ureteral calculi, 15% due to upper urinary tract infection, 2.5% for flank pain, 2.5% for hydronephrosis, and 5% for an unrecorded reason. Among the 80 patients in the prestenting group, the median duration of preoperative ureteral stenting was 42 days (range: 7-76). Patient demographic, clinical and renal stone characteristics were compared between the non-prestent and prestent groups, as shown in Table 1. No significant differences were observed in any of the variables described in Table 1 between the nonprestent and prestent groups. The median stone size in the non-prestent group and prestent group was 14.2 mm and 14.1 mm, respectively (p = 0.878). The incidence of calyceal stones in the lower pole was 44.2% in the nonprestent group and 55% in the prestent group (p = 0.163). Post-operative imaging consisted of plain x-rays for 98% of cases. Pre-operative imaging included 48% CT scans and 52% plain x-rays. Early outcomes were evaluated by Stone-Free Rate (SFR) at 4 weeks after RIRS, and late outcomes were evaluated by SFR 6 months after RIRS. Operative data, stone profiles, and clinical outcomes were compared between the non-present and present groups, as described in Table 2. The mean operative time was identical in both groups (45 min; p = 0.845). After RIRS, postoperative ureteral stent placement was performed in all included patient of this study (Table 2). The median duration of stenting before stent removal was 24 days and 19 days in the non-prestent and prestent groups, respectively (p = 0.931). Calcium stones, mostly consisting of calcium oxalate monohydrate, were the most common stone composition (34.9% in the nonprestent group vs. 47.5% in the prestent group; p =

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Table 1. Patient demographic, clinical and renal stone characteristics compared between the non-prestent (group A) and prestent (group B). Variables Age (years), mean ± SD Gender, n (%) Male Female BMI (kg/m2) Mean ± SD Comorbidities, n (%) Diabetes mellitus Hypertension Dyslipidemia Gout Coronary artery disease Preoperative eGFR, n (%) eGFR < 60 eGFR > 60 Kidney side, n (%) Right kidney Left kidney Total stone size (mm), (mean ± SD) Total stone size in lower pole Total stone size in non-lower pole Stone location, n (%) Lower pole Non-lower pole

Group A (n = 43) 53.2 ± 12.2

Group B (n = 40) 56.3 ± 12.5

18 (41.9%) 25 (58.1%) 21.3 ± 4.5

19 (47.5%) 21 (52.5%) 24.1 ± 5.3

12 (27.9%) 25 (58.1%) 16 (37.2%) 1 (2.3%) 4 (9.3%)

9 (22.5%) 20 (50%) 16 (40%) 2 (5.0%) 1 (2.5%)

9 (20.9%) 34 (79.1%)

11 (27.5%) 29 (72.5%)

19 (44.2%) 24 (55.8%) 14.2 ± 3.1 13.9 ± 3.3 14.4 ± 3.1

15 (37.5%) 25 (62.5%) 14.1 ± 3.5 13.8 ± 3.4 14.5 ± 3.9

19 (44.2%) 24 (55.8%)

22(55%) 18 (45%)

Table 3. Intraoperative and postoperative complications compared between the non-prestent (group A) and prestent (group B). Complications

p-value

Intraoperative complications Overall intraoperative complication Ureteric injury grade I Ureteric injury grade II Ureteric injury grade III Postoperative complications Overall postoperative complication Clavien-Dindo Classification Grade 1 Clavien-Dindo Classification Grade 3 A

0.116 0.565

0.116 0.536 0.466 0.969 0.718 0.689 0.427

Operative time (minutes) Median (range) Ureteral access sheath size (Fr) 11/13 12/14 Postoperative stent (Fr) 6 Fr 7 Fr Length of hospital stay (days), median (range) Duration of postoperative stenting (days), median (range) Major stone composition Calcium oxalate monohydrate Calcium oxalate dihydrate Calcium phosphate Non-calcium Stone-free rate at 4 weeks SFR of lower pole stone SFR of non-lower pole stone Stone-free rate at 6 months SFR of lower pole stone SFR of non-lower pole stone Increase in SFR from 4 weeks to 6 months

Group B (n = 40) 45 (12–122) (n = 36)

29 (67.4%) 15 (34.9%)

8 (22.2%) 28 (77.8%)

38 (88.37%) 5 (11.63%) 1 (1–16) 24 (5–47)

32 (80%) 8 (20%) 1 (1–17) 19 (9–160)

15 (34.9%) 8 (18.6%) 16 (37.2%) 4 (9.3%) 25 (58.12%) 11 (25.6%) 14 (32.6%) 33 (76.74%) 15 (34.88%) 18 (41.86%) 19.6%

19 (47.5%) 5 (12.5%) 10 (25%) 6 (15%) 27 (67.5%) 12 (30%) 15 (37.5 %) 34 (85%) 16 (40%) 18 (45%) 17.1%

p-value

7 (16.3%) 5 (11.6%) 3 (6.9%) 1 (2.3%)

3 (7.5%) 1 (2.5%) 1 (2.5%) 1 (2.5%)

0.061 0.052 0.724 1

13 (30.2%) 12 (27.9%) 1 (2.3%)

7 (17.5%) 6 (15%) 1 (2.5%)

0.071 0.037 0.678

0.219). There was a significant difference in UAS size between the groups (77.8% of the prestented group used 12/14 Fr, while 67.4% of the non-prestented group used 11/13 Fr; p < 0.001). The SFRs at 4 weeks after RIRS were 58.12% in the non-prestent group and 67.5% in the prestent group (p = 0.089). At 6 months after RIRS, the SFRs in the non-prestent and prestent groups were 76.74% and 85%, respectively (p = 0.081). Although the SFRs in the prestent group were notably higher than those in the non-prestent group at both follow-up time points, these differences did not reach statistical significance. The SFR increased by 18.62% in the non-prestent group and 17.5% in the prestent group from the 4-week follow-up to the 6-month follow-up. Intraoperative and postoperative complications were compared between the non-prestent and prestent groups (Table 3). Intraoperative complications occurred in 12.5% of the 83 patients included in the study, defined as ureteral wall injury graded according to the endoscopic classification proposed by Traxer et al. (6) (please see Appendix). The rate of ureteral injury was non-significantly lower in the prestent group (7.5%) than in the non-prestent group (20.8%) (p = 0.063), and most injuries in both groups were grade I. Postoperative complications, including fever and urosepsis, showed no significant differences between the groups. At the 6-month follow-up, no ureteric stricture or new incidences of hydronephrosis or hydroureter were detected in any study patient.

0.307 0.878 0.868 0.836 0.163

Table 2. Operative data, stone profiles, and clinical outcomes compared between the non-prestent (group A) and prestent (group B). Group A (n = 43) 45 (18–102) (n = 43)

Group B (n = 40)

A p-value < 0.05 indicates statistical significance.

A p-value < 0.05 indicates statistical significance. SD, standard deviation; BMI, body mass index; eGFR, estimated glomerular filtration rate.

Variables

Group A (n = 43)

p-value 0.845 < 0.001

0.089

0.758 0.931 0.219

DISCUSSION

RIRS stands as a widely employed treatment for renal calculi due to several factors. Reported Stone-Free Rates (SFRs) for RIRS are noted to be comparable to those achieved through percutaneous nephrolithotomy (PCNL) and surpass those of extracorporeal shockwave lithotripsy (ESWL) for patients with small to medium-sized stones. RIRS is characterized as less invasive with lower morbidity when compared to PCNL, which is commonly preferred for larger stones carrying a higher risk of major complications (7, 8). While various studies on URS have reported SFRs for renal and ureteral calculi (8-10), specific data regarding the impact of preoperative ureteral stenting on SFR, particularly in renal stone sizes of 1-2

0.089 0.881 0.741 0.081 0.326 0.398 0.477

A p-value < 0.05 indicates statistical significance. Fr, French size; SFR, stone-free rate.

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cm, remains limited (4, 11-15). Jones et al. (11, 16) were the pioneers in reporting that the insertion of a ureteral stent, following the failure of initial URS, significantly improved the success rate of calculus extraction during the second URS. Subsequent studies aimed to validate these findings, and although most reported similar results, the majority focused on SFRs for ureteral stones or small renal stones (4, 11, 13-15). The influence of preoperative ureteral stenting on SFR in large renal stones (diameter: 1-2 cm) after RIRS procedures has not been addressed in existing literature. No significant differences were found for any evaluated patient and renal stone characteristics listed in Table 1. Prior studies have identified stone size and location as the most significant predictors of SFR after RIRS (17, 18). As indicated in Table 2, the UAS size used in the prestent group was significantly larger than that in the non-prestent group (p < 0.001), aligning with findings reported by Hyeong et al. (5). This could result from passive ureteral dilation from preoperative ureteral stenting (5). Despite the improved accessibility afforded by a larger UAS size, there was no significant difference in SFRs between the groups. Our preference for using UAS size 11/13 Fr stems from its lack of impact on SFRs or complications. Additionally, reports suggest that intrarenal pressure during RIRS does not significantly differ between 11/13 Fr and 12/14 Fr UAS (19). The primary benefit of a larger UAS size lies in increased irrigation fluid flow during the procedure (19). Moreover, the ureteral injury rates did not significantly differ when using a larger-sized UAS (20). SFRs reported in the literature vary widely (54-96%) for renal stones sized 1-2 cm after a single session of RIRS (18). This variability may be attributed to differences in the definition of 'stone-free' and variations in the imaging methods used during follow-up. Previous studies considered a residual stone size of 4 mm (21) and 2 mm (22) as clinically significant. Imaging modalities for stone detection include plain radiography, ultrasound, and CT scans, each possessing different sensitivity and specificity (23). While CT scans offer higher sensitivity and specificity, the increased radiation exposure to the patient favors the use of plain radiography or ultrasound. In this study, the overall SFR at 4 weeks and 6 months of follow-up was 67.5% and 85% in the prestent group, and 58.12% and 76.74% in the nonprestent group, respectively, representing a 12.5-18.62% increase in SFR after a more extended follow-up period. Our study defines SFR as ≤ 2 mm of residual stone size, lower than sizes reported in other studies (11, 12). While studies by Hyeong et al. (5) and Sung et al. (25) found no significant association between preoperative ureteral stenting and stone clearance, studies by Netsch et al. (11) and Kawahara et al. (12) reported improved SFRs after RIRS with preoperative ureteral stenting. These discrepancies may stem from differences in knowledge, technology, and instruments available at the time of these studies. In our study, SFRs at 4 weeks after RIRS were not significantly different between the non-prestent and prestent groups (62.65% vs. 67.5%, respectively; p = 0.089). Similarly, SFRs at 6 months after surgery showed no significant differences between the non-prestent and prestent groups (76.74% vs. 85%, respectively; p = 0.081). This finding aligns with Bal et al. (26), who

reported that preoperative ureteral stenting before RIRS may not significantly impact the one-month postoperative SFR. Notably, we observed that the SFR in both groups improved with a longer duration of follow-up, requiring no additional procedure. Specifically, the SFR increased by 18.62% in the non-prestent group and 12.5% in the prestent group from the 4-week follow-up to the 6-month follow-up. There were no significant differences in overall intraoperative or postoperative complications between the prestent and non-prestent groups (p = 0.061 and p = 0.0710, respectively), consistent with previous studies (11-13). Most cases of ureteral injury in this study were grade I injuries. Although the incidence of ureteral injury resulting from UAS insertion was lower in the prestent group (7.5%) than in the non-prestent group (16.3%), no significant difference was observed between the groups. It's worth noting that a larger UAS size could be used in the pre-stented group (12/14 Fr) than in the non-prestented group (11/13 Fr). Traxer et al. (6) reported that the incidence of ureteral injury grade III could be decreased by prestenting, but our study lacked sufficient cases of grade III injury to support this assertion.

CONCLUSIONS

The findings from this research indicate that there was no notable disparity in the Stone-Free Rate (SFR) between the group with preoperative ureteral stenting and the group without it, both at the 4-week and 6-month postoperative assessments. Moreover, there was no significant contrast in complications observed during both the surgery and the recovery phase between these two groups. Additionally, it is noteworthy that the SFR showed an increase at the 6-month mark compared to the 4-week assessment in both groups, and this improvement occurred without any supplementary procedures.

ACKNOWLEDGMENTS

Thanks to Prof. Dr. Hossam Hamdy, President of Gulf Medical University for his suggestion.

REFERENCES

1. De Coninck V, et al. Systematic review of ureteral access sheaths: facts and myths. BJU Int. 2018; 122:959-969. 2. Kaplan AG, et al. Use of ureteral access sheaths in ureteroscopy. Nat Rev Urol. 2016; 13:135-140. 3. Basem A. Fathi, Ahmed A. Elgammal, Tamer A. Abouelgreed, et al. The outcomes of flexible ureteroscopy for renal calculi of 2 cm or more with and without the use of ureteral access sheath: A retrospective study. Arch Ital Urol Androl. 2023; 95:1 https://doi.org/ 10.4081/aiua.2023.11524 4. Lumma PP, et al. Impact of ureteral stenting prior to ureterorenoscopy on stone-free rates and complications, World J Urol. 2013; 31:855-859. 5. Yuk HD, et al. The effect of preoperative ureteral stenting in retrograde Intrarenal surgery: a multicenter, propensity score-matched study. BMC Urol. 2020; 20:147. 6. Traxer O, Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access

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sheath during retrograde intrarenal surgery. J Urol. 2013; 189:580584.

retrograde intrarenal surgery in renal stone patients: a propensity score-matched study. Transl Androl Urol. 2020; 9:276-283.

7. Pietropaolo A, et al. Endourologic management (PCNL, URS, swl) of stones in solitary kidney: a systematic review from European association of urologist’s young academic urologists and uro-technology groups. J Endourol. 2020; 34:7-17.

26. Bai P-D, et al. Effect of preoperative double-J ureteral stenting before flexible ureterorenoscopy on stone-free rates and complications. Current Med Sci. 2021; 41:140-144.

8. Chung BI, et al. Ureteroscopic versus percutaneous treatment for medium-size (1-2-cm) renal calculi, J. Endourol. 2008; 22:343-346. 9. Ghani KR, Wolf JS Jr. What is the stone-free rate following flexible ureteroscopy for kidney stones? Nat Rev Urol. 2015; 12:281-288. 10. Jones P, et al. Outcomes of ureteroscopy (URS) for stone disease in the paediatric population: results of over 100 URS procedures from a UK tertiary centre, World J. Urol. 2020; 38:213-218. 11. Netsch C, et al. Impact of preoperative ureteral stenting on stonefree rates of ureteroscopy for nephroureterolithiasis: a matchedpaired analysis of 286 patients, Urology. 2012; 801214-1219.

Correspondence Tamer A. Abouelgreed (Corresponding Author) dr_tamer_ali@yahoo.com; tamerali.8@azhar.edu.eg Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt & Gulf medical university, Ajman, UAE

12. Kawahara T, et al. Preoperative stenting for ureteroscopic lithotripsy for a large renal stone. Int J Urol. 2012; 19:881-885. 13. Yang Y, et al. Preoperative double-J stent placement can improve the stone-free rate for patients undergoing ureteroscopic lithotripsy: a systematic review and meta-analysis. Urolithiasis. 2018; 46:493499.

Mohamed A. Elhelaly elhelalymohammed@yahoo.com El-Sayed I. El-Agamy abuamr1978@yahoo.com Rasha Ahmed rashaahmed1511@gmail.com Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

14. Assimos D, et al. Preoperative JJ stent placement in ureteric and renal stone treatment: results from the Clinical Research Office of Endourological Society (CROES) ureteroscopy (URS) Global Study. BJU Int. 2016; 117:648-654. 15. Rubenstein RA, et al. Prestenting improves ureteroscopic stonefree rates, J. Endourol. 2007; 21:1277-1280.

Yasser M. Haggag uro_doc@yahoo.com Department of Urology, Faculty of Medicine, Al-Azhar University, Asyut., Egypt

16. Jones BJ, et al. Use of the double pigtail stent in stone retrieval following unsuccessful ureteroscopy. Br J Urol. 1990; 66:254-256. 17. Molina WR, et al. The S.T.O.N.E. Score: a new assessment tool to predict stone free rates in ureteroscopy from pre-operative radiological features. Int Braz J Urol. 2014; 40:23-29.

M. Abdelwadood wadoodaref@gmail.com Department of Urology, Faculty of Medicine, Ain Shams University, Cairo, Egypt

18. Tonyalı S, et al. Prediction of stone-free status after single-session retrograde intrarenal surgery for renal stones. Turk J Urol. 2018; 44:473-477.

Salma F. Abdelkader salmafathy4@gmail.com Department of Radiology, Faculty of Medicine Ain Shams University, Cairo, Egypt

19. Rehman J, et al. Characterization of intrapelvic pressure during ureteropyeloscopy with ureteral access sheaths. Urology. 2003; 61:713-718.

Sameh S. Ali drsamehsaied@yahoo.com Department of Radiology, Sheikh Khalifa general Hospital, UAQ, UAE

20. Tracy CR, et al. Increasing the size of ureteral access sheath during retrograde intrarenal surgery improves surgical efficiency without increasing complications. World J Urol. 2018; 36:971-978.

Naglaa M. Aboelsoud nglaa.mahmoud@gmail.com Department of Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

21. Takazawa R, Kitayama S, Tsujii T, Successful outcome of flexible ureteroscopy with holmium laser lithotripsy for renal stones 2 cm or greater. Int J Urol. 2012; 19:264-267. 22. Rippel CA, et al. Residual fragments following ureteroscopic lithotripsy: incidence and predictors on postoperative computerized tomography. J Urol. 2012; 188:2246-2251.

Mosab F. Alassal mosabalassal32@gmail.com Department of Vascular Surgery, Saudi German Hospital, Ajman, UAE

23. Jackman SV, et al. Plain abdominal x-ray versus computerized tomography screening: sensitivity for stone localization after nonenhanced spiral computerized tomography. J Urol. 2000; 164: 308310. K. Assantachai et al. Heliyon. 2023; 9:e15801 7.

Gehad A. Bashir almansosory670@gmail.com Department of Urology, Sheikh Khalifa Medical City, Abu Dhabi, UAE Tarek Gharib tarekgh78@yahoo.com Department of Urology, Faculty of medicine, Benha University, Benha, Egypt

24. Kanno T, et al. The utility of the kidneys-ureters-bladder radiograph as the sole imaging modality and its combination with ultrasonography for the detection of renal stones, Urology. 2017; 104:4044. 25. Sung LH, Cho DY, The role of preoperative ureteral stenting in

Conflict of interest: The authors declare no potential conflict of interest.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12102

DOI: 10.4081/aiua.2023.11691

ORIGINAL PAPER

Study the mRNA level of IL-27/IL-27R pathway molecules in kidney transplant rejection Aftab Karimi 1, Ramin Yaghobi 2, Jamshid Roozbeh 3, Zahra Rahimi 1, Afsoon Afshari 3, Zahra Akbarpoor 1, Mojdeh Heidari 2 1 Zarghan branch, Islamic Azad University, Zarghan, Iran;

2 Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz; Iran;

3 Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Summary

Background: Renal transplantation stands as the sole remedy for individuals afflicted with end-stage renal diseases, and safeguarding them from transplant rejection represents a vital, life-preserving endeavor posttransplantation. In this context, the impact of cytokines, notably IL-27, assumes a critical role in managing immune responses aimed at countering rejection. Consequently, this investigation endeavors to explore the precise function of IL-27 and its associated cytokines in the context of kidney transplant rejection. Methods: The study involved the acquisition of blood samples from a cohort of participants, consisting of 61 individuals who had undergone kidney transplantation (comprising 32 nonrejected patients and 29 rejected patients), and 33 healthy controls. The expression levels of specific genes were examined using SYBR Green Real-time PCR. Additionally, the evaluation encompassed the estimation of the ROC curve, the assessment of the relationship between certain blood factors, and the construction of protein-protein interaction networks for the genes under investigation. Results: Significant statistical differences in gene expression levels were observed between the rejected group and healthy controls, encompassing all the genes examined, except for TLR3 and TLR4 genes. Moreover, the analysis of the Area Under the Curve (AUC) revealed that IL-27, IL-27R, TNF-α, and TLR4 exhibited greater significance in discriminating between the two patient groups. These findings highlight the potential importance of IL-27, IL-27R, TNF-α, and TLR4 as key factors for distinguishing between individuals in the rejected group and those in the healthy control group. Conclusions: In the context of kidney rejections occurring within the specific timeframe of 2 weeks to 2 months post-transplantation, it is crucial to emphasize the significance of cytokines mRNA level, including IL-27, IL-27R, TNF-α, and TLR4, in elucidating and discerning the diverse immune system responses. The comprehensive examination of these cytokines’ mRNA level assumes considerable importance in understanding the intricate mechanisms underlying kidney rejection processes during this critical period.

KEY WORDS: IL-27; Kidney; Transplantation; Rejection. Submitted 30 August 2023; Accepted 7 September 2023

INTRODUCTION

End-stage kidney diseases (ESKD) afflict a significant number of patients, and regrettably, there is currently no avail-

able cure to restore their kidney function. As a result, kidney transplantation stands as the sole established treatment option (1). The preservation of transplanted kidneys is of paramount importance to ensure graft survival (2). Consequently, kidney transplant rejection (KTR) represents an irreparable detriment in this context. KTR is characterized by an inflammatory response accompanied by distinct pathological changes in the graft, triggered by the recognition of non-self-donor antigens present in the allograft by the recipient's immune system. Acute rejection, which can manifest within days to weeks after transplantation, can manifest in two forms: antibody-mediated rejection (ABMR) and acute T-cell-mediated rejection (TCMR). The interplay between the innate and adaptive immune systems plays a crucial role in the processes leading to transplant rejection. Nonetheless, T lymphocytes emerge as the primary cellular players in the development of rejection. Further investigations have revealed the critical involvement of numerous cytokines and costimulatory molecules in this intricate immune response (3). Numerous investigations have been conducted with the aim of comprehensively unraveling the intricate dynamics underlying transplant rejection in KTRs, particularly in relation to the assessment of pro- and/or anti-inflammatory cytokines' involvement in this process. Among these cytokines, Interleukin-27 (IL-27) assumes a position of utmost significance. IL-27 exerts its influence on both the innate and adaptive branches of the immune system through various mechanisms that contribute to distinct immune responses (4, 5). Previous studies have provided insights into the involvement of IL-27 in various transplantation contexts. Le Texier et al. proposed that transforming growth factor (TGF)β1 and IL-27 contribute to tolerance mechanisms in cardiac allograft transplantation (6). In our previous investigation, we demonstrated that IL-27 acts as an anti-inflammatory cytokine in the context of liver transplant rejection (7). Furthermore, an innovative role of IL-27 in lymphopenia-induced CD8+ T cell proliferation has been reported, suggesting that targeting B cell-derived cytokines could enhance the efficacy of lymph-ablation and improve transplant outcomes (8). Additionally, a separate study presented data indicating that IL-27 could serve as a potential immunological marker for identifying post-transplant neoplasia accurately (9).

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11691

A. Karimi, R. Yaghobi, J. Roozbeh, Z. Rahimi, A. Afshari, Z. Akbarpoor, M. Heidari

Building upon these collective findings and drawing from previous studies, the present study aims to assess the importance of IL-27 cytokine mRNA level and its associated molecules, including IL-27R (also referred to as TCCR or WSX1), interferon (IFN)-γ, tumor necrosis factor (TNF)-α and its receptors (TNFRA and B), Toll-like receptor (TLR)3, TLR4, interferon regulator factor (IRF)3, and IRF7, in the context of kidney transplant rejection without the need to estimate their protein level.

relevant information, such as history of cancer, alcohol or tobacco use, and vasculitis renal disease. Individuals with these conditions were excluded from the study, as were those who experienced multiple episodes of rejection. Additionally, no mixed rejection samples were included in the study. A routine immunosuppressive regimen was used for all patients consisted of tacrolimus or cyclosporine with mycophenolate mofetil and steroids. The blood level of 150-200 mg/mL was considered the therapeutic target for CsA (5 mg/kg/d) or for tacrolimus (8-10 mg/mL).

MATERIALS AND METHODS

Molecular analyses The buffy coat and plasma of all samples were separates using Ficol (Nycomed, Zurich, Switzerland) gradient for further analysis.

Patients This study included 61 adult kidney transplant recipients. Out of them, 32 had stable grafts, while 29 exhibited biopsy-proven rejection signs. The participants were selected from patients admitted to Abu Ali Sina Hospital's Transplant ward between 2018 and 2021, with an average of 350 kidney transplants per year. Protocol biopsies were conducted for all transplanted patients showing signs of graft rejection, with specialized pathologists using the Banff 10 classification to diagnose all rejected samples. The samples used in this study were chosen from the biopsy-proven ones, with 25% being TCMR and the remaining being ABMR. Blood samples were collected from all participants in the study, including 61 kidney transplant patients and 33 healthy controls. The healthy controls chosen were agematched normal individuals who had not experienced any infections or drug use for at least six months prior to sampling. Healthy controls were selected from hospital staff who volunteered to participate in our research. They were asked to answer related health questions, and a simple blood test was taken. The samples were treated with EDTA, and informed consent was obtained from all patients. The patients were then divided into two groups: a nonrejected group with 32 patients and a rejected group with 29 patients. The rejected samples were collected from kidney transplanted patients who referred to the hospital with graft rejection signs between 2 weeks and 2 months after transplantation. The blood samples included in the rejection group were taken before biopsy and after biopsy confirmation. All samples were selected from patients who had received their first transplant and were non-sensitized (Luminex flow PRA negative). Additionally, we have randomly selected from recipients who didn't show any signs of rejection between 2 weeks and 2 months after transplantation. The Ethics Committee of Shiraz University of Medical Sciences approved the study, and all protocols adhered to the ethical guidelines of the Declaration of Helsinki. KTR patients underwent routine HLA and ABO blood matching tests, and all transplanted kidneys were from cadaver donors. Blood samples were screened for BK polyoma virus, cytomegalovirus (CMV), hepatitis B (HBV) and C (HCV), and human immunodeficiency virus (HIV) infection. Samples that tested positive for any of these infections were excluded from the study. The study enrolled adult participants aged 18-74 years, excluding samples from younger participants. A questionnaire was created to collect demographic data and other

RNA extraction and cDNA synthesis In order to extract the total RNA of each patient sample and controls buffy coats, Trizol™ (Invitrogen, Carlsbad, CA, USA) was used according to manufacturer protocols. Furthermore, for evaluating the purity and concentration of extracted RNAs in each sample, their optimal density in 260/280 nm was calculated. 500 ng of total RNA used for cDNA synthesis by using Takara kit (Dalian, Japan) according to the manufacturer's instruction. Quantitative Real-time PCR analysis (SYBR Green) The expression level of different studied genes was analyzed using pre-designed primers (Table 1). Both GAPDH (Glyceraldehyde 3-phosphate dehydrogenase) and βactin genes were studied for internal control. Finally, Table 1. The sequences of the primer pairs used for gene amplification. Gene names and mRNA IDs IL-27 NM_145659.3 IL-27R NM_004843.4 IFN-γ NM_000619.3 TNF-α NM_001065.4 TNFARA NM_001065.4 TNFARB NM_001066.3 TLR3 NM_003265.3 TLR4 NM_003266.4 IRF3 NM_001197122.2 IRF7 NM_001572.5 GAPDH NM_001357943.2

Primer sequences (5’to 3’) Forward: GTGAACCTGTACCTCCTGCC Reverse: CGTGGTGGAGATGAAGCAGA Forward: CGGAGCTGAAGACCATACCC Reverse: CGCCCGACAAATCCTCTTCT Forward: CAGCTCTGCATCGTTTTGGG Reverse: TCCGCTACATCTGAATGACCTG Forward: CTTCTGCCTGCTGCACTTTG Reverse: CTACAGGCTTGTCACTCGGG Forward: GAGAGGCCATAGCTGTCTGG Reverse: CTCTCACACTCCCTGCAGTC Forward: CACATGCCGGCTCAGAGAAT Reverse: AGCTGGGTGTATGTGCTGTC Forward: GGGCAAGAACTCACAGGCCAGG Reverse: 5’-AAGGGCCACCCTTCGGAGCA Forward: 5’- TCAAGCCAGGATGAGGACTGGGT Reverse: 5’- CAGCAATGGCCACACCGGGA Forward: 5’- TTGGGGACTTTTCCCAGCC Reverse: 5’- TCCAGAATGTCTTCCTGGGT Forward: 5’- GTGAGGGTGTGTCTTCCCTG Reverse: 5’- TCGTCATAGAGGCTGTTGGC Forward: 5’-GGACTCATGACCACAGTCC Reverse: 5’-CCAGTAGAGGCAGGGATGAT

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11691

Length (bp)

Annealing temperature (°C)

111

114

110

128

124

144

147

118

119

IL-27/IL-27R pathway molecules in kidney transplant rejection

GAPDH selected as internal control due to its less expression fluctuations in different samples. The real-time mix for each primer pair was set up, using 10 µl of SYBR Premix Ex TaqII kit (Takara, Shiga, Japan), 0.2 µl of ROX dye (used for normalization), 0.8 µl of each forward and reverse primers (10pM) and 2 µl of synthesized cDNA. The total volume of each reaction reached to 20 µl adding sterile water. The amplification reaction was done in Step One Plus Real Time instrument (ABI, Step One Plus, USA). The cycling program used for amplification of each primer pair was 1 cycle of 95ºC/2 mins, followed by 40 cycles of annealing temperature of each gene/20 secs and 72ºC/30 secs. Previously the optimum annealing temperature of each gene was set up and used in real-time programming (for more information about the primer sequences refer to our previous report 11). At the end of each real-time, melting curves were generated by the instrument in order to verify the specificity of the amplification reaction. Finally, normalizing all data was executed using the result of GAPDH gene amplification.

Table 2. The underlying disease, and blood factors’ distribution among rejected and nonrejected patients.

PPI (protein-protein interaction) construction For more investigation around the interactions between studied genes with each other at the protein level, the Search Tool for the Retrieval of Interacting Genes (STRING, https://string-db.org/) was used in order to produce the PPI network.

women = 40.75 years). The rejected group were also composed of 29 patients consisting of 20 (69%) men (mean age of men = 42.9 years, mean age of women = 32.9 years). The most abundant blood groups in rejected group were A+ (31%) and O+ (34.5%), nonrejected group were B+ (31.3%) and O+ (37.5%), and control group were A+ (34.8%) and B+ (31.5%). The underlying disease distribution is also categorized in Table 2. Some important blood factors that are listed in this table, were considered in both studied groups of patients. Statistical analysis between the two patients’ groups shows the significant difference for all parameters.

Underlying diseases

Blood factors (mean; mg/DLit)

Study groups number (%) Rejected Nonrejected 9 (31) 7 (21.9) 3 (10.3) 3 (9.4) 3 (10.3) 7 (21.9) 14 (48.4) 15 (46.8) 60.52 36.65 4.08 1.24 110 94.08 8.4 8.29 134.84 136.82 5.2 4.6

HTN DM ADPKD Others BUN Cr FBS Serum Ca Serum Na Serum K

p value < 0.01 < 0.01 0.015 0.031 0.015 0.02

Autosomal dominant polycystic kidney disease (ADPKD), Hypertension (HTN), Diabetes mellitus (DM), Blood Urea Nitrogen (BUN), Creatinine (Cr), fasting blood sugar (FBS), serum calcium (Serum Ca), serum sodium (Serum Na) and serum potassium (Serum K).

Statistical analysis All data was collected in EPSPS ver. 22 (SPSS, Chicago, IL, USA). In order to calculate the mRNA expression level of studied genes, Livak (2-ΔΔCt) method was used. To analyze the variation in the gene expression levels in studied groups of patients, nonparametric tests were performed. Furthermore, Table 3. two-sided Spearman correlation The AUC, p value, cut-off value, sensitivity and specificity of the studied genes analysis was performed to estimate are estimated and categorized. the variables’ relationship (GraphPad Software, Prism 6.01, CA, USA). The Gene Name Gene ID AUC p value Cut off value Sensitivity Specificity receiver operating characteristic (ROC) (95% CI) (95% CI) (95% CI) curve analysis, sensitivity, and speciIL-27 246778 0.870 < 0.001 > 115.36 75.86 90.62 ficity of studied genes were deter(0.759-0.942) (56.5-89.7) (75.0-98.0) mined using MedCalc (MedCalc IL-27R (WSX-1) 9466 0.765 < 0.001 > 10.7 68.97 87.50 Software, Ostend, Belgium) Statistical (0.639-0.864) (49.2-84.7) 71.0-96.5 Software version 17.9. Finally, p < IFN-γ 3458 0.522 0.771 > 2.25 93.10 28.12 0.05 was considered as statistically (0.390-0.652) (77.2-99.2) (13.7-46.7) significant. TNF-α

7124

RESULTS

TNFR1

7132

Patients' demographic details In this study, 61 kidney transplanted patients participated which were divided into two groups. These transplanted patients were composed of 41 (67%) men (mean age = 44.8 years) and 20 (33%) women (mean age = 36.7 years). The nonrejected group were composed of 32 patients and 21 (65.5%) of them were men (mean age of men = 45.7 years, mean age of

TNFR2

71323

IRF3

3661

IRF7

3665

TLR3

7098

TLR4

7099

0.818 (0.698-0.905) 0.516 (0.384-0.646) 0.581 (0.448-0.706) 0.583 (0.432-0.691) 0.629 (0.496-0.749) 0.650 (0.494-0.748) 0.704 (0.573-0.814)

< 0.001

> 630.35

0.836

≤ 75.58

0.277

> 2.38

0.268

0.077

≤ 11.55

0.037

≤ 1.27

0.004

> 0.23

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11691

48.28 (29.4-67.5) 79.31 (60.3-92.0) 86.21 (68.3-96.1) 96.55 (82.2-99.9) 86.21 (68.3-96.1) 58.62 (38.9-76.5) 86.21 (68.3-96.1)

100.00 (89.1-100.0) 34.38 (18.6-53.2) 34.38 (18.6-53.2) 25.00 (11.5-43.4) 40.63 (23.7-59.4) 68.75 (50.0-83.9) 59.38 (40.6-76.3)

A. Karimi, R. Yaghobi, J. Roozbeh, Z. Rahimi, A. Afshari, Z. Akbarpoor, M. Heidari

Figure 1. The expression level of the studied genes compared between nonrejected and rejected, and control groups; The comparison is done by evaluating the fold change of gene through livak method (2-ΔΔCt).

compared among patients’ groups and healthy controls. This comparison is summarized in Figure 1 and statistical analysis showed that the difference in the expression level of genes between rejected group of patients and healthy control was statistically significant (p < 0.0001) in all studied genes except for TLR3 and TLR4 genes. The same comparison between nonrejected and healthy control group showed that in all genes this statistical comparison showed significant difference. Also, it is worth mention-

Gene expression compared in nonrejected and rejected KTR The mRNA expression level of all the studied genes were

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11691

IL-27/IL-27R pathway molecules in kidney transplant rejection

Figure 2. The ROC curve analysis of the studied genes; the results of ROC curve analysis demonstrate that IL-27, IL-27R, TNF-α and, TLR4 seems to be important candidates for discriminating nonrejected from rejected KTRs.

ing that the statistical analysis between rejected and nonrejected groups showed significant difference in expression level of some of the studied genes (IL-27, IL-27R, TNF-α and TLR4). Finally, the expression level of TNFR1 and TLR3 was higher in nonrejected group versus the other two groups and the expression level of IRF3 in both of the patient groups was less than control group.

Correlation study of selected genes in rejected KTRs Studying the relation between the increased cytokines in rejected KTRs, in Figure 3 it is showed that only IL-27R with TNF-α (r = 0.4574; p = 0.0126) and TLR4 (r = 0.5730; p = 0.0012) had significant positive correlation. Correlation between blood factors and studied genes in rejected KTRs The relationship between studied lab indices with all the studied genes were analyzed. The analysis that was performed for finding the relation between studied gene expression levels and the blood factors in rejected KTRs showed that the expression level of IL-27R negatively and IFN-γ and TNFR2 positively correlate with serum Ca. As well, both TNFR2 and IRF7 positively correlate with serum Na and K, respectively in rejected KTRs (the figures are not shown).

ROC curve analysis of expression level of genes between nonrejected and rejected KTRs In order to evaluate the sensitivity and specificity of different studied genes between nonrejected and rejected groups of patients, ROC curve analysis used. The mentioned data is summarized in Figure 2 and Table 3. Also, the area under the ROC curve (AUC) for measuring the 2D (two-dimensional) area underneath the ROC curve was determined. These results show that some genes such as IL-27 (p < 0.001, AUC = 0.870), IL-27R (p < 0.001, AUC = 0.765), TNF-α (p < 0.001, AUC = 0.818) and TLR4 (p = 0.004, AUC = 0. 708) seems to be more important for discrimination between the two patients’ groups.

PPI Network Construction for studied genes In order to check the interactions of studied genes in the protein level and to confirm their relevance to each other, the PPI network was produced for all genes using the

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11691

A. Karimi, R. Yaghobi, J. Roozbeh, Z. Rahimi, A. Afshari, Z. Akbarpoor, M. Heidari

Figure 3. Correlation between increased cytokines in rejected KTRs which showed that IL-27R with TNF-α and TLR4 had positively significant correlation.

Figure 4. The PPI network shows the association of all studied genes in protein level.

STRING database. The result of PPI network showed that all 10 studied biomarkers had several interactions with each other (Figure 4).

DISCUSSION

Although the incidence of acute rejection in kidney transplant recipients has decreased, it remains a significant concern post-transplantation (12-15). A better understanding of this procedure can aid in predicting and preventing acute rejection in patients (16). Currently, serum creatinine is the gold standard for monitoring renal grafts (17). However, it is not specific or sensitive enough. Noninvasive and more robust methods are therefore needed. Cytokines and their receptors play a central role in allograft rejection. Therefore, in this study, we aimed to identify potential biomarkers such as IL-27 and its related cytokines and receptors (IL-27R, IFN-γ, TNF-α, IRF3 and 7, TLR3, and TLR4) in kidney transplant recipients. Upon stimulation through TLR signaling, antigen presenting cells (APCs) rapidly initiate production of IL-27 4,18. IL-27 plays a critical role in initiating T cell responses by binding to its receptor, IL-27R (19). The main producers of IL-27R are activated T cells and natural killer (NK) cells (20). In vitro studies suggest that IL-27 is not essential for TH1 cell Archivio Italiano di Urologia e Andrologia 2023; 95(4):11691

IL-27/IL-27R pathway molecules in kidney transplant rejection

differentiation in vivo, and its primary function appears to be as a negative regulator of the immune system (21). Two other studies have also identified the role of IL-27 in promoting tolerance in transplantation (6, 22). IL-27 has been shown to synergize with IL-12 in promoting proliferation of naive CD4+ T cells and production of IFN-γ from NK cells and CD4+ T cells (4)]. Based on these findings, this molecule is a potential candidate as a potent predictive and diagnostic marker. In a previous study, we examined the expression rate of IL-27 in liver transplant patients during the first week of acute rejection. However, no significant changes were observed between the rejected and non-rejected groups 7. Our team also evaluated the expression level of other related cytokines, such as IL-17, in this context (23). In our current research, we investigated the expression level of IL-27 in kidney transplant patients during the period between 2 weeks to 2 months post-transplantation. Our findings revealed a significant increase in IL-27 expression level among rejected patients compared to nonrejected patients. The same pattern was observed for the IL-27 receptor (IL-27R), with a statistically significant increase in the rejected group. The ROC curve analysis for both IL-27 and IL-27R were also significant. In response to TLR4 signals, NF-kB is activated and binds to the IL-27p28 promoter (24). Additionally, IFN-γ exhibits synergistic effects in this system (25), working in cooperation with other cytokines such as TNF-α. Various studies have been conducted to evaluate the role of IFN-γ in transplant rejection (26-28), and our study shows an increase in IFN-γ expression levels even in the blood of stable renal graft recipients compared to healthy individuals (p < 0.05). Furthermore, our results demonstrate a significant increase in kidney transplant rejection patients compared to healthy individuals. The reason for the increase in IFN-γ production post-transplantation is related to modifications in the extent of methylation of its promoter (28). TNF-α plays a crucial role by binding to its receptors (TNFR1 and TNFR2) expressed on the surface of various target cells. Immunological responses are attributed to the signals produced through TNF-α binding to TNFR1, while T cells are affected by binding to TNFR2 (29). Studies have reported synchronized elevation of TNF-α and TNFR2 in rejected kidney transplant patients (30, 32). Our data supports this finding, showing a significant increase in both TNF-α and TNFR2 levels in rejected patients compared to healthy controls. Furthermore, TNF-α levels were significantly higher in rejected patients than in stable graft participants, as demonstrated by ROC curve studies with a p-value of < 0.05. Other studies have also reported elevated protein levels of TNF-α in serum (33, 24) and urine (34) samples from kidney transplant rejected patients. The expression levels of the TLR4 gene and protein in solid organ transplants have been investigated in various studies (35-38). These studies have detected an increased expression level of the TLR4 gene in the liver (39) and kidney (40, 41) in blood and tissue biopsies of patients experiencing acute rejection episodes, respectively. Our results are consistent with these studies, as we also found a significant increase in TLR4 expression rates in patients with transplant rejection compared to other study groups

(non-rejected and normal). Additionally, ROC curve analysis demonstrated that this gene can be considered a valuable prognostic factor for renal transplant rejection by distinguishing between rejected and non-rejected patients. However, there is insufficient evidence to support the importance and role of the TLR3 gene in graft rejection based on our study and others (42, 43). The TLR4 pathway activates a mediator molecule called TRIF (ToAll/IL-1R-related domain containing adaptor inducing IFN), which then triggers the translocation of IRF3 and 7 to the nucleus via a MyD88-independent signaling pathway. Previous research has shown that the IRF3/IRF7 heterodimer plays a crucial role in viral infections, inflammatory diseases, and septic shock by regulating IFN production (44). These two molecules are known to be key regulators of IFN production induction. However, their role in kidney transplant rejection is not well understood. Our findings indicate that IRF3 expression levels are significantly lower in both rejected and non-rejected patient groups compared to healthy controls, while IRF7 expression levels are significantly higher in both patient groups. Additionally, our PPI network analysis revealed a strong correlation between the proteins of these genes as potential biomarkers for kidney transplant rejection. This study has demonstrated the importance of increased gene expression levels, particularly in the rejected group. However, what is more crucial is the ability of these genes to differentiate between rejected and non-rejected patients. Among all the genes studied, IL-27, IL-27R, TNF-α and TLR4 were found to be significantly expressed in the rejected group of KTRs. These four genes also showed significant variations in ROC curve analysis (p < 0.05). Ultimately, this study aimed to identify a critical gene expression pattern related to transplant rejection that could potentially serve as biomarkers for predicting and diagnosing rejection independently of protein level expression.

CONCLUSIONS

In our current research, we propose that monitoring the mRNA expression patterns of certain cytokines, such as IL-27 and its receptor (IL-27R), TNF-α, and TLR4 genes in the blood of patients, could have non-invasive prognostic and diagnostic potential and free researchers from testing protein level. This could guide clinical decisions regarding the appropriate extent of immunosuppressive therapy for each patient and potentially improve outcomes following kidney transplantation.

FUNDING

This study was supported by Shiraz University of Medical Sciences (grant No. 14555). Funding sources had no influence over in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

ACKNOWLEDGEMENTS

The authors wish to thank Shiraz University of Medical Sciences for the support and funding preparation.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11691

A. Karimi, R. Yaghobi, J. Roozbeh, Z. Rahimi, A. Afshari, Z. Akbarpoor, M. Heidari

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Correspondence Aftab Karimi aftabkarimi4955@yahoo.com Zahra Rahimi z.rahimi1@yahoo.com Zahra Akbarpoor maahsamoon70@gmail.com Zarghan branch, Islamic Azad University, Zarghan, Iran Ramin Yaghobi rayaviro@yahoo.com Mojdeh Heidari mozhde.heidari@gmail.com 1Zarghan branch, Islamic Azad University, Zarghan, Iran Jamshid Roozbeh roozbehj@hotmail.com Afsoon Afshari PhD of Molecular Genetics (Corresponding Author) afsafshari@yahoo.com Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11691

DOI: 10.4081/aiua.2023.11978

ORIGINAL PAPER

Brucella epididymo-orchitis: A single-center experience with a review of the literature Rawa Bapir 1, 2, 3, Ahmed Mohammed Abdalqadir 2, Esmaeel Aghaways 4, Hemn Hussein Bayz 5, Hiwa O. Abdullah 1, 3, Shaho F. Ahmed 1, Berun A. Abdalla 1, 3, Jihad Ibrahim Hama 6, Bryar Othman Muhammed 5, Karokh Fadhil Hamahussein 1, 7, Farman Mohammed Faraj 2, Fahmi Hussein Kakamad 1, 3, 4 1 Smart Health Tower, Madam Mitterrand Street, Sulaimani, Kurdistan, Iraq;

2 Department of Urology, Sulaimani Surgical Teaching Hospital, Sulaimani, Iraq; 3 Kscien Organization, Hamdi Street, Azadi Mall, Sulaimani, Kurdistan, Iraq;

4 College of Medicine, University of Sulaimani, Madam Mitterrand Street, Sulaimani, Kurdistan, Iraq; 5 Smart Health Tower Raparin, Rania, Sulaimani, Kurdistan, Iraq; 6 Research Center, University of Halabja, Halabja, Iraq;

7 Kurdistan Center for Gastroenterology and Hepatology, Sulaimani, Kurdistan, Iraq.

of infection, particularly in developing countries where there is inadequate control over animal infections. While the prevalence of brucellosis in developed countries is currently minimal, isolated cases do arise within occupational cohorts at risk, such as farmers, veterinarians, and laboratory and slaughterhouse personnel (3). Brucellosis is linked to a range of genitourinary infections in males, such as brucellar epididymo-orchitis (BEO), cystitis, prostatitis, interstitial nephritis, pyelonephritis, exudative glomerulonephritis, the formation of renal and testicular abscesses, and seminal vesiculitis (3). BEO is an infrequent complication of brucellosis, occurring in 5.7% of cases, and it is commonly unilateral. The prevailing symptoms encompass fever, scrotal pain, and swelling, chills or rigors, malaise, generalized discomfort, fatigue, and headache. The incidence and nature of complications are contingent upon the specific strain of the infecting Brucella, the patient's age, and the duration of the illness (1, 3, 4). It typically affects young and middle-aged individuals, and failure to prompt diagnosis or inadequate management can lead to various complications, such as testicular abscess, necrotizing orchitis, atrophy, infarction, suppurative necrosis, infertility, tumor, and aspermia (5, 6). Furthermore, the disease can mimic testicular tumors and tends to recur more than once, which makes it more challenging (1, 7). Despite the higher incidence and morbidities of brucellosis in developing countries, few case series on BEO are available in the literature (5, 8-13). The current study is a single-center experience focusing on the clinical manifestations, diagnosis, and treatment outcomes of BEO, with a literature review of the published case series. The references have been inspected for credibility based on the most up-to-date criteria (14).

Summary

Brucella epididymo-orchitis (BEO) is a rare complication of brucellosis. Despite the high incidence of brucellosis in developing countries, few case series on BEO are available. This study focuses on the clinical presentations, diagnosis, and treatment of BEO with a review of the literature. This study included consecutive BEO patients diagnosed and treated at Smart Health Tower between 2021 and 2023. The required data were retrospectively collected from patients' profiles. The BEO diagnosis was established through scrotal Doppler ultrasound in cases with a positive Rose Bengal test and positive IgG and IgM results for brucellosis, in addition to scrotal pain and swelling. This study included 11 cases whose ages ranged from 22 to 55 years. Most of the cases presented with testicular pain (72.7%), followed by fever (63.6%) and arthralgia (63.6%). The right side (54.5%) was slightly more affected than the left side (45.5%). The major abnormal laboratory finding was an elevated C-reactive protein (82%). The treatment was conservative, in which a combination of gentamicin, doxycycline, and rifampicin was administered to the patients for about 6-8 weeks. One case underwent an orchiectomy due to the abscess formation. All the patients responded well to the treatment, with no recurrence. In the Middle East, brucellosis remains a concerning infectious disease. Early diagnosis, aimed at preventing abscess formation and other complications, takes first priority to avoid invasive interventions.

KEY WORDS: Brucellosis; Brucella; Orchitis; Genitourinary infection; Orchiectomy; Zoonosis. Submitted 14 October 2023; Accepted 7 November 2023

INTRODUCTION

Brucellosis, known as Malta fever, is a zoonotic multiorgan disease caused by infection with Brucella species. The major sources of infection are dogs, sheep, cattle, goats, swine, camels, and reindeer. Human infection can occur through direct contact, inhalation of the microbe, consumption of contaminated meat, or ingestion of unpasteurized milk (1, 2). Millions of people globally are at risk

METHODS Study design This study was a single-center case series involving con-

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secutive BEO patients diagnosed and treated at the urology clinic of Smart Health Tower (SHT) between January 2021 and January 2023. Patients provided explicit consent to partake and to authorize the publication of any related data in this study. The study was ethically evaluated by the scientific committee of SHT.

managed in SHT between 2021 and 2023 were enrolled in this study. Statistical analysis The arrangement and coding of the data were performed using Microsoft Excel 2019. For qualitative data analysis (descriptive statistics), the Statistical Package for the Social Sciences (SPSS) Version 25 was utilized. The data were presented as means, frequencies, and percentages.

Data collection After data de-identification, the required data were retrospectively collected from patients' profiles within the urology clinic's database. The extracted information included patient demographics, occupation, clinical presentations, laboratory findings [erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), complete blood count, liver function tests, Rose Bengal test (RBT), antiBrucella antibodies (IgG and IgM) by the enzyme-linked immunosorbent assay (ELISA), and urine culture], ultrasound (U/S) examination, strategy and outcome of treatment, and follow-up.

Literature review Overall, 15 studies with 393 cases were reviewed in this series, of which most were conducted in Turkey (53.3%), followed by Iran (20%) and one study per Kuwait, Saudi Arabia, Greece, and Spain (3-5, 8-13, 15-20). The raw data of each reviewed study is shown in Table 1. The mean age of the cases was 34.5 ± 2.71, and most of them (76.6%) were at risk of infection as they either had close contact with animals or used raw meat and unpasteurized milk products. The right and left sides were affected nearly equally, and bilateral involvement has been reported in 51 cases (13%). The major reported symptoms were fever (79.4%), pain (77.9%) and swelling (70%) of the testicles or scrotum, and sweating (57%) (Table 2). The three most commonly reported abnormal laboratory findings were high ESR (63%), CRP (57.3%), and WBC (29.8%). In all cases, the diagnosis was primarily based on clinical findings, with confirmatory tests including Brucella antigen tests (97.5%), Doppler U/S (63.6%), and positive blood cultures (23.2%). Doppler U/S found 7 cases (1.8%) of testicular abscesses. The majority of cases (95.4%) underwent conservative treatment with antibiotics, while orchiectomy and drainage procedures were conducted in 2.8% and 0.3% of cases, respectively. A good outcome was achieved in 97.7% of patients, whereas nine cases (2.3%) failed to respond to the treatment.

Diagnosis strategy The diagnosis of brucellosis was established based on clinical symptoms consistent with brucellosis, a positive RBT, and positive anti-Brucella antibodies (IgG and IgM) on the ELISA. The BEO was diagnosed when patients had pain and swelling of the scrotum with enlarged testicles and/or epididymis during the physical examination. The BEO diagnosis was confirmed by scrotal Doppler U/S in cases with a positive RBT and positive IgG and IgM results for brucellosis. The U/S features of BEO were testicular vascularity, enlargement, nonhomogenous echotexture, and heterogeneous or hypoechoic echogenicity. Eligibility criteria All the confirmed cases of BEO who were diagnosed and

Table 1. Raw data of each reviewed series on BEO, or Brucella orchitis. Author (year)

Country

No. Case

Alarbid et al (2023) (8) Kuwait Khodadadi et al (2023) (5) Iran Gozdas et al (2020) (9) Turkey Naz et al (2016) (15) Turkey Aydemir et al (2015) (4) Turkey Savasci et al (2014) (10) Turkey Gonen et al (2013) (16) Turkey Sofian et al (2013) (17) Iran Güneşet al (2010) (18) Turkey Celen et al (2009) (3) Turkey Roushan et al (2009) (13) Iran Colmenero et al (2007) (19) Spain Papatsoris et al (2002) (20) Greece Kadikoylu et al (2002) (11) Turkey Memish et al (2001) (12) Saudi Arabia

11 50 25 21 6 28 14 40 15 27 53 48 17 12 26

Risk factors Animal contact RMMPI 8 0 11 15 14 15 14 16 2 0 N/A N/A 6 11 19 20 5 10 2 25 37 4 9 11 17 8 12 N/A N/A 10

Age (mean) 32.5 38.1 36 44.6 39 31 41 ** 40 27 28.2 35.5 36.6 30.1 30 N/A

Major Symptoms Fever Chills TSS TSP Sweating Arthralgia Dysuria Anorexia Headache 10 0 0 0 0 0 0 0 0 32 31 30 45 30 17 0 12 3 16 0 25 25 12 14 4 12 0 14 0 13 21 7 10 0 2 0 3 1 4 5 1 2 2 0 0 9 8 28 28 10 1 8 8 0 12 0 N/A N/A 10 4 0 0 0 37 0 N/A N/A 36 20 13 0 0 14 3 15 15 12 8 0 0 0 24 16 21 27 19 20 6 13 10 43 0 54 54 40 12 0 0 0 48 42 48 48 40 0 2 0 0 13 0 0 0 0 0 4 0 0 12 0 12 12 6 0 0 3 0 25 14 26 26 1 6 4 3 4

Symptoms Duration (mean/day) N/A 11.26 20 N/A 22* N/A ≤ 30 ≤ 30 <14->42 N/A 29 52.5 N/A N/A <14->42

Affected site R L Both N/A N/A N/A 10 14 26 N/A N/A 2 10 10 1 3 2 1 11 16 1 8 6 0 12 16 12 9 5 1 N/A N/A 2 30 22 1 21 25 2 N/A N/A N/A N/A N/A N/A 15 9 2

RMMPI: Raw meat or milk product ingestion; N/A: non-available; TSS: testicular or scrotal swelling; TSP: testicular or scrotal pain; R: right; L: left; CRP: C-reactive protein; WBC: white blood cell; ESR: erythrocyte sedimentation rate, ALT: Alanine transaminase; AST: Aspartate aminotransferase; ALP: Alkaline Phosphatase; U/S: Ultrasound; CSV: conservative; OT: orchiectomy; UNK: unknown.

* The duration is for only 4 cases. ** Median age.

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CRP N/A 30 22 17 6 20 14 27 15 26 N/A 48 N/A N/A N/A

WBC N/A 13 4 3 2 18 3 10 6 10 19 7 6 10 6

ESR N/A 30 12 11 3 19 13 29 10 25 41 30 13 4 8

Abnormal Laboratory findings ALT AST ALP Anemia Blood culture Urine culture N/A N/A N/A 0 11 N/A 15 9 16 0 0 1 12 6 N/A 8 1 N/A N/A N/A N/A 6 8 N/A N/A N/A N/A 0 2 0 14 11 N/A 1 5 N/A 8 7 N/A 1 4 0 N/A N/A N/A 22 N/A N/A 7 8 N/A 1 0 N/A 9 8 5 0 10 0 N/A N/A N/A N/A 8 0 N/A N/A N/A N/A 27 0 N/A N/A N/A N/A 9 0 N/A N/A N/A 0 2 N/A N/A N/A 2 0 4 0

Diagnosis tools Brucella antigen test Positive Blood Culture 11 11 50 0 25 1 21 8 6 2 28 5 14 4 40 0 15 0 27 10 53 8 39 27 17 9 12 2 25 4

During the follow-up periods, which were different for each study, 11 cases (2.8%) of recurrence have been documented (Table 2).

Abscess U/S 0 50 21 18 5 28 1 0 0 27 53 18 17 12 0

0 0 1 0 0 2 0 1 1 0 1 1 0 0 0

CSV UNK 50 25 21 6 21 14 40 15 27 53 48 17 12 26

Treatment OT Drainage UNK UNK 0 0 0 1 1 0 0 0 7 0 0 0 0 0 1 0 0 0 2 0 0 0 0 0 0 0 0 0

Outcome

Recurrence

All Good All Good All Good 2 failures All Good 4 failures All good All good All good All good 6 Failures 1 Failure All good All good All good

0 0 0 2 0 0 1 0 0 1 1 3 0 2 1

presented with testicular pain (72.7%), followed by fever (63.6%), arthralgia (63.6%), sweating (45.5%), and scrotal swelling (45.5%). Regarding the laterality, the right side (54.5%) was slightly more affected than the left side (45.5%). Abnormal laboratory findings were elevated CRP (82%), anemia (27.3%), elevated WBC (18.2%), low WBC (9%), and elevated alanine transaminase (ALT) (9%). In addition, RBT and IgG and IgM antibodies for Brucella were positive in all the cases. The treatment strategy was conservative, in which a combination of gentamicin, doxycycline, and rifampicin was administered to all

RESULTS

This study included 11 cases whose ages ranged from 22 to 55 years, with a median and mean age of 31 and 35.3 ± 12.12, respectively. More than half of the cases were workers (55%), and the remaining were shepherds (27%), a butcher, and a student. The majority of the cases Table 2. Summary of the published series on BEO, or Brucella orchitis. Variables Country of studies Turkey Iran Kuwait Saudi Arabia Greece Spain Demographic data Age (mean of means) ± SD Risk factors Contact with animal Raw meat or milk product ingestion Affected site Right side Left side Bilateral N/A Major symptoms * Fever Testicular or scrotal pain Testicular or scrotal swelling Sweating Chills Arthralgia Anorexia Dysuria Headache

Frequency/Percentage

Variables Abnormal Laboratory findings * High ESR High CRP High WBC Positive blood culture High ALT High AST High ALP Anemia Positive urine culture Diagnostic tools Brucella antigen tests Scrotal Doppler ultrasound Positive blood culture Testicular abscess Treatment Conservative (antibiotics) Orchiectomy Drainage Unknown Outcome Good Failure Follow-up Recurrence

8 (53.3%) 3 (20%) 1 (6.7%) 1 (6.7%) 1 (6.7%) 1 (6.7%) 34.5 ± 2.71 156 (39.7%) 145 (36.9%) 129 (32.8%) 125 (31.8%) 51 (13%) 124 (31.5%) 312 (79.4%) 306 (77.9%) 276 (70%) 224 (57%) 115 (29.3%) 114 (29%) 53 (13.5) 43 (11%) 17 (4.3%)

Frequency/Percentage 248 (63%) 225 (57.3%) 117 (29.8%) 91 (23.2%) 65 (16.5%) 49 (12.5%) 23 (6%) 39 (10%) 1 (0.3%) 383 (97.5%) 250 (63.6%) 91 (23.2%) 7 (1.8%) 375 (95.4%) 11 (2.8%) 1 (0.3%) 11 (2.8%) 384 (97.7%) 9 (2.3%) 11 (2.8%)

* Other symptoms and laboratory findings have been reported in the reviewed studies, but this study reviewed

the most common of them.

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Table 3. Baseline characteristics of the BEO patients. Variables Demographics

Frequency/Percentage

Age range (median, mean ± SD), years Occupation Worker Shepherd Butcher Student Clinical presentations Testicular pain Fever Arthralgia Sweating Scrotal swelling Right Left Splenomegaly Chills Affected site Right Side Left Side Laboratory findings Elevated CRP (> 5 mg/dL) Anemia (< 13 g/dL) Elevated WBC (> 11000) low WBC (< 4000) Elevated ALT (> 50 IU/L) Positive Rose Bengal test Positive IgG and IgM for Brucella Ultrasonography findings Vascularity Testicular enlargement Heterogenous texture Heterogenous echogenicity Unretrieved Diagnosis Epididymo-orchitis Orchitis Treatment therapy (Duration) Gentamicin + Doxycycline + Rifampicin (6-8 w) Secondary treatment Orchiectomy

20-55 (31, 35.3 ± 12.12)

products and fresh cheese more commonly in the spring (3). The review of the literature revealed that the majority of the cases were reported in Turkey, followed by Iran, which supported the previous claim. In addition, two reviewed studies were conducted in developed countries like Greece and Spain (19, 20). The major risk factors for BEO are direct contact with animals, inhalation of infectious aerosols, and ingestion of raw meat or unpasteurized milk products (1, 7). Among the 393 reviewed cases, 76.6% were at risk of infection (3-5, 8-13, 15-20). In the present study, three cases were shepherds and one was a butcher, whereas for the remaining seven cases, it was unknown whether they had a risk factor for infection or not. Scholars reported a higher susceptibility to infection among young males. Savasci et al. conducted a retrospective analysis of 28 cases of BEO, revealing that the majority of cases occurred between the second and third decades of life, with an average age of 31 years (10). In accordance with that finding, the mean ages of the reviewed and present cases were 34.5 and 35.3 years, respectively. This raises a noteworthy concern, as brucellosis could potentially exert adverse effects on the reproductive outcomes of sexually active young adults (9). In around 20-40% of cases, Brucella orchitis is considered to stem directly from epididymitis (1). A study by Baykan et al. found that approximately 67% of 24 male cases showed involvement of both the epididymis and testes (21). While Celen et al. reported a bilateral testis involvement rate of less than 10%, Baykan et al. recorded a relatively higher rate of 21% (3, 21). The bilateral involvement in the reviewed literature was 13%, which is more compatible with Celen et al. than Baykan et al. In the present series, there was no bilateral involvement, and epididymo-orchitis was found in about 55% of the cases. In general, BEO patients have acute symptoms for about two weeks at the time of presentation (22). The primary manifestations of brucellosis can be fever, chills, sweating, nausea, vomiting, myalgia, arthritis, and osteoarticular involvement. In addition to previous symptoms, scrotal pain and swelling may be indicators of BEO (1). Among the 15 reviewed studies, the prevalent reported symptoms were fever (79.4%), scrotal pain (77.9%), scrotal swelling (70%), and sweating (57%). In line with the literature, the most common presentations in our cases were testicular pain (72.7%), fever (63.6%), arthralgia (63.6%), sweating (45.5%), and scrotal swelling (45.5%). Regarding the incidence of BEO in patients with brucellosis, it has been reported to occur in 2% to 20% of the cases (1). In their study, Celen et al. documented 27 (18.8%) cases of BEO within a cohort of 143 patients with brucellosis. Meanwhile, Papatsoris et al. identified 25 (2.5%) BEO cases among a group of 995 cases with brucellosis (3, 20). To distinguish BEO from non-specific epididymo-orchitis, several factors have been reported to be considered, such as animal contact history, consumption of raw milk or cheese, gradual onset, extended duration, distinctive undulant fever, mild local inflammation, and the lack of lower urinary tract symptoms alongside insignificant leukocytosis (22). On the contrary, Celen et al. mentioned WBC as an important indicator of BEO (3). All the cases in the reviewed studies and in the present study had more than one of the distinguishing factors.

6 (55%) 3 (27%) 1 (9%) 1 (9%) 8 (72.7%) 7 (63.6%) 7 (63.6%) 5 (45.5%) 5 (45.5%) 3 (27.3%) 2 (18.2%) 4 (36.4%) 4 (36.4%) 6 (54.5%) 5 (45.5%) 9 (82%) 3 (27.3%) 2 (18.2%) 1 (9%) 1 (9%) 11 (100%) 11 (100%) 10 (91%) 7 (63.6%) 6 (54.5%) 4 (36.4%) 1 (9%) 6 (54.5%) 5 (45.5%) 11 (100%) 1 (9%)

the cases for about 6-8 weeks (Table 3). One case underwent orchiectomy as a secondary treatment due to the abscess formation. All the patients responded well to the treatment. After more than 2 years of follow-up for the first case and one year for the newest case, no recurrence has yet been reported.

DISCUSSION

Brucellosis represents an endemic multisystemic infectious disease within specific geographical areas such as the Middle East, the Arabian Peninsula, the Mediterranean region, and India. Its prevalence is significantly greater in rural environments in comparison to urban settings (1). The disease is commonly reported in developing countries; however, it can also be seen in developed countries due to immigration and travel (19). It has been reported that the preponderance of the cases is affected during the spring and summer, which may be caused by consuming milk

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Brucella epididymo-orchitis

A high WBC was reported in 29.8% of the reviewed cases and 18.2% of the present cases, which may not support the observation of Celen et al. (3). Distinguishing between BEO and non-specific epididymoorchitis is crucial, as treatment delay raises the chance of contralateral involvement, tissue necrosis, and systemic symptoms. Thus, in regions where brucellosis is endemic, having a suspicion alone justifies commencing therapy while waiting for definitive lab test results (8, 21). Another challenge in the diagnosis of BEO is mimicking the disease as a testicular tumor, epididymitis, trauma, hematocele, or torsion of the testis (1, 4). Aydemir et al. reported a case of BEO that was diagnosed as a testicular tumor based on a U/S examination and later confirmed to be BEO by conducting tumor markers, magnetic resonance imaging (MRI), and tube agglutination tests. In another study, Bapir et al. (1) reported a misdiagnosed case of BEO that appeared as a tumor in both Doppler U/S and MRI. Then, the diagnosis was corrected using tumor markers and an RBT test. The diagnosis of Brucella orchitis can be established by considering a combination of serology, ultrasonography, and the existence of typical symptoms such as fever, testicular pain, enlargement, and inflammation (1). The primary diagnostic approach for brucellosis is the serum agglutination test, and a positive result is defined as a titer ratio exceeding 1:160 when accompanied by distinct clinical symptoms. Nevertheless, in cases of prolonged brucellosis, agglutination test titers might be absent or below 1:160 (1). In such instances, the disease can be detected better by using other serologic tests like Coombs’ anti-Brucella test, immunocapture agglutination test, 2-mercaptoethanol agglutination test, or ELISA, as the immune response to the infection causes an initial increase in IgM antibodies followed by a switch to increasing IgG antibodies within a few weeks of infection (19). In total, 97.5% of the cases in the reviewed studies were diagnosed based on the various Brucella antigen tests. Due to the mentioned drawback of the serum agglutination test, all the cases in the present study were diagnosed by RBT and ELISA tests. Abnormal blood investigation findings are often mild and not very specific. Prolonged infection might cause a slight drop in hemoglobin levels, and a moderate increase in ESR is commonly seen. Liver function tests may show a mild to moderate elevation in ALT and aspartate aminotransferase (AST) levels. A high CRP level is a noteworthy finding in most cases (3, 17). Colmenero et al. reported a positive blood culture in 65.8% of patients with brucellosis and stated the necessity of the method in diagnosing brucellosis. Furthermore, the positivity of blood culture in BEO cases has been reported to be 53-69% (22). The most significant laboratory findings in the reviewed studies were positive Brucella antigen tests (97.5%), high ESR (63%), and CRP (57.3%). In contrast to the previous findings, the blood culture was positive in only 23.2% of the 393 reviewed cases. In the present study, an elevated CRP was the dominant finding (82%), after positive RBT (100%) and ELISA (100%). No blood culture was conducted in this study because the diagnosis of brucellosis was based on RBT and ELISA. Ultrasonography is usually vital for excluding the suspicion of an abscess or tumor rather than confirming the primary diagnosis. The frequent U/S features of BEO are tes-

ticular enlargement, hypervascularity, inhomogeneous echotexture, and heterogeneous or hypoechoic echogenicity. These features can also be seen in other etiologies of orchitis. Thus, the U/S examination cannot be relied on solely for the diagnosis of BEO (1, 9). All these features could be seen in the U/S examination of our cases, of which vascularity was the most prevalent finding (91%). It has been indicated that using medications like rifampicin, streptomycin, tetracycline, ciprofloxacin, doxycycline, and cotrimoxazole for at least six weeks has a significant impact on managing brucellosis (1). A suggested approach involves taking a daily combination of doxycycline (200 mg) and rifampicin (600 mg) for around six weeks. It's worth noting that using a single drug for treatment has a higher likelihood of failure compared to using a combination, so medical treatment should involve the use of two or three antibiotics together (1, 10, 21). The rate of treatment failure and the requirement for orchiectomy have been reported to vary from 0% to 40% and from 0% to 5.1%, respectively. In accordance, the rates of treatment failure, recurrence, and orchiectomy among the reviewed cases were 2.3%, 2.8%, and 2.8% consecutively. All patients in this series were treated with antibiotic combinations. One orchiectomy (9%) was conducted due to abscess formation, and no recurrence was reported during the follow-up period.

CONCLUSIONS

In developing countries, especially in the Middle East, brucellosis remains a concerning infectious disease. As it is commonly diagnosed in young adults, it may have unfavorable effects on the reproductive activity of this group. An early diagnosis to prevent abscess formation and other complications is the first priority to avoid invasive interventions. RBT and ELISA, in addition to clinical presentations, may be sufficient for diagnosis.

REFERENCES

1. Bapir R, Ahmed SF, Tahir SH, et al. Brucella orchitis presenting as a testicular mass mimicking a testicular tumor: a rare case report. African Journal of Urology. 2023; 29:5. 2. Nahas RS, Alsulami A, Lashkar MO, Thabit AK. Brucella epidydimo-orchitis successfully treated with dual oral drug regimen: A case report with differential diagnoses of malignancy and tuberculosis. Radiol Case Rep. 2022; 17:3485-9. 3. Celen MK, Ulug M, Ayaz C, et al. Brucellar epididymo-orchitis in southeastern part of Turkey: an 8 year experience. Braz J Infect Dis. 2010; 14:109-15. 4. Aydemir H, Budak G, Budak S, et al. Different presentation types of primary Brucella epididimo-orchitis. Arch Ital Urol Androl. 2015; 87:151-3. 5. Khodadadi J, Dodangeh M, Nasiri M. Brucellar epididymo-orchitis: Symptoms, diagnosis, treatment and follow-up of 50 patients in Iran. IDCases. 2023; 32:e01736. 6. Zana HM, Fenk MM, Binaiy NF, et al. Cancer publications in one year (2022); a cross-sectional study. Barw Medical Journal. 2023; 1(2). 7. Tanyel E, Tasdelen-Fisgin N, Sarikaya-Genc H, et al. Brucella epididymo-orchitis relapsing three times despite treatment. Int J Infect Dis. 2008; 12:215-7.

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8. Alarbid A, Salem SM, Alenezi T, et al. Early predictors of Brucella epididymo-orchitis. Urol Ann. 2023; 15:158-61.

epididymo-orchitis (BEO) compared to those without BEO. Turk J Med Sci. 2016; 46:1323-8.

9. Gozdas HT, Bal T. Brucellar epididymo-orchitis: a retrospective study of 25 cases. Aging Male. 2019; 23:29-32.

16. Gonen I, Umul M, Sozen H, Kaya O. Brucellar epididymo-orchitis in Southwest Anatolia, Turkey: A retrospective study of 14 patients. Acta Medica Mediterranea. 2013; 29:509-13.

10. Savasci U, Zor M, Karakas A, et al. Brucellar epididymo-orchitis: a retrospective multicenter study of 28 cases and review of the literature. Travel Med Infect Dis. 2014; 12:667-72.

17. Sofian M, Aghakhani A, Banifazl M, et al. Differentiation of Brucella-induced epididymo-orchitis from nonspecific epididymoorchitis in an endemic area for brucellosis. Journal of Medical Microbiology and Infectious Diseases. 2013; 1:8-13.

11. Kadikoylu G, Tuncer G, Bolaman Z, Sina M. Brucellar Orchitis in Innerwest Anatolia Region of Turkey: a report of 12 cases. Urol Int. 2002; 69:33-5.

18. Günes M, Geçit I, Bilici S, Demir C, et al. Brucellar epididymoorchitis: report of fifteen cases. Van Medical Journal. 2010; 17:131-5. 19. Colmenero JD, Munoz-Roca NL, Bermudez P, et al. Clinical findings, diagnostic approach, and outcome of Brucella melitensis epididymo-orchitis. Diagnostic microbiology and infectious disease. 2007; 57:367-72.

12. Memish ZA, Venkatesh S. Brucellar epididymo-orchitis in Saudi Arabia: a retrospective study of 26 cases and review of the literature. BJU international. 2001; 88:72-6. 13. Hasanjani Roushan MR, Baiani M, Javanian M, Kasaeian AA. Brucellar epididymo-orchitis: Review of 53 cases in Babol, northern Iran. Scand J Infect Dis. 2009; 41:440-4.

20. Papatsoris AG, Mpadra FA, Karamouzis MV, Frangides CY. Endemic brucellar epididymo-orchitis: a 10-year experience. International journal of infectious diseases. 2002; 6:309-13.

14. Aso SM, Jaafar OA, Hiwa OB, et al. Kscien’s List; A New Strategy to Discourage Predatory Journals and Publishers (Second Version). Barw Medical Journal. 2023; 1:1-3.

21. Baykan AH, Sayiner HS, Inan I. Brucella and non-Brucella epididymo-orchitis: comparison of ultrasound fndings. Med Ultrason. 2019; 21:246-250.

15. Naz H, Korkmaz P, Cevik F, Aykin N. The clinical and laboratory characteristics, treatments, and outcomes of patients with Brucella

22. Al-Tawfiq JA. Brucella Epididymo-orchitis: A consideration in endemic area. International Braz J Urol. 2006; 32:313-5.

Correspondence Rawa Bapir, MD Dr.rawa@yahoo.com Hiwa Abdullah, MD hiewaom96@gmail.com Shaho Ahmed, MD shahomedi87@gmail.com Berun Abdalla, MD berun.anwer95@gmail.com Smart Health Tower, Madam Mitterrand Street, Sulaimani, Kurdistan, Iraq Esmaeel Aghaways, MD esmaeel.aghaways@gmail.com College of Medicine, University of Sulaimani, Madam Mitterrand Street, Sulaimani, Kurdistan, Iraq Hemn Bayz, MD hemn.bayz@gmail.com Smart Health Tower Raparin, Karux Str, Rania, Sulaimani, Kurdistan, Iraq Jihad Hama, MD jihad.hama@gmail.com Bryar Muhammed, MD bryar.muhammed@gmail.com Research Center, University of Halabja, Halabja, Iraq Karokh Hamahussein, MD karokh12@gmail.com Kurdistan Center for Gastroenterology and Hepatology, Sulaimani, Kurdistan, Iraq Farman Faraj, MD farman.faraj@gmail.com Ahmed Abdalqadir, MD ahmed.abdalqadir@gmail.com Department of Urology, Sulaimani Surgical Teaching Hospital, Sulaimani, Iraq Fahmi Hussein Kakamad, MD (Corresponding Author) fahmi.hussein@univsul.edu.iq College of Medicine, University of Sulaimani Doctor City, Building 11, Apartment 50 Madam Mitterrand Street, HC8V+F66, 46000 Sulaymaniyah, Kurdistan, Iraq Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11978

DOI: 10.4081/aiua.2023.11869

ORIGINAL PAPER

Relation between myostatin levels and malnutrition and muscle wasting in hemodialysis patients Amal H. Ibrahim 1, Sammar A. Kasim 1, Alshimaa A. Ezzat 2, Noha E. Ibrahim 3, Donia A. Hassan 4, Amira Sh. Ibrahim 5, Tamer A. Abouelgreed 6, Ehab M. Abdo 7, Naglaa M. Aboelsoud 2, Nermeen M. Abdelmonem 8, Mohammad Thabet Alnajem 9, Ahmed A. Aboomar 10 1 Department of Internal Medicine, Nephrology Unit, Al-Azhar University, Cairo, Egypt; 2 Department of Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt;

3 Department of Microbial Biotechnology, Biotechnology Research Institute, National Research Centre (NRC), Giza, Egypt; 4 Department of Clinical Pathology, Al-Azhar University, Cairo, Egypt;

5 Department of Rheumatology and Rehabilitation, Faculty of Medicine for girls, Al-Azhar University, Cairo, Egypt; 6 Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt;

7 Department of Vascular Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt; 8 Department of Radiology, Thumbay University Hospital, Ajman, UAE; 9 Department of Radiology, Tawam Hospital, Alain, UAE;

10 Department of internal medicine, Nephrology Unit, Faculty Medicine, Tanta University, Tanta, Egypt.

Summary

Background and aim: Malnutrition is one of the most troublesome comorbidities among hemodialysis patients (HD). Myostatin (MSTN) belongs to the transforming growth factor-β superfamily. In HD patients, MSTN effects are not limited to skeletal muscle growth. The present study aimed to assess MSTN levels in HD patients and its relation to various clinical and biochemical parameters. Patients and methods: The present case control study included 60 patients on HD for at least three years. In addition, there were age and sex-matched healthy subjects who constitutes the control group. Nutritional status was evaluated using the malnutrition inflammation score (MIS). Muscle wasting in the present study was evaluated using the lean tissue index (LTI) as assessed by the body composition monitor (BCM). Rectus Femoris Muscle (RFM) thickness was also measured as indicator for nutritional status of patient. Results: The present study included 60 HD patients, and ageand sex-matched healthy controls. Patients expressed significantly higher myostatin levels when compared to controls [median (IQR): 221.3 (153.5-688.2) versus 144.8 (97.0-281.7), p < 0.001]. According to MIS, patients were classified into those with no/mild malnutrition (n = 22) and others with moderate/severe malnutrition (n = 38). Comparison between the two subgroups revealed that the former group had significantly lower myostatin levels [167.7 (150.3-236.3) versus 341.7 (160.9-955.9), p = 0.004]. According to LTI, patients were classified into those with muscle wasting (n = 23) and others without muscle wasting (n = 37). Comparative analysis showed that patients in the former group had significantly higher myostatin levels [775.1 (325.1-2133.7) versus 161.8 (142.6-302.3), p < 0.001]. Conclusions: Myostatin seems to be a promising marker for identification of malnutrition and muscle wasting in HD patients.

KEY WORDS: Hemodialysis; Malnutrition; Muscle wasting; Myostatin. Submitted 23 September 2023; Accepted 13 November 2023

INTRODUCTION

Malnutrition is one of the most troublesome comorbidities among hemodialysis patients (HD) (1). Factors responsible for malnutrition in HD patients include dialysis factors (e.g. low dialysis adequacy, low quality dialysis membranes and techniques) and dietary factors (e.g. poor appetite and low diet quality) (2). Poor nutritional status in HD patients was linked to cognitive impairment (3), cardiac dysfunction (4), hospitalization and mortality (5). Assessment of the nutritional status in HD patients is of paramount importance for the sake of better quality of life and clinical outcomes. However, there is a lack of consensus regarding the gold standard indicators (6). Fortunately, our understanding of the pathological mechanisms involved in malnutrition and muscle wasting in HD patients has markedly improved over years. One of the significant achievements in this context is identification of myostatin (MSTN)/activin system and its transcriptional system (7). MSTN, also known as growth development factor-8 (GDF-8) was discovered in 1997. It belongs to the transforming growth factor-ß superfamily. The present study aimed to assess MSTN levels in HD patients and its relation to various clinical and biochemical parameters.

PATIENTS AND METHODS

The present case control study was conducted at Al-Azhar University Hospitals, Cairo, Egypt. The Research Ethics Committee of the Faculty of Medicine, Al-Azhar University (FMG-IRB). approved the study protocol and written informed consent was obtained from all participants before enrollment in line with Helsinki Declaration. The study included 60 HD patients who were undergoing hemodialysis for at least rhree years through mature arteriovenous fistula that was fashioned by vascular team in vas-

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A.H. Ibrahim, S.A. Kasim, A.A. Ezzat, et al.

cular department. Patients were excluded if they had other neurological, gastrointestinal or endocrinal conditions with direct effect on the nutritional status or if they have associated malignant tumors. A Control group was selected from hospital staff. They were age and sex-matched healthy subjects who constitutes the control group. All participants were submitted to sophisticated history taking, thorough clinical assessment and examination of arterio-venous fistula (AVF) and standard laboratory investigations. All participants were subjected to Ultrasound measurement of rectus femoris muscle thickness by a high frequency linear transducer (L12-4 Linear Active Probe) connected to an ultrasound machine (Philips Affinity 30, by: Singha’s medical system India private limited, New Delhi). The ultrasound probe was placed perpendicular to the long axis of the thigh on its anterior surface. The obtained B-mode cross sectional image was adjusted to visualize the rectus femoris muscle, the subcutaneous tissues and the femur. After identifying the muscle tissue, the maximum muscle thickness of the rectus femoris muscle was obtained by scanning the muscle through its length until its insertion into the patella. Nutritional status was evaluated using the malnutrition inflammation score (MIS) (8). Recent studies proved that MIS assessment in HD patients is well correlated with biochemical parameters (9) and showed better performance (10) and prognostic value (11). Patients were divided into two groups according to their MIS values as mild (MIS < 6) and moderate/severe malnu-

Table 1. Association between PPLA score and risk factors for kidney stones or stone recurrence.

Age (years) mean ± SD Male/female n BMI Comorbidities n (%) DM HTN IHD COPD HCV HD duration (months) Kt/V Laboratory findings mean ± SD/median (IQR) Hb (gm/dL) WBCs Platelets Creatinine (mg/dL) Urea (mg/dL) FBS (mg/dL) Albumin (gm/dL) Cholesterol (mg/dL) Triglycerides (mg/dL) Calcium (mg/dL) Phosphorus (mg/dL) Sodium Potassium PTH (pg/mL) Uric acid (mg/dL) Ferritin (ng/mL) hsCRP (mg/L) Myostatin

trition (MIS ≥ 6). Muscle wasting in the present study was evaluated using the lean tissue index (LTI) as assessed by the body composition monitor (BCM). LTI was considered a reliable indicator of skeletal muscle mass (12). In HD patients, low LTI was related to poor prognosis (13). Patients with LTI < 10.0% of the normal reference range were considered to have muscle wasting (14). Kt/v was calculated by dialysis machine, and we take the results from the machines screen. Control patients had controls had only measurement of myostatin. Statistical analysis Data obtained from the present study were presented as number and percent, mean and standard deviation (SD) or median and interquartile range (IQR). Numerical variables were compared using t test or Mann-Whitney U t test, as appropriate while categorical variables were compared using chi-square test. Spearman’s correlation coefficient was used to correlate numerical variables. Binary logistic regression analysis was used to identify predictors of the study outcomes. All statistical procedures were accomplished using SPSS (Version 27, IBM Corporation, IL, USA).

RESULTS

The present study included 60 HD patients and age- and sex-matched healthy controls. Patients expressed signifi-

Malnutrition Moderate/severe n = 38 56.5 ± 7.4 16/22 24.3 ± 3.7

All patients n = 60 54.0 ± 7.9 29/31 24.4 ± 3.4

No/mild n = 22 49.5 ± 6.9 13/9 24.6 ± 2.9

23 (38.3) 31 (51.7) 17 (28.3) 11 (18.3) 9 (15.0) 47.0 (28.0-76.0) 1.3 ± 0.1

9 (40.9) 13 (59.1) 7 (31.8) 4 (18.2) 3 (13.6) 45.5 (28.8-67.5) 1.4 ± 0.1

14 (36.8) 18 (47.4) 10 (26.3) 7 (18.4) 6 (15.8) 49.5 (21.0-79.8) 1.3 ± 0.1

0.76 0.38 0.65 0.98 0.82 0.84 0.003

9.8 ± 1.3 5.4 ± 2.0 188.0 ± 61.9 8.2 ± 2.4 110.0 ± 32.3 119.6 ± 46.0 4.0 ± 0.4 158.4 ± 44.0 172.3 ± 114.5 8.9 ± 0.8 4.5 ± 1.5 138.9 ± 4.8 4.9 ± 0.6 407.5 (191.8-895.0) 5.8 ± 1.4 829.4 (752.4-1689.0) 111.2 (88.2-121.5) 221.3 (153.5-688.2)

10.4 ± 0.3 4.7 ± 1.8 167.1 ± 63.1 7.9 ± 2.0 97.6 ± 30.1 117.2 ± 44.2 4.2 ± 0.2 146.3 ± 34.6 131.8 ± 42.7 8.7 ± 0.8 4.2 ± 1.5 140.1 ± 5.4 4.8 ± 0.6 512.5 (233.0-897.8) 5.6 ± 1.7 789.0 (370.8-1689.0) 89.5 (68.6-111.5) 167.7 (150.3-236.3)

9.5 ± 1.6 5.9 ± 2.0 200.3 ± 58.6 8.4 ± 2.6 117.1 ± 31.7 120.9 ± 47.5 3.8 ± 0.4 165.5 ± 47.6 195.7 ± 135.4 8.9 ± 0.8 4.6 ± 1.4 138.1 ± 4.3 5.0 ± 0.6 407.5 (187.0-897.8) 5.9 ± 1.3 1408.5 (752.4-1726.3) 113.9 (100.9-124.0) 341.7 (160.9-955.9)

< 0.001 0.009 0.015 0.4 0.047 0.54 < 0.001 0.13 0.026 0.41 0.51 0.017 0.033 0.78 0.56 0.21 < 0.001 0.004

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p value 0.001 0.21 0.056

Myostatin in hemodialysis

Age (years) mean ± SD Male/female n BMI Comorbidities n (%) DM HTN IHD COPD HCV HD duration (months) Kt/V Laboratory findings mean ± SD/median (IQR) Hb (gm/dL) WBCs Platelets Creatinine (mg/dL) Urea (mg/dL) FBS Albumin (gm/dL) Cholesterol Triglycerides Calcium (mg/dL) Phosphorus (mg/dL) Sodium Potassium PTH (pg/mL) Uric acid (mg/dL) Ferritin (ng/mL) hsCRP (mg/L) Myostatin

Age (years) mean ± SD Male/female n BMI Comorbidities n (%) DM HTN IHD COPD HCV HD duration (months) Kt/V Laboratory findings mean ± SD/median (IQR) Hb (gm/dL) WBCs Platelets Creatinine (mg/dL) Urea (mg/dL) FBS Albumin (gm/dL) Cholesterol Triglycerides Calcium (mg/dL) Phosphorus (mg/dL) Sodium Potassium PTH (pg/mL) Uric acid (mg/dL) Ferritin (ng/mL) hsCRP (mg/L)

+ve n = 23 58.3 ± 5.2 9/14 23.5 ± 3.5

-ve n = 37 51.2 ± 8.2 20/17 25.5 ± 0.7

p value

12 (52.2) 13 (56.5) 7 (30.4) 5 (21.7) 4 (17.4) 71.0 (42.0-101.0) 1.24 ± 0.12

11 (29.7) 18 (48.7) 10 (27.0) 6 (16.2) 9 (24.3) 42.0 (24.0-57.0) 1.37 ± 0.11

0.082 0.55 0.78 0.59 0.53 0.005 < 0.001

8.7 ± 0.7 6.5 ± 1.8 220.3 ± 46.2 8.0 ± 1.7 120.7 ± 30.3 124.3 ± 51.1 3.7 ± 0.4 177.9 ± 51.6 226.9 ± 158.5 9.0 ± 0.8 4.8 ± 1.5 137.1 ± 3.6 5.1 ± 0.5 338.0 (187.0-895.0) 5.9 ± 0.9 825.5 (807.0-1603.0) 113.6 (109.1-121.9) 775.1 (325.1-2133.7)

10.5 ± 1.2 4.8 ± 1.9 168.1 ± 62.2 8.3 ± 2.8 103.3 ± 32.1 116.6 ± 42.9 4.2 ± 0.3 146.3 ± 33.9 138.4 ± 55.2 8.8 ± 0.9 4.3 ± 1.5 139.9 ± 5.1 4.8 ± 0.6 420.0 (262.0-900.5) 5.7 ± 1.7 833.2 (531.6-1689.0) 100.6 (71.5-131.5) 161.8 (142.6-302.3)

< 0.001 < 0.001 < 0.001 0.58 0.041 0.53 <0.001 0.006 0.016 0.32 0.24 0.026 0.11 0.84 0.61 0.41 < 0.001 < 0.001

Myostatin levels Low High n = 30 n = 30 50.3 ± 7.8 57.6 ± 6.4 12/18 17/13 23.9 ± 3.0 25.0 ± 3.8

< 0.001 0.26 0.12

p value < 0.001 0.2 0.22

10 (33.3) 18 (60.0) 9 (30.0) 7 (23.3) 6 (20.0)

13 (43.3) 13 (43.3) 8 (26.7) 4 (13.3) 3 (10.0)

0.43 0.2 0.77 0.32 0.28

1.34 ± 0.13

1.3 ± 0.14

0.28

10.1 ± 1.3 5.2 ± 2.0 182.1 ± 60.5 8.3 ± 2.1 110.1 ± 29.5 126.8 ± 52.0 4.1 ± 0.3 155.4 ± 40.2 137.1 ± 55.2 8.8 ± 0.9 4.4 ± 1.5 138.7 ± 4.8 5.0 ± 0.7 311.5 (195.3-897.8) 5.7 ± 1.4 1374.0 (370.8-1835.8) 101.3 (72.0-116.2)

9.5 ± 1.3 5.7 ± 2.0 194.1 ± 63.7 8.1 ± 2.7 109.8 ± 35.4 112.4 ± 38.5 3.8 ± 0.4 161.5 ± 47.9 207.5 ± 145.1 8.9 ± 0.8 4.6 ± 1.4 139.0 ± 4.8 4.9 ± 0.5 687.0 (187.0-906.3) 5.9 ± 1.5 825.5 (752.4-1689.0) 113.7 (101.8-122.6)

0.059 0.32 0.46 0.87 0.97 0.23 0.003 0.59 0.018 0.59 0.51 0.79 0.58 0.32 0.66 0.75 0.005

Table 2. Comparison between hemodialysis patients with and without muscle wasting regarding clinical and laboratory findings.

cantly higher myostatin levels when compared to controls [median (IQR): 221.3 (153.5-688.2) versus 144.8 (97.0-281.7), p < 0.001]. According to MIS, patients were classified into those with no/mild malnutrition (n = 22) and others with moderate/severe malnutrition (n = 38). Comparison between both subgroups revealed that subjects in the former group were significantly younger (49.5 ± 6.9 years versus 56.5 ± 7.4, p = 0.001) with higher Kt/V (1.4 ± 0.1 versus 1.3 ± 0.1, p = 0.003), higher hemoglobin levels (10.4 ± 0.3 gm/dl versus 9.5 ± 1.6, p < 0.001), higher albumin levels (4.2 ± 0.2 gm/dl versus 3.8 ± 0.4), lower triglycerides levels (131.8 ± 42.7 mg/dL versus 195.7 ± 135.4, p = 0.026), lower hsCRP [89.5 (68.6-111.5) mg/dL versus 113.9 (100.9-124.0), p < 0.001] and lower myostatin levels [167.7 (150.3236.3) versus 341.7 (160.9-955.9), p = 0.004] (Table 1). According to LTI, patients were classified into those with muscle wasting (n = 23) and others without muscle wasting (n = 37). Comparative analysis showed that patients in the former group are significantly older (58.3 ± 5.2 years versus 51.2 ± 8.2, p < 0.001) with longer HD duration [71.0 (42.0-101.0) months versus 42.0 (24.0-57.0), p = 0.005], lower Kt/V (1.24 ± 0.12 versus 1.37 ± 0.11, p < 0.001), lower hemoglobin (8.7 ± 0.7 gm/dL versus 10.5 ± 1.2, p < 0.001), lower albumin (3.7 ± 0.4 gm/dL versus 4.2 ± 0.3, p < 0.001), higher cholesterol (177.9 ± 51.6 mg/dL versus 146.3 ± 33.9, p = 0.006) and higher triglycerides (226.9 ± 158.5 mg/dL versus 138.4 ± 55.2, p = 0.016). They also showed significantly lower RFM thickness (0.8 +/_ 0.2 versus 1.4 +/- 0.3 cm p 0.001). and significantly higher hsCRP [113.6 (109.1-121.9) mg/dL versus 100.6 (71.5-131.5), p < 0.001] and myostatin 775.1 (325.1-2133.7) versus 161.8 (142.6-302.3), p < 0.001] levels (Table 2). Comparison between patients with low (< median) and high (≥ median) myostatin levels identified that patients with high myostatin levels were significantly older (57.6 ± 6.4 years versus 50.3 ± 7.8, p < 0.001) with lower albumin levels (3.8 ± 0.4 versus 4.1 ± 0.3 gm/dL, p = 0.003) and higher hsCRP levels [113.7 (101.8122.6) mg/dL versus 101.3 (72.0-116.2), p = 0.005] (Table 3). Correlation analysis recognized significant

Table 3. Comparison between hemodialysis patients with low and high myostatin levels regarding clinical and laboratory findings.

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A.H. Ibrahim, S.A. Kasim, A.A. Ezzat, et al.

Table 4. Correlation between myostatin levels and clinical and laboratory findings in the studied patients.

Figure 2. Performance of myostatin levels in identification of muscle wasting.

Myostatin levels Age BMI HD duration Kt/V Hb WBCs Platelets Creatinine Urea FBS Albumin Cholesterol Triglycerides Calcium Phosphorus Sodium Potassium PTH Uric acid Ferritin hsCRP

r 0.47 0.16 -0.03 -0.21 -0.29 0.17 0.22 0.13 0.08 -0.22 -0.37 0.14 0.26 -0.06 0.24 -0.07 -0.03 0.24 0.18 -0.03 0.38

p <0.001 0.22 0.85 0.11 0.027 0.19 0.09 0.3 0.52 0.098 0.004 0.29 0.041 0.66 0.031 0.58 0.83 0.06 0.17 0.84 0.003

DISCUSSION

K = clearance of a solute (ml/min). t = time (min. or hr.). v = volume of distribution of a solute (ml or liter).

Patients suffering from chronic kidney disease (CKD), mainly those undergoing hemodialysis (HD), often present malnutrition and muscle wasting, which directly correlate with morbidity and mortality (15). In CKD patients, an up-regulation of Myostatin gene expression in skeletal muscle has been found, which was related to IL-6 expression, suggesting a link between MSTN and microinflammation (16). Moreover, it has also been recently described that uremic toxins may accelerate muscle atrophy, by inducing Myostatin expression (17). Myostatin is secreted by the skeletal myocytes into the bloodstream to act back on the secretory cells limiting their proliferation (18). Its actions on the muscular system are mediated through activation of the ubiquitin-proteasome system resulting in inhibition of satellite muscle cell proliferation and differentiation with induction of proteolytic muscle cells (19). In HD patients, MSTN effects are not limited to skeletal muscle growth. They are also linked to insulin resistance, inflammation and cardiovascular morbidity (20). However, studies assessing MSTN in HD patients are scarce and their results are inconsistent, with some studies (21) showing that patients have MSTN levels comparable to healthy controls and others reporting higher levels of MSTN in the studied patients (22). The present study detected significantly higher myostatin levels in patients under maintenance HD as compared to healthy controls. In addition, we noted higher myostatin expression in HD patients with moderate/severe malnutrition in contrast to their counterparts with no/mild malnutrition. Moreover, those with muscle wasting showed significantly higher myostatin levels in contradiction to their peers without muscle wasting. Our conclusions are supported by previous studies. The study of Koyun et al. (23), also noted significantly higher myostatin levels in HD patients as compared to controls. In addition, the study of Delanaye et al. (24),

linear correlation between myostatin levels and age (r = 0.47, p < 0.001), hemoglobin (r = -0.29, p = 0.027) albumin (r = -0.37, p = 0.004) and hsCRP (r = 0.38, p = 0.003) (Table 4). ROC curve analysis showed good performance of myostatin levels in identification of moderate/severe malnutrition [AUC (95%CI): 0.72 (0.6-0.85)] (Figure 1) and muscle wasting [AUC (95% CI: 0.83 (0.72-0.94)] (Figure 2). Figure 1. Performance of myostatin levels in identification of moderate/severe malnutrition.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11869

Myostatin in hemodialysis

tality in maintenance hemodialysis patients. Am J Kidney Dis. 2001; 38:1251-63.

reported significant association between muscle mass and myostatin levels. They also noted a significant association between myostatin levels and mortality. The present study also identified a significant correlation between myostatin levels and patients age in accordance with the study of Han et al. (25). Likewise, the study of Yasar et al. (26), on renal transplantation, hemodialysis and peritoneal dialysis patients showed that myostatin levels were highest in HD patients. Furthermore, they revealed that myostatin was negatively correlated with handgrip strength (HGS, albumin, estimated glomerular filtration rate, and Kt/V. However, myostatin had no correlation with inflammatory markers or appendicular skeletal muscle index. Moreover, the study of Bataille et al. (27), found that myostatin together with activin were increased in patients with CKD without increased production attributing this increase to the impaired renal clearance. Similar conclusions were also reported by the study of Widajanti et al. (28), on elderly HD patients. In contrast to our findings, the study of Lee et al. (29), concluded that lower myostatin levels were associated with lower muscle mass. In addition, Esposito et al. (21), found no significant differences between HD patients and healthy controls regarding myostatin levels. They also recognized a positive correlation between myostatin levels and patients’ age and muscle mass.

9. Bakkal H, Dizdar OS, Erdem S, et al. The Relationship Between Hand Grip Strength and Nutritional Status Determined by Malnutrition Inflammation Score and Biochemical Parameters in Hemodialysis Patients. J Ren Nutr. 2020; 30:548-555. 10. Avesani CM, Sabatino A, Guerra A, et al. A Comparative Analysis of Nutritional Assessment Using Global Leadership Initiative on Malnutrition versus Subjective Global Assessment and Malnutrition Inflammation Score in Maintenance Hemodialysis Patients. J Ren Nutr. 2022;32:476-482. 11. Brandão da Cunha Bandeira S, Cansanção K, Pereira de Paula T, Peres WAF. Evaluation of the prognostic significance of the malnutrition inflammation score in hemodialysis patients. Clin Nutr ESPEN. 2020; 35:109-115. 12. Parthasarathy R, Oei E, Fan SL. Clinical value of body composition monitor to evaluate lean and fat tissue mass in peritoneal dialysis. Eur J Clan Nutr. 2019; 73:1520-1528. 13. Hwang SD, Lee JH, Lee SW, et al. Risk of overhydration and low lean tissue index as measured using a body composition monitor in patients on hemodialysis: a systemic review and meta-analysis. Ren Fail 2018; 40:51-59. 14. Rosenberger J, Kissova V, Majernikova M, et al. Body composition monitor assessing malnutrition in the hemodialysis population independently predicts mortality. J Ren Nutr. 2014; 24:172-6. 15. Moorthi RN, Avin KG. Clinical relevance of sarcopenia in chronic kidney disease. Curr Opin Nephrol Hypertens. 2017; 26:219-228.

CONCLUSIONS

16. Verzola D, Procopio V, Sofia A, et al. Apoptosis and myostatin mRNA are upregulated in the skeletal muscle of patients with chronic kidney disease. Kidney Int. 2011; 79:773-782.

The results of the present study suggest that myostatin may be a promising marker for identification of malnutrition and muscle wasting in hemodialysis patients. It shows significant association with poor hemodialysis adequacy, anemia and inflammatory marker.

17. Enoki Y, Watanabe H, Arake R, et al. Indoxyl sulfate potentiates skeletal muscle atrophy by inducing the oxidative stress-mediated expression of myostatin and atrogin-1. Sci Rep. 2016; 6:32084. 18. Lee SJ. Myostatin: A Skeletal Muscle Chalone. Annu Rev Physiol. 2023; 85:269-291.

REFERENCES

1. Badrasawi M, Zidan S, Sharif I, et al. Prevalence and correlates of malnutrition among hemodialysis patients at hebron governmental hospital, Palestine: cross-sectional study. BMC Nephrol. 2021; 22:214.

19. Bataille S, Chauveau P, Fouque D, et al. Myostatin and muscle atrophy during chronic kidney disease. Nephrol Dial Transplant. 2021; 36:1986-1993.

2. Sahathevan S, Khor BH, Ng HM, et al. Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review. Nutrients. 2020; 12:3147.

20. Esposito P, Picciotto D, Battaglia Y, et al. Myostatin: Basic biology to clinical application. Adv Clin Chem. 2022; 106:181-234. 21. Esposito P, Battaglia Y, La Porta E, et al. Significance of serum Myostatin in hemodialysis patients. BMC Nephrol. 2019; 20:462.

3. Rotondi S, Tartaglione L, Pasquali M, et al. Association between Cognitive Impairment and Malnutrition in Hemodialysis Patients: Two Sides of the Same Coin. Nutrients. 2023; 15:813.

22. Esposito P, La Porta E, Calatroni M, et al. Modulation of Myostatin/Hepatocyte Growth Factor Balance by Different Hemodialysis Modalities. Biomed Res Int. 2017; 2017:7635459.

4. Choi SR, Lee YK, Cho AJ, et al. Malnutrition, inflammation, progression of vascular calcification and survival: Inter-relationships in hemodialysis patients. PLoS One. 2019 ; 14: e0216415.

23. Koyun D, Nergizoglu G, Kir KM. Evaluation of the relationship between muscle mass and serum myostatin levels in chronic hemodialysis patients. Saudi J Kidney Dis Transpl. 2018; 29:809-815.

5. Sá Martins V, Adragão T, Aguiar L, et al. Prognostic Value of the Malnutrition-inflammation Score in Hospitalization and Mortality on Long-term Hemodialysis. J Ren Nutr. 2022; 32:569-577

24. Delanaye P, Bataille S, Quinonez K, et al. Myostatin and InsulinLike Growth Factor 1 Are Biomarkers of Muscle Strength, Muscle Mass, and Mortality in Patients on Hemodialysis. J Ren Nutr. 2019; 29:511-520.

6. Bolasco P. Hemodialysis-Nutritional Flaws in Diagnosis and Prescriptions. Could Amino AcidLosses be the sharpest “Sword of Damocles"? Nutrients. 2020; 12: 1773.

25. Han DS, Chen YM, Lin SY, et al. Serum myostatin levels and grip strength in normal subjects and patients on maintenance haemodialysis. Clin Endocrinol. 2011; 75:857-63.

7. Verzola D, Barisione C, Picciotto D, et al. Emerging role of myostatin and its inhibition in the setting of chronic kidney disease. Kidney Int. 2019; 95:506-517.

26. Yasar E, Tek NA, Tekbudak MY, et al. The Relationship between Myostatin, Inflammatory Markers, and Sarcopenia in Patients with Chronic Kidney Disease. J Ren Nutr. 2022; 32:677-684.

8. Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. A malnutrition-inflammation score is correlated with morbidity and mor-

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27. Bataille S, Dou L, Bartoli M, et al. Mechanisms of myostatin and activin A accumulation in chronic kidney disease. Nephron Dial Transplant. 2022; 37:1249-1260.

Insulin Resistance in Elderly Patients Undergoing Hemodialysis. J Aging Res. 2022; 2022:1327332. 29. Lee SM, Kim SE, Lee JY, et al. Serum myostatin levels are associated with abdominal aortic calcification in dialysis patients. Kidney Res Clin Pract. 2019; 38:481-489.

28. Widajanti N, Soelistijo S, Hadi U, et al. Association between Sarcopenia and Insulin-Like Growth Factor-1, Myostatin, and

Correspondence Amal H. Ibrahim, MD mkellany@yahoo.com Department of Internal Medicine, Nephrology Unit, Al-Azhar University, Cairo, Egypt Sammar A. Kasim, MD summerahmed1983@yahoo.com Department of Internal Medicine, Nephrology Unit, Faculty Medicine, Al-Azhar University, Cairo, Egypt Alshimaa A. Ezzat, MD Dr.alshimaa83@gmail.com Department of Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Noha E. Ibrahim, MD Nohaelsayed855@gmail.com Department of Microbial Biotechnology, Biotechnology Research Institute, National Research Centre (NRC), Giza, Egypt Donia A. Hassan, MD dr.donia1@hotmail.com Department of Clinical Pathology, Al-Azhar University, Cairo, Egypt Amira Sh. Ibrahim, MD Amirashahin694@gmail.com Department of Rheumatology and Rehabilitation, Faculty of Medicine for girls, Al-Azhar University, Cairo, Egypt Tamer A. Abouelgreed, MD (Corresponding Author) dr_tamer_ali@yahoo.com tamerali.8@azhar.edu.eg Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Ehab M. Abdo, MD ehababdo48@yahoo.com Department of Vascular Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Naglaa M. Aboelsoud, MD nglaa.mahmoud@gmail.com Department of Radiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Nermeen M. Abdelmonem, MD neeermeeenmohamed@gmail.com Department of Radiology, Thumbay University Hospital, Ajman, UAE Mohammad Thabet Alnajem, MD mtnajem@gmail.com Department of Radiology, Tawam Hospital, Alain, UAE. Ahmed A. Aboomar, MD ahmed_abo_omar12@yahoo.com Department of internal medicine, Nephrology Unit, Faculty Medicine, Tanta University, Tanta, Egypt

Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11869

DOI: 10.4081/aiua.2023.12128

ORIGINAL PAPER

The effect untreated right subclinical varicocele on the outcomes of contralateral left clinical varicocelectomy in infertile patients Sevgin Yılmaz 1, Murat Topcuoğlu 2, Murat Çakan 1, Ali Akkoç 2, Murat Uçar 2 1 Department of Urology, University of Health Sciences Dıskapı Training And Research Hospital, Ankara, Turkey; 2 Department of Urology, Faculty of Medicine, Alanya Alaaddin Keykubat University, Alanya Turkey.

by physical examination and graded into three as grade I (dilated veins palpable with Valsalva), grade II (dilated veins palpable during rest but not visible) and grade III (dilated veins visible and palpable during rest (5). Subclinical varicocele (SCV) is the abnormal dilatation of the veins of the pampiniform plexus that cannot be detected by physical examination but can be diagnosed by imaging modalities (6). Although CV is diagnosed by physical examination, physical examination can be unsatisfactory or confusing due to factors such as a patient's history of scrotal surgery, coexisting hydrocele, obesity, or improper examination. As such, the European Association of Urology (EAU) guideline recommends that imaging studies must be used to confirm the diagnosis in infertile men with CV (7). At the present time, scrotal color Doppler ultrasound (CDUS) has become the most widely used imaging technique for the diagnosis and classification of both CV and SCV (5, 6). Although US and European guidelines recommend that treatment should only be offered for palpable varicoceles in infertile males, different trials have reported conflicting results demonstrating the benefits of repairing subclinical varicocele (6, 9-10). According to EAU, varicocelectomy should only be performed in patients with CV, impaired semen analysis and infertility lasting ≥ 2 years (11). Although isolated unilateral SV in infertile patients is not at all an indication for varicocele repair, the management of infertile men with unilateral SV and contralateral CV remains a controversial issue and there is no consensus on whether bilateral varicocele repair is superior to unilateral varicocele repair in patients with left clinical varicocele (LCV) and right SCV (12-13). Reported conflicting outcomes may be due, in part, to the small study size, different study designs, and the effect of varicocelectomy techniques in different studies. For infertile patients with left CV and right SCV, it is worthwhile to study whether bilateral or unilateral surgical repair should be performed. In the present study, we performed a retrospective study of oligoasthenospermic infertile patients diagnosed with solitary LCV or LCV with RSV. We compared the improvement in spermiogram parameters after left varicocelectomy between the two groups of patients. We aimed to determine whether the presence of an untreated right SCV influenced the spermiogram parameters after left clinical varicocelectomy.

Summary

Purpose: The management of infertile patients with unilateral subclinical varicocele (SCV) and contralateral clinical varicocele (CV) remains controversial. We aimed to evaluate the effect of untreating SCV on the outcome of contralateral clinical varicocelectomy in infertile patients with oligoasthenozoospermia (OA). Materials and methods: Infertile patients with the diagnosis of OA who underwent left varicocelectomy were retrospectively evaluated. While all patients in the study had left clinical varicocele (LCV), some patients had concomitant right SCV. Patients were divided into two groups according to the presence or absence of a right SCV accompanying LCV as group 1; (LCV n = 104) or group 2; (LCV with right SCV, n = 74). Patients were evaluated with spermiogram parameters, pregnancy rates and serum levels of follicle stimulating hormone, luteinizing hormone, total testosterone at the first year of the follow-up. Results: The mean sperm concentration increased significantly in both groups. However, group 1 showed significantly greater improvement than group 2. The ratio of progressive motile sperm in group 1 was increased significantly whereas no significant change was shown in group 2. Both the spontaneous pregnancy rate and the pregnancy rate with ART were statistically lower in the group of patients with right SCV. No statistically significant difference was detected in serum hormone levels in both groups after varicocelectomy operations. Conclusions: Untreated right SCV may have adverse impact on the outcomes of left clinical varicocelectomy. In this context, the right testis can be considered in terms of treatment in patients with right SCV accompanying left CV.

KEY WORDS: Infertility; Subclinical Varicocele; Varicocelectomy. Submitted 24 November 2023; Accepted 5 December 2023

INTRODUCTION

According to the World Health Organization, the overall prevalence of primary infertility ranges between 3.9% and 16.8%, and up to 60% of infertility cases have been reported to be associated with men (1-2). Varicocele is the most common curable cause of male infertility and present in nearly 25% of men with abnormal semen quality and 35% of men with primary infertility (3-4). Varicocele can be classified as clinical or subclinical based on the radiological and clinical criterions. Clinical varicocele (CV) is diagnosed

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12128

Sevgin Yılmaz, Murat Topcuoğlu, Murat Çakan, Ali Akkoç, Murat Uçar

MATERIALS AND METHODS

in this study was performed with computer software (Statistical Package for Social Sciences, version 10.0; SPSS, Chicago, IL). As a result of Kolmogorov-Smirnov normality test, since the distribution of the measurements was suitable for normal distribution, the number of data was sufficient, and there were no outliers, tests that provided the parametric test approach were applied (p > 0.05).

This retrospective study includes one hundred seventyeight primary infertile males with the findings of oligoasthenospermia (oligospermia and asthenospermia) in at least 2 consecutive semen analyses. Primary infertility is defined as never been involved in a conception and the failure to obtain a natural pregnancy at least 12 months of following regular unprotected sexual intercourse. The study protocol was reviewed and approved by the Institutional Review Board of Health Science University, Dışkapı Training and Research Hospital (No. 143/07). The study was performed according to the Declaration of Helsinki. As per our protocol, recurrent varicocele, secondary infertility, necrospermia, endocrinopathy, history of orchitis and cryptorchidism, use of vitamins or hormonal supplements, abnormal peripheral karyotype, Y chromosome microdeletion and cases whose partners have got fertility problems were excluded from the study. Patients with severe oligoasthenospermia (TMSC < 1x106/mL) and azoospermia were also excluded from the study. A medical history was taken, and a scrotal examination was performed by the same physician in an upright position during normal breathing and Valsalva manoeuvres. Two consecutive spermiograms were performed before the treatment and at the first year of the treatment. Pregnancy rates were recorded at the first year control visit. Semen samples were acquired by masturbation following three days of abstinence. Data including scrotal examination, medical history and two consecutive spermiograms at baseline and at the first year of the treatment, were retrieved from the electronic patient folders. Spermiogram analysis data were recorded as the average of two semen samples. Semen samples were analysed for volume, sperm count, concentration, motility, morphology, viability. Oligoasthenospermia is defined according the criteria’s which were recognized by the WHO in 2010 (normal total sperm count, ≥ 39x106, normal sperm concentration ≥ 15x106/mL, and normal typical morphology > 4%, normal progressive motility > 32% (14). CV was diagnosed by physical examination and graded according to Dubin grading system (grade I to III). Scrotal CDUS was used to diagnose SCV and to confirm CV. The diagnostic criterion of a SCV is the presence of dilated veins in the pampiniform plexus > 2 mm, demonstrating reflux during the Valsalva manoeuvre on CDU without any physical examination finding (15). Patients were divided into groups as group 1 (LCV and right testis without varicocele n = 104) or group 2 (LCV with RSV, n = 74) according to whether LCV was associated with right SCV or not. Patients in both groups underwent left microsurgical subinguinal varicocelectomy. Primary endpoint of the study was to compare the groups in terms of seminal response, and pregnancy rates following varicocelectomy. Secondary endpoint of the study was to compare the changes in testicular volume and serum hormone profile between the groups at the first year of the surgery. All measurement data are presented as the mean SD with paired or unpaired Student-t test used for statistical evaluation. The chi-square test was used to compare sperm parameters. One-sample Kolmogorov-Smirnov was used to test the normal distribution. Analysis of the data obtained

RESULTS

A total of 178 primary infertile males with impaired semen parameter who went unilateral left varicocelectomy were retrospectively evaluated. Of the 178 patients, 104 were in group 1 and 74 were in group 2. The demographic and baseline characters of the patients were presented in Table 1. The mean age of the patients was 33.1 ± 6.2 years in the group 1 and 32.6 ± 6.4 years in the group 2 (p =.326). The group 1 and group 2 had an infertility duration of 30.4 ± 4.6 and 32.6 ± 4.1 months which revealed no statistical difference (p =.422). The baseline seminal parameters including mean sperm concentration, progressive motility, normal sperm morphology and viability were comparable between the two groups. In addition, no statistically significant differences were observed in terms of, right and left testicular volume and serum

Table 1. Baseline data of the infertile patients in both groups.

Age !nfertility period (months) Left Varicocel Grade Grade 1 (n) Grade 2 (n) Grade 3 (n) Sperm Concentration x106/mL Progressive Motile (a+b) (%) Normal sperm morphology (%) Sperm viability (%)

Testis Volume (mL) (Right) Testis Volume (mL) (Left) FSH level (mIU/mL) LH level (mIU/mL) TT (ng/dL) (median)

Group 1 (n = 104) X ± s.d. (µ-IQR) 33.10 ± 6.20 (32.50-5.70) 30.40 ± 4.60 (30.20-7.10)

Group 2 (n = 74) X ± s.d. (µ-IQR) 32.60 ± 6.40 (31.80-5.50) 32.60 ± 4.10 (31.40-6.90)

P value

10 (10%) 60 (58%) 34 (33%) 5.50 ± 1.90 (5.90-1.50) 19.20 ± 4.93 (20.50-5.00) 8.42 ± 2.57 (8.70-2.50) 56.00 ± 11.22 (57.30-10.50) (22.50-6.50) 14.6 ± 3.6 (14.50-3.50) 13.75 ± 2.80 (14.20-4.00) 8.40 ± 4.30 (8.50-3.50) 6.40 ± 1.10 (6.50-1.50) 406.23 ± 202.25 (417.00-75.00)

7 (9%) 41 (55%) 26 (35%) 4.42 ± 1.73 (4.75-1.30) 18.41 ± 3.72 (19.00-6.50) 7.68 ± 1.93 (8.00-3.00) 52.00 ± 10.83 (53.50-9.50) (24.20-6.00) 14.1 ± 3.4 (15.60-3.00) 14.01 ± 3.40 (14.50-3.00) 7.70 ± 4.70 (8.00-4.00) 5.80 ± 0.90 (6.00-1.00) 432.47 ± 287.23 (438.00-87.00)

.876 .549 .343 .234

For Left Varicocel Grade 15% of expected cell counts less than 5. µ, Population Mean; IQR, Interquartile Range; FSH, Follicle Stimulating Hormone; LH, Luteinizing Hormone; TT, Total Testesterone.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12128

.326 .422

.767 .876 .432

.232 .384 .321 .156 .146

Effects of untreated unilateral subclinic varicocele

Table 2. Change in sperm parameters and pregnancy rates in both groups following left varicocelectomy.

Sperm Concentration (106/mL) Progressive Motility (%)

Group 1 (n = 104) Pre-operative Post-operative X ± s.d. X ± s.d. (µ-IQR) (µ-IQR) 5.52 ± 1.90 24.30 ± 5.32 (5.70-4.00) (24.10-7.00) 19.21 ± 4.90 46.31 ± 9.44 (19.50-6.50) (49.5-10.20) 8.40 ± 2.50 14.20 ± 3.70 (8.50-4.00) (15.00-5.50) 50,00 ± 11.20 69,00 ± 16.80 (55.20-14.50) (70.5-15.50) 48(46%) 42 (40%) 6 (6%)

.002 .013

Group 2 (n = 74) Pre-operative Post-operative X ± s.d. X ± s.d. (µ-IQR) (µ-IQR) 4.40 ± 1.72 13.21 ± 2.90 (5.00-3.00) (12.50-5.50) 18.40 ± 3.71 26.11 ± 5.40 (17.50-4.50) (28.30-7.50) 7.60 ± 1.90 10.9 ± 5.91 (8.40-2.50) (10.40-3.00) 48,00 ± 10.80 56,00 ± 12.4 (52.55-12.20) (58.70-13.0) 20 (27%) 18 (24%) 2 (5%)

P Po 1-2

.045

.032

.042

.026

cant difference was observed between the groups in both spontaneous pregnancy rates and pregnancy rates with ART (p = .018). There was no significant change in testicular volume and serum hormone levels after surgery in both groups.

DISCUSSION

In this retrospective, non-randomized study, we aimed to show the Sperm viability (%) .034 .048 .047 effect of untreated SCV on the outcome of contralateral varicocelecPregnancy rates(n) .018 tomy for LCV. We showed less Spontaneous improvement in semen parameters ART and also lower pregnancy rates in For Pregnancy rates 18% of expected cell counts less than 5. the group of patients with right µ, Population Mean; IQR, Interquartile Range; ART: Assisted Reproductive Technology. SCV and LCV compared to patients with LCV following left varicocelectomy. Varicocele is one FSH, LH and TT levels between the two groups before the of the leading cause of impaired spermatogenesis and the surgery. The changes of semen parameters in the first year most common correctable cause of male infertility (16). after left varicocelectomy in the two groups are shown in The main purpose of varicocelectomy in male infertility is Table 2. There were statistically significant increases in to improve the semen parameters, achieve natural concepsperm concentration, and progressive motility, viability in tion, and reduce the level of assisted reproductive techboth groups, while the normal morphology remained nology. Several studies have suggested that varicocelectounchanged for both groups after the varicocelectomy. my has a beneficial effect on sperm parameters and fertiliAfter the surgery, the mean sperm concentration ty status in infertile men only with palpable varicocele (3increased significantly in both groups, but the improve17). According to EAU and AUA guidelines, varicocelecment in group 1 was significantly greater than the group 2 tomy should only be performed in infertile men with CV (increased to 24.3 ± 5.3 in group 1 versus 13.2 ± 2.9 in and abnormal spermiogram (18, 19). Recently, due to the group 2, respectively, p = .032). In addition observed increasing popularity of CDUS, the diagnosis of SCV has changes in progressive sperm motility, (to 46.3 ± 9.4 in increased. The increase in the detection rate of bilateral group 1, versus to 26.1 ± 5.4 in group 2, p = .026), viavaricocele is mainly due to the neglect of the detection of bility (to 69 ± 16.8 in group 1 versus to 56 ± 12.4 in SV in previous reports (20). The impact of SCV on the group 2, p = .047) were more statistically significant in sperm parameters is still debated and the clinical signifigroup 1 compared to group 2. In the first-year control of cance of repairing sonographically detected varicocele is varicocelectomy, the pregnancy rate was 46% in group 1, controversial regarding male infertility (5, 21). Since prewhile this rate was 26% in group 2. A statistically signifivious trials have reported that varicocele size had no effect on pregnancy rates, leading to the conclusion that very small varicoceles, even SCV should be diagTable 3. Change in bilateral testicular volume and hormone profile in both groups following left nosed and treated (6, 22). varicocelectomy. Evidence that varicocele size does not correlate with pathology in tesGroup 1 (n = 104) Group 2 (n = 74) ticular structure or sperm paramePre-operative Post-operative P Pre-operative Post-operative P P Po 1-2 ters is supported by the demonX ± s.d. X ± s.d. X ± s.d. X ± s.d. stration that SCV also may have a (µ-IQR) (µ-IQR) (µ-IQR) (µ-IQR) damaging effect on the spermatoTestis Volume (ml) (Right) 14.6 ± 3.6 14.4 ± 3.40 .734 14.1 ± 3.4 14.2 ± 2.6 .956 .876 genesis (23). SCV may be a milder (14.8-2.50) (14.5-2.50) (14.3-3.00) (14.0-2.50) form of CV with the same pathoTestis Volume (ml) (Left) 13.7 ± 2.8 14.2 ± 3.10 .646 14.3 ± 3.2 14.4 ± 2.8 .845 .640 genic mechanism and the results (13.9-3.20) (14.0-3.00) (14,7-3.50) (15.0-2.80) showed that 28% of SCV in adoFSH level (mIU/mL) 13.6 ± 4.30 12.2 ± 4.90 .221 12.7 ± 4.7 11.6 ± 3.9 .134 .244 lescent patients progressed to CV (13.5-4.00) (12.0-6.00) (12.5-4.50) (12.0-4.00) (24-25). Dhabuwala et al. showed LH level (mIU/mL) 15.4 ± 4.10 14.5 ± 4.20 .642 (14.8 ± 0.9) 14.6 ± 4.00 .934 .784 that seminal response and fertility (16.5-5.00) (15.0-5.00) (15,5-2.0) (14.0-4.00) were improved after subclinical TT (ng/dl) 290 ± 168 310 ± 176 .634 305 ± 187 340 ± 202 .440 .510 varicocelectomy and suggested (median) (300-90) (325-100) (310-100) (355-120) that SCV may have similar deleteµ, Population Mean; IQR, Interquartile Range; FSH, Follicle-Stimulating Hormone; LH, Luteinizing Hormone; TT, Total Testesterone. rious effects as CV (6). In contrast Normal sperm morphology (%)

.532

.446

.342

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12128

Sevgin Yılmaz, Murat Topcuoğlu, Murat Çakan, Ali Akkoç, Murat Uçar

to these studies, it has been suggested that the improvement in semen parameters after the surgical treatment of SCV is associated with lower success rates compared to CV surgery (26). A review evaluating three randomized clinical trials emphasized no evidence of benefit following varicocelectomy in infertile men with SCV (27). Likewise, Jarow et al. showed that the improvement in semen quality after subclinical varicocelectomy was statistically lower than CV repair and pointed out that the benefit from subclinical varicocelectomy is questionable (28). Although there is no prominent consensus on the management of SCV, another issue discussed in the literature is the management of infertile patients with unilateral SCV accompanying contralateral CV. We did not perform right subclinical varicocelectomy in the group of patients with right SCV as recommended by current guidelines, and we assessed the results of left varicocelectomy in both groups of patients. In our study, spermiogram parameters (e.g., concentration, progressive motility, motility,) were significantly improved after left varicocelectomy in patients with left CV. Significant improvement was shown only in sperm concentration and progressive motility in patients with right SCV and left CV. Statistically better improvement in sperm parameters including concentration, progressive motility, total motility were shown in left CV patients compared to patients with left CV and right SCV at the first year of the surgery. A trial including one hundred forty-five infertile males with left CV or left CV with right SCV investigated the seminal response following either unilateral or bilateral varicocele repair. The authors showed that patients who underwent bilateral varicocele repair had more significant improvement in semen parameters (sperm concentration and progressive motility) and had higher spontaneous pregnancy rate compared to patients those underwent left varicocele repair (29) . In a recent metaanalysis including six hundred thirty-seven patients of either left CV or left CV with right SCV, improvement in spermiogram parameters following bilateral varicocelectomy or unilateral varicocelectomy were compared (30). Statistically significant improvement in progressive sperm motility, sperm morphology was reported in favour of the bilateral varicocelectomy group. However, no statistically significant differences were revealed in sperm concentration between two groups. In a randomized controlled study, more significant changes in seminal response were shown in bilateral varicocelectomy compared to unilateral left varicocelectomy in infertile males with left CV and right SCV (31). Subsequent right varicocelectomy improved semen quality in 56% of patients, with a pregnancy rate of 43% in selected infertile patients those with no improvement in sperm parameters following left varicocelectomy. A recent study evaluating the outcomes bilateral varicocelectomy reported that, bilateral varicocele was found to be as high as 98.5% after radiologic assessment and subclinical varicocelectomy may be useful to avoid disease recurrence and optimize treatment outcomes (32). Contrary to these findings, Grasso et al. claimed that the benefit of repairing right SCV associated with left CV was not substantial, given the possible additional morbidity and additional operative time (33). Secondary endpoint of the study was to compare the changes in testicular volume and serum hormone profile

between the groups. There were no significant differences in bilateral testicular volume between the two groups at baseline and the first year of surgery. Similar to the negative effect of CV on testicular volume, it has been reported in previous studies that testicular volume decreases in SCV (34). Although Pasqualotto et al. did not observe an increase in mean left testicular volume in patients with left CV and right SCV who underwent bilateral varicocelectomy, they observed a significant increase in in the mean volume of right testis following bilateral varicocelectomy (35). They suggested that the varicocelectomy may increase the testicle size and this may be the reason for the surgery’s leading to an improvement in semen analysis. We evaluated hormone profile at baseline and compared the serum hormone levels at the first year of postoperative period. Neither preoperative abnormalities nor significant changes in serum hormone levels following varicocelectomy were observed in either group of our study. Zheng et al. indicated that SCV did not affect hormone levels, as they were unable to find statistical differences in hormone levels between patients with left CV only and right SCV with left CV (36). Our study has some limitations which need to be considered while evaluating its findings. First, it is a retrospective study that can be affected by all potential weaknesses stemming from its retrospective design. Second, according to current guidelines, we performed left varicocelectomy only in the bilateral varicocele group and assessed the deleterious effect of SCV on sperm quality, rather than subclinical varicocelectomy direct impact.

CONCLUSIONS

The topic of whether to repair or not to repair the ipsilateral SCV in patients with contralateral CV is still controversial. Untreated right SCV may have detrimental effects on sperm parameters. This hypothesis should be supported by the larger case studies with the outcomes of right SCV repair in patients with accompanying left CV.

REFERENCES

1. Calverton, Maryland, USA: ORC Macro and the World Health Organization; 2004. World Health Organization. Infecundity, Infertility, and Childlessness in Developing Countries. DHS Comparative Reports No 9. 2. Sadock BJ, Sadock VA. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2003. Kaplans and Sadocks Symptoms of Psychiatry Behavioral Sciences Clinical Psychiatry; pp. 872-4. 3. Ficarra V, Cerruto MA, Liguori G, et al. Treatment of varicocele in subfertile men: The Cochrane review. A contrary opinion. European Urology. 2006; 49:258-263. 4. Kroese AC, De Lange NM, Collins J, Evers JL. Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev. 2012; 10:CD000479. 5. Jarow JP. Effects of varicocele on male fertility. Hum Reprod Update. 2001; 7:59-64. 6. Dhabuwala CB, Hamid S, Moghisi KS. Clinical versus subclinical varicocele: improvement in fertility after varicocelectomy Fertil Steril. 1992; 57:854-857.

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Effects of untreated unilateral subclinic varicocele

embolization for varicoceles in subfertile men. Cochrane Database Syst Rev. 2012; CD000479.

7. WHO, WHO Manual for the Standardized Investigation, Diagnosis and Management of the Infertile Male. 2000, Cambridge University Press: Cambridge.

28. Jarow JP, Ogle SR, Eskew LA. Seminal improvement following repair of ultrasound detected subclinical varicocele. J Urol. 1996; 155:1287-1290.

8. Lee J, Binsaleh S, Lo K, Jarvi K. Varicoceles: The diagnostic dilemma. J. Androl. 2008; 29:143-6.

29. Elbendary MA, Elbadry AM. Right subclinical varicocele: how to manage in infertile patients with clinical left varicocele? Fertil Steril. 2009; 92:2050-3.

9. Niu Y, Wang D, Chan Y, et al. Comparison of clinical outcome of bilateral and unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: a meta-analysis of randomized controlled trials. Andrologia. 2018; 50:e13078.

30. Niu Y, Wang D, Chen Y, et al. Comparison of clinical outcome of bilateral and unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: A meta-analysis of randomised controlled trials. Andrologia. 2018; 50:e13078.

10. Report on varicocele and infertility: A committee opinion. Practice Committee of the American Society for Reproductive Medicine; Society for Male Reproduction and Urology Fertil Steril. 2014; 102:1556-60.

31. Sun XL, Wang JL, Peng YP, et al. Bilateral is superior to unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: a prospective randomized controlled study. Int Urol Nephrol. 2018; 50:205-10.

11. Jungwirth A, Giwercman A, Tournaye H, et al. European Association of Urology Working Group on Male Infertility: the 2012 update. Eur Urol. 2012; 62:324-332.

32. Almekaty KM, Elsharkawy AM, Zahran MH, et al. Bilaterality of varicocele: The overlooked culprit in male infertility. Case series study. Arch Ital Urol Androl. 2023; 95:11580.

12. Sun XL, Wang JL, Peng YP, et al. Bilateral is superior to unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: a prospective randomized controlled study. Int Urol Nephrol. 2018; 50:205-210. 13. Marsman JW, Schats R. The subclinical varicocele debate Hum Reprod.1994; 9:1-8.

33. Grasso M, Lania C, Castelli M, et al. Bilateral varicocele impact of right spermatic vein ligation on fertility. J Urol. 1995; 153:18471848.

14. Cooper TG, Noonan E, Von Eckardstein S, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update. 2010; 16:231-45.

34. Zini A, Buckspan M, Berardinucci D, Jarvi K. The influence of clinical and subclinical varicocele on testicular volume. Fertil Steril. 1997; 68:671-674.

15. Tsampoukas G, Dellis A, Papatsoris A. Bilateral disease and intratesticular haemodynamics as markers of dyspermia in patients with subclinical varicocele: A prospective study. Arab J Urol. 2019; 17:298-304.

35. Pasqualotto FF, Lucon AM, De Góes PM, et al. Is it worthwhile to operate on subclinical right varicocele in patients with grade II-III varicocele in the left testicle? J Assist Reprod. Genet. 2005; 22:227231.

16. Chiba K, Fujisawa M. Clinical outcomes of varicocele repair in infertile men: a review. World J Mens Health. 2016; 34:101-109.

36. Zheng YQ, Gao X, Li ZJ, et al. Efficacy of bilateral and left varicocelectomy in infertile men with left clinical and right subclinical varicoceles: A comparative study. Urology. 2009; 73:1236-1240.

17. Marmar JL, Agarwal A, Prabakaran S, et al. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril. 2007; 88:639-648. 18. Dohle GR, Colpi GM, Hargreave TB, et al. EAU guidelines on male infertility. Eur Urol. 2005; 48:703-711. 19. Sharlip ID, Jarow JP, Belker AM, et al. Best practice policies for male infertility. Fertil Steril. 2002; 77:873-882. 20. Scherr D, Goldstein M. Comparison of bilateral versus unilateral varicocelectomy in men with palpable bilateral varicoceles. J Urol. 1999; 162:85-88.

Correspondence Sevgin Yılmaz sevginyilmaz80@gmail.com Murat Çakan muratcakandr@yahoo.com Department of Urology, University of Health Sciences Dıskapı Training And Research Hospital, Ankara, Turkey

21. Unol D, Yeni E, Verit A, Karatas OF. Clomiphene citrate versus varicocelectomy in treatment of subclinical varicocele: a prospective randomized study. Int J Urol. 2001; 8:227-30. 22. McClure DR, Khoo D, Jarvi K, Hricak H. Subclinical varicocele: The effectiveness of varicocelectomy. J Urol. 1991; 145:789-791. 23. Dubin L, Amelar RD. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril. 1970; 21:606-609.

Murat Topcuoğlu muraturo@yahoo.com Ali Akkoç aliakkoc@gmail.com Murat Uçar ucarmurat07@gmail.com Department of Urology, Faculty of Medicine, Alanya Alaaddin Keykubat University, Alanya Turkey

24. Chen SS. Significant predictive factors for subfertility in patients with subclinical varicocele. Andrologia. 2017; 49. 25. Cervellione RM, Corroppolo M, Bianchi, A. Subclinical varicocele in the pediatric age group. J Urol. 2008; 179:717-719. 26. Marks JL, McMahonen R, Lipschultz LI. Predictive parameters of successful varicocele repair. J Urol. 1986; 136:609-612. 27. Kroese AC, De Lange NM, Collins J, Evers JL. Surgery or

Conflict of interest: The authors declare no potential conflict of interest.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12128

DOI: 10.4081/aiua.2023.11906

ORIGINAL PAPER

Seminal calbindin 2 level in azoospermia and oligoasthenoteratozoospermia and its correlation with seminal and hormonal parameters Sameh Fayek GamalEl Din 1, Noha Abdelhafeez Abdelkader 2, Mohamed Yousry El-Amir 1, Asmaa Anter Sayed Ahmed 3, Hesham Fouad Abdel-latif 1, Mohamed Farag Azmy 4 1 Department of Andrology, Sexology and STDs, Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt; 2 Department of Clinical and Chemical Pathology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt; 3 Egypt Ministry of Health & Population, Cairo, Egypt;

4 Department of Andrology, Sexology and STDs, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt.

semen analysis (2). Defective sperm motility in the form of decreased progressive motility or absence of motility is defined as asthenozoospermia which is usually accompanied by oligozoospermia or teratozoospermia (3). Harbouring above 85% morphologically abnormal sperms in semen is considered teratozoospermia (TS). TS is classified into monomorphic and polymorphic. In monomorphic TS, all sperms have the same morphological abnormality while in polymorphic type, there are different varieties of abnormal sperm morphologies (4). Calbindin 2 (CALB 2; Calretinin; 29 kDa Calbindin) is a calcium binding protein that is mostly secreted in the nervous system as well as the ovary, the adrenal glands, and the testis. The main function of CALB 2 is to buffer intracellular calcium ion to stop Ca2+ overload as well as a Ca2+ receptor (5). Ca2+, which is also a second messenger in the cytoplasm, plays an essential role in different physiological functions such as cell proliferation and apoptosis (6). Additionally, it regulates the synthesis of reproductive hormones (7). The primary studies revealed that the highest CALB 2 was secreted in the cytoplasm of Leydig cells of adult rats in synchrony with androgen level so postulating that CALB 2 might prompt steroidogenesis (8). Increment in viability and proliferation of Leydig cells by CALB 2 was attributed to inhibition of mitochondrial related apoptotic pathway through inducing ERK1/2 and AKT pathways as well as supressing cell apoptosis (9). Interestingly, CALB 2 can be deployed as a marker of normal and neoplastic Leydig cells of the testis as well as diagnosing atypical Leydig cell tumor (10). Non obstructive azoospermia (NOA) and OAT of unknown causes are common and are noticed in a high sector of infertile men. However, the underlying molecular mechanisms of these conditions remain unknown (11). We aimed to assess seminal CALB 2 expression in men with different semen parameters as well as to investigate potential correlations between seminal CALB 2 and different semen parameters in OAT patients. Furthermore, we aimed to find any correlation between seminal CALB 2 and reproductive hormones in NOA patients.

Summary

Objectives: We aimed to assess seminal calbindin 2 (CALB 2) expression in men with different semen parameters as well as its correlation with reproductive hormones in azoospermic patients and different semen parameters in oligoasthenoteratozoospermic patients. CALB 2 is also known as calretinin and 29 kDa calbindin. Materials and methods: This prospective study was performed on 96 cases from the andrology outpatient clinic divided into 3 groups as follows: group 1 including 32 non obstructive azoospermic (NOA) patients, group 2 including 32 patients with oligoasthenoteratozoospermia (OAT), and Group 3 including normozoospermic individuals as controls. Semen analysis and estimation of seminal CALB 2 concentrations by enzyme linked immunosorbent assay (ELISA) technique were performed for all participants. Reproductive hormones were measured in nonobstructive NOA patients. Results: The mean seminal CALB 2 level was higher in OAT patients compared to NOA patients and controls (7.8 ± 1.30 ng/ml, 7.3 ± 0.80 and 7.4 ± 1.0, respectively). Furthermore, the study had shown strong positive correlations between CALB 2 and sperm normal forms in controls and OAT patients. In contrast, there was no significant correlation between seminal CALB 2 and any of the reproductive hormones measured in NOA patients. Conclusions: Seminal CALB 2 may play a role in increasing the abnormal forms in OAT patients.

KEY WORDS: Non obstructive azoospermia; Oligoasthenoteratozoospermia; normozoospermia; Seminal CALB 2 (Calretinin & 29 kDa Calbindin); Reproductive hormones. Submitted 2 October 2023; Accepted 9 October 2023

INTRODUCTION

Abnormalities in the form of oligozoospermia, asthenozoospermia, teratozoospermia and high percentage of sperm DNA fragmentation are associated with decreased probability to conceive (1). Oligozoospermia is classically defined when sperm count is below 10M/mL. 15 M is the 5% percentile of the new 2021 WHO manual for

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S. Fayek GamalEl Din, N. Abdelhafeez Abdelkader, M. Yousry El-Amir, et al.

PATIENTS AND METHODS

was evaluated by using pre-coloured glasses (Testsimplets) and the eosin Y test was applied to evaluate sperm vitality.

The current prospective study was conducted in the andrology outpatient clinic during the period from April (2021) till January (2022). Approval by the local research and ethical committee was obtained that conforms to Helsiniki declaration (2013) (FMBUREC/09052021) (12). Written informed consents were obtained from the patients who were involved in the study. The study was performed on 96 randomized patients using simple numbering method. They were divided into 3 groups as follows: group (1) comprised of 32 NOA patients. Group (2) comprised of 32 patients with OAT. Group (3) comprised of 32 patients with normal semen parameters as controls.

Determination of CALB 2 Human CALB 2 was determined using Calretinin ELISA Kits supplied by SinoGeneClon Biotech Co., Ltd. Cat. No.: SG00383. This kit uses the Sandwich-ELISA principle with sensitivity 0.01 ng/mL and detection range 0.06-4 ng/mL. The microtiter plate of the Calretinin ELISA is coated with a capture antibody. The diluted sample was added and any antigen present bound to capture antibody. After a washing step, the detecting antibody (biotinylated anti-calretinin antibody) was added and bound to antigen. After another washing step the enzyme conjugate streptavidinperoxidase was added and bound to detect the antibody. The following substrate TMB/peroxidase reaction was monitored at 450 nm (reference wavelength at 620 nm).

Inclusion criteria of the patients Any infertile patient with normal testicular volume was included.

Determination of reproductive hormones in NOA patients Blood samples were obtained from azoospermic patients, and then samples were left to clot for 1 hour at room temperature or overnight at 2-8°C before centrifugation for 20 min at 1000×g at 2-8°C. The supernatant was collected to carry out the assay. Follicle stimulating hormone (FSH) was determined using ELISA Kits supplied by Elabscience Biotechnology, Inc, United States. Cat. No.: E-ELH1143. This kit used the sandwich-ELISA principle with sensitivity 0.94 mIU/mL and detection range 1.56-100 mIU/mL. Luteinizing hormone (LH) was determined using ELISA Kits supplied by Elabscience Biotechnology, Inc, United States. Cat. No.: E-EL-H6019. This kit used the sandwich-ELISA principle with sensitivity: 0.1mIU/mL and detection range 0.16-10mIU/mL. Serum prolactin was measured according to human prolactin (PRL) OneStep ELISA Kit (Boster Biological Technology, Pleasanton CA, USA, Catalog # EK7006) with analytical sensitivity 11.7 pg/mL and assay range 15.6-1000 pg/mL. Testosterone was determined using ELISA Kits supplied by MyBioSource, Inc., San Diego, USA. Cat. No.: MBS580035. Estradiol was determined using ELISA Kits supplied by Thermo Fisher Scientific, Inc. Third Avenue Waltham, MA USA. Cat. No.: KAQ0621. This kit used the sandwich-ELISA principle with sensitivity: 5 pg/mL and detection range 13-935 pg/mL.

Exclusion criteria of the patients Any patient with varicocele, smoker, leukocytospermia, abnormal karyotyping and finally evidence of severe uncontrolled medical diseases was excluded from the study. Inclusion criteria of the controls Any healthy age matched individual was recruited in group 3. Sample size was calculated using G power. At least 89 participants should be included in the three groups using F tests - ANCOVA: Fixed effects, main effects and interactions as well as a priori analysis (13). The participants were asked about any relevant medical history and were subjected to clinical examination. Also, 5 cc blood was withdrawn from each participant for hormones investigation [FSH, LH, total testosterone, estradiol, prolactin (PRL)] and semen analysis. Furthermore, all participants were asked about a history of hernia repair, scrotal surgery, pelvic surgery, endoscopic urethral instrumentation, or genitourinary infection. Testicular volume of all participants was routinely determined by Prader’s orchidometer. Furthermore, scrotal duplex was done for all participants to exclude varicocele. Semen analysis Semen samples were collected by masturbation following abstinence for 3-4 days. A special wide-mouth container was used to collect semen and incubated at 37°C until semen was liquefied. Semen analysis was then performed within 1 hour following the WHO manual criteria (5th edition, 2010) (14). Duplicate semen analyses were performed twice at the beginning and 3 months after initiating the study and the average of the two values was used for analysis. The same investigator performed all semen analyses to optimize repeatability (15). Seminal analysis was carried out within 30 minutes after liquefaction. The volume, viscosity, pH and appearance of semen were evaluated together with sperm concentration, progressive and total motility and morphology. Sperm concentration was evaluated using a Makler counting chamber (Irvine Scientific, Santa Ana, CA, USA) under an optical microscope (Nikon, Nikon Europe B.V., Amsterdam, The Netherlands) at 200x magnification. Sperm morphology

Statistical analysis Analysis of data was performed using SPSS v. 23 (Statistical Package for Social science) for Windows. Mean, standard deviation (SD), minimum and maximum were used to describe quantitative variables whereas number (No.) and percentages (%) were used to describe qualitative variables. Shapiro/Kolomogrov tests of normality were utilized to test for normality. The Chi square test was used to determine the statistical difference of the categorical data between the two groups. Pearson correlation was used to test the correlation between different quantitative variables.

RESULTS

There was no significant difference between the studied participants regarding their baseline characteristics (Table 1).

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Furthermore, one case had atrophic right Table 1. testis and 3 cases presented with small Sociodemographic characteristics of the participants. testis in NOA patients. There were three Group (1) Group (2) Group (3) P value cases with absent right epididymis and azoospermic patients oligoasthenoteratozoospermic normozoospermia 4 cases with absent vas deferens in the (n = 30) (OAT) (n = 30) (n = 30) Mean SD Mean SD Mean SD same group. Age (years) 33.3 ± 10.4 30.4 ± 8.1 29 ± 6.7 0.15 Additionally, the medians of FSH, LH, Marital status N % N % N % Testosterone, E2, and prolactin in NOA Single 5 16.7 patients were 5.40, 6.35, 4.50, 42.00 Married without offspring 16 53.3 30 100 and 7.50, respectively. Married with offspring 9 30.0 30 100 Furthermore, there was no significant P value was calculated using Chi-square test. difference between NOA, OAT and normozoospermic participants regarding seminal CALB 2 level (7.3 ± 0.80 ng/ml; 7.8 ± 1.40 ng/ml; 7.4 ± 1.0 ng/ml, p = 0.15, respectively). relations between sperm normal forms and seminal CALB Although seminal CALB 2 levels in NOA and OAT groups 2 levels in normozoospermic and OAT cases (Tables 3-4). were not significantly different to levels of normozoospermic participants (p > 0.05), yet, there was a higher predicTable 2. tive role of seminal CALB 2 levels in predicting OAT cases Cutoff values, area under the curve (AUC), sensitivity, compared to azoospermic cases (Table 2, Figures 1-2). specificity, positive predictive values and negative predictive Moreover, there were significant linear strong positive corvalues of seminal CALB 2 in azoospermic and oligoasthenoteratozoospermic (OAT) cases.

Figure 1. Receiver Operating characteristic curve for prediction of non obstructive azoospermia (compared with normozoospermia) using seminal calretinin level.

Azoospermic cases 0.92 7.2500 0.493 60 % 46% 60% 45%

P-value Cut off AUC Sensitivity Specificity Positive predictive value Negative predictive value

OAT cases 0.15 7.7500 0.609 50% 66% 50% 65%

Table 3. Correlation between seminal calbindin 2 (CALB 2) and age and semen parameters in normozoospermic participants. Age Sperm concentration (106/ml) Sperm total motility (%)

Figure 2. Receiver Operating characteristic curve for prediction of oligoathenoteratospermia (compared with normozoospermia) using seminal calretinin level.

Sperm normal forms (%)

Normozoospermic cases Pearson correlation (r) p-value Pearson correlation (r) p-value Pearson correlation (r) p-value Pearson correlation (r) p-value

Seminal CALB 2 (ng/ml) 0.055 0.77 -0.072 0.71 0.285 0.13 0.709 0.00

P value was calculated using Pearson correlation.

Table 4. Correlation between seminal calbindin 2 (CALB 2) and age and semen parameters in oligoasthenoteratozoospermic (OAT) cases. Age Sperm concentration (106/ml) Sperm total motility (%) Sperm normal forms (%)

OAT cases Pearson correlation (r) p-value Pearson correlation (r) p-value Pearson correlation (r) p-value Pearson correlation (r) p-value

P value was calculated using Pearson correlation.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11906

Seminal CALB 2 (ng/ml) -0.596 0.00 -0.088 0.64 0.347 0.06 0.763 0.00

S. Fayek GamalEl Din, N. Abdelhafeez Abdelkader, M. Yousry El-Amir, et al.

correlation between CALB 2 and any of the reproductive hormones measured in NOA cases. On the contrary, several studies have demonstrated a potential link between CALB 2 and steroidogenesis and reproductive hormones. Firstly, steroidogenesis in Leydig cells can be enhanced by increased free Ca2+ (18). In the same context, Altobelli et al. (2017) had detected CALB 2 immunoreactivity in human fetal testis, testis Leydig cells, seminiferous epithelium and epididymal epithelial cells (13). They assumed that CALB 2 is involved in the processes of production and/or secretion of hormones as well as in all calcium dependent differentiation processes that occur during gonadal development suggesting its involvement in steroidogenesis and spermatogenesis (13). However, the role played by CALB 2 cannot be precisely determined similarly to other calciumbinding proteins that behave differently in the presence of this ion to the extent that they are classified as “Ca-buffer” or “Ca sensor” proteins (19). This uncertainty of their exact role is due to the possible exposure of their hydrophobic residues after binding with calcium (19). Admittedly, our study is no free from limitations. Firstly, the small sample size can be considered as a major limitation. Moreover, the inability to use immunohistochemistry in the azoospermic cases to properly localize the site of production of CALB 2 can be regarded as another limitation. Also, not including cases of obstructive azoospermia could be seen as an additional limitation. Besides, another limitation was including one case with atrophic right testis and 3 cases with small testis in NOA patients. Finally, we were unable to evaluate reproductive hormones in all participants.

Table 5. Correlations between seminal calbindin 2 (CALB 2) and age and reproductive hormones in azoospermic patients. Age FSH LH Total testosterone Estradiol Prolactin

Azoospermic cases Pearson correlation (r) p-value Pearson correlation (r) p-value Pearson correlation (r) p-value Pearson correlation (r) p-value Pearson correlation (r) p-value Pearson correlation (r) p-value

Seminal CALB 2 (ng/ml) 0.032 0.87 -0.329 0.17 -0.307 0.22 -0.282 0.29 -0.173 0.46 -0.167 0.59

P value was calculated using Pearson correlation.

However, there was a significant linear strong negative correlation between age and seminal CALB 2 levels in OAT cases (Table 4). Finally, there was no significant linear correlation between seminal CALB 2 levels and any of the reproductive hormones measured in NOA cases (Table 5).

DISCUSSION

The present study is a case-control study conducted comparing seminal CALB 2 expression in men with normal semen parameters, OAT and NOA. The mean seminal CALB 2 level was higher in OAT cases compared to azoospermic cases and controls. Although, the values of seminal CALB 2 levels in OAT and azoospermic cases were not significantly different compared to normozoospermic participants, there was a higher predictive role of seminal CALB 2 levels in predicting OAT cases compared to NOA cases. Moreover, there was no significant linear correlation between seminal CALB 2 level and any of the reproductive hormones measured in NOA cases. On the other hand, there were significant linear strong positive correlations between sperm normal forms and seminal CALB 2 levels in normozoospermic and OAT cases. There was a high significant linear negative correlation between age and seminal CALB 2 level in OAT cases. Bar-Shira Maymon et al. (16) demonstrated that the expression of CALB 2 in abnormal Sertoli cells in non-obstructive azoospermia contributes to the multifactorial etiology of spermatogenic failure. In the same context, GamalEl Din et al. (17) demonstrated a negative impact of seminal CALB 2 on sperm normal forms in patients with varicocele (17). Furthermore, OAT patients showed the highest median seminal CALB 2 compared to the patients of other 2 groups in the current study. This can be explained by the fact that OAT patients would have more immature Sertoli cells compared to azoospermic patients and controls. Thus, they have increased levels of CALB 2 expression by the seminiferous epithelium and consequently have increased levels of seminal CALB 2. This agrees with GamalEl Din et al. (2023) who demonstrated that patients with bilateral varicocele had higher seminal CALB 2 compared to unilateral varicocele (17). Interestingly, the current study did not show any

CONCLUSIONS

In brief, seminal CALB 2 may play a role in increasing the abnormal forms in OAT cases.

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Seminal CALB 2 and azoospermia and OAT

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8. Liu S. Expression of calretinin in the testes of rats at diferent development stages. J Reprod Med. 2014; 21:70-76. 9. Xu W, Zhu Q, Zhang B, et al. Protective effect of calretinin on testicular Leydig cells via the inhibition of apoptosis. Aging. 2017; 9:1269.

15. Alahmar AT, Sengupta P, Dutta S, Calogero AE. Coenzyme Q10, oxidative stress markers, and sperm DNA damage in men with idiopathic oligoasthenoteratospermia. Clin Exp Reprod Med. 2021; 48:150.

10. Augusto D, Leteurtre E, De La Taille A, et al. Calretinin: a valuable marker of normal and neoplastic Leydig cells of the testis. Appl Immunohistochem Mol Morphol. 2002; 10:159-162.

16. Bar-Shira Maymon B, Yavetz H, Yogev L, et al. Detection of calretinin expression in abnormal immature Sertoli cells in non-obstructive azoospermia. Acta Histochem. 2005; 107:105-12.

11. Nasirpour H, Key YA, Kazemipur N, et al. Association of rubella, cytomegalovirus, and toxoplasma infections with recurrent miscarriages in Bonab-Iran: A case-control study. Gene Cell Tissue. 2017; 4:e60891.

17. GamalEl Din SF, Zeidan A, Salam MAA, et al. Seminal Calbindin 2 in Infertile Men With Varicocele: A Prospective Comparative Study. Reprod Sci. 2023; 30:3077-3083.

12. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013; 310:2191-4.

18. Ascoli M. Immortalized Leydig Cell Lines as Models for Studying Leydig Cell Physiology. In A. H. Payne & M. P. Hardy (eds) Contemporary Endocrinology: The Leydig Cell in Health and Disease. Humana Press (USA). 2007; pp. 373-381.

13. Altobelli GG, Pentimalli F, D'Armiento M, et al. Calretinin immunoreactivity in the human testis throughout fetal life. J Cell Physiol. 2017; 232:1872-1878.

19. Baimbridge KG, Celio MR, Rogers JH. Calcium-binding proteins in the nervous system. Trends in neurosciences. 1992; 15:303-308.

Correspondence Sameh Fayek GamalEl Din, MD (Corresponding Author) samehfayek@kasralainy.edu.eg Mohamed El-Amir, MD yousr82@kasralainy.edu.eg Hisham Foaad, MD hisham.foaad@kasralainy.edu.eg Department of Andrology and STDs Kasr Al-Ainy, Faculty of Medicine Cairo University, Al-Saray Street, El Manial, Cairo, 11956, Egypt Noha Abdel Kader, MD noha.abdelkader@med.bsu.edu.eg Department of Clinical and Chemical Pathology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt Asmaa Anter, MD allahtaim2@gmail.com Egypt Ministry of Health & Population, Cairo, Egypt Mohamed Azmy, MD mohamed.Azmy@med.bsu.edu.eg Department of Andrology, Sexology and STDs, Faculty of Medicine Beni-Suef University, Beni-Suef, Egypt Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11906

DOI: 10.4081/aiua.2023.11593

ORIGINAL PAPER

Effects of testosterone replacement on lipid profile, hepatotoxicity, oxidative stress, and cognitive performance in castrated wistar rats Oumayma Boukari, Wahid Khemissi, Soumaya Ghodhbane, Aida Lahbib, Olfa Tebourbi, Khemais Ben Rhouma, Mohsen Sakly, Dorsaf Hallegue Laboratory of Integrated Physiology, Department Life Sciences, Faculty of Sciences of Bizerte, University of Carthage, Jarzouna 7021, Bizerte, Tunisia.

Summary

Objective: Androgen deficiency is associated with multiple biochemical and behavioral disorders. This study investigated the effects of testosterone replacement and Spirulina Platensis association on testosterone deficiency-induced metabolic disorders and memory impairment. Methods: Adult male rats were randomly and equally divided into four groups and received the following treatments for 20 consecutive days. Control group: non-castrated rats received distilled water. Castrated group received distilled water. Testosterone treated group: castrated rats received 0.20 mg of testosterone dissolved in corn oil by subcutaneous injection (i.p.). Spirulina co-treated group: castrated rats received 0.20 mg of testosterone (i.p.) dissolved in corn oil followed by 1000 mg/kg of Spirulina per os. Results: Data showed that castration induced an increase in plasma ALT, AST, alkaline phosphatase (PAL), cholesterol, and triglycerides level. Castrated rats showed a great elevation in SOD and CAT activities and MDA and H2O2 levels in the prostate, seminal vesicles, and brain. Testosterone deficiency was also associated with alteration of the spatial memory and exploratory behaviour. Testosterone replacement either alone or with Spirulina combination efficiently improved most of these biochemical parameters and ameliorated cognitive abilities in castrated rats. Conclusions: Testosterone replacement either alone or in combination with Spirulina improved castration-induced metabolic, oxidative, and cognitive alterations.

KEY WORDS: Castration; Testosterone; Spirulina Platensis; Cognition; Oxidative stress. Submitted 18 July 2023; Accepted 30 July 2023

INTRODUCTION

With aging men can develop several cognitive and metabolic impairments due to the reduction in endogenous testosterone production (1). Androgen deficiency is referred to as hypogonadism, it is a health issue that can occur within men aged from 40 to 80 years old and includes fatigue, cognitive and mood disorders as clinical symptoms (2). It is also associated with common medical conditions such as hypertension, diabetes, and obesity (3). In fact, a very common consequence of testosterone deficiency in men is a decline in some forms of memory such as episodic and working memory (4, 5).

Numerous animal studies including models of castrated rodents were useful to mimic the hypogonadism medical condition and evaluate the effects of androgen depletion on the cognitive functions (6). Multiple tasks were used to assess the spatial learning and working memory abilities of castrated rodents varying from navigating toward hidden platform in a pool of water in the Morris water maze test (7), to look for displaced objects in the novel object recognition and location tests (8). Although, the mechanism by which testosterone influences the working of spatial memory is poorly understood, many of the animal studies showed a positive correlation between high/optimum testosterone level and better cognitive abilities in males including improved spatial memory (9, 10). Moreover, on a physiological level it has been reported that testosterone deficiency caused metabolic disorders including changes in body composition, fat distribution (11) and promoted oxidative stress and inflammation (12). The main treatment for hypogonadism in men is testosterone replacement therapy (TRT). Therapeutic options for TRT varied from oral and injectable testosterone administration to patches and testosterone gels. Innovations and advances in TRT during the years have enhanced the role and safety of the use of testosterone as a metabolic hormone and had beneficial effects on obesity, cardiovascular and hepatic diseases (13). Many research data nonetheless consolidated the long-term side effects of the TRT. In fact, long-term use of TRT has been associated with elevated oncologic risks mainly in the prostate (14) as well as the likelihood of developing obstructive sleep apnea and erythrocytosis (15). Therefore, potential alternatives, mainly plants and their derived natural substances, are being studied to replace and/or minimize the TRT side effects. For instance, onion supplementation was positively correlated to an increase in Luteinizing Hormone (LH) production and has been proven to reduce testis oxidative stress (16). Ginger supplementation effect on intoxicated rats was also hypothesized to reduce oxygen species production and lipid peroxidation in the gonads thus improving testosterone level (17). Arthrospira platensis also commercialized under the name of Spirulina is a cyanobacterium which captured the scientists and food industry’s attention during the last few decades for its high nutritional as well as potential thera-

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11593

O. Boukari, W. Khemissi, S. Ghodhbane, A. Lahbib, O. Tebourbi, K. Ben Rhouma, M. Sakly, D. Hallegue

Experimental design Ten days after surgery, rats were randomly assigned in 4 groups, five animals per group, and treated for 20 consecutive days as follows: Group 1 (Control group): non-castrated rats received distilled water orally (10 ml/kg). Group 2: Castrated group (CT) was given distilled water orally after castration (10 ml/kg). Group 3: Testosterone treated group (TT) castrated rats received 5 mg/kg of testosterone (SigmaAldrich,Co, St Louis, MO, USA) dissolved in corn oil by subcutaneous injection (26). Group 4: Spirulina co-treated group (SP) castrated rats received 5 mg/kg of testosterone dissolved in oil by subcutaneous injection followed by 10 ml/kg orally of Spirulina (1000 mg/kg) (BioAlgues Tunisia). During the experiment period, all rats were monitored daily for body weight. Behavior tests were performed at the end of the treatments.

peutic values (18-20). The huge interest in Spirulina is essentially due to its high protein level and the protein quality as it contains essential amino acids as well as the availability of vitamins and minerals notably vitamin B12, iron and calcium (21). Many human and animal studies on the effects of Spirulina intakes have been reported, yet their results varied regarding the duration of administration, the doses and target groups. In fact, evidence from animal studies were in favour of a potential reproprotective effect of Spirulina particularly by enhancing antioxidant enzymes activities, hence restoring the production of testosterone in bifenthrin-intoxicated mice (22),and mitigating pro-inflammatory cytokines in furan exposed rats (23). Additionally, a previous study showed that Spirulina supplementation could prevent the memory impairment in senescence-accelerated mice through counteracting oxidative stress damages (24) which calls attention to the possible beneficial effect of Spirulina in mitigating memory and metabolic impairment induced by testosterone deficiency in castrated group. The present study was assigned to analyse the effects of testosterone replacement with or without Spirulina combination on castration-induced metabolic, oxidative stress and cognitive alterations in adult male Wistar rats.

Biochemical analyses Rats were sacrificed by decapitation under slight ether anesthesia. Blood was collected in EDTA tubes and centrifuged at 4°C at 4000 rpm for 15 minutes. Plasma was recuperated and stored at -25°C for further biochemical determinations. Organs, brain, prostate, and seminal vesicles were immediately dissected out, washed in saline solution, weighed, and stored for further oxidative stress measurement. Cholesterol, triglycerides, alkaline phosphatase (PAL), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were determined using commercial analysis kits (BioMaghreb, Tunisia) according to the manufacturer’s instructions.

MATERIALS AND METHODS Animals Male Wistar rats weighing 155-250 gr at the beginning of the experiment, purchased from Pasteur Institute, Tunisia, were housed in separate cages under controlled conditions of temperature (25°C) and a 12:12 light/dark cycle. All animals were provided with water and food ad libitum. All rats were acclimatized 10 days prior to the beginning of the experiment. Animals were cared for in compliance with the Institutional Ethics Committee code of practice for the Care and Use of Animals for Scientific Purposes. The experimental protocols were approved by the Ethics Committee of Faculty of Sciences, Bizerta, Tunisia.

Oxidative stress measurement Tissue was homogenized in Tris-buffered saline (TBS). The homogenate was centrifuged at 4°C at 9000 rpm for 10 minutes and supernatants were collected. Protein level was estimated by Bradford method (27). Superoxide dismutase (SOD) and catalase (CAT) activities were measured in tissue homogenates according to Misra and Fridovich (28) and Aebi methods (29) respectively. Lipid peroxidation was assessed by measuring the malondialdehyde (MDA) level according to the Draper and Hadley method (30). Hydrogen peroxide (H2O2) level was measured according to Jabri et al. (31).

Castration surgery The castration surgery was performed under ether anaesthesia. All rats were bilaterally castrated, each testis was excised through a small incision at the posterior end of the scrotum and then ligated. The testis was exposed by performing a transverse resection on both scrota in the supine position, and the spermatic cord and blood vessels were ligated and resected (25).

Behavioural testing Animals were habituated to the arena the day following the 20 days of treatment and then submitted to the object location test (OLM) (32) and the novel object recognition test (NOR) 24 hours later (33). Both behavioural tests were performed between 08:00 am and 03:00 pm (Figure 1).

Figure 1. Object location (OLM) and Novel object recognition (NOR) tests. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11593

Metabolic and cognitive effects of testosterone replacement

preference for the novel object); the recognition index (R1) representing the percentage of time spent with the novel object relative to the total exploration time. The indexes were calculated respectively as follows D1 = (t1-t2) /(t1+t2); R1=t1/(t1+t2) ×100 (34).

Assessment of spatial memory using object location memory test (OLM) The arena was a metal circular area with a 50 cm wall and divided into 1 central and 6 peripheral parts of equal surface. Testing consisted of one habituation day and one OLM testing day. On both days, testing was performed between 8:00 am and 04:00 pm and rats were brought to the testing room 15 minutes prior to the start of the testing. During the habituation day, rats were free to explore the vacant arena for 15 minutes. On the OLM testing day, two trials were performed, training and testing trials. During the training trial, two identical objects were placed 5 cm away from the wall such that they are counterbalanced in the arena, each rat was placed then in the centre of the arena and allowed to explore it for 5 minutes. Rats were placed back into their cages following the training trial for a 1h interval between trials. During the testing trial, one of the objects was moved to a quadrant diagonal from the other object, each rat was then replaced in the arena and allowed to explore for 5 minutes. The apparatus was cleaned with 30% alcohol and dried prior to the start of each trial for every rat. Rat movements were tracked and recorded using the Debut video recorder program. A rat is considered exploring an object when its nose was within 2 cm from the object. Touching and sniffing activities were counted as exploration, while sitting on the object was not. Rats who don't meet these criteria were excluded from all analyses. To analyse cognitive performance, the following data were measured: the time spent exploring the object moved to a novel place (T1), the object remaining in the familiar place (T2), and the investigation time (%) i.e., which represents the percentage of the time spent in exploring the objects relative to the total time of the trial. Indexes measurements were also considered (34). Discrimination index (D1) represented the ability of the rat to distinguish the new object location from the familiar one; this index varies between -1 and +1 with a positive value indicating more preference for the displaced object. D1 is calculated as follows D1 = (T1-T2)/(T1+T2). Recognition index (R1) represented the percentage of time spent exploring the displaced object relative to the total exploration time and was calculated as follows: R1=T1/(T1+T2) ×100.

Statistical analyses Statistical analysis of data was performed using a one-way analysis of variance (ANOVA) followed by Tukey's post hoc test for multiple comparison. Data were expressed as mean ± standard error of the mean. A value of p < 0.05 was considered statistically significant. Data were analysed using GraphPad Prism 5 software.

RESULTS Serum biochemical analyses As shown in Table 1, castrated rats expressed statistically increased plasma levels of ALT, AST, PAL, cholesterol, and triglycerides compared to control group. In contrast, testosterone replacement (TT) alone or in combination with and Spirulina (SP) restored these parameters to normal levels. Evaluation of antioxidant enzyme activities Data showed that castration increased significantly SOD and CAT activities in the prostate, seminal vesicles, and the brain in comparison with the control group (Table 2). Importantly, testosterone replacement significantly ameliorated the abnormal levels of the antioxidant enzymes in the three tissues compared to control levels. However, cotreatment with Spirulina did not significantly improve these effects in SP group. Evaluation of hydrogen peroxide (H2O2) and lipid peroxidation levels Figures 2,3 and 4 showed that MDA levels respectively in prostate, seminal vesicles, and brain, were significantly higher in castrated group in comparison with control group. These increases were associated with a significant increase in H2O2 levels as compared with control group. A significant and identical decrease in MDA and H2O2 tissue contents was noticed in TT and SP groups as compared to castrated rats. Indeed, there were no remarkable changes in these oxidative stress parameters between control, TT and SP groups.

Assessment of spatial memory using novel object recognition memory test (NOR) An hour after the OLM last testing trial, the familiar object was replaced with a novel object. Rats were placed in the centre of the arena and allowed to explore it for 5 minutes comprising one old object that was used in the last trial of the OLM test and one novel object. The arena was cleaned with 30% alcohol and air-dried prior to the commencement of each trial for every rat. Rat movements were tracked and recorded using the Debut video recorder program. To analyse cognitive performance, the following data were collected: time spent in exploring the novel object(t1), the familiar object(t2), and the investigation time (%), which represents the percentage of the time spent in exploring the objects relative to the total time of the trial. The indexes that were considered were: the discrimination index (D1) representing the ability of the rat to distinguish the novel object from the familiar one (this index varies between -1 and +1 with a positive value indicating more

Table 1. Biochemical parameters in control, castrated, testosterone and Spirulina treated rats. Parameters ALT (U/L) AST (U/L) PAL (U/L) Cholesterol (g/l) Triglycerides (g/l)

Control 35.35 ± 3.39 17.50 ± 0.95 18.70 ± 1.92 1.09 ± 0.12 1.25 ± 0.14

CT 88.90 ± 7.5 * 32.38 ± 3.88 * 56.93 ± 7.39 * 1.97 ± 0.13 * 3.10 ± 0.14 *

TT 46.81 ± 6.62 # 23;98 ± 2.66 30.02 ± 3.45 # 1.29 ± 0.07 # 1.78 ± 0.09 #

Values are expressed as mean ± SEM. CT: Castrated group; TT: Testosterone treated group; SP: Testosterone and Spirulina co-treated group. ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; PAL: Alkalin phosphatase. * p < 0.05 as compared to control group. # p < 0.05 as compared to CT group.

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SP 41.85 ± 5.28 # 24.33 ± 3.11 20.43 ± 1.17 # 1.06 ± 0.11 # 1.75 ± 0.15 #

O. Boukari, W. Khemissi, S. Ghodhbane, A. Lahbib, O. Tebourbi, K. Ben Rhouma, M. Sakly, D. Hallegue

Table 2. Effect of testosterone replacement in combination or not with Spirulina on antioxidant enzymes activities in prostate, seminal vesicles, and brain tissues in castrated rats. Prostate

C CT TT SP

SOD (U/mg proteins) 6.73 ± 1.32 13.4 ± 1.45 * 7.45 ± 1.58 11.68 ± 1.83

CAT (umol/min/mg protein) 74.02 ± 8.65 165 ± 15.13 * 130.8 ± 3.35 * 109.2 ± 6.18 #

Seminal vesicles SOD CAT (U/mg proteins) (umol/min/mg proteins) 13.28 ± 1.59 93.65 ± 10.56 40.72 ± 4.26 * 199.4 ± 23.83 * 30.49 ± 1.65 * 137.7 ± 18.88 23.92 ± 1.83 # 124 ± 19.05 #

Brain SOD (U/mg proteins) 12.67 ± 1.82 54.57 ± 5.67 * 22.28 ± 0.99 # 22.48 ± 1.41 #

CAT (umol/min/mg proteins) 73.90 ± 4.1 140.8 ± 10.89 * 97.63 ± 3.23 # 96.82 ± 4.31 #

Values are expressed as mean ± SEM. C: Control; CT: Castrated group; TT: Testosterone treated group; SP: Testosterone and Spirulina co-treated group. SOD: Superoxide dismutase; CAT: Catalase.

* p < 0.05 as compared to control group. # p < 0.05 as compared to CT group.

Figure 2. Effect of testosterone replacement in combination or not with Spirulina on prostate MDA and H2O2 levels of castrated rats. Values are expressed as mean ± SEM. CT: Castrated group; TT: Testosterone treated group; SP: Testosterone and Spirulina co-treated group. MDA: Malondialdehyde; H2O2: Hydrogen peroxide; * p < 0.05 compared to control group. # p < 0.05 as compared to CT group.

Figure 3. Effect of testosterone replacement in combination or not with Spirulina on seminal vesicles MDA and H2O2 levels in castrated rats. Values are expressed as mean ± SEM. CT: Castrated group; TT: Testosterone treated group; SP: Testosterone and Spirulina co-treated group. MDA: Malondialdehyde; H2O2: Hydrogen peroxide; * p < 0.05 compared to control group. # p < 0.05 as compared to CT group.

Figure 4. Effect of testosterone replacement in combination or not with Spirulina on brain MDA and H2O2 levels in castrated rats Values are expressed as mean ± SEM. CT: Castrated group; TT: Testosterone treated group; SP: Testosterone and Spirulina co-treated group. MDA: Malondialdehyde; H2O2: Hydrogen peroxide; * p < 0.05 compared to control group. # p < 0.05 as compared to CT group.

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Table 3. Effect of testosterone replacement in combination or not with Spirulina on castrated rats’ behaviour during OLM and NOR tests.

Investigation time (%) Recognition index Discrimination index

Control 11 ± 0.83 78.31 ± 0.43 0.56 ± 0.008

Object location memory test CT TT 5.61 ± 0.37 * 8.22 ± 0.97 38.50 ± 3.15 * 77.51 ± 0.46 # * -0.23 ± 0.07 0.55 ± 0.009 #

SP 8.67 ± 0.83 77.85 ± 0.97 # 0.56 ± 0.01 #

Control 14.47 ± 1.19 81.27 ± 1.65 0.63 ± 0.03

Novel object recognition test CT TT 3.94 ± 0.57 * 11.80 ± 0.44 # 34.35 ± 2.43 * 75.66 ± 1.37 # * -0.31 ± 0.04 0.51 ± 0.02 #

SP 11.94 ± 0.43 # 77.85 ± 1.95 # 0.55 ± 0.03 #

Values are expressed as mean ± SEM. CT: Castrated group; TT: Testosterone treated group; SP: Testosterone and Spirulina co-treated group.

* p < 0.05 as compared to control group. # p < 0.05 as compared to CT group.

triglycerides were remarkably increased after castration in CT rat group in comparison with the control group. Our findings are in harmony with previous studies of testosterone deficiency effect on lipid profiles in aging male rats (38) and orchiectomized rats (39). Testosterone level appears to have complicated relationship with cholesterol metabolism regulation and its associated anomalies, in a matter of facts low testosterone levels is associated with pro atherogenic lipid profiles in men (2), particularly lower levels of the high-density lipoprotein cholesterol (HDL-C). As steroid hormones can bind and interact with specific DNA domains it has been suggested that testosterone is involved in the molecular metabolism of cholesterol within the liver through the upregulation of several genes namely the hepatic lipase (HL), the scavenger B1 receptor (SR-B1) (40), and the nuclear liver X receptor (LXR) (41). Both HL and SR-B1 mediate and facilitate the uptake of HDL into hepatocytes, thereby stimulate the cholesterol uptake and efflux. Studies demonstrated that increased activity of SR-B1 and HL were linked to cholesterol level lowering effect of testosterone administration (40). It was also suggested that testosterone is involved in the liver uptake of low-density lipoprotein cholesterol (LDLC) through the modulation of the PCSK9-LDLR pathway, thus the clearance of LDL-C from circulation (42). Importantly, our study showed that plasma lipid profile perturbations were reversed by testosterone replacement either alone or in association with Spirulina in castrated rats. Our results are in line with previous studies which have demonstrated that testosterone replacement therapy (43) and Spirulina platensis supplementation (44) ameliorated serum cholesterol and triglycerides levels respectively in castrated or high fat diet-fed rats. Liver enzymes such as transaminases (ALT, AST) and ALP are sensitive biomarkers widely used to assess liver injury (45). Thus, these intracellular proteins are released into the blood upon hepatocyte damage. Our results showed that in castrated rats, these enzymes greatly increased in plasma above normal value. However, supplementation with testosterone or testosterone plus Spirulina were effective in improving these liver damage biomarkers. Oxidative stress is a major mechanism of tissue injury, it is induced by the imbalance between the production of the oxygen reactive species (ROS) and the antioxidant system (46). It is generally caused by lipid accumulation, and DNA damages and leads to the loss of organ functions. The occurrence of oxidative stress is linked to aging, aging-related diseases and diverse clinical conditions including diabetes and heart diseases (47, 48). Previously, it has been shown that low testosterone level

Assessment of memory performances In the OLM trial, castrated rats exhibited statistically decreased investigation time as compared to control group, while no significant difference in the investigation time was noticed between the control, TT and SP groups (Table 3). Compared with the other groups, castrated rats displayed less preference for the displaced object in the novel place since they spent equal time exploring the object remained in the familiar location and the displaced one. Moreover, the comparison of the discrimination index between control and castrated group revealed a significant lower index in CT group as compared to control, TT and SP treated groups. In NOR tests, the investigation time was also significantly decreased in castrated group as compared to control group. This effect was totally reversed in testosterone and testosterone plus Spirulina treated groups. Furthermore, control, TT, and SP treated groups showed a clear tendency to explore the novel object rather than the familiar object. In fact, these rats showed a significantly higher recognition index in comparison to castrated group and spent more than 75% of their investigation time with the novel object. Castrated rats showed no preference for the novel object as they displayed a decreased recognition index as compared to control group. The comparison of the discrimination index between castrated and control group showed that castrated rats had a significantly decreased index as compared to control group which showed a non-distinguish of the novel object. However, treated rats with testosterone alone or in combination with Spirulina displayed a comparable discrimination index to the control group and a significant increase in the discrimination index value as compared to the castrated group.

DISCUSSION

Testosterone is a key hormone that has been known for its major role in carbohydrates, lipids, and proteins metabolism (35, 36). Testosterone deficiency has been linked to an increase in body fat mass, impairment in glucose and lipid tolerance, as well as oxidative stress imbalance; all these factors can contribute to metabolic disorders (37). In this regard, we assessed castration effect on adult male rats and evaluated whether testosterone could mitigate physiological perturbations induced by testosterone deficiency. In addition, we investigated the possible potential of the filamentous cyanobacterium, Spirulina platensis, to enhance the androgen effect in castrated rats. Our results revealed that plasma levels of cholesterol and

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O. Boukari, W. Khemissi, S. Ghodhbane, A. Lahbib, O. Tebourbi, K. Ben Rhouma, M. Sakly, D. Hallegue

results of Pintana et al. (56), that showed a cognitive decline in rats with testosterone deprivation. Whereas rats who received testosterone replacement of 0.20 mg/kg spent significantly more time exploring objects than castrated group and showed a significantly greater preference for the displaced and the novel object in comparison to castrated rats. Coherently, testosterone replacement displayed a positive discrimination index and a higher recognition index in comparison to CT group. Our findings contradicted the results of Borbélyovà et al. (57) who reported no effect of low testosterone concentration neither acute testosterone treatment on the exploratory behaviour and memory performance assessed by the Open Field test in aged and castrated male rats. This difference in results can be explained by several limitations namely the difference in the treatment period and the behavioural tests used. Castrated rats who received Spirulina co-treatment also exhibited significantly more time exploring the objects in the arena, they displayed a higher discrimination and recognition index as compared to castrated group. In agreement with our results, previous data showed that Spirulina could improve memory deficit induced by scopolamine in rats through modulation of oxidative stress imbalance (58). Further, Wang et al. (59), reported that Spirulina could impart appreciable relief in L-methionine induced cognitive deficit in rats by counterbalancing the acetylcholinesterase activity and brain oxidative enzymes activity.

is correlated to an imbalance of the oxidative stress status. In the study of Mancini et al. (49), sixteen patients with hypogonadism were compared to ten healthy patients to investigate the role of testosterone in the oxidative stress mechanism showing that a lipid antioxidant enzyme Coenzyme Q10 (CoQ10) was reduced in the hypogonadism condition and that the testosterone replacement therapy resulted in an increase in CoQ10 serum level (49). Furthermore, in vitro assays showed that low testosterone treatment could decrease lipid peroxidation and the ROS production in TM3 Leydig cells (50). In the present study we revealed that castrated rats showed a remarkable increase in SOD and CAT activities in the prostate, seminal vesicles, and the brain in comparison with the control group. Whereas testosterone replacement result in a significant increase in the level of these antioxidant enzymes. However, cotreatment with Spirulina did not significantly improve these effects towards TT group. Testosterone deficiency also significantly increased both MDA and H2O2 levels in prostate, seminal vesicles, and brain, in comparison with control group. Interestingly, administration of testosterone either alone or in combination with Spirulina restored these changes induced by castration. Our results are consistent with previous studies that have showed that oral administration of Spirulina prevented repro-toxicity by mitigating lipid peroxidation in testis of furan-intoxicated rats (23) and counterbalancing the perturbation of antioxidant enzymes in cadmium-intoxicated mice (51). However, the fact that Spirulina cotreatment did not enhanced the positive effects of testosterone in castrated rats suggested that androgen actions might involve other mechanisms unrelated to oxidative stress. The loss of bioavailable testosterone in male is associated with a dysfunction in androgen responsive tissues including the brain. A vast majority of human and animal studies demonstrated that testosterone deficiency causes a decline in cognitive performance (52) and affective behaviour in males (53). Some data reported conflicting results and supported a non-consistent effect of androgens (54). Studies on molecular mechanism of androgen action on the brain indicated that testosterone have a direct impact on glial cells thereby can modulate the myelinisation mechanism, synapse, and dendritic branching number as well as neuron growth (55). It has also been shown that even though gonadotropic neurons do not express androgen receptors, testosterone can modulate these neurons through a neuropeptide called kisspeptin which is not only expressed in the hypothalamic-pituitary-gonadal axis (HPG) but also in the limbic regions of the brain implicated in the emotional and cognitive behaviour (Mills et al., 2018. However, the exact causality of the relationship between testosterone levels and brain functions is still not firmly established. In our study we performed OLM and NOR cognitive tests to assess the spatial memory performance in rats. Our data demonstrated that castration caused less interest in exploring objects in both the OLM and NOR trials. Likewise, the discrimination index of CT group displayed a negative value which indicate the incapacity of castrated rats to distinguish the novel object and the novel location of the object. These findings are along with previous

CONCLUSIONS

This study demonstrated that testosterone deficiency led to an increase in plasma cholesterol and triglycerides as well as AST, ALT, and PAL levels associated with unbalanced oxidative status and cognitive impairment. Testosterone replacement could counteract these castration-induced changes. However, there were no notable effects when testosterone was combined with Spirulina in castrated rats. Further investigations are needed to understand the underlying mechanisms of testosterone deficiency-induced alterations.

ACKNOWLEDGEMENTS

Authors express their sincere thanks to Professor Youssef Krichen, CEO of Bio Algae Tunisia company for the free supply of phycocyanin and Dr Sihem Ben Hassine for her technical assistance.

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44. Hua P, Yu Z, Xiong Y, Liu B, Zhao L. Regulatory Efficacy of Spirulina platensis Protease Hydrolyzate on Lipid Metabolism and Gut Microbiota in High-Fat Diet-Fed Rats. Int J Mol Sci. 2018; 19:4023.

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Correspondence Oumayma Boukari Oumayma.boukari@gmail.com Wahid Khemissi w.khemissi2007@gmail.com Soumaya Ghodhbane ghodhbanes@yahoo.fr Aida Lahbib lahbib.aida@gmail.com Olfa Tebourbi tebourbi.olfa@gmail.com Khémaïs Ben Rhouma k.benrhouma2015@gmail.com Mohsen Sakly (Corresponding Author) mohsensakly@gmail.com Dorsaf Hallegue dorsafhallegue@yahoo.fr Laboratory of Integrated Physiology, Department Life Sciences, Faculty of Sciences of Bizerte, University of Carthage, Jarzouna 7021, Bizerte, Tunisia Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):11593

DOI: 10.4081/aiua.2023.11669

ORIGINAL PAPER

Autologous mesenchymal stem cell therapy for diabetic men with erectile dysfunction. Is it promising? A pilot study Mohamed A. Alhefnawy 1, Emad Salah 2, Sayed Bakry 3, Taymour M. Khalifa 4, Alaa Rafaat 2, Refaat Hammad 4, Ali Sobhy 5, Ahmed Wahsh 2 1 Department of Urology, Benha University, Egypt;

2 Department of Urology, Al-Azhar University, Egypt;

3 Department of Embriology and Genetic engineering, Faculty of Science, Al-Azhar University, Egypt; 4 Department of Dermatology and Andrology, Al-Azhar University, Egypt; 5 Department of Clinical Pathology, Al-Azhar University, Egypt.

ronal degeneration, and fibrosis, all of which lead to the erectile dysfunction development (6). Although phosphodiesterase type 5 inhibitors (PDE5i) are beneficial in treating erectile dysfunction in the majority of patients, their effectiveness is much reduced in diabetic people (7). This is likely due to the decreased generation of nitric oxide (NO) as a consequence of endothelial dysfunction (8). ED linked with diabetes is similarly very resistant to PDE5i therapy, with a 44% success rate opposed to an 85% success rate for hypogonadal ED patients (9). Patients with diabetes and erectile dysfunction had the greatest incidence of therapy termination with PDE5Is (28/36, or 78 percent) (10). Therefore, finding an effective therapy for ED linked with diabetes is one of the most significant goals of modern ED research. Recent treatment techniques, like as gene therapy and stem cell therapy, are being investigated to treat diabetic ED more successfully. Stem cell is a possible therapy for diabetic ED. Multiple stem cell types have been utilized to cure ED, including BMSC, ADSC, and USC (11-13). Stem cells may develop into several cell types, such as smooth muscle cells (SMC), neurons and vascular endothelial cells. In addition, they may emit paracrine substances that may boost angiogenesis and cell survival (14). A study was conducted in our Urology Department from March 2016 to September 2018.

Summary

Purpose: to assess safety and efficacy of autologous mesenchymal bone marrow stem cell injection in penile cavernosal tissue for erectile dysfunction therapy in diabetic men. Methods: The subjects of this study were diabetic men suffering erectile dysfunction, non-responding to maximum dose of oral PDE5I. Mesenchymal bone marrow stem cells were aspirated and injected after preparation in both corpora cavernosa at 3, 9 o’clock position. Erectile function was assessed by the International Index of Erectile Function and penile Doppler study, before and after 6 months after injection. Results: 4 patients out of 10 achieve hard erection adequate for satisfactory coitus, and 2 patients achieved penile hardness with addition of pharmacological therapy with sildenafil 100mg. Peak systolic velocity increased significantly in 4 patients (2 arteriogenic and 2 mixed erectile dysfunction), from 12∼22 cm/s to 32∼69 cm/s. Variations in end-diastolic velocity increased substantially in 2 patients with venogenic insufficiency alone at follow-up from 4∼5 cm /s to -4∼-3 cm/s. Conclusions: Despite promising stem cell treatment efficacy for patients with erectile dysfunction, more clinical studies and researches are still warranted.

KEY WORDS: Erectile dysfunction; Diabetes; Stem cell. Submitted 21 August 2023; Accepted 7 September 2023

In 1995, the global erectile dysfunction (ED) prevalence was evaluated to be 152 million and is expected to reach 322 million by 2025 (2). ED may be organic, psychogenic or a combination. ED organic type is divided into vasculogenic, neurogenic, cavernous, drug-induced, systemic disease-related and hormonal categories (2). Diabetic men tend to experience ED more frequently and 10-15 years earlier than non-diabetic men (3). Diabetes-related ED is a serious issue that has a significant influence on patients' life quality and family harmony (4). In addition, ED in diabetic people is more resistant and severe to treatment than in nondiabetic patients (5). Pathogenic impact of diabetic ED comprises endothelium malfunction, smooth muscle composition reduction, neu-

METHODS The study was conducted after ethical committee approval. For all men included in the study, explanation of the study procedures was done and informed consent was onbtained before enrollment. Inclusion criteria Diabetic adult men with HbA1c between 6.5% and 10% with diagnosis of diabetes mellitus dated more than 5 years. Having a consistent sexually active partner. Inadequate sexual activity in spite of taking the maximal dosage of oral PDE5I during the last eight weeks.

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M.A. Alhefnawy, E. Salah, S. Bakry, et al.

Then genitalia were sterilized again, MSCs were injected in both corpora cavernosa at 3 and 9 o’clock position.

Exclusion criteria History of bone marrow disorders, neurogenic ED, gentamycin hypersensitivity. History of severe cardiovascular disease (angina, arrhythmias, cardiac failure, and stroke), renal failure, and respiratory failure as life-threatening conditions. Positive HIV, HBV, HCV, and syphilis tests. Cancer history during the last five years. HbA1c levels more than 10 percent. Uncontrolled hypertension or hypotension (systolic blood pressure > 170 or 90 mm Hg, diastolic blood pressure > 100 or 50 mm Hg). Anticoagulant therapy. Severe infectious disease. Testosterone concentration less than 200ng/dL Having a penile implant or be open to getting one, Patients with alterations in penis morphology. Subjects participating in additional clinical studies in the previous 30 days. Subjects unable to comply with procedure. All participants were subjected to detailed medical and sexual history including IIEF questionnaire, physical examination including (general and genital examination) and laboratory work up including testosterone level, HBA1C, prolactin, LH and FSH. Evaluation of general condition by cell blood count (CBC), liver function, renal function, and thyroid function tests, lipid and coagulation profile was done for all patients. Penile Doppler Ultrasound was done for all patients. Normal peak systolic velocity was defined as a value ≥ 35 ml/second and normal end diastolic velocity was defined as a value ≤ 3 ml/second.

Outcome measures Six months following injection, IIEF and Peak systolic velocity (PSV) and End diastolic velocity (EDV) were tested for changes from baseline (preoperative). Statistical analysis: Using statistical program for social sciences (SPSS) version 23.0 for Windows, the acquired data were edited, structured, tabulated, and statistically analyzed. Data are displayed as mean, SD, frequency, and percentage. Student's t test was used to compare continuous variables (two-tailed). We compared categorical variables using the chi-square (2) and Fisher's exact tests (if needed). The level of significance was accepted if the P value < 0.05.

RESULTS

This study included 10 diabetic patients complaining of ED, mean age 52 years and HBA1c range from 6.5 -9.5. Hyperlipidaemia was detected in 6 (60%) patients. Table 2 demonstrates the demographic characteristics of the studied patients. Erectile function was assessed by IIEF- score and penile Doppler study. Two patients have pure arterial insufficiency, 4 (40%) patients have pure veno-occlusive disor-

Table 1. 6-question IIEF Questionnaire.

Table 2. Demographic characteristics of the studied patients.

IIEF Patient Questionnaire The 6-question IIEF Questionnaire (Table 1) is a validated, multidimensional, self-administered study that has shown beneficial in clinical studies for assessing erectile dysfunction and treatment effects. This questionnaire in addition to the penile Doppler were performed before and 6 months after injection. Patients with poor IEEF scores (17 out of 30) in D (Erectile Function) were eligible for mesenchymal stem cell treatment.

Parameters Age (years) Mean + SD Range (Min-Max) Residence Rural Urban Education Illiterate Secondary High Socio-economic level Low Middle High Medical diseases Diabetes Hyperlipidemia

Procedures Under sterile conditions with local anesthetics, ten ml mesenchymal stem cell (MSCs) were aspirated from the bone marrow of the iliac crest of the candidate. After lab processing, the sample was brought to the operative theater. In the operation room, the patient was positioned in the supine position. Genitalia were sterilized and penile block was performed.

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All cases n = 10 52.3 ± 6.4 25 (40-65) N (%) 3 (30.0%) 7 (70.0%) N (%) 5 (50.0%) 3 (30.0%) 2 (20.0%) N (%) 4 (40.0%) 3 (30.0%) 3 (30.0%) N (%) 10 (100.0%) 6 (60.0%)

Autologous mesenchymal stem cell therapy for diabetic men with erectile dysfunction

der and 4 (40%) patients mixed arteriogenic and vasculogenic insufficiency as declared by penile Doppler study, Table 3 shows the ED type among the studied patients. The effect of single intracavernosal injection of BMSc on erectile function were assessed using IIEF-6 questions as shown in Table 4 and penile Doppler study at 6 months, as in Table 5 and 6, comparing the PSV and EDV before and after injection at 6 months.

isolated from many adult tissues such as adipose tissue, skeletal muscle, brain and skin. As their name suggests, MSCs are defined by their ability of self- renewal and differentiation into various phenotypes (multipotency). The therapeutic effect of MSCs has consistently been demonstrated and these benefits are mostly attributed to their ability to produce an array of bioactive molecules. This is known as paracrine action of MSCs and it involves stimulation of angiogenesis and revascularization, modulation of immune and inflammatory responses, inhibition of apoptosis and trophic effects such as stimulation of mitosis, proliferation and differentiation of intrinsic stem progenitor cells (21). Different routes have been suggested for the delivery of stem cells, and research continues to assess the most effective route of instillation. Some studies have involved the direct injection of cells into the organ of concern (2224). Other studies have investigated intraperitoneal or intravenous injections of stem cells (25). Studies have shown that less than 1% of stem cells infused via the intravenous route reach the target tissue, and those that do reach the target tissue dissipate after a few days (26). In preclinical studies, the intravenous injection of ADSCs has been shown to lead to improvements in erectile function (27). The intracorporal injection of stem cells for ED treatment has been commonly evaluated in preclinical studies, as it is both straightforward and logical (28). Periprostatic injection, with or without a concurrent intracorporal injection, has also been attempted (29, 30). Many preclinical trials have been performed to investigate the safety, efficacy, and mechanisms of stem-cell therapy for ED in animal models. Soebadi et al. in 2016 summarized these studies (31). As stated by those authors, these preclinical trials have provided ample data on the utilization of both bone marrow stem cells and ADSCs for ED. Almost all of the studies reported improved erectile function in various animal models of CN injury, vascular insufficiency, diabetes mellitus, hyperlipidemia, and aging. Human data on stem-cell therapy for ED are finally emerging approximately 10 years after the first reports on animal models. We have 4 very important published human clinical trials which employed stem cells in patients with ED, as summarized below. Bahk et al. (24) injected 1.5×107 umbilical MSC into the corpora of 7 ED patients with DM and noted improvement when coupled with oral PDE5i. The International Index of Erectile Function (IIEF)-5, global assessment questionnaire, erection diary, blood glucose diary, and medication dosage were monitored for 9 months. Three participants regained morning erections in 1 month, 2 participants achieved erection successful for penetration in conjunction with PDE5i for 6 months. Yiou et al. (22) administered BMSC in men with ED after radical prostatectomy. Four equal groups of patients were given escalating doses of BMSC (2 ×107, 2 × 108, 1 × 109, and 2 × 109, respectively). IIEF-15, erection hardness scale, penile duplex and penile NO release tests were all used to assess erectile function. Significant improvement was noted in 9 of 12 patients treated in combination with an oral PDE5i. Haahr et al. (23) injected ASC into 17 men with a history of prostatectomy to determine safety and efficacy. Five patients had minor adverse events related to liposuction,

Table 3. Classification of erectile dysfunction in the studied patients. All cases n = 10 N (%) 6 (60.0%) 4 (40.0%)

Type Single Mixed

Table 4. Comparison of International Index of Erectile Dysfunction before and after injection (Total n = 10).

All cases n = 10

Before treatment Mean ± SD 12.7 ± 2.16

After treatment Mean ± SD 19.2 ± 5.75

P-value 0.026 S

Table 5. Comparison of peak systolic velocity (PSV) before and after injection at 6 months (Total n = 10).

All cases n = 10 Mixed cases n = 4 Arteriogenic cases n = 6

Before injection Mean ± SD 25 ± 12.5 13.75 ± 6.13 16.33 ± 6.21

After injection Mean ± SD 40.9 ± 18.9 25.5 ± 13.2 38.8 ± 22.8

P-value 0.016 S 0.16 NS 0.036 S

Table 6. Comparison of End Diastolic velocity EDV before and after injection at 6 months (Total n = 10).

All cases n = 10 Mixed cases n = 4 Arteriogenic cases n = 6

Before injection Mean ± SD 3.9 ± 5.4 5.07 ± 2.08 6.12 ± 2.7

After injection Mean ± SD 0.9 ± 4.09 3.33 ± 1.15 2.37 ± 3.8

P-value 0.026 S 0.37 NS 0.022 S

DISCUSSION

DM is a systematic disease that affects every part of the body. In the penis, it is associated with reduced contents of all three key components for erectile function, namely, cavernous nerve (CN), cavernous endothelial cells (CEC) and smooth muscle cells (CSMC) (15-19). The reduction of CEC content is likely due to DM-induced apoptosis in CEC as demonstrated by immune-histochemical analysis of corpora cavernosa (CC) samples between diabetic and nondiabetic patients (20).Thus, how to prevent and/or reverse these pathological processes is critically important for the effective treatment of DM-associated ED. In this regard, stem cells (SC) therapy has been considered promising, due to SC’s well-known regenerative capacity (18). MSCs, initially isolated from bone marrow, have later been

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Table 7. Results of clinical trials on stem-cell therapy for erectile dysfunction. Results

Assessment

Treatment

Cause of ED

Number of men

First author (year)

Improved rigidity in 2/7, able to penetrate with PDE5i

IIEF-5, SEP, GAQ

Umbilical blood SC

Diabetes

Bahk (2010) (33)

3/8 improved erection; IIEF change not significant

PSV, IIEF

Placental-derived SC

Organic

Levy (2016) (36)

IIEF-5

Adipose-derived SC

5∼18 months after radical prostatectomy

Haahr (2016) (35)

IIEF-15, EHS, color Doppler ultrasound

Bone marrow mononuclear cells

22 months after radical prostatectomy

Yiou (2016) (34)

8/11 continent men and 0/6 incontinent men recovered erection 1/12 hard erection; 9/12 needed ICI, PDE5i, or VCD. Impreved EHS and IIEF

2 men has redness or swelling at the injection site, and 1 patient developed a scrotal and penile hematoma. They used IIEF-5 to evaluate erectile function and found 8 of 17 men able to achieve an erection for successful intercourse with no mention of use of oral medications. Levy et al. (32) injected adult placental-matrix-derived stem cells (unknown cell number) in a study of 8 men with ED, and assessed peak systolic velocity, end-diastolic velocity, stretched penile length, penile width. Five patients at 3 months achieved erections for successful intercourse with use of PDE5i. The only measure significantly improved was peak systolic velocity. We summarized this previously mentioned 4 published clinical trials on stem-cell therapy for ED in Table 7. The present study includes 10 diabetic patients type 2 aged 40-65 complaining of erectile dysfunction. After clinical examination and evaluation, the cause of erectile dysfunction in these patients has been cleared: four patients had mixed arteriogenic and vasculogenic insufficiency, four patients had pure venogenic insufficiency and two patients had pure arteriogenic cause. These patients cannot satisfy sexual activity with proper sexual stimulation in spite of taking maximum dose of oral PDE5I within last 8 weeks. In this study we injected patients with MSC-derived stem cells and followed them for 6 months with Doppler parameters and the IIEF questionnaire. All patients agreed that bone marrow stem-cell therapy had some effect on ED, although it was insufficient in some patients. The effects of treatment on erectile function and penile vascular parameters were assessed using the IIEF-15 and by color duplex Doppler ultrasound. The peak systolic velocity was found to have improved to a statistically significant extent in 4 patients (2 arteriogenic and 2 mixed ED), from 12~ 22 cm/s to 32~69 cm/s. Changes in end-diastolic velocity were found to have improved to statistically significant extent in 2 patients with venogenic insufficiency at follow-up from 4~5 cm/s to -4~-3 cm/s. At follow-up, in two patients (mixed ED), changes in PSV were not statistically significant for both PSV and EDV. Two patients with venogenic ED had no improvement in EDV measurement after injection of MSCs. Changes in end-diastolic velocity were found to be not statistically significant in four patients (two withe venogenic insufficiency and two with mixed ED). Four patients achieved hard erection adequate for satisfactory coitus, and two achieved penile hardness with addition of pharmacological therapy with sildenafil 100 mg. As regard to our study all patients with arteriogenic ED have significant improvement in duplex penile U/S and

penile hardness, and improvement in PSV was observed in two patients with mixed ED; in four patients with venogenic ED, two patients had significant improvement in duplex U/S and penile hardness and two patients no significant improvement; two patients with mixed ED had no significant increase in both peak systolic velocity and end diastolic velocity and no improvement in penile hardness.

CONCLUSIONS

Autologous stem-cell therapy is considered a viable treatment option for diabetic ED patients. Despite this overwhelming enthusiasm, several questions remain to be answered before the widespread use of these complex techniques. First, the mode of action still needs to be determined and the safety of the treatment to be established. Next, most effective mode of delivery has yet to be ascertained, although intracorporal injection seems to be the route of choice based on the clinical trials that have been published. Additionally, the ideal timing, type, source and dosage of stem cell for treatment still need to be established. Finally, further researches and wide based clinical trials on stem cell therapy for erectile dysfunction are warranted. Acknowledgments All authors would like to express their sincere gratitude to all team of the department of Urology, Al-Azhar University, Assuit Branch.

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28. Alwaal A, Hussein AA, Lin CS, Lue TF. Prospects of stem cell treatment in benign urological diseases. Korean J Urol. 2015; 56:257-65. 29. Choi WY, Jeon HG, Chung Y, et al. Isolation and characterization of novel, highly proliferative human CD34/CD73-double-positive testis-derived stem cells for cell therapy. Stem Cells Dev. 2013; 22:2158-73.

11. Nishimatsu H, Suzuki E, Kumano S, et al. Adrenomedullin mediates adipose tissue-derived stem cell-induced restoration of erectile function in diabetic rats. J Sex Med. 2012; 9:482-93. 12. Ouyang B, Sun X, Han D, et al. Human urine-derived stem cells alone or genetically-modified with FGF2 Improve type 2 diabetic erectile dysfunction in a rat model. PLoS One. 2014; 9:92825.

30. You D, Jang MJ, Lee J, et al. Periprostatic implantation of human bone marrow-derived mesenchymal stem cells potentiates recovery of erectile function by intracavernosal injection in a rat model of cavernous nerve injury. Urology 2013; 81:104-10.

13. Qiu X, Lin H, Wang Y, et al. Intracavernous transplantation of bone marrow derived mesenchymal stem cells restores erectile function of streptozocin-induced diabetic rats. J Sex Med 2011; 8:427-36.

31. Soebadi MA, Moris L, Castiglione F, et al. Advances in stem cell research for the treatment of male sexual dysfunctions. Curr Opin Urol. 2016; 26:129-39.

14. Lin CS, Xin Z, Dai J, et al. Stem-cell therapy for erectile dysfunction. Expert Opin Biol Ther. 2013; 13:1585-97.

32. Levy J, Marchand M, Iorio L, et al. Determining the feasibility of managing erectile dysfunction in humans with placental-derived stem cells. J Am Osteopath Assoc. 2016; 116:e1-e5.

15. Albersen M, Lin G, Fandel TM, et al. Functional, metabolic, and morphologic characteristics of a novel rat model of type 2 diabetesassociated erectile dysfunction. Urology. 2011; 78:476.e1-8. 16. Dashwood MR, Crump A, Shi-Wen X, Loesch A. Identification of neuronal nitric oxide synthase (nNOS) in human penis: a potential role of reduced neuronally-derived nitric oxide in erectile dysfunction. Curr Pharm Biotechnol. 2011; 12:1316-21.

Correspondence Mohamed Abdelrahman Alhefnawy, MD (Corresponding Author) dr.mohamedalhefnawy@gmail.com Assistant Professor of Urology, Benha University Fareed Nada Street 13518, Banha, Egypt

17. Zhou F, Xin H, Liu T, et al. Effects of icariside II on improving erectile function in rats with streptozotocin-induced diabetes. J Androl. 2012; 33:832-44.

Emad Salah, MD emadeldeen_salah@hotmail.com Alaa Rafat, MD dralaarafaat@gmail.com Ahmed Wahsh, MD hudaahmed320@gmail.com Professor of Urology Al-Azhar University, Egypt

18. Cellek S, Foxwell NA, Moncada S. Two phases of nitrergic neuropathy in streptozotocin-induced diabetic rats. Diabetes. 2003; 52:2353-62. 19. Qiu X, Lin G, Xin Z, et al. Effects of low-energy shockwave therapy on the erectile function and tissue of a diabetic rat model. J Sex Med. 2013; 10:738-46.

Sayed Bakry, MD sbakry@azhar.edu.eg Professor of Genetic Engineering, Al-Azhar University, Egypt

20. Costa C, Soares R, Castela A, et al. Increased endothelial apoptotic cell density in human diabetic erectile tissue--comparison with clinical data. J Sex Med. 2009; 6:826-35.

Taymour Khalifa, MD taymour.khalifa@gmail.com Professor of Dermatology, Venereology and Andrology, Al-Azhar University, Egypt

21. Liang X, Ding Y, Zhang Y, et al. Paracrine mechanisms of mesenchymal stem cell-based therapy: current status and perspectives. Cell Transplant. 2014; 23:1045-1059.

Refaat Hammad, MD refaat-ragab@yahoo.com Assistant Professor of Dermatology and Andrology, Al-Azhar University, Egypt

22. Yiou R, Hamidou L, Birebent B, et al. Safety of intracavernous bone marrow-mononuclear cells for postradical prostatectomy erectile dysfunction: an open dose-escalation pilot study. Eur Urol. 2016; 69:988-91.

Ali Sobhy, MD dralisobhy@azhar.edu.eg Assistant Professor of Clinical Pathology, Egypt

23. Haahr MK, Jensen CH, Toyserkani NM, et al. Safety and potential effect of a single intracavernous injection of autologous adiposederived regenerative cells in patients with erectile dysfunction following radical prostatectomy: an open-label phase I clinical trial. EBioMedicine 2016; 5:204-10.

Conflict of interest: The authors declare no potential conflict of interest.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):11669

DOI: 10.4081/aiua.2023.12155

ORIGINAL PAPER

The role of the general practictioner in the management of urinary calculi Domenico Prezioso 1, Gaetano Piccinocchi 2, Veronica Abate 3, Michele Ancona 2, Antonio Celia 4, Ciro De Luca 1, Riccardo Ferrari 5, Pietro Manuel Ferraro 6, Stefano Mancon 7, Giorgio Mazzon 4, Salvatore Micali 5, Giacomo Puca 1, Domenico Rendina 3, Alberto Saita 7, Salvetti Andrea 2, Andrea Spasiano 8, Elisa Tesè 2, Alberto Trinchieri 9 1 Dipartimento Neuroscienze, Scienze della Riproduzione ed Odontostomatologia Università Federico II, Naples, Italy; 2 Società Italiana di Medicina Generale, Florence, Italy;

3 Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy; 4 S.C. Urologia ULSS 7 Pedemontana, Bassano del Grappa (VI), Italy;

5 Department of Urology, University of Modena and Reggio Emilia, Baggiovara (MO), Italy;

6 Sezione di Nefrologia, Dipartimento di Medicina, Università degli Studi di Verona, Verona, Italy; 7 Department of Urology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; 8 Università Cattolica del Sacro Cuore, Roma, Italy; 9 Urology School, University of Milan, Milan, Italy.

izens (2). The cost of working days lost due to illness must be added to these costs. Hospitals can take care of the surgical treatment of the disease and the diagnosis of diseases associated with urinary stones, but they are not able to provide follow-up and secondary and primary prevention of the disease on their own. Collaboration between GPs and hospitals is crucial to achieve these objectives (3-7). For this reason, a shared guideline between the associations of GPs and clinicians of academic and hospital structures is necessary to define the methods of intervention and tasks assignment.

Summary

Background: The prevalence of kidney stones tends to increase worldwide due to dietary and climate changes. Disease management involves a high consumption of healthcare system resources which can be reduced with primary prevention measures and prophylaxis of recurrences. In this field, collaboration between general practitioners (GPs) and hospitals is crucial. Methods: a panel composed of general practitioners and academic and hospital clinicians expert in the treatment of urinary stones met with the aim of identifying the activities that require the participation of the GP in the management process of the kidney stone patient. Results: Collaboration between GP and hospital was found crucial in the treatment of renal colic and its infectious complications, expulsive treatment of ureteral stones, chemolysis of uric acid stones, long-term follow-up after active treatment of urinary stones, prevention of recurrence and primary prevention in the general population. Conclusions: The role of the GP is crucial in the management and prevention of urinary stones. Community hospitals which are normally led by GPs in liaison with consultants and other health professional can have a role in assisting multidisciplinary working as extended primary care.

METHODS

A panel composed of 4 general practitioners from the Società Italiana di Medicina Generale (SIMG) and 8 academic and hospital clinicians expert in the treatment of urinary stones from the Club Litiasi Urinaria (CLU) met with the aim of identifying the activities that require the participation of the GP in the management process of the patient with kidney stones. The panel met for the first time to read the index of the guidelines for urinary stones of the European Association of Urology (8) with the aim of identifying the topics of greatest interest for collaboration between GPs and hospitals. Each topic was assigned to a team made up of a GP and two hospital doctors who had the task of drafting a text illustrating the role of the GP and the method of collaboration with the hospital. The texts were circulated for corrections and modifications. The panel met a second time to approve the final text in Italian which was published on www.simg. Finally, a short version in English language was written to be published after approval of the panel.

KEY WORDS: Urinary calculi; General practice; Renal colic; Diagnosis; Treatment; Prevention; Primary care; Recommendation. Submitted 2 December 2023; Accepted 19 December 2023

INTRODUCTION

Urinary stones are a very common disease that causes patients to suffer due to its painful symptoms and the repeated surgical procedures necessary to remove stones from the urinary tract. In some cases it can cause renal failure and, albeit rarely, mortality (1). The management of urinary stones involves the use of considerable economic resources at the expense of health services and cit-

Prevalence, etiology, risk of recurrence Epidemiology of urolithiasis in Italy The prevalence of urinary calculi has been evaluated in

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some studies in Italy, ranging between 1.7 and 7.5%, depending on the population studied and the period of the study (9-13). A study (14) based on the Health Search/CSD Longitudinal Patient Database (HS) compiled by 650 General Practitioners demonstrated in the Italian adult population in 2012 a prevalence of urolithiasis of 4.14% and an incidence of 0.323%. The prevalence was higher in males (4.53% versus 3.78%). Regional differences were demonstrated with higher prevalence in southern regions and islands (4.26-6.08%) than in central (3.75-5.35%) and northern regions (2.62-3.71%) In southern regions and islands the male to female ratio (M/F) was in favor of females while in central and northern cities it was in favor of males. Some studies have demonstrated seasonal variations in the incidence of cases of renal colic observed in the Emergency Department of hospitals in various Italian cities. In Padua (15) an association was demonstrated between the date of presentation for renal colic and higher environmental temperature and humidity, in particular higher rates of presentations for renal colic were observed when temperature was > 27°C and relative humidity > 45%. Similar observations on the relationship between environmental temperature and rate of renal colic were made in Parma, Cuneo, and Rome (16-18). In one study (19) the age of patients with renal colic in the summer period was higher than in the rest of the year, probably due to a greater number of patients with uric acid stones who tend to be older. Finally, another study carried out in Ferrara (20) on data from the period 1990-96, demonstrated that renal colic occurs with a circadian rhythm which has a peak in the early morning and a minimum in the afternoon. Other studies have shown that the epidemiological characteristics of urinary calculi in Italy have varied over time. The prevalence of urinary stones increased from 1986 to 1998 by 40% in males and by 20% in females (10). From 2001-2003 to 2016-18, the mean age of patients increased from 45.8+/- 15.4 years to 57.9+/- 14.8 years and the frequency of calcium oxalate monohydrate stones increased from 44 to 51% (21). From 1986-1998 to 2005-2010, a change of the urinary biochemical characteristics of renal stone formers patients in Italy was observed. Patients observed in 2005-2010 showed higher urinary volume, lower urinary sodium, and lower urinary saturation for calcium oxalate and uric acid (22) than those observed in 1986-1998. In parallel, they have higher levels of physical activity and lower blood pressure levels. In conclusion, the general increase in the prevalence of stones appears to be linked to an increase of patients forming a single stone or presenting low stone recurrence in association with a lower urinary biochemical risk. Finally, in Italy some studies have demonstrated the correlation between urinary stones and some chronic diseases such as arterial hypertension and osteoporosis. In about 700 workers of a factory in Pozzuoli, in the suburban area of Naples, the prevalence of stones was evaluated in normotensive subjects (13.4%), in untreated hypertensive patients (20.3%) and in treated hypertensive patients (32.8 %) demonstrating an independent association between arterial hypertension and the prevalence of urolithiasis (23). In a case-control study, patients with

kidney stones demonstrated increased vascular stiffness and decreased bone density (24). In a study carried out in Naples in a population of over 12.000 women aged over 40 who had performed DEXA bone densitometry: incident nephrolithiasis was evaluated in the months following the examination, demonstrating an increased lithiasis risk (HR = 1.33) in patients with osteoporosis (25). Similarly, a study of more than 7,000 ultrasound bone densitometries demonstrated that urolithiasis is an additional risk factor for osteoporosis (26). Recurrence Urinary calculi tend to recur. After 7 years from the first stone episode 27% of patients presented one or more recurrent episodes (27). Cystine, struvite, uric acid, brushite and apatite stones are at higher risk compared with calcium oxalate stones (28). Classification of urinary stones Urinary stones are classified according to: • composition and etiology; • site; • size; • radiological characteristics. Composition and etiology According to etiology they can be divided into stones from infectious causes, stones from non-infectious causes, stones from genetic defects, and drug-related stones (Table 1). Calcium oxalate stones are the most common. The main metabolic abnormalities associated with calcium oxalate stones are hypercalciuria (30-60%) and hyperoxaluria (26-67%), followed by hyperuricosuria (15-46%), hypomagnesiuria (7-23%) and hypocitraturia (5-29%) (29). Calcium phosphate stones can present as carbonate apatite which can be associated with urinary tract infections (UTI) or brushite which crystallizes in the presence of high concentrations of calcium and phosphate, regardless of UTI. Possible causes of calcium phosphate stones include hyperparathyroidism, renal tubular acidosis, and UTIs. Calcium stones can be secondary to some specific pathologies including primary hyperparathyroidism, sarcoidosis, primary hyperoxaluria, enteric hyperoxaluria, distal renal tubular acidosis. Table 1. Classification according to etiology and stone composition. From non-infectious causes

From infectious causes

Genetic causes

Calcium oxalate Calcium phosphate Uric acid Ammonium magnesium phosphate Carbonate apatite Ammonium urate Cystine Xanthine 2.8-di-hydroxyadenine

Drug-related

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Primary hyperparathyroidism (HPT) causes approximately 5% of urinary calcium (calcium oxalate and/or calcium phosphate) stones. In fact, the increase in parathormone (PTH) induces hypercalcaemia, hypercalciuria, hypophosphatemia and renal phosphate loss. The laboratory diagnosis is implemented by ultrasound of the neck and scintigraphy of the parathyroid glands, and by computerized bone densitometry to assess the presence of osteoporosis. Primary hyperparathyroidism complicated by kidney stones or osteoporosis may require surgical treatment (30). Granulomatous diseases, such as sarcoidosis, may be complicated by hypercalcemia and hypercalciuria because of overproduction of calcitriol with increased intestinal calcium absorption and PTH suppression (31). Primary hyperoxaluria (PH) is a rare hereditary genetic disease with increased endogenous production of oxalate, renal stone formation and nephrocalcinosis which can lead to end stage renal failure requiring kidney-liver transplantation (32). Enteric hyperoxaluria occurs in patients with intestinal fat malabsorption, such as in cases of intestinal resection, bariatric surgery, Crohn's disease, or pancreatic insufficiency. Increased fatty acids link to calcium in the intestinal lumen reducing availability of calcium to form insoluble complexes with oxalate and causing intestinal hyperabsorption of free oxalate (33). Renal tubular acidosis occurs due to impaired tubular reabsorption of protons (type 1) or bicarbonates (type 2) in the nephron. It can be acquired (e.g. in the case of recurrent pyelonephritis, acute tubular necrosis, autoimmune diseases, drugs, etc.) or hereditary. Especially in the type 1 form, where urine pH is always > 5.8, there is a high probability of calcium phosphate stone formation (34, 35). Uric acid stones account for 10% of kidney stones and have a high risk of recurrence (36). They are mainly caused by undue low urinary pH, decreased excretion of ammonia in the urine (e.g. gout), increased endogenous production of acids (e.g. metabolic syndrome) or increased loss of bases (diarrhoea). Another risk factor is hyperuricosuria, secondary to dietary excess (high dietary intake of animal proteins), excessive endogenous production, myeloproliferative disorders, gout, drug intake (in particular chemotherapy, thiazides and loop diuretics) and tumor cell lysis or catabolic processes. Ammonium urate stones are rare, accounting for less than 1% of all forms of kidney stones, and are associated with urinary tract infection or intestinal malabsorption, hypokalemia, and malnutrition. Finally, some drugs can promote the formation of kidney stones by various mechanisms: drug crystallization in the urinary tract as a consequence of overdosage and/or dehydration (allopurinol, ceftriaxone, quinolones, sulfonamides, etc.); alteration of metabolism with increased risk of urinary saturation (acetazolamide, topiramate, furosemide, laxatives, excess of vitamin D or calcium supplements between meals, etc.) (37, 38).

20 and larger than 20 mm. The size of the stones should be considered in association with stone location, presence and degree of hydronephrosis, clinical symptoms and signs. Stone location Stones can be classified according to their anatomical location as kidney, ureteral and bladder stones. Renal stones can be further divided as upper, middle or lower caliceal stones and renal pelvic stones; ureteral stones as proximal, mid or distal ureteral stones. Different locations, in association with the other characteristics of urinary stones, require different therapeutic approaches. Stone location is associated with specific clinical presentation requiring a differential diagnosis. Radiological characteristics Urinary stones can also be classified according to their radiodensity at plain abdomen X-ray (Rx) as radiopaque or radiolucent (39). Radiolucent are not demonstrated on X-ray. Non-enhanced computed tomography (CT) can be also used to classify stones according to their density, measured in Hounsfield units (HU) (40). Weakly radio-opaque and radio-lucent stones at X-ray can be well demonstrated on non-enhanced CT. Table 2. Classification of urinary stones by their radiodensity. Radio-opaque Calcium oxalate monohydrate (COM) Calcium oxalate dihydrate (COD) Calcium phosphate

Weakly radio-opaque Ammonium magnesium phosphate (Struvite) Cystine

Radio-lucent Uric acid

Clinical presentation Urinary stones can present with different symptoms and signs. Renal colic is a characterized by acute flank pain, often radiating to the groin, and associated with hematuria and dysuria. Microhematuria and episodes of urinary tract infection associated with chronic low back pain and/or evening fever can also be associated with kidney stones. Asymptomatic urinary stones can be diagnosed during investigations for other pathologies. GP and hospital should collaborate in the diagnosis and treatment of patients with renal colic according to shared protocols (7, 8, 41, 42). Statement 1 - The role of GP The GP has a role in initial diagnosis and monitoring of patients with renal colic, management of analgesic therapy and prevention of obstructive and infectious complications. The patient with symptoms of renal colic often firstly refers to the GP, who has an important role in the emergency management. Clinical evaluation is crucial for differential diagnosis between renal colic and acute low back pain of other causes. When office ultrasound is available, diagnosis can be facilitated by demonstration of direct (urinary

Stone size Size of urinary stones is crucial for treatment planning. It is usually expressed according to the largest diameter and stratified in the following groups: up to 5 mm, 5-10, 10-

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stone) or indirect (urinary tract dilatation/hydronephrosis) signs. The initial step is pain treatment: the first choice are nonsteroidal anti-inflammatory drugs (NSAIDs); opioids are more frequently associated with side effect as vomiting and stunning, and risk of dependence; antispasmodics are not suitable. If pain is not controlled, the GP must advise access to the emergency room for further diagnostic investigations. When pain is associated with fever, the GP should administer parenteral antibiotics plus antipyretics. Respiratory rate (=/> 22), systolic blood pressure (=/< 100 mmHg) and state of consciousness must be evaluated. If these parameters are altered and sepsis is suspected, the GP must advise immediate access to the emergency room for diagnostics (ultrasonography, CT) and emergency treatment (stenting, nephrostomy). In the suspect of urinary stones because of the presence of other symptoms, as microhematuria and episodes of urinary tract infection associated with chronic low back pain or fever, abdominal ultrasound should be performed.

acid composition can be predicted from stone radiodensity on CT (HU < 500) and low urine pH values (pH < 5.2). Demonstration of the stone on ultrasound in the absence of radiopaque images on the abdominal X-ray may be an alternative to CT (48). Undersaturation of the urine with respect to uric acid causes the dissolution of uric acid stones and can be achieved by alkalizing the urine with citrate or bicarbonate, increasing urine volume and reducing the excretion of uric acid (allopurinol) (49-54). Statement 3 - The role of GP The oral chemolytic treatment of pure uric acid stones with oral administration of alkalizing agents can be performed on the recommendation of the urologist or nephrologist (or directly from the GP). The GP has a very important role in increasing treatment compliance and follow-up. The success of the therapy depends on the patient's compliance which can be increased with selfmeasurement of urine pH several times a day and weekly checks to evaluate the diary of pH values and urine volumes. Stone size should be monitored frequently (every two weeks) until the stone has dissolved. Treatment should be ended after three months if the stone has not reduced in size.

Expulsive therapy After the resolution of the acute symptomatology, the patient with ureteral calculi can be followed up with a treatment aimed at the spontaneous stone passage. In presence of risk factors (severe hydronephrosis, long-lasting hydronephrosis, large stones, infection resistant to antibiotic treatment, recurrent pain) or in case of prolonged observation without stone passage, surgical treatment for the removal of the stone must be planned (43-47).

Extracorporeal and endoscopic therapy The modern treatment of urinary stones is based on extracorporeal or endoscopic lithotripsy (8). Stone fragments are eliminated through the urinary tract or suctioned through endoscopic instruments. The choice of treatment depends on location, size and composition of the stone, morphology of the urinary tract, renal function, possible presence of urinary tract infection, any anticoagulant therapy and general conditions of the patient The treatment is chosen by the urologist according to the aforementioned characteristics of the stone and his personal experience. At the end of the treatment, the patient is discharged with indications on the management of residual fragments and possible complications. Followup of actively treated patients for urinary stones should be under the responsibility of the urologist who performed the treatment.

Statement 2 - The role of GP The GP has a role in the management of expulsive and analgesic therapy and in the prevention of obstructive and infectious complications. Obstructive and infectious complications are renal failure, pyelonephritis, and urosepsis. There is no validated protocol that defines the necessary diagnostic tests and their timing in the followup of patients with ureteral stones treated conservatively or with medical expulsive therapy, but only the opinion of experts and the results of some systematic reviews. Based on these observations a moderate increase in water intake should be suggested. Observation or medical expulsive therapy should not be prolonged beyond 4 weeks. Patients should be monitored for infectious complication (white blood count, C-reactive protein, urinalysis, and urine sediment) and promptly referred to the emergency department in case of systemic inflammatory response syndrome (SIRS). Analgesic therapy has to be monitored in order to prevent digestive complications of NSAIDs (gastroprotection) and risk of prolonged opioids (addiction). Patients should be informed of off-label use of alpha-blockers (especially in young men and in women where use is not justified by concomitant benign prostatic hyperplasia) and of the side effects of alpha-blockers (anejaculation for tamsulosin and silodosin, syncope).

Statement 4 - The role of GP The GP must be aware of the complications that can arise in the post-operative period in the patient undergoing lithotripsy. The main complications are represented by infections/sepsis, obstruction of the urinary tract (hydronephrosis), and hemorrhage (for percutaneous lithotripsy). The GP must recognize the early onset of complications and send the patient to the emergency department, as these complications cannot be treated at home and require rapid management by an expert team. In the case of post-operative nephrostomy and/or ureteral stent placement, the management of these devices is demanded to urologists and hospitals.

Chemolysis Uric acid stones can be dissolved with chemolytic therapy. Pure uric acid stones can be suspected in case of age onset > 50 years, male sex, and diabetes mellitus. Uric

Stones in pregnancy Urinary calculi in pregnancy are a rare event which nevertheless requires careful management to avoid damage to the mother and the unborn child (55). Ultrasonography is

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General advice for the prevention of recurrence All patients with kidney stones should follow general prophylaxis measures in order to reduce the risk of recurrence. General measures can be associated with a targeted pharmacological treatment based on the chemicalphysical analysis of the stone in patients classified as high risk (7).

the first-line method of diagnostic imaging in pregnant women. Magnetic resonance imaging (MRI) is a second-line procedure used to define the level of the obstruction and to visualize the stones. Radiography and CT, due to the use of ionizing radiation, should be avoided. The recommended initial treatment is conservative with hydration and analgesics, if necessary, with the addition of antibiotics (56), since in 75% of cases there is a resolution of the symptoms and in 40-80% spontaneous expulsion. In symptomatic cases refractory to medical therapy or in the presence of infection or persistent obstruction, it is advisable to place a double J stent or alternatively a nephrostomy, under local anesthesia and if possible, under ultrasound control. However, both the stent and the nephrostomy are a potential risk of infection, and require periodic replacements, especially if the placement is performed in the first or second trimester of pregnancy. Therefore, some authors suggest performing a first-line rigid or flexible ureteroscopy as an effective procedure not burdened by obstetric complications. Despite the studies performed on some cell lines, the effects of shock waves on the fetus are not fully known at present and therefore shock wave lithotripsy (SWL) is not indicated during pregnancy and the reported cases generally refer to accidental treatments.

Statement 7 - The role of GP The GP has an important role in advising on an adequate diet and lifestyle. A constant intake of at least 2.5-3 liters of liquids per day should be recommended to guarantee a diuresis of at least 2.5 liters of clear urine in 24 hours. The patient should prefer water intake. Consumption of soda and sugary drinks is associated with a higher risk of urinary stones, while the intake of water, coffee, tea, beer, wine and orange juice are associated with a lower risk of urinary stones. The patient must be instructed to consume a varied and balanced diet, following the recommendations of Mediterranean diet. Should be recommended: • increased intake of fruit and vegetables, at least 5 servings a day (alkaline content of the vegetarian diet increases the urinary pH); • avoiding intake of foods high in oxalate and vitamin C (especially in patients who show high oxalate excretion); • limiting the intake of animal proteins (maximum 0.81 g/kg of body weight)(as they favor hypocitraturia, lowering of urinary pH, hyperoxaluria and hyperuricuria); • not limiting calcium intake but ensuring an intake at least equal to the daily calcium requirement of 10001200 mg per day (to promote the formation of nonabsorbable calcium-oxalate salts in the intestinal lumen and reduce intestinal absorption of oxalate); • not exceeding 3-5 g of sodium per day (as a higher intake is associated with increased calcium excretion, reduced citrate excretion and greater risk of sodium urate crystal formation); • limiting the intake of foods rich in purines (no more than 500 mg/day) in patients with hyperuricuric calcium oxalate and uric acid stones.

Statement 5 - The role of GP The GP has a role in patient monitoring, in the prevention of obstructive and infectious complications and in the management of analgesic therapy. The choice of analgesic therapy must be careful, avoiding NSAIDs, which are associated with pulmonary hypertension and premature closure of the ductus arteriosus, and codeine. Paracetamol is an option (category B according to the FDA) for analgesic and antipyretic treatment. Morphine must be used in low doses and for limited periods of time (category C). Beta-lactam antibiotics and fosfomycin are generally considered safe and effective in pregnancy. The use of fluoroquinolones and tetracyclines is not recommended. In the event that the pain symptomatology is refractory to medical therapy or pain symptomatology is associated with hyperpyrexia or in the suspicion of urosepsis, the GP must advise immediate access to the emergency department. Stones in the renal transplant recipient Kidney transplant recipients may suffer from calculi both due to the presence of calculi in the kidney already at the time of transplantation, and due to the greater risk of de novo lithiasis due to various risk factors: recurrent urinary tract infections due to immunosuppressive therapy, tendency to alkalize the urine, hyperfiltration, renal tubular acidosis, serum hypercalcaemia due to tertiary hyperparathyroidism (57).

Adequate physical activity should be recommended. For adults over the age of 18, at least 150 minutes of moderate-intensity physical activity per week, especially walking, cycling, or playing a sport at a non-competitive level is recommended. Finally, the maintenance of a normal body mass index, i.e. less than 30 kg/m2 and correct control of blood pressure with systolic blood pressure values below 135 mm Hg and diastolic blood pressure values below 85 mm Hg must be recommended.

Statement 6 - The role of GP The GP must be aware of the greater risk of stones in patients with renal transplants, must contribute to an early diagnosis by means of abdominal ultrasound (and possibly non-enhanced CT) and guide the patient towards an adequate therapeutic procedure, reserving conservative treatment under close follow up to only asymptomatic and highly compliant patients with small stones.

Metabolic evaluation The chemical composition of the stone should always be identified, preferably by infrared spectroscopy or X-ray diffraction (7, 8). In patients at high risk of recurrence, an individualized metabolic assessment is required, including: measurements of blood levels of creatinine, sodium,

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potassium, chloride, calcium (ionized or total corrected for albumin), phosphate and uric acid; measurement of urine pH and urine specific gravity; 24-hour urine collection with measurement of urine volume and concentration of calcium, oxalate, uric acid, citrate, sodium and magnesium (7, 8). In case of hypercalcemia, determination of blood parathyroid hormone (PTH) and vitamin D levels is recommended to rule out hyperparathyroidism. In case of struvite or ammonium urate stones, urine culture is recommended.

• recurring urinary tract infections (UTIs); • drugs with potential lithogenic effect: cortisone, laxatives, some antibiotics, topiramate; • previous urological procedures. GP should encourage to modify risky dietary habits as: • reduced calcium intake (which can cause hyperoxaluria); • low fruit consumption; • reduced fluid intake. Physical activity should be encouraged in conjunction with increased fluid intake to compensate for sweating losses. Finally, it is useful to correct excess weight, sedentary lifestyle, arterial hypertension, and metabolic pathologies predisposing to stone formation (dyslipidemia, hyperuricemia, diabetes, etc.).

Pharmacological prevention In patients at high risk of recurrence, drug therapy should be considered. Alkaline citrates (5-12 g per day) in case of calcium oxalate or uric acid stones. Thiazide diuretics at a dosage of between 25 and 50 mg per day in case of oxalate and/or calcium phosphate stones (monitoring blood pressure, advising the execution of a densitometric examination and of periodic dermatological visits). Magnesium at a dosage between (200 and 400 mg per day) in case of calcium oxalate stones associated with hypomagnesiuria or enteric hyperoxaluria (taking care not to induce diarrhea). Allopurinol (100-300 mg/day) in case of uric acid or calcium oxalate stones associated with hyperuricemia/hyperuricuria or of ammonium urate stones (alternatively febuxostat at 80-120 mg/day). Calcium supplements (up to 2000 mg) 20 minutes before meals in case of enteric hyperoxaluria, to reduce intestinal absorption of oxalate. Tiopronine (800 and 2000 mg per day) in case of cystine stones, to reduce the urinary excretion of cystine, in combination with alkalizing citrates to increase the solubility of cystine (as a second-line drug to reduce the excretion of cystine, captopril at a dose between 75 and 150 mg).

Follow up After treatment for urinary stones, patients without residual stones should be monitored for no less than 2 years in the case of radio-opaque stones and no less than 3 years in the case of radiolucent stones. A 5-year follow-up window allows for a greater margin of safety that can be evaluated on the basis of cost-effectiveness (58, 59). In patients with residual stones no greater than 4mm, disease progression and need for intervention are reported in less than 40%. Stones are expelled spontaneously within the fourth year in 25-33% of cases. An instrumental follow-up window of 48 months is therefore recommended in these patients. Residual stones greater than 4 mm in diameter should require retreatment unless there are contraindications suggesting conservative follow-up. Populations of patients diagnosed with metabolic abnormalities undergoing medical therapy require monitoring and follow-up for adverse reactions and compliance for a period of 4 years. In patients diagnosed with metabolic abnormalities not undergoing specific medical therapy, an extension of the follow-up window to at least 10 years is strongly recommended. The reference imaging method for follow up is plain X-ray and renal ultrasound for patients with radiolucent stones. Computed tomography should be avoided as a first-line follow-up method to minimize patient exposure to ionizing radiations. In the presence of residual fragments, the follow-up must be extended for 4-5 years by alternating ultrasound and CT (considering the risk of exposure to ionizing radiation).

Primary prevention Primary prevention is mainly entrusted to the GP and to the media (newspapers, TV, books, Internet). Statement 8 - The role of GP The GP should suggest measures to prevent the risk of stone formation to her/his patients who have not formed stones, particularly in those with a family history of the disease or other risk factors. Risk factors can be highlighted by a thorough medical history: • familiarity; • dietary habits (energy intake, quantity and type of fluids, intake of salt, animal proteins, calcium, oxalate, carbohydrates, and potassium); • lifestyle; • urological pathologies: bladder diverticula, renal cysts, urethral strictures, horseshoe kidney, UPJ stenosis, ureterocele, etc. • non-urological pathologies that can cause urinary stones: obesity, diabetes, dyslipidemia, arterial hypertension, IBD (Crohn's disease and rectocolitis), hyperparathyroidism;

Statement 9 - The role of GP The GP who identifies a progression in the size of the stone should refer the patient to the urologist to evaluate the need of active therapeutic intervention. In patients with metabolic abnormalities on drug treatment, the GP should monitor any adverse reactions and help increase patient compliance with medical therapy. The GP can intercept patients who may have missed follow-up and, conversely, discourage the use of opportunistic diagnostic procedures outside the follow-up windows, illustrating the lack of evidence of the benefit of monitoring procedures after an adequate recurrence-free period.

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Urinary calculi in general practice

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Correspondence Domenico Prezioso, MD dprezioso@libero.it Giacomo Puca, MD giacomopuca40@gmail.com Ciro De Luca, MD cirodeluca96@libero.it Dipartimento Neuroscienze, Scienze della Riproduzione ed Odontostomatologia, Università Federico II Napoli, Naples, Italy

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Gaetano Piccinocchi, MD Società Italiana di Medicina Generale, Florence, Italy piccinocchi.gaetano@simg.it

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Pietro Manuel Ferraro, MD pietromanuel.ferraro@univr.it Sezione di Nefrologia, Dipartimento di Medicina, Università degli Studi di Verona, Verona, Italy

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Stefano Mancon, MD stefano.mancon@humanitas.it Resident Humanitas University, Rozzano (Mi), Italy

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Salvatore Micali, MD salvatore.micali@unimore.it Università Modena e Reggio Emilia, Baggiovara (Mi), Italy

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Andrea Salvetti, MD dr.andreasalvetti@gmail.com Segretario SIMG Toscana Coordinatore AFT_Sud AUSL Sud Est Regione Toscana

57. Piana A, Basile G, Masih S, et al. En representación del grupo de trabajo de trasplante renal de la sección de Jóvenes Urólogos Académicos (YAU) de la Asociación Europea de Urología (EAU). Kidney stones in renal transplant recipients: A systematic review. Actas Urol Esp (Engl Ed). 2023:S2173-5786(23)00101-4.

Andrea Spasiano, MD andrea.spasiano01@icatt.it Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy

58. Tzelves L, Geraghty R, Lombardo R, et al. Duration of Followup and Timing of Discharge from Imaging Follow-up, in Adult Psatients with Urolithiasis After Surgical or Medical Intervention: A Systematic Review and Meta-analysis from the European Association of Urology Guideline Panel on Urolithiasis. Eur Urol Focus. 2022: S2405-4569(22)00146-8.

Alberto Trinchieri, MD alberto.trinchieri@gmail.com Urology School, University of Milan, via Commenda 15, Milan, Italy

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Conflict of interest: The authors declare no potential conflict of interest.

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12155

DOI: 10.4081/aiua.2023.12049

SYSTEMATIC REVIEW

The prophylactic omentectomy procedure in reducing the complication rate of continuous ambulatory peritoneal dialysis in pediatric: A systematic review and meta-analysis GedeWirya Kusuma Duarsa 1, Ronald Sugianto 2, Pande Made Wisnu Tirtayasa 3, Ni Made Apriliani Saniti 4, Komang Harsa Abhinaya Duarsa 5 1 Department of Urology, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G Ngoerah General Hospital, Bali, Indonesia; 2 Medical Doctor Study Program, Faculty of Medicine, Universitas Udayana, Bali, Indonesia;

3 Department of Urology, Faculty of Medicine, Universitas Udayana, Universitas Udayana Teaching Hospital, Bali, Indonesia;

4 Department of Surgery, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G Ngoerah General Hospital, Bali, Indonesia; 5 Undergraduate Medical Doctor Study Program, Faculty of Medicine, Universitas Udayana, Bali, Indonesia.

Summary

Introduction: The role of the omentectomy procedure on Continuous Ambulatory Peritoneal Dialysis (CAPD) catheter placement in pediatric patients has been differently evaluated in the literature, with some studies showing improvement while others showing no difference. Our study aims to define the advantages of omentectomy compared to a procedure without omentectomy. Methods: The literature searching in online databases (PubMed/MEDLINE, Cochrane Library, EMBASE, Scopus, and ClinicalTrial.gov) following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, has been registered on PROSPERO (CRD42023412846). The protocol was performed through April 2023 and focused on pediatric patients treated with an omentectomy procedure and related complications. The risk of bias in each study was assessed using the risk of bias for the non-randomized control trials (ROBINS-I). The effect estimates were extracted as risk ratios with 95% confidence intervals (CI). The heterogeneity of the studies was considered as high heterogeneity if I2 values above 50% or p < 0.05. Results: In the total of 676 articles identified in the database searching for screening, nine studies with 775 patients met the criteria for inclusion. The omentectomy procedure significantly showed a lower incidence of catheter obstruction compared to the control group, (OR 0.24 [95% CI, 0.12-0.49], p < 0.0001, I2 = 0%). Moreover, omentectomy demonstrated a similar trend in the rate of removal or reinsertion of the catheter with high heterogeneity, OR 0.25 [95% CI, 0.12-0.51), p = 0.0002, I2 = 70%). Conclusions: The omentectomy procedure showed a lower incidence of catheter obstruction and complications leading to removal or reinsertion of the catheter.

KEY WORDS: Continuous ambulatory peritoneal dialysis; Omentectomy; Omental procedure; Pediatric; Renal failure; Complication. Submitted 5 November 2023; Accepted 11 November 2023

hemodialysis, PD has the advantage to be performed in a continuous ambulatory setting, called Continuous Ambulatory Peritoneal Dialysis (CAPD). Other advantages are less risk to induce hemodynamic instability due to less pro-inflammatory effect involved with the procedure, providing nutritional support via dextrose in the dialysate, lower cost in long-term treatment due to minimal hospital visits or home-care hemodialysis, especially in a remote or rural setting where long-term dialysis is hardly obtained (24). The mortality risk for patients treated with PD is better than with hemodialysis in the short-term and long-term survival is better (1). Even though CAPD treatment was less common than hemodialysis, CAPD has recently become the preferred mode of treatment for pediatric patients with ESRD (1, 5). Despite these facts, CAPD is related to several mechanical complications related to catheter placement, including catheter obstruction by omentum, clot, or fibrin, and catheter migration out of the pelvis. Other complications are hypoalbuminemia, hyperglycemia, and infection, which can lead to peritonitis. All complications can lead to catheter failure, needing catheter removal or reinsertion (2, 6). According to ISPD Guidelines, the insertion of catheters in pediatric patients had an 18% of complication rate, including peritonitis, block of catheter, and catheter leakage (7). The omentectomy procedure, partial or total, was hypothesized for lowering the complication incidence. However, the role of the omentectomy procedure on CAPD catheter placement in pediatric patients has been differently evaluated in the literature, with some studies showing improvement while others showing no difference (6, 8-11). Our study aims to define the advantages of omentectomy as a prophylactic procedure in pediatric patients.

METHODS

INTRODUCTION

The systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and MetaAnalysis (PRISMA) (12). Our protocol was registered in the PROSPERO database (CRD42023412846).

Renal replacement therapy for pediatric patients with endstage renal disease (ESRD) can be through both peritoneal dialysis (PD) and hemodialysis modalities (1). Compared to

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ies was evaluated with the risk of bias in non-randomized studies of interventions (ROBINS-I) tool by two reviewers (13). Based on the eligibility of the information, the study was classified as low, moderate, serious, or critical for each domain. In case of discrepancies in the scores, the reviewers discussed to define a mutually accepted score.

Search strategy According to the PRISMA statement, the systematic search was conducted in electronic databases, including PubMed/MEDLINE, Cochrane Library, EMBASE, Scopus, and ClinicalTrial.gov for studies published until April 2023. The literature search included the following terms: (peritoneal dialysis[MeSH Terms]) OR continuous ambulatory peritoneal dialysis[MeSH Terms] OR (peritoneal dialysis[Title/Abstract] OR continuous ambulatory peritoneal dialysis[Title/Abstract] OR catheter dialysis [Title/Abstract] OR CAPD[Title/Abstract]) AND (omentum[MeSH Terms] OR bursa, omental[MeSH Terms] OR omentectomy[Title/Abstract] OR omental procedure [Title/Abstract] OR omentum procedure[Title/Abstract]).

Statistical analysis All dichotomous outcomes of retrospective studies were estimated as odd ratios (OR) with 95% confidence intervals (CI). When the heterogeneity of the studies showed a p value < 0.05, the random-effects model will be used for the calculation. The meta-analysis data were presented as a Forest plot using the RevMan version 5.4 application.

Eligibility criteria For the systematic review, we included studies reporting about pediatric patients, below 18 years old, diagnosed with the end-stage renal disease treated by CAPD. The exclusion criteria were studies that did not compare the outcome or report a comparative outcome without any data on omentectomy. Review articles, case reports, case series, animal studies, and editorial articles were not eligible for this study. The literature screening was done for the article in English only. Study selection Two author reviewers, at least one specialized in pediatric urology, independently evaluated the citations and abstracts. Each reviewer identified article titles relevant to the topic. The selection processes of the study initiate with assessing the clarity of the eligibility criteria and the consistency of each author's decisions. The literature was screened by two reviewers independently (G.W.K.D. and R.S.) for the study's eligibility. First, the studies were screened by the title and the abstract, then they proceeded to full-text screening. In case of disagreement with the study selection, a third author (P.M.W.T) helped to solve controversies.

RESULTS

A total of 676 articles were identified in the database searching for screening. After duplicate removal and 573 studies were screened by title and abstract. Out of them 27 studies were identified as potentially eligible studies and assessed by full-text for eligibility. Nine studies (14-22) including 775 patients met the criteria for inclusion, as shown in Figure 1.

Figure 1. Literature Search and Selection Flow Chart.

Data extraction One reviewer conducted data extraction, while another double-checked it to tabulate the necessary data for each study. Data were extracted by two reviewers (G.W.K.D. and R.S.) from all the included studies, including the first author's name, publication date, place were studies were performed, sample mean age, sex, surgical procedure, complication rate (including catheter malposition, migrating catheter, catheter failure, catheter leakage, bleeding, and peritonitis). Catheter failure was defined as the complication of CAPD that needed the removal or re-insertion of the catheter, while catheter obstruction was defined as the occlusion of the catheter due to omental wrapping or fibrin deposition. Risk of bias assessment The risk of bias assessment of included studArchivio Italiano di Urologia e Andrologia 2023; 95(4):12049

Peritoneal dialysis with omentectomy in pediatric patients

Table 1. Characteristics study and profile patient of the included studies. Author

Location

Study surgery Retrospective Review

Total patients 31

Age (year) 3.8 ± 6.5

Sex (Gender, %) Male, 55 Female, 45

Operation technique Open Laparotomy

Ahmed, 2012 (14)

Saudi Arabia

Cribs, 2012 (15)

USA

Retrospective Review

Male, 56 Female, 44

Laparoscopy and Open Approach

Ladd, 2011 (16)

USA

Retrospective Review

163

6.3 ± 5.6

Male, 49.1 Female, 50.9

Laparoscopy and Open Surgery

LaPlant, 2018 (17)

USA

Retrospective Review

153

4 ± 5.3

N/A

Open and Laparoscopy Surgery

Macchini, 2006 (18)

Italy

Retrospective Review

6.3 ± 6.1

Male, 61.5 Female, 38.5

Open Technique

Numanoglu, 2008 (19)

South Africa

Prospective Cohort

8.6

Male, 53.8 Female, 46.2

Laparoscopy Technique

Schuh, 2021 (20)

USA

Retrospective Review

184

7.4 (0.27-14.7)

Male, 62.5 Female, 37.5

Open and Laparoscopy technique

Pumford, 1994 (21)

United Kingdom

1-10 (range)

United Kingdom

7.8

Male, 47.6 Female, 52.4 N/A

Mini-Laparotomy

Lewis, 1995 (22)

Retrospective Review Retrospective Review

Mini Laparotomy

Complication Peritonitis Catheter Occlusion by omentum Catheter Malposition Catheter leakage Catheter Occlusion omentum and fibrin plug Dialysate Leakage Perforation Catheter Occlusion by omental wrapping, fibrin plug Peritonitis Catheter Malposition Dialysate Leakage Intestinal Perforation Catheter Disruption Catheter Leakage Infection Adhesion Catheter Migration Ventral Hernia Infection Inguinal Hernia Catheter Dislocation Catheter Obstruction by intestinal organs Catheter Leakage Catheter Obstruction by fibrinous adhesion, fimbria, sigmoid colod, omentum Catheter Leakage Bleeding Displacement Infection Mechanical Failure Infection Catheter Migration Catheter Leakage Catheter obstruction

Catheter survival time N/A

177 ± 204 days

759 days for omentectomy 198 days for non-omentectomy

585 days, range 36–2872 days

80% > 12 months 62% > 24 months 58% > 48 months

6.4 ± 6.3 months

39 days (17-112)

Catheter obstruction by omentum Peritonitis Appendicitis

N/A N/A

N/A: not available. Data are expressed as mean ± standard deviation or median (min-max interquartile range) or count %, as appropriate.

Table 2. Risk of Bias Assessment. Study Ahmed 2012 LaPlant 2018 Ladd 2011 LaPlant 2018 Manchini 2006 Numanoglu 2008 Schuh 2021 Pumford 1994 Lewis 1995

Design Retrospective Review Retrospective Review Retrospective Review Retrospective Review Retrospective Review Prospective Cohort Retrospective Review Retrospective Review Retrospective Review

Bias due to confounding Serious Serious Serious Serious Serious Serious Serious Serious Serious

Bias in selection of participants into the study No Information Serious Serious Serious No Information No Information Moderate Serious Serious

Bias in measurement of interventions Serious Serious Serious Serious Moderate Serious Moderate Serious Serious

Bias due to departures from intended interventions Moderated No Information Moderated No Information Low Moderate Moderated No Information No Information

Four studies were conducted in America, three in Europe, one in Africa, and another in Asia. The characteristics of included studies are summarized in Table 1.

Bias due to missing data Low Low Moderated Low Low Low Moderate No Information No Information

Bias in measurement of outcomes Moderated Moderate Serious Moderate Moderate Moderate Moderated Serious Serious

Bias in selection of the reported result Moderated Moderate Serious Moderate Moderate Serious Moderated Moderate Serious

Overall bias Serious Serious Serious Serious Serious Serious Serious Serious Serious

The risk of bias assessment showed that all included studies have a serious bias, as shown in Table 2. The funnel plot used to assess the publication bias and heterogeneity

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Figure 2. Funnel Plot showing that the analysis of removal or reinsertion and leakage of the catheter has high heterogeneity.

is presented in Figure 2. The meta-analysis was assessed for four comparative outcomes: complications leading to removal or reinsertion, catheter obstruction, infections, and catheter leakage. Among 339 patients in four studies, the omentectomy procedure significantly showed a lower incidence of catheter obstruction compared to the control group (OR 0.24 [95% CI, 0.12-0.49], p < 0.0001, I2 = 0%) as in the Forest plot shown in Figure 3A (16, 18, 21, 22). Moreover, omentec-

tomy demonstrated a similar trend for removal or reinsertion of the catheter in five studies, including 685 patients, with high heterogeneity (OR 0.25 [95% CI, 0.12-0.51), p = 0.0002, I2 = 70%). Forest plot is shown in Figure 3B (14-17, 19, 20). The complication of peritonitis and catheter leakage were reported only in two studies for each complication (16, 17, 22). In contrast, the analysis of both complications demonstrated insignificant results with no heterogeneity

Figure 3. Forest plot pooled effect estimated showed statistical significance. A) Omentectomy showed a lower incidence of complications lead to catheter removal in pediatric patients; B) Omentectomy showed a lower incidence of complication specific to catheter obstruction compare than without performing omentectomy.

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Figure 4. Forest plot pooled effect estimated showed an insignificant result. A) Omentectomy procedure was compared to non-omentectomy for peritonitis, showing an insignificant different result; B) Odds of catheter leakage was insignificantly higher in patients with omentectomy.

found (p-value heterogeneity > 0.05). The omentectomy procedure has a insignificantly lower incidence of infections leading to peritonitis (OR 0.61 [95% CI, 0.28-1.34], p = 0.22, I2 = 73%), as shown in Forest plot in Figure 4A. The omentectomy procedure showed a insignificantly higher incidence of catheter leakage compared to CAPD without omentectomy (OR 1.55 [0.70-3.45], p = 0.28, I2 = 0%), as shown in Forest plot in Figure 4B.

or peritonitis, resolve with conservative treatment, while the catheter obstruction, due to omental blockage, fibrin blockage, clot blockage, or catheter migration with obstruction, may necessitate removal or replacement (10). Even if catheter-related infections and peritonitis can be resolved by medication, peritonitis is the more common cause of catheter revision in the first year of treatment (27). The study by Phan et al. demonstrated that nonomentectomy catheter insertion was associated with a high re-operative rate for infection and malfunction (25). Therefore, the malfunction of the catheter, related to obstruction and catheter migration, often leads to catheter failure (7). Moreover, pediatric patients have thinner abdominal muscle layers compared to adults making it difficult to affix the catheter in place, but it helps prevent catheter tip movement and catheter liquid leakage to the skin. These differences might contribute to the different complication rates in pediatrics (15).The comparative studies demonstrated that omentectomy is a statistically significant protective factor in ages below one year old to lower the incidence of early obstruction. The catheter placement with an omentectomy procedure was postulated as a preventive measure against catheter failure due to fluid entrapment or obstruction (24, 27). In this study, the analysis of odds of catheter failure and catheter obstruction in pediatrics significantly assessed the advantage of omentectomy procedures, which means that omentectomy reduces the risk of catheter failure and catheter obstruction due to omental wrap. The same result was shown in a meta-analysis study by Kim et al. in the general population (28). The current guidelines for PD in pediatrics did not discuss in deepl regarding the effect of omentectomy procedures (7, 29, 30). On the contrary, there were several recommendations for successful peritoneal dialysis in infants

DISCUSSION

In pediatric renal replacement therapy, CAPD is the preferred treatment option which can be performed at home by low-trained caregivers without routinely visiting the hospital. To reduce the complication of CAPD, catheter insertion and the improvement in out-hospital care are essential (23). The catheters used for PD are varied, including rigid catheters, Tenckhoff catheters, which consist of straight, swan neck, or coiled, and adapted catheters, either from nasogastric tube, surgical drain, or dialysis catheter. However, the most preferred catheter in CAPD is a flexible cuffed, single or double cuffed, catheter, which can be placed through laparoscopic surgery, open surgery, or the Seldinger technique (a guidewire technique under local anesthesia). The omentectomy procedure can be performed only in surgical insertion, either laparoscopic or open technique (2, 23). Despite the catheter variability and differences in insertion methods, the comparison of different types and different techniques did not affect the complication rate of CAPD (24, 25). The complication of CAPD catheter may lead to PD failure, which prompts catheter removal/reinsertion or return to hemodialysis. The most common causes of CAPD failure are catheter-related infection and malfunction (26). However, most infectious complications, catheter-related

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G.W. Kusuma Duarsa, R. Sugianto, P.M.W. Tirtayasa, et al.

and children. The most common complication is peritonitis, minimalized by prophylactic antibiotics and a downward or lateral exit site placement, appropriate distance from the ostomy site and double-cuffed peritoneal dialysis catheter. For catheter leakage, prevention depend by subcutaneous tissue. Therefore, in infants weighing below 3 kg it is recommended to use a single cuff due to the lack of substantial subcutaneous tissue. The other recommendations are delaying initiation of peritoneal dialysis post-catheter insertion for more than 48 hours, using low fill volumes when initiation is started, and using a Tenckhoff catheter (7, 30, 31). Our study meta-analysis is an update on omentectomy outcome, with more specific analysis in pediatric patients. The previous study by Kim et al. has a similar design, but it analyses omental procedures in the general population (27). The limitation of our study is that all included studies were retrospective studies, which are at high risk of bias. Therefore, this study cannot differentiate confounding factors that may affect the outcome, including children’s age, weight, type of catheter, surgical techniques (laparoscopic or open surgical), and out-hospital care. However, the current literature demonstrated that those confounding factors, except the patient’s age, did not statistically affect the results. Our meta-analysis study brings conclusive finding for controversial advantages of the prophylactic omentectomy procedure. Besides, inclusion studies demonstrated a low heterogeneity, which ascertains the findings of the analysis. The rating of the evidence base of this study according to the GRADE criteria, classified it as moderate (32). Finally, we encourage all academicians to perform further research on the omentectomy procedure, as a mono-factor, to decrease the incidence of CAPD complications.

2. de Galasso L, Picca S, Guzzo I. Dialysis modalities for the management of pediatric acute kidney injury. Pediatr Nephrol. 2020; 35:753-65.

4. Niang A, Iyengar A, Luyckx VA. Hemodialysis versus peritoneal dialysis in resource-limited settings: Curr Opin Nephrol Hypertens. 2018; 27:463-71. 5. Pindi G, Kawle V, Sunkara RR, et al. Continuous Ambulatory Peritoneal Dialysis Peritonitis: Microbiology and Outcomes. Indian J Med Microbiol. 2020; 38:72-7. 6. Rasmussen SK. An overview of pediatric peritoneal dialysis and renal replacement therapy in infants: A review for the general pediatric surgeon. Semin Pediatr Surg. 2022; 31:151193. 7. Nourse P, Cullis B, Finkelstein F, et al. ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 Update (paediatrics). Perit Dial Int J Int Soc Perit Dial. 2021; 41:139-57. 8. Aksu N, Alparslan C, Yavascan O, et al. A single-center experience on percutaneously performed partial omentectomy in pediatric peritoneal dialysis patients. Ren Fail. 2014; 36:755-9. 9. Baksi A, Asuri K, Vuthaluru S, et al. Does laparoscopic omentectomy reduce CAPD catheter malfunction: A three-arm pilot randomized trial. Indian J Nephrol. 2022; 32:299. 10. Reissman P, Lyass S, Shiloni E, et al. Placement of a peritoneal dialysis catheter with routine omentectomy-does it prevent obstruction of the catheter? Eur J Surg. 2003; 164:703-7. 11. Radtke J, Schild R, Reismann M, et al. Obstruction of peritoneal dialysis catheter is associated with catheter type and independent of omentectomy: A comparative data analysis from a transplant surgical and a pediatric surgical department. J Pediatr Surg. 2018; 53:640-3. 12. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 372:n71. 13. Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016; 355:i4919. 14. Ali Ahmed AM, Safer MM, Badughiash AS, et al. Risk factors for peritoneal dialysis catheter failure in children: Ann Pediatr Surg. 2012; 8:35-8. 15. Cribbs RK, Greenbaum LA, Heiss KF. Risk factors for early peritoneal dialysis catheter failure in children. J Pediatr Surg. 2010; 45:585-9. 16. Ladd AP, Breckler FD, Novotny NM. Impact of primary omentectomy on longevity of peritoneal dialysis catheters in children. Am J Surg. 2011; 201:401-5. 17. LaPlant MB, Saltzman DA, Segura BJ, et al. Peritoneal dialysis catheter placement, outcomes and complications. Pediatr Surg Int. 2018; 34:1239-44. 18. Macchini F, Valadè A, Ardissino G, et al. Chronic peritoneal dialysis in children: catheter related complications. A single centre experience. Pediatr Surg Int. 2006; 22:524-8. 19. Numanoglu A, Rasche L, Roth MA, et al. Laparoscopic Insertion with Tip Suturing, Omentectomy, and Ovariopexy Improves Lifespan of Peritoneal Dialysis Catheters in Children. J Laparoendosc Adv Surg Tech. 2008; 18:302-5. 20. Schuh MP, Nehus E, Liu C, et al. Omentectomy reduces the need for peritoneal dialysis catheter revision in children: a study from the Pediatric Nephrology Research Consortium. Pediatr Nephrol. 2021; 36:3953-9. 21. Pumford N, Cassey J, Uttley WS. Omentectomy with Peritoneal Catheter Placement in Acute Renal Failure. Nephron. 1994; 68:327-8. 22. Lewis M, Webb N, Smith T, Roberts D. Routine Omentectomy is Not Required in Children Undergoing Chronic Peritoneal Dialysis. Adv Perit Dial. 1995; 11:293-5

3. Spector BL, Misurac JM. Renal Replacement Therapy in Neonates. NeoReview. 2019; 20:e697-710.

23. Bieber S, Mehrotra R. Peritoneal Dialysis Access Associated Infections. Adv Chronic Kidney Dis. 2019; 26:23-9.

CONCLUSIONS

Our meta-analyses demonstrated that the CAPD with omentectomy as prophylactic procedure in pediatrics is advantageous. In fact, although the omentectomy procedures might increase the risk of catheter exit leakage (p = 0.28), it significantly showed a lower incidence of catheter obstruction (p < 0.0001, OR 0.24) and complications leading to removal or reinsertion of the catheter (p < 0.0001, OR 0.25).

FUNDING STATEMENT

Our study received funding from Universitas Udayana in contract no: B/1.683/UN14.4.A/PT.01.03/2023 for the cost of research and publication.

REFERENCES

1. Himmelfarb J, Vanholder R, Mehrotra R, Tonelli M. The current and future landscape of dialysis. Nat Rev Nephrol. 2020; 16:573-85.

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Peritoneal dialysis with omentectomy in pediatric patients

24. Lemoine C, Keswani M, Superina R. Factors associated with early peritoneal dialysis catheter malfunction. J Pediatr Surg. 2019; 54:1069-75.

Infectious and mechanical complications: Experience of a tertiary hospital in Elazıg, Turkey. Niger J Clin Pract. 2022; 25:1227. 29. Gilbert J, Lovibond K, Mooney A, Dudley J. Renal replacement therapy: summary of NICE guidance. BMJ. 2018; 363:k4303.

25. Phan J, Stanford S, Zaritsky JJ, DeUgarte DA. Risk factors for morbidity and mortality in pediatric patients with peritoneal dialysis catheters. J Pediatr Surg. 2013; 48:197-02.

30. Canadian Association of Pediatric Nephrologists (CAPN) and Peritoneal Dialysis Working Group, White CT, Gowrishankar M, Feber J, Yiu V. Clinical practice guidelines for pediatric peritoneal dialysis. Pediatr Nephrol. 2006; 21:1059-66.

26. Tiewsoh K, Soni A, Dawman L, et al. Chronic peritoneal dialysis in children with chronic kidney disease: An experience from a North Indian teaching institute. J Fam Med Prim Care. 2021; 10:3682.

31. Sanderson KR, Harshman LA. Renal replacement therapies for infants and children in the ICU: Curr Opin Pediatr. 2020; 32:360-6.

27. Kim JK, Lolas M, Keefe DT, et al. Omental Procedures During Peritoneal Dialysis Insertion: A Systematic Review and MetaAnalysis. World J Surg. 2022; 46:1183-95.

32. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011; 64:383-94.

28. Bakal U, Sarac M, Tartar T, et al. Peritoneal dialysis in children:

Correspondence Gede Wirya Kusuma Duarsa (Corresponding Author) gwkurology@gmail.com Department of Urology, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia Jl. Sudirman, Denpasar, Bali, Indonesia, 80113 Ronald Sugianto rsugianto@student.unud.ac.id Medical Doctor Study Program, Faculty of Medicine, Universitas Udayana, Bali, Indonesia Pande Made Wisnu Tirtayasa wisnu_tirtayasa@unud.ac.id Department of Urology, Faculty of Medicine, Universitas Udayana, Universitas Udayana Teaching Hospital, Bali, Indonesia Ni Made Apriliani Saniti apriliani.saniti@gmail.com Department of Surgery, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G Ngoerah General Hospital, Bali, Indonesia Komang Harsa Abhinaya Duarsa abhinaya.duarsa@gmail.com Undergraduate Medical Doctor Study Program, Faculty of Medicine, Universitas Udayana, Bali, Indonesia Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12049

DOI: 10.4081/aiua.2023.12018

SYSTEMATIC REVIEW

A systematic review and meta-analysis on the efficacy of preoperative renal artery embolization prior to radical nephrectomy for renal cell carcinoma: Is it necessary? Gullyawan Rooseno 1, 2, Lukman Hakim 1, 2, Tarmono Djojodimedjo 1, 2 1 Department of Urology, Faculty of Medicine, Universitas Airlangga;

2 Dr. Soetomo General-Academic Hospital, Surabaya, East Java, Indonesia.

Summary

Introduction: Radical nephrectomy for Renal Cell Carcinoma (RCC) is still the treatment of choice for all stages except for stage I and IV, which need patient selectivity. The purpose of Renal Artery Embolization (RAE) pre-operative before radical nephrectomy is to facilitate resection, reduce bleeding, and reduce the time to surgery, but the necessity of this procedure is still debatable. This study investigates the efficacy of pre-operative Renal Artery Embolization (PRAE) before radical nephrectomy for RCC patients. Methods: The systematic searches based on PRISMA guidelines were conducted in Pubmed, Scopus, Web of Science, Medrxiv, and ScienceDirect databases with pre-defined keywords. Both analyses, quantitative and qualitative, were performed to assess blood loss, transfusion rate, surgical time, Intensive Care Unit (ICU) stay, and hospital stay. Results: A total of 921 patients from 8 eligible studies were included. The blood loss was significantly lower in the PRAE group compared to the control group (p = < 0.00001; SMD -20 mL; 95%CI -0.29, -0.12). There is no statistically significant difference between RAE and without RAE in the transfusion rate nephrectomy (p = 0.53, OR 0.65; 95% CI 0.16, 2.57), mean operative time (p = 0.69; SMD 5.91; 95% CI -23.25, 35.07), mean length of hospital stay (p = 0.05; SMD 0.56; 95% CI 0.00, 1.12), and mean length of stay in the ICU (p = 0.45; SMD 11.61; 95% CI -18.35, 41.57) Conclusions: PRAE before radical nephrectomy significantly reduces blood loss in RCC patients but is similar in the surgical time, transfusion rate, and length of hospital stay and ICU stay.

KEY WORDS: Renal artery embolization; Renal cell carcinoma; Radical nephrectomy. Submitted 21 October 2023; Accepted 2 November 2023

INTRODUCTION

Renal cell carcinoma (RCC) accounts for 5% and 3% of all malignancies, respectively, and is more prevalent in industrialized nations. It is the sixth most common cancer in men and the eighth most common cancer in women. Over 400,000 new cases in 2018 and 175,000 fatalities globally were reported (1). According to estimates, there are 2,4-3 instances of kidney cancer per 100,000 people in Indonesia, and the majority of these cases are T2 or above when they first show (2).

According to NCCN guidelines, radical nephrectomy (RN) is the treatment of choice for renal mass in all stages, except for stage I and stage IV which requires patient selectivity. The kidney, perirenal adipose tissue, adrenal glands, and surrounding lymph nodes are all removed during radical nephrectomy. The surgical management of RCC has evolved substantially over the last two decades, from an open approach to minimally invasive surgery using laparoscopy (3). In massive and complex renal mass, extensive neovascularization, and local invasion is still challenging for surgeons who perform RN in these patients. Intraoperative bleeding which can be life-threatening is the most common complication during this procedure. Intraoperative bleeding in radical nephrectomy can be massive and may require transfusion or in some severe cases, intraoperative death may occur (4, 5). Renal artery embolization (RAE) is a technique that reduces or stops the flow of blood via the renal arteries. Almgard conducted this procedure on humans for the first time in the 1970s. This method can stop spontaneous bleeding from the tumor, primary angiomyolipoma treatment, palliative treatment for unresectable renal masses, and as an adjunctive preoperative treatment prior to radical nephrectomy for primary renal masses (6, 7). Local edema surrounding the infarcted kidney occurs in 2-3 days after RAE. This event was thought to facilitate dissection by providing cleavage that can alleviate the surgery (8, 9). The necessity of preoperative renal artery embolization (PRAE) prior to radical nephrectomy has been often debated and its benefit is still questioned. Massive and complex renal masses with significant neovascularization and extensive local invasion remain a surgeon's nightmare when doing RN. A systematic review and metaanalysis study conducted by Shanmugasundaram et al. about PRAE prior to partial nephrectomy demonstrated a significant reduction in estimated blood loss with manageable post-embolization syndrome. Previous metaanalysis regarding pre-operative RAE were performed in patients with partial nephrectomy, whereas there is no meta-analysis that has concluded the role of RAE in radical nephrectomy. This study aims to determine the effect of preoperative RAE prior to radical nephrectomy for RCC, compared to those without preoperative RAE (10).

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METHODS

egorized into three groups. A score ranging from 0 to 3 implicates a low-quality study, a score from 4 to 6 implicates a medium-quality study, and a score from 7 to 9 implicates a high-quality study. For randomized controlled trial (RCT) studies, the assessment of potential research bias was conducted using the Cochrane RoB tools V2, which evaluates four domains, such as randomization process, deviations from intended intervention, missing outcome data, measurement, and selection of reported outcome (12).

Review protocol and search strategy This study followed a predetermined protocol according to the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). The literature searches were conducted using several databases (11), including Pubmed, Scopus, Web of science, Medrxiv and ScienceDirect. The selected keywords used for the search were described as “renal cell carcinoma”, “RCC”, “Renal Cancer”, “Kidney Cancer”, “Renal Carcinoma”, “Artery Embolization”, “Angioembolization”, “RAE”, “Total Nephrectomy”, and “Radical Nephrectomy”. The study's protocol was registered with PROSPERO (CRD42023450827).

Data analysis The measured end points included intraoperative blood loss, the number of patients receiving transfusions, the length of ICU stay and the length of hospitalization and operation time. For the dichotomous variable, the analysis used a p-value below 0.05 as a significant result and an Odds Ratio (OR) with a 95% Confidence Interval (CI). The continuous variable was assessed using Standardized Mean Difference (SMD). Heterogeneity between studies was evaluated using I2, where an I2 value above 50% indicated high heterogeneity and a random-effects model was applied for pooled analysis. The fixed-effects model was designed for I2 was less than 50%. The results were provided in Forest plots and descriptive narratives. The statistical analysis was conducted using RevMan 5.4 in Windows.

Eligibility criteria The inclusions criteria for this study were as follows: comparative studies, written in English, having at least two comparison groups, and reporting data on intraoperative blood loss, the number of patients receiving transfusions, the length of ICU stay and the length of hospitalization and operation time in radical nephrectomy with or without preoperative renal artery embolization. During the selection process, studies that fell under the following categories were excluded: animal experimental studies, non-English studies, duplicated studies, unpublished articles, and Figure 1. studies without full-text. The full PRISMA Flow Chart. search and selection process was demonstrated using 2020 PRISMA flow diagram (Figure 1). Data extraction and risk of bias assessment Two independent researchers collected the data using a predefined extraction template. In cases of discrepancies or disagreements during data extraction, a third investigator would be involved to discuss and make the final decision. The extracted information encompassed various aspects, including study details (authors, country, publication date, study design, sample size) and baseline characteristic such as age, embolic agents, histopathology, also qualitative and quantitative outcomes (intraoperative blood loss, transfusion rate, the length of ICU stay and the length of hospitalization and operation time). The assessment of potential research bias in non-randomized studies was conducted using the Newcastle-Ottawa Scale (NOS), which evaluates parameters related to selection, comparability, and exposure. The results obtained from the NOS assessment are cat-

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Renal artery embolization prior to radical nephrectomy

Table 1. Characteristic of the study. Author (year)

Country

Intervention

Bakal et al., 1993 (13)

Study design Retrospective

Age (Mean ± SD) 63.75 (± 12.25)

America

Jaganjac et al., 2014 (14)

Retrospective

Germany

RAE Without Rae RAE Without Rae

24 69 50 51

Time before surgery 24 Hours

Clavien-Dindo (N) -

24-48 Hours

May et al., 2009 (15)

Retrospective

Germany

RAE Without Rae

189 189

60.3 (± 90.4)

1-12 Days

Singsaas et al., 1979 (16)

Retrospective

America

Retrospective

China

12 12 24 30

Tang et al., 2020 (17)

RAE Without Rae RAE Without Rae

Gianturco-Anderson-Wallace

16 Hours

59 (± 11.8) 59.3 (± 8.9)

Gelatin sponge

3 Hours

Subramanian et al., 2008 (18)

Retrospective

America

RAE Without Rae

135 90

61.25 (± 4.9) 62.5 (± 4.6)

Absolute Ethanol and Occlusion baloon

24 Hours

Cochetti et al., 2019 (19)

Randomize Prospective cohort

Italy

RAE Without Rae

30 34

64.87 (± 13.26)

24 Hours

RAE Without Rae

9 37

66 (± 3.42)

Haemostatic Absorbable Gelatin Sponge (Spongostan, Ethicon™, Somerville, NJ, USA), Polyvinyl Alcohol (PVA) Embolization particles (Contour, Boston Scientific ™, Marlborough, MA, USA), and metallic spirals -

Velasco et al., 2021 (20)

Retrospective

Spain

Grade 0-I (33) grade II (10) grade III (1) grade V (2)

64 (± 20.75) 61 (± 12)

RESULTS

Embolant agent 98% absolute ethanol and baloon occlusion 96% alcohol or Ivalon 150-250 μ particles Central embolization of supply vessel: metal spirals Gelfoam, Gianturco-Wallace

Outcome Mean transfusion volume, volume tumor Pain, transfusion rate, operative time, hematuria

Transfusion rate, cancer-specific survival, overall survival, and complication Blood loss and transfusion volume ICU length of stay, blood loss, transfusion rate, complications Operative time, total vascular bypass, blood loss, transfusion rate, complications, hospital length of stay, length of ICU stay, perioperative mortality operative time, blood loss, transfusion rate and length of hospitalization

Transfusion rate and complication

Table 2. Characteristic of cancer.

Study search Our preliminary search found 1477 results. Fifteen fullarticles were retrieved for eligibility. Following the assessment of the full-text articles, eight were eliminated for several reasons, including differences in intervention, population, and incomplete data. The remaining eight publications were investigated further, as shown in Figure 1. Clinical characteristics of the included participants were described in Table 1.

Author (year) Bakal et al., 1993 (14) Jaganjac et al., 2014 (15) May et al., 2009 16

Singsaas et al., 1979 (17) Tang et al., 2020 (18)

Baseline characteristic of the study This research included a total of 921 patients with a mean age of 66 years, ranging from 59 to 66 years old. These participants comprised various articles published between 1979 and 2021. The embolant agent used was absolute ethanol, baloon occlusion, metal spirals, Gelfoam, Gianturco-Wallace, Gianturco-Anderson-Wallace, Gelatin sponge, Coil embolization, and Dehydrated alcohol with balloon occlusion. The baseline characteristics are presented in Table 2.

Histopathology Renal cell carcinoma Clear cell carcinoma, papillary carcinoma, chromophobe carcinoma, and spindle cell carcinoma (pleomorph) Clear cell renal cell carcinoma,

Subramanian et al., 2008 (19) Renal cell carcinoma, adrenocortical carcinoma, leiomyosarcoma,

Risk of bias assessment The comparative and exposure aspects of the selection

Cochetti et al., 2019 (20)

RCC, oncocytoma, chromophobe, papillary, solitary fibrous tumour, KS, TCC

Velasco et al., 2021 (21)

Clear cell carcinoma, chromophobe, papillary, anaplastic, collecting ducts, squamous cell carcinoma, nephroblastoma

Archivio Italiano di Urologia e Andrologia 2023; 95(4):12018

Clinical staging -

T3a: 19 T3b: 31 T3c: 4 T2-T3a: 2 T3b: 156 T3c: 57 T4: 6 T2b: 23 T3a: 27 T3b: 9 T4: 5 T3a: 44 T4: 2

G. Rooseno, L. Hakim, T. Djojodimedjo

Table 3. New Ottawa scale analysis. Author (year) Bakal et al., 1993 14 Jaganjac et al., 2014 15 May et al., 2009 16 Singsaas et al., 1979 17 Tang et al., 2020 18 Subramanian et al., 2008 19 Velasco et al., 2021 21

Study design Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective Retrospective

Selection **** *** *** ** **** **** ***

Comparability ** * ** ** ** ** **

Outcome *** *** *** ** * *** **

Total 9 7 8 6 7 9 7

random-effects (I2 = 91%; p = < 0.00001), there is no statistically significant difference in the transfusion rate between PRAE and without PRAE in patient undergoing radical nephrectomy (p = 0.53, OR 0.65; 95%CI 0.16, 2.57) (Figure 3).

Meta analysis of mean blood loss Based on a meta-analysis of the four papers included with fixed-effects (I2 = 3%; p = 0.38), there is statistically significant difference in the mean blood loss between PRAE and without PRAE in patient undergoing radical nephrectomy, which mean blood loss was lower on PRAE group (p = < 0.00001; SMD -0.20; 95%CI -0.29, -0.12) (Figure 4).

were well addressed, with adequate follow-up duration and relatively low dropout rates. Based on the final assessment, two studies received a NOS score of nine, while the remaining studies received scores ranging from 6 to 8, indicating a low risk of bias (Table 3). One study assessed using the Cochrane RoB tool V2 (Figure 2). The bias assessment result revealed that the study has a low risk of bias overall.

Meta analysis of mean operative time Based on a meta-analysis of the four papers included with random-effects (I2 = 76%; p = 0.005), there is no statistically significant difference in mean operative time between RAE and without RAE in patient undergoing radical nephrectomy (p = 0.69; SMD 5.91; 95% CI 23.25, 35.07) (Figure 5).

Meta analysis of transfusion rate Based on a meta-analysis of the six papers included with

Figure 2. Risk of bias analysis using Cochrane RoB tool V2.

Figure 3. Forest plot for transfusion rate.

Figure 4. Forest plot for mean blood loss [in liter (L)].

Figure 5. Forest plot for mean operative time (in minutes).

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Renal artery embolization prior to radical nephrectomy

Figure 6. Forest plot for men length of stay of the hospital (in days).

Figure 7. Forest plot for mean length of stay in the ICU (in hours).

PRAE demonstrated an insignificant difference in lowering the number of patients who need transfusions after radical nephrectomy. For other malignancies, PRAE can reduce the risk of massive intraoperative blood loss in hypervascular tumors, which makes PRAE the most common treatment for renal malignancies. However, these results did not align with reducing the risk of blood transfusion (23). Another study demonstrated a contrasting result, that the embolization of the renal artery before nephrectomy leads to a significant reduction in intraoperative blood loss in line with the reduction in the units of blood transfused. In specific patients, such as renal insufficiency, and anemia, and those undergoing transplant, the protection in transfusion is greater (24). This finding can be caused by factors that influence the condition of patients' transfusion requirements, such as transfusion policy factors, pre-operative baseline hemoglobin, and complications of the procedures (22). One of the iatrogenic complications of RAE, which may explain these results, include bleeding at the puncture site and iatrogenic vascular damage (25). The benefits of PRAE are locating the abnormal blood vessels and managing without losing normal renal parenchyma. Moreover, another advantage of RAE is visualizing the renal vasculature, which is helpful for tumor resection procedures (26). Despite these advantages, there was no significant difference regarding the length of time for surgery between the preoperative RAE group and the control group. It can be concluded that this occurs because the duration of surgery is not directly related to PRAE but rather to the procedural and technical difficulties during surgery. The main goal of RAE is not to reduce tumor size but to reduce bleeding (27). The effect of longer operative time, increasing estimated blood loss, and surgical complications may increase the number of blood transfusions, which certainly also prolong the length of stay in the ICU and hospital (28). Based on the fact that PRAE reduce the risk of large intraoperative blood loss and minimized the complication risk for surgical procedure, the other analysis performed in this study is the length of stay in the hospital and ICU (5), which showed that the PRAE group did not affect the length of stay in either hospital or ICU. Despite these

Meta analysis of mean length of stay Based on a meta-analysis of the three papers included with fixed effect (I2 = 34%; p = 0.22), there is no statistically significant difference in mean length of stay between RAE and without RAE in patient undergoing radical nephrectomy (p = 0.05; SMD 0.56; 95% CI 0.00, 1.12) (Figure 6). Meta analysis of mean length of stay in the ICU Based on a meta-analysis of the two papers included with random-effect (I2 = 93%; p = 0.0001), there is no statistically significant difference in mean length of stay in the ICU between RAE and without RAE in patient undergoing radical nephrectomy (p = 0.45; SMD 11.61; 95% CI -18.35, 41.57) (Figure 7).

DISCUSSION

Intraoperative bleeding is one of the greatest sources of concern for surgeon who will perform RN which is our primary focus of this investigation. Preoperative embolization of advanced renal tumors has also been employed to theoretically facilitate RN completion by reducing intraoperative blood loss, induce edema in the surrounding tissue to facilitate excision, and allowing early renal vein ligation. This study showed that RCC patients in the group that received RAE before radical nephrectomy showed less bleeding compared to control group. Research by Zhang et al., showed that 25% of patients experienced bleeding after radical nephrectomy, with the number of patients requiring blood transfusions around 20% (5). RAE is a procedure to reduce or completely stop renal artery blood flow by means of catheterization and arterial embolization. When RAE was first developed in the 1970s, increasing technological advances expanded the usefulness of the RAE procedure (3, 21). The mechanism of PRAE is to reduce bleeding by preventing the vascularization to grow and develop from the main branches of the renal arteries. In addition, it reduces blood flow to tumor cells and limits neovascularization, which help operator for better view and enhancing technique (22). Although PRAE can reduce blood loss during operation,

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facts, the differences in hospitalization policies might have a role in in-hospital duration for every hospital. Studies included in this meta-analysis have various delay from RAE to the surgery, the earliest was three hour and the longest was twelve days. The optimal delay for performing RAE would be: maximizing the benefit of tissue oedema after RAE, allowing the surgeon to proceed before formation of collateral vessels, and minimizing the patient's post-infarction syndrome. The optimal delay performing RAE is 24-48 hours before the surgery (29). The purpose for delaying nephrectomy for 2-3 days was the development of local oedema, which was supposed to facilitate resection. Nephrectomy at intervals greater than 3 days was deemed to become progressively more challenging due to increased collateral vasculature (9). Our study is a structured study assessing the effect of RAE on patients undergoing radical nephrectomy, which has no consensus and agreement regarding the most optimal time for this procedure. However, the limitation of this study is that most of the included studies performed RAE before nephrectomy at different time periods, which could lead to bias in the study data. The authors considered that this study has not analyzed the staging of RCC, average preoperative hemoglobin level, mean hemoglobin level of patients receiving transfusions, histological type, intraoperative events, and treatment constraints that may affect the conclusion of this study. We recommend performing multicenter RCT studies with selective criteria aimed to evaluate the effectiveness and safety of PRAE, which cannot be fully analyzed in this study.

my for renal cell carcinoma: a retrospective study comparing transperitoneal and retroperitoneal approaches using a standardized reporting methodology in two Chinese centers. Chin J Cancer. 2013; 32:461-8.

CONCLUSIONS

15. May M, Brookman-Amissah S, Pflanz S, et al. Pre-operative renal arterial embolisation does not provide survival benefit in patients with radical nephrectomy for renal cell carcinoma. BJR. 2009; 82:724-31.

6. Almgård LE, Slezak P. Treatment of Renal Adenocarcinoma by Embolization. Eur Urol. 1977; 3:279-81. 7. Li D, Pua B, Madoff D. Role of Embolization in the Treatment of Renal Masses. Semin intervent Radiol. 2014; 31:070-81. 8. Luo SH, Huang H, Chu JG, et al. Value of Nephrectomy Following Renal Artery Embolization vs. Nephrectomy Alone for Big Renal Cell Carcinoma: A Retrospective Analysis. Int J Radiol Med Imag. 2018; 4:126. 9. Kalman D, Varenhorst E. The Role of Arterial Embolization in Renal Cell Carcinoma. Scandinavian Journal of Urology and Nephrology. 1999; 33:162-70. 10. Shanmugasundaram S, Cieslak JA, Sare A, et al. Preoperative embolization of renal cell carcinoma prior to partial nephrectomy: A systematic review and meta-analysis. Clin Imaging. 2021; 76:205-12. 11. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009; 339:b2700. 12. Sterne JAC, Savovic J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019; 366:l4898. 13. Bakal CW, Cynamon J, Lakritz PS, Sprayregen S. Value of Preoperative Renal Artery Embolization in Reducing Blood Transfusion Requirements during Nephrectomy for Renal Cell Carcinoma. J Vasc Interv Radiol. 1993; 4:727-31. 14. Jaganjac S, Schefe L, Avdagi E, et al. Preoperative Kidney Tumor Embolization as Procedure for Therapy of Advanced Kidney Cancer. Acta Inform Med. 2014; 22:302.

The systematic review and meta-analysis showed that PRAE prior to radical nephrectomy might have potential to reduce blood loss in RCC patient. Radical nephrectomy with PRAE were comparable for surgical time, transfusion rate, and ICU stay. Further RCT studies are needed, involving multicenters, and taking into account factors that cannot be controlled in this study.

16. Singsaas MW, Chopp RT, Mendez R. Preoperative renal embolization as adjunct to radical nephrectomy. Urology 1979; 14:1-4 17. Tang G, Chen X, Wang J, et al. Adjuvant instant preoperative renal artery embolization facilitates the radical nephrectomy and thrombectomy in locally advanced renal cancer with venous thrombus: a retrospective study of 54 cases. World J Surg Onc. 2020; 18:206.

ACKNOWLEDGEMENT

We gratefully acknowledge the statistical advice of Ida Bagus Gde Tirta Yoga Yatindra, MD.

18. Subramanian VS, Stephenson AJ, Goldfarb DA, et al. Utility of Preoperative Renal Artery Embolization for Management of Renal Tumors With Inferior Vena Caval Thrombi. Urology. 2009; 74:154-9.

REFERENCES

19. Cochetti G, Zingaro MD, Boni A, et al. Renal artery embolization before radical nephrectomy for complex renal tumour: which are the true advantages? Open Medicine. 2019; 14:797-804.

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA: a cancer journal for clinicians. 2019; 69:7-34.

20. Caño Velasco J, Polanco Pujol L, Herranz Amo F, et al. Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus. Actas Urológicas Españolas. 2021; 45:615-22.

2. Umbas R, Safriadi F, Mochtar CA, et al. Urologic cancer in Indonesia. Jpn J Clin Oncol. 2015; 45:708-12.

21. Davis C, Boyett T, Caridi J. Renal artery embolization: application and success in patients with renal cell carcinoma and angiomyolipoma. Semin Intervent Radiol. 2007; 24:111-6.

3. Motzer RJ, Jonasch E, Agarwal N, et al. Kidney Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw.. 2022; 20:71-90.

22. Muller A, Rouvière O. Renal artery embolization—indications, technical approaches and outcomes. Nat Rev Nephrol. 2015; 11:288301.

4. Whiting D, Challacombe B, Madaan S, et al. Complications After Radical Nephrectomy According to Age: Analysis from the British Association of Urological Surgeons Nephrectomy Audit. J Endourol. 2022; 36:188-96.

23. Lionberg A, Jeffries J, Van Ha TG. Renal Artery Embolization for Neoplastic Conditions. Semin intervent Radiol. 2020; 37:420-5. 24. Panarese A, D’Anselmi F, De Leonardis M, et al. Embolization of

5. Zhang ZL, Li YH, Luo JH, et al. Complications of radical nephrecto-

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Renal artery embolization prior to radical nephrectomy

the renal artery before graft nephrectomy: a comparing study to evaluate the possible benefits. Updates Surg. 2021; 73:2375-80.

renal tumors improves surgical outcomes: A case series. Int J Surg Case Rep. 2015; 15:116-8.

25. Haochen W, Jian W, Li S, et al. Superselective renal artery embolization for bleeding complications after percutaneous renal biopsy: a single-center experience. J Int Med Res. 2019; 47:1649-59.

28. Naito S, Kato T, Tsuchiya N. Surgical and focal treatment for metastatic renal cell carcinoma: A literature review. Int J of Urology. 2022; 29:494-501.

26. Rochon P, Hu J. Renal Artery Embolization for Renal Biopsy Bleed. Semin intervent Radiol. 2016; 33:342-6.

29. Schwartz MJ, Smith EB, Trost DW, Vaughan ED. Renal artery embolization: clinical indications and experience from over 100 cases. BJU Int. 2007; 99:881-6.

27. Reinhart HA, Ghaleb M, Davis BR. Transarterial embolization of

Correspondence Gullyawan Rooseno, MD gullyawanrooseno@gmail.com Lukman Hakim, MD lukman-h@fk.unair.ac.id Tarmono Djojodimedjo, MD (Corresponding Author) tar_urology@yahoo.com Department of Urology, Faculty of Medicine, Universitas Airlangga Dr. Soetomo General-Academic Hospital, Surabaya, East Java, Indonesia Jl. Mayjen Prof. Dr. Moestopo No.6-8, Surabaya, East Java, Indonesia, 60286

Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12018

DOI: 10.4081/aiua.2023.12003

LETTER TO EDITOR

New minimally invasive solutions for Benign Prostatic Obstruction (BPO) management: A position paper from the UrOP (Urologi Ospedalità Gestione Privata) Rosario Leonardi 1, 2, Francesca Ambrosini 3, Rafaela Malinaric 3, Angelo Cafarelli 1, 4, Alessandro Calarco 1, 5, Renzo Colombo 1, 6, Ottavio de Cobelli 1, 7, Ferdinando De Marco 1, 8, Giovanni Ferrari 1, 9, Giuseppe Ludovico 1, 10, Stefano Pecoraro 1, 11, Domenico Tuzzolo 1, Carlo Terrone 3, 12, Guglielmo Mantica 1, 3, 12 1 Urologi Ospedalità Gestione Privata (UrOP);

2 Casa di Cura Musumeci GECAS, Gravina di Catania, Italy; 3 IRCCS Ospedale Policlinico San Martino, Genova, Italy; 4 Urology Unit, Villa Igea, Ancona, Italy;

5 Villa Pia Hospital, Via Folco Portinari 5, Rome, Italy;

6 Department of Urology, Vita e Salute San Raffaele University, Milan, Italy;

7 Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy; 8 I.N.I. Grottaferrata, Roma, Italy;

9 Hesperia Hospital, Modena, Italy;

10 Ospedale Miulli, Acquaviva delle Fonti, Bari, Italy; 11 NEUROMED, Avellino, Italy;

12 Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy.

KEY WORDS: Prostatic hyperplasia; Minimally invasive surgical procedures; Lower urinary tract symptoms; Sexual dysfunction; Urologic surgical procedures. Submitted 19 October 2023; Accepted 16 November 2023

To the Editor, In recent years, alternative solutions have been proposed to obtain effective results comparable to TURP, which is currently considered the gold standard, and laser vapo-enucleation techniques (1, 2), but with the possibility of maintaining sexual functions. In recent years there has been a growing trend towards ejaculation preservation. Although the results of TURP (3), and most laser enucleation techniques are undoubted in the Benign Prostatic Hyperplasia (BPH) and Lower Urinary Tract Symptoms (LUTS) management, they often lack in the preservation of ejaculation. All the alternative recently proposed interventions (Rezum, AquaBeam, Urolift, TPLA, i-TIND, LEST) are procedures considered by some authors to be promising in both managing BPO and preserving sexual functions. However, all these methods are limited by a lack of long-term follow-up that would evaluate the efficacy over time, possible complications related to the method and the correct patient selection for a specific method. The aim of this letter is to summarize the available evidence and provide clinicians with practical recommendations on the use of the brand new minimally invasive techniques for the management of BPO.

LEONARDI EJACULATION SPARING TECHNIQUE (LEST)

The LEST is an ablative technique fully described in 2019 (4). It is the evolution of a technique described in 2009 (5) that achieved outcomes similar to TURP, while expanding the indication to larger prostates and preserving ejaculation. This is a debulking laser technique with the aim of preserving the “genital sphincter” (anatomical structure that include the para-urethral musculature, distinguished in proximal and distal portion, and in part the musculature of the bladder neck). Other anatomical landmarks, essential to preserve ejaculation, are the orifices of ejaculatory ducts and the floor of prostatic urethra. The preliminary results showed an IPSS improvement of about 59% (p < 0.001) at 3 months followup and 67% (p < 0.001) at 12 months follow-up. Similarly, the Q max improvement was about +179% (p < 0.001) and +163% (p < 0.001) at 3- and 12-months follow-up, respectively (5). The Quality of Life (QoL) was 3.5+/-1.2 at the baseline while 1.3+/-1.2 and 1.2+/-0.4 at 3 and 6 months, respectively. An antegrade ejaculation is maintained in about 80% of cases in patients without a middle lobe, although in the presence of a middle lobe this rate drops to about 50% (5). In the beginning, prostates with a size of no more than 60 grams were included (5). Currently, the technique is proposed for any prostate size, with pure vaporization for a small prostate and enucleation for a large prostate (4, 5). No severe Archivio Italiano di Urologia e Andrologia 2023; 95(4):12003

R. Leonardi, F. Ambrosini, R. Malinaric, et al.

complications were described, except for minor bleeding at the beginning of urination, which usually occurs for 40 days after surgery. The reason for this lies in the preservation of mucosal areas of the prostatic urethra, that obviously must not be coagulated, that cover the structure to be preserved and that represent the key points of the technique. The authors are working to a variation of technique for the treatment of prostates with median lobe and the preliminary results show an increasing preservation of anterograde ejaculation compared to the past.

AQUABEAM/AQUABLATION

Aquablation, first described in 2015, uses a heat-less robotic system called AcquaBeam (AcquaBeam®, Procept BioRobotics, Redwood Shores, CA, USA), which combines ultrasound-guided waterjet technology with advanced planning software for precise ablation of prostate tissue and real-time monitoring during the procedure (6). The technique is recommended for patients with desires of preservation of sexual function and in case of moderate, to severe LUTS secondary to benign prostatic enlargement (volume 30-80 gr) and/or obstruction with underlying BPH (7). The procedure is performed under loco-regional or general anesthesia and 2-4 days of hospitalization are usually required (7-9). One of the main advantages of Aquablation is the short median operative time and resection time [30.5, IQR (24-35) and 4, IQR (3.1-4.9), respectively (10)]. Sexual outcomes are promising with de novo ejaculatory dysfunction observed in 26.7% of patients and absence of de novo erectile dysfunction (10). The efficacy of Aquablation was demonstrated in the United States (U.S.) cohort of the Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue (WATER) study, a double-blinded, multicenter, prospective, randomized controlled trial (RCT) comparing TURP vs. Aquablation in patients with moderate-severe LUTS and a prostate size of 30-80 mL (8). The hypothesis of non-inferiority of Aquablation in improving IPSS was demonstrated at 6 months (8) and 1 year (11). The benefits in symptom relief were not at the expense of sexual dysfunction. Among sexually active men, patients treated with Aquablation experienced statistically significant lower rate of anejaculation (at 6 months: 10% vs 36% in TURP, p = 0.0003; at 1 year: 9% versus 45% in TURP, p = .0006) (8, 11). Symptom reduction and Qmax improvement results were maintained at 2 years (12) and 3 years of follow-up (9), with statistically comparable improvements in IPSS scores between groups (3-year improvement difference: 0.6 points, 95% CI -3.3-2.2, p = 0.7) (9). The same results were reported in patients with large prostates (80-150 mL) (8) at 1 year and 2 year follow-up (WATER II) (13-15). The non-inferior efficacy of Aquablation was objectively demonstrated in another RCT (Aquablation vs. TURP), were bladder outlet obstruction was measured at 6-month follow-up by using the urodynamic test (16). Bhojani et al. reported an increase in Qmax of 14.3 ml/sec and a IPSS decrease of 15.6 points (17). Enthusiasm for the functional outcomes is tempered by concerns about its effectiveness in achieving hemostasis. After ablation, haemostasis is usually achieved using a Foley balloon catheter on traction or diathermy or low-powered laser (18). Because of the risk of bleeding, hospitalization for monitoring and bladder irrigation is usually required (19). In the WATER II trial, 7.9% of the patients required transfusion and/or reintervention due to postoperative bleeding (15). The 6-month rates of grade 2 and 3 Clavien-Dindo events account for 13.3% (10). Most authors found no significant change in IIEF-15 at 1 year follow-up (20, 21). In most series 0% to 2% of patients required surgical reintervention (i.e. TURP/HoLEP) for unsuccessful therapy (15, 21). According to the EAU and AUA guidelines (2, 22), Aquablation should still be considered under investigation considering the lack of long term follow-up and the uncertainties about bleeding risk.

REZŪ M

In the Rezūm system, thermal energy obtained with high frequency is released in the form of water vapor when the vapor changes from the gaseous to the liquid phase upon contact with the tissue. After the injections, the steam at 107°C distributes into the interstitial tissue spaces and releases stored thermal energy to the prostate tissue, causing cell necrosis. The procedure can be performed in an out-patient setting, using a local transurethral anesthesia. Transrectal prostatic block can be performed, if required (23).The operative time is usually less than 1 hour (23, 24) The efficacy of Rezūm has been evaluated in RCTs and systematic reviews (24-30). McVary at al. reported the results of a blinded trial in which patients were randomized 2:1 between Rezūm System thermal therapy and control (they received no treatment other than rigid cystoscopy simulating surgery) up to 4 years of follow-up. They found symptom relief at three months followup which was confirmed after 12 months, 2 years and 4 years (25, 26, 28). Only the Rezum group was followed up. No de novo erectile dysfunctions were recorded at one year while erectile and ejaculatory functions were preserved (25). Antegrade ejaculation is maintained between 100% and 96.6% (31, 32). Patients with troublesome LUTS but low prostate volume (< 30 g) also experienced significant relief of LUTS (33). The Rezūm could effectively treat patients with median lobes (25, 34, 35), urinary retention (36, 37) and large prostate volumes (≥ 80 g) (31, 33, 35, 38, 39). Nevertheless, the improvement of Qmax, IPSS and QoL was assessed only in an early to intermediate follow-up period (maximum 5 years). The gold standard TURP improved IPSS, QoL, and Qmax at 3 months and maintained its effect for at least 10 years (40). Medical and surgical retreatment rates for Rezūm were reported up to 18.9% at 5 years (26) and 10.8% at 2 years (41), respectively.The Rezūm system could be a viable alternative option for the treatment of LUTS due to BPO leading to an improvement in BPH symptoms, preserving sexual function with a 3%-6% risk of developing ejaculatory dysfunction, and being associated with a low surgical recurrence rate over five years (26, 29). Nevertheless, the level of evidence is low and impaired by several limitations (27) including the lack of a RCT directly comparing the Rezūm system with the gold standard, and providing a long-term follow-up. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12003

New minimally invasive solutions for Benign Prostatic Obstruction

TRANS-PERINEAL LASER ABLATION OF THE PROSTATE (TPLA)

TPLA is one of the most recent ‘ultra-minimally invasive’ ablative surgical treatment available. It uses a low-power diodelaser as the energy source and a small needle is inserted percutaneously transperineally (usually one needle for each lobe) (42), preserving the urethra as opposed to the more traditional transurethral approaches. According to the studies available in literature, TPLA was recommended in case of moderate-severe LUTS with an IPSS above 8 or 12 (43, 43-45) and prostate volume > 30 mL. There is one series which did not include patients with a median lobe (46). The procedure can be performed in an ambulatory surgical center, with a relative short operative time [mean setting time 21.33 ± 7.59 and lasing time 8.43 ± 0.79, respectively (44)]. TPLA resulted in statistically significant improvement in IPSS and QoL scores from baseline in most of the available studies (43, 45-48), with Frego et al. observing the greatest reduction in IPPS score (Δ = −16.0 at 12 months) (48). The longest follow-up reported in literature is 3 years, with a significant improvement in IPSS (-37.2%; p < 0.01), Qmax (+ 45.8%; p < 0.01) and median MSHQ-EjD (60%; p < 0.01) (49). A recent series published by Minafra et al. reported that TPLA results are acceptable even after 3 years (49). The results in terms of ejaculatory function are impressive (43, 47, 48, 50). In particular, in some cases, ejaculatory function assessed by the MSHQEjD questionnaire was not only preserved but even improved (44, 46, 51). No de novo erectile dysfunction was reported (51) The complication rate is generally low and not severe with a 6-month rates of grade 2 Clavien-Dindo events of 4.6% (44). A case of prostatic abscess was reported by De Rienzo et al. and by Manenti et al. (4.8% and 4.9%, respectively) managed with percutaneous drainage and antibiotic therapy (44, 46). Bertolo et al. recently reported for the first time the results of the comparison between TPLA and the gold standard (TURP) (52). They found a preservation of the ejaculatory function in 96% of cases of TPLA. Both treatments significantly improved the median Qmax, but the main advantage was observed for TURP (TPLA vs TURP: 15.2 mL/s vs 26.0 mL/s; p < 0.001) (52). More research is needed to evaluate the rate of pharmacological or surgical re-intervention in the long term after TPLA. Overall, all available data come mainly from a few pilot studies with short follow-up (maximum 3 years) and a limited number of patients, the strength of evidence for which is low and insufficient to make a recommendation. TPLA remains under investigation, but it could be considered for people interested in preserving sexual and ejaculatory function.

UROLIFT

The prostatic urethral lift (PUL, Urolift, Neotract Inc. Pleasanton, CA, USA) has passed the test of clinical evaluation within 4 years after introduction and was approved by Food and Drug Administration in the 2013 (2). This tissue retracting, permanent implant has a capsular, external tab made of nitinol connected to the plyethylene terephtalate monofilament and a urethral end piece made of stainless steel (53). During urethroscopy, in the ambulatory setting, the tissue-retracting implants are placed at the 2 and 10-o'clock positions guaranteeing integrity of the neurovascular bundle and dorsal plexus. Another advantage that Urolift offers is tailoring the implants based on the patients' anatomy, regulating the monofilaments' length and tension (54). Ideal candidates are patients with prostatic volume between 20 and 70 cc, with 'kissing' lateral lobes of the prostate, IPSS > 12, Qmax < 15 mL/s and with less than 350cc of post-void residual volume. To deploy the device, the operator uses a needle that is then anchored, with the internal side in the urethra, and with the outer side on the surface of the prostatic capsule. Usually, catheterization is not necessary following this procedure. Contraindications are men with prostatic volume over 80-100 gr, voluminous median lobe and history of urinary retention (55). The recent evidences did not show superiority of the Urolift when compared to the gold-standard (56-58), TURP, but it does, however reduce severity of LUTS. Currently, the largest RCT available (the L.I.F.T. study) comparing PUL vs. a sham control reported durable improvements in IPSS (36%), QoL (50%), and Qmax (44%) at 5-years (58). Also, an increase in maximum urine flow-rate (Qmax) from 7.88 to 11.08 was evidenced in the same period. Some comparative studies described superiority of the Urolift to other minimally invasive techniques when it comes to erectile dysfunction. Actually, Sexual Health Inventory for Men (SHIM) scores were greater in the Urolift (14.8) versus other groups (9.2) (59). Moreover, new generation of the PUL, marketed as Urolift 2, was launched in March 2022. There are some drawbacks to PUL technique, like reported adverse events and high costs. The majority of adverse events were mild, such as transient hematuria, dysuria, pelvic pain, blood clots and incontinence (60), but some Authors reported formation of pelvic hematoma (61), one of which needed surgical intervention (62), and another that resulted in acute kidney injury and progression of chronic kidney disease (63). Also, the LIFT trial reported the need for retreatment or surgical intervention in 13.6% of patients (54). On the other hand, at longer follow-up (5 years), there were no adverse event reported related to sexual function (58). Currently, the Urolift is recommended as an alternative non-ablative technique to men with LUTS interested in preserving ejaculatory function, with prostates < 70 mL and no middle lobe by the guidelines of the European Association of Urology (2).

TEMPORARILY IMPLANTED NITINOL DEVICE (ITIND)

The temporary implantable nitinol device (first generation: TIND; second generation: iTind) (Medi-Tate®; Medi-Tate Ltd., Or Akiva, Israel) is a recent promising non ablative minimally invasive solution for the management of LUTS/BPH (64). One of the advantages of the technique is the fact that most cases can only be achieved with the use of local anesthetic, with light intravenous sedation if required (65). Similarly, most patients can be managed with a day-surgery hospital access. Another advantage, comparing to implantable devices, is that iTind is a temporary device which avoids the potential complications associated with a permanent device. The iTind seems to be of particular benefit to LUTS/BPH patients Archivio Italiano di Urologia e Andrologia 2023; 95(4):12003

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(IPSS > 12 points and Qmax ≤ 12 ml) seeking a minimally invasive treatment associated with a significant improvement in symptoms with the preservation of sexual function. ITind could be also recommended in case of BPH and sclerosis of the bladder neck. In most series, prostate size was quite small (less than 60-75 cc). Porpiglia et al. showed an IPSS and Qmax improvement by -45% and +67% respectively, at 12 months follow-up (66). Similar results were found in the MT02 study, a single arm multicentric study involving 81 patients (67). Other series are published, with good results but with shorter follow-up (68). The device and the procedure appear to be moderately safe, with a low number of complications (mostly urinary retention, UTIs, device displacement, hematuria) and in particular not high grade according to the Clavien-Dindo classification. A randomized trial based on 175 patients showed no de novo ejaculatory or erectile dysfunction (69). At two-year follow-up, 4 of 81 patients required subsequent surgery (TURP/HoLEP) (70). The longest published follow-up is 36 months (71). Currently, the iTind is not recommended in the guidelines, even though considered a promising technique, waiting for the results of ongoing randomized controlled trials comparing iTind to a reference technique.

DISCUSSION AND CONCLUSIONS

All the new minimally-invasive techniques for the treatments of LUTS due to BPO were developed because of the necessity to offer a patient-tailored, successful, viable treatment for BPH while maintaining sexual and ejaculatory function (4, 6, 42, 58). Now more than ever, the patients are well informed about all the possibilities that new technologies can offer and how can we, as urologists, improve their quality of life by maintaining good both functions, urinary and sexual. Also, quick recovery period and rare serious adverse effect of these minimally invasive technologies make them even more attractive (24). Seemingly, they are a relatively easy choice to make when compared to the gold standard, TURP, and maybe should be the first one at some point in well selected candidates, but there are some drawbacks to take in consideration such as, in some cases, higher costs, availability, surgical experience of the operators and higher rates of retreatments (24). These are major reasons why urologists should be very careful when proposing new techniques to the patients, choosing the right candidates for the right procedure, and giving them all the necessary information regarding. Some of the most important parameters to consider are patients' general health status, prostate volume, and strong desire to preserve ejaculation (2, 72, 73). The doctor-patient relationship, patient-tailored therapy, shared decision, and correct informed consent are more important than ever. From the national health-care institutions' prospective these treatments, if preformed in ambulatory setting, can be extremely useful as they can alleviate the long waiting lists for surgical treatments that require surgical staff, hospitalization, and post-operative care. For example, Rezum, iTind and Urolift can all be offered to the patients in 'day surgery' regime (36, 55, 69). This can be an important advantages for healthcare systems in the post SARS-CoV-2 era (74, 75). On the other hand, to be able to offer these kinds of services, urologists preforming them must be adequately prepared and trained, and not only on the procedure itself, but on adverse events and complications. The scarcity of specialized training centers and fairly limited diffusion of these novel techniques pose quite an important obstacle in using them, especially in the smaller, more peripheral hospitals. In addition to that, it should be mentioned that some of these techniques did never undergo randomized trials (i.e. iTind), and the outcomes of these studies never systematically evaluated using validated outcome measures, therefore the rate of retreatments is still quite uncertain. Furthermore, there is a lack of long-term follow-up results, and for that manner it could be difficult to give the patients precise and complete information. Nevertheless, minimally invasive treatments are on the rise, especially Urolift in the United States (76). One of the greatest benefits of minimally invasive techniques is the preservation of sexual function. De novo erectile function is anedoctal and ejaculatory dysfunction is generally low (15.4% with LEST, 3-6% in Rezum, 26.7% in Aquablation (24, 30). ITind and Urolift had no impact on ejaculatory dysfunction. It is worth noting that all minimally invasive techniques are relatively young and have a short follow-up, with the exception of LEST (Laparoscopic Endoscopic Single-Site Surgery), which has a follow-up of up to 12 years (4, 5). This remarkable longevity of follow-up data for LEST sets it apart from other procedures and underscores its potential and reliability. In addition, LEST provided immediate relief of LUTS after catheter removal, whereas Rezum, Urolift, and iTind provided good results only after some time (2 weeks to six months). Obviously, the incorporation in the guidelines and insurance companies are also important factors to consider when implementing them. Moreover, Urolift is mentioned as the valid alternative in some guidelines, while others are not mentioned or are discouraged because of higher retreatment rates (73) Also, not all guidelines agree on the recommendations [NICE vs. AUA (72, 73)]. The need for cautious interpretation of current analytical results stems primarily from the everevolving landscape of safety and efficacy data on these innovative techniques. Currently, ongoing studies are comparing these procedures not only with transurethral resection of the prostate (TURP) (NCT05762198, NCT05840549) but also with various alternative treatments, including purely medical interventions. Pending the results of these ongoing studies, these techniques are very promising and appear to be attractive alternative options for future treatment of the disease in selected patients. In conclusion, we would like to provide our position related to each one of the techniques presented. The LEST showed promising results in terms of functional outcomes with significant improvements in IPSS and Qmax, while preserving sexual function. Aquablation shows efficacy in improving IPSS and Qmax with favorable sexual outcomes. Concerns about hemostasis and Archivio Italiano di Urologia e Andrologia 2023; 95(4):12003

New minimally invasive solutions for Benign Prostatic Obstruction

bleeding risk remain, but the short operative time and the possibility of an outpatient setting make it a valuable option for patients seeking both symptom relief and preservation of sexual function. Rezūm provides significant relief for LUTS, with a low risk of ejaculatory dysfunction. Nevertheless, the level of evidence remains low, and further long-term studies are needed to prove its efficacy compared to the gold standard TURP. TPLA shows a remarkable improvement in IPSS and QoL scores, with impressive results in ejaculatory function preservation. Due to the limited short-term data and the small number of patients, TPLA should remain under investigation. Urolift proves effective in reducing LUTS severity with durable improvements in IPSS and Qmax, and shows superiority in preserving erectile function. Despite the reported adverse events, its outpatient nature and the easy implantation make Urolift an attractive option for selected patients. iTind is a promising non-ablative solution, that offers significant improvement in symptoms with minimal impact on sexual function. Its temporary nature and low complication rates are the main advantage, especially for patients seeking a minimally invasive treatment approach. In conclusion, all of these minimally invasive techniques offer multiple options for patients with BOO, balancing efficacy, preservation of sexual function, and potential benefits to the healthcare system. As ongoing studies continue to validate their long-term outcomes and cost-effectiveness, urologists must carefully consider patient preference and individual health context when recommending these innovative approaches.

REFERENCES

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Three years outcomes of transperineal laser ablation of the prostate. Minerva Urol Nephrol. 2023; 75:471-478. 50. Rosati D, Lombardo R, De Nunzio C, et al. Transperineal Interstitial Laser Ablation of the Prostate, A Novel Option for Minimally Invasive Treatment of Benign Prostatic Obstruction. Eur Urol 2021; 80:673-674. 51. Sessa F, Bisegna C, Polverino P, et al. Transperineal laser ablation of the prostate (TPLA) for selected patients with lower urinary tract symptoms due to benign prostatic obstruction: a step-by-step guide. Urol Video J 2022; 15:100167. 52. Bertolo R, Iacovelli V, Cipriani C, et al. Ejaculatory function following transperineal laser ablation vs TURP for benign prostatic obstruction: a randomized trial. BJU Int 2023; 132:100-108. 53. Magistro G, Stief CG, Woo HH. Mini-Review: What Is New in Urolift? Eur Urol Focus 2018; 4:36-39. 54. Roehrborn CG, Gange SN, Shore ND, et al. 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Correspondence Rosario Leonardi, MD leonardi.r@tiscali.it Casa di Cura Musumeci GECAS, Gravina di Catania, Italy Francesca Ambrosini, MD (Corresponding Author) f.ambrosini1@gmail.com Rafaela Malinaric, MD rafaela.malinaric@gmail.com Carlo Terrone, MD carlo.terrone@hsanmartino.it Guglielmo Mantica, MD guglielmo.mantica@gmail.com IRCCS Ospedale Policlinico San Martino, Genova, Italy Largo Rosanna Benzi 10, 16132, Genova, Italia Angelo Cafarelli, MD info@angelocafarelli.it Urology Unit, Villa Igea, Ancona, Italy Alessandro Calarco, MD info@alessandrocalarco.com Villa Pia Hospital, Via Folco Portinari 5, Rome, Italy Renzo Colombo, MD colombo.renzo@hsr.it Ottavio De Cobelli, MD ottavio.DeCobelli@unimi.it Department of Urology, Vita e Salute San Raffaele University, Milan, Italy Ferdinando De Marco, MD info@clinicavillamargherita.it I.N.I. Grottaferrata, Roma, Italy Giovanni Ferrari, MD visite@giovanniferrariurologo.it Hesperia Hospital, Modena, Italy Giuseppe Ludovico, MD g.ludovico@miulli.it Ospedale Miulli, Acquaviva delle Fonti, Bari, Italy Stefano Pecoraro, MD cup@diagnosticamedica.org NEUROMED, Avellino, Italy Domenico Tuzzolo, MD info@casadelsole.it Urologi Ospedalità Gestione Privata (UrOP) Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12003

DOI: 10.4081/aiua.2023.12118

LETTER TO EDITOR

National consensus survey on management approaches for upper urinary tract obstruction: A comparative analysis of retrograde ureteric stent and percutaneous nephrostomy Vasco Quaresma 1, 2, Francisca Magalhães 2, Lorenzo Marconi 1, 2, João Lima 1, 2, Manuel Lopes 1, Ana-Marta Ferreira 1, Pedro Nunes 1, 2, Arnaldo Figueiredo 1, 2 1 Urology Department, Centro Hospitalar e Universitário de Coimbra, Portugal; 2 Faculty of Medicine of the University of Coimbra, Portugal.

Submitted 22 November 2023; Accepted 2 December 2023

To the Editor, Upper urinary tract obstruction (UUTO) is a common scenario in clinical practice, and it is caused by a variety of diseases. Lithiasis, tumours and strictures are some of the principal aetiologies (1). Multiple factors may influence both the need for decompression of the obstructed collecting system and the urgency of procedure. To our knowledge, there is limited agreement among clinicians about the optimal method, timing of intervention and even some indications for decompression. Both percutaneous nephrostomy (PCN) and retrograde ureteral catheterization (RUC) have established efficacy for decompression of upper urinary tract (2). Furthermore, the high success and low complication rates of these drainage procedures make both alternatives attractive (3-5). However, there is great disagreement on which of the two methods is better for the patient and for a specific clinical setting (3-5). There are currently insufficient studies that directly compare both methods, and most works have retrospective and heterogenous design (3-5). There are two randomized studies addressing efficacy of RUC vs PCN in patients with obstructive ureteral calculi and infection (2, 6). One randomized controlled trial with 42 patients, demonstrated no significant difference in time to definitive drainage, clinical normalization of index parameters (white blood count and temperature), or length of hospital stay (2). Another randomized prospective trial with 40 patients, concluded that percutaneous nephrostomy was superior to retrograde ureteric stent, with shorter period of iv antibiotics, superior quality of life, less use of analgesia and no access failures on PCN arm (3). Previous studies also addressed which method was superior according to clinical indication. Double J stent was the first choice of Urologists when facing patients with uncomplicated benign disease and patients with coagulopathy (7). Availability, logistics, and experience with PCN or ureteric stent techniques vary internationally, nationally, and even locally (4). Desobstruction method selection is made by local practice, patient characteristics, expertise, and facilities (4). Acute upper urinary tract obstruction is most commonly due to calculus. The existing guidelines by European Association of Urology only recommend definitive treatment of the cause of obstruction after infection has been resolved (8). However, further to the emerging role for the use of primary ureteroscopy (URS) in the management of non-infective ureteric stones (9), recent data showed that URS can effectively and safely manage febrile hydronephrosis due to ureteric stone disease, when combined with strong antibiotics in select clinical situations (10, 11). Based on the above findings, the decision to choose the best method for decompression of the renal collecting system depends on the clinical scenario, the physician’s expertise, hospital environment and costs. That decision is made without guidelines about the best method for decompression and the perfect timing. This work aims to build a consensus survey among Urologists in Portugal, that may be the basis for subsequent development of guidelines to support the decision on the best method of upper urinary tract clearance, according to the clinical situation and intrinsic factors of the patient.

PATIENTS AND METHODS

The study was approved by institutional ethical committee (CE-099/2022). Opinion based questionnaire was available via Google Forms and sent to all Portuguese urologists using the Portuguese Urological Association (APU) associates database. All gathered data was anonymised. Written inform consent to participate in the study was collected. Survey was designed by Urologists with experience in UUTO and pretested with 10 urologists. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12118

V. Quaresma, F. Magalhães, L. Marconi, et al.

All respondents were invited to answer questions about their urological experience, their working place and resources of urology unit. Three sets of questions were provided on questionary to survey urologists opinion on the indication, timing, and the preferred method. First, clinicians were invited to decide when to drain the urinary tract, given different clinical scenarios. Answers were given in the form of a Likert scale with 5 levels (Totally agree to decompress to Totally disagree to decompress) and were followed by an assessment of the priority of each decompression (<1h; 1-3h; 3-12h; >12h). Urologists were also invited to choose the preferable method (PCN or RUC) for the previously designed clinical scenarios. Lastly, five questions directed to primary URS role were incorporated, to define the possibility of choosing this option over PCN or RUC. Residents with less than 3 years of clinical practice were excluded from the final analysis. Data analysis regarding agreement was categorised into three degrees of agreement: ‘‘clear agreement’’ (> 75% agreement), ‘‘broad agreement’’ (50-75%) and ‘‘no broad consensus’’ (less than 50%). Descriptive analyses were performed using standard summary statistics - median, mode and frequency distribution. Mann-Whitney U Test was used to analyze differences between groups of experts. Specialist questionaries were evaluated using standard summary statistics according to previously defined degrees of agreement. SPSS version 25 was used.

RESULTS Survey population and group differences analysis We obtained a total of 104 answers, covering more than 35% of national urology specialists. In the study population, 76% of participants were currently working in a central or metropolitan emergency department and carried out assistance activity in the emergency department. A total of 70% of the answers were given by specialists and the remaining 30% by residents with more than 3 years of experience. Most answers (57%) were given by clinicians with more than 10 years of expertise in urology and 97% of the answers were given by physicians who perform PCN and RUC in their daily clinical practice. Most urologists (57%) reported a minimum of 2 patients per day requiring UUT decompression in their hospital. There were no significant differences between residents and specialists’ answers (p > 0.05), groups of years of experience (p > 0.05) and activity in emergency department (p > 0.05). When analyzing the answers by the number of patients per day requiring UUT decompression, answers of experts significantly differed in the indications for decompression in case of MET refractory colic (p < 0.05) and AKI without complications (p < 0.05). Questions with significantly different responses in the four previous groups were excluded from the following global analysis. Indications for upper urinary tract decompression The complete results of survey regarding the indication and timing for upper urinary tract decompression are summarized on Table 1. Urologists had clear agreement that decompression of the upper urinary tract is mandatory with fever (99% agreement) and clinical signs of sepsis (100% agreement). In case of fever, there was a broad agreement it should be performed in less than 3 hours (64%) and a clear agreement it should be performed in a time interval of less than 12 hours (99%). When clinical signs of sepsis are present, there was a clear agreement that it should be performed in less than 3 hours (85%). Most urologist answered it should be done in less than 1 hour (66%). Regarding the need to decompress the UUT when the patient presents with AKI (increase of serum Cr > 50% in 48h or diuresis < 0.5ml/kg/h for > 6h), there was a clear agreement that UUT decompression should be performed (75%). When complications are present, such as fluid overload or altered state of consciousness, Table 1. 96% urologist agree with decompression. Opinions regarding the adequacy of UUT decompression according Regarding time to decompression, AKI to clinical scenarios. without complications can be delayed more than 3 hours (broad agreement), with 18% of the clinicians stating that it could even be deferred to the next day. When complications are present, 83% said it should be done in less than 3 hours, reaching a clear agreement. There was also clear agreement (81%) that decompression should take place in presence of leukocytosis and increased CRP, with 93% (clear agreement) stating that it should be performed within the first 12 hours. When questioned about the CRP values that should motivate UUT decompression, there was a clear agreement that UUT decompression should not be performed with CRP values lower than 5 mg/dl (89%), when no other symptoms or Archivio Italiano di Urologia e Andrologia 2023; 95(4):12118

Management of upper urinary tract obstruction

laboratory parameters are present. Only 9% of the surveyed urologists would decompress the UUT with CRP values of 3-5 mg/dL. If the patient presents with obstruction caused by lithiasis, refractory to medical expulsive therapy (MET), 66% would clear the UUT and 64% agreed to postpone the procedure to the following day, thus reaching a broad agreement for both questions. If the patient is on medical expulsive therapy, 74% think it is appropriate for the patient to wait 3 or more weeks until desobstruction (broad agreement). Regarding UUT decompression when the patient has a single functioning kidney, there was a clear agreement (100%) that desobstruction should be performed, with 98% of the clinicians agreeing that it should be done within the first 12 hours (clear agreement). PCN vs RUC according to clinical setting The complete results of survey regarding the best method for decompression of UUT are summarized on Table 2. There was broad agreement that both methods were equally adequate in case of fever and sepsis. Among the few clinicians who chose one of the procedures over the other in case of fever, 79% chose to submit the patient to RUC. In case of sepsis, the majority (54%) considered both methods equally effective. Septic shock, on other hand, didn’t meet agreement, with 44% preferring PCN and 38% showing no preference. There was a clear agreement that RUC is superior in patients with coagulation alterations (98%), undergoing antiaggregant medication (84%), taking oral anticoagulants (NOAC/Warfarin) (97%). When UUT is present associated with slight hydronephrosis, there is clear agreement thar RUC is superior to PCN (94%). Regarding UUT unblocking during pregnancy, although most stated that it is better to perform PCN (49%), no broad agreement was achieved. It was broadly agreed that PCN is preferred in cases of obstruction with blood clots (67%), renal abscess (60%), and pyonephrosis (67%). In cases of UUTO caused by calculi, if the Table 2. size of the stone is < 5 mm, there is a clear Opinions regarding the adequacy of primary URS to unblock UUTO giving agreement that RUC is superior (76%). different clinical scenarios. With calculus of 5-10 mm, RUC is also the preferable method (70%, broad agreement). In case of calculus with > 10 mm or Steinstrasse, no agreement was reached. There was a clear agreement on performing PCN (80%) in the presence of a locally advanced tumor, and a broad agreement on performing PCN (61%) in the context of adenopathic conglomerates. When asked about the method that most preserves patient’s quality of life, 85% of the clinicians stated that RUC is the superior method (clear agreement). We reached broad agreement that, for both male and female patients, both methods are equally adequate. For young adult population and for a professionally active patient, 74% (broad agreement) and 82% (clear agreement) of the clinicians considered RUC more suitable than PCN, respectively. In obese patients, 88% agreed that RUC is the superior method (clear agreement). On the other hand, for elderly patients, or palliative care and dependent patients, no agreement was reached. Primary URS in patients with lithiasis Regarding UUT decompression in case of ureteric lithiasis, when asked about the role of primary URS, there was clear agreement that it should not be performed with fever, signs of sepsis and increased inflammatory parameters in blood analysis. We reached a broad agreement that, in the case of lithiasis and AKI, it may be appropriate to use primary URS. There was also clear agreement regarding Archivio Italiano di Urologia e Andrologia 2023; 95(4):12118

V. Quaresma, F. Magalhães, L. Marconi, et al.

decompression in case of lithiasis refractory to MET. The results are summarized on Table 3.

Table 3. Opinions regarding the adequacy of primary URS to unblock UUTO giving different clinical scenarios.

DISCUSSION

The ideal method for decompression should be easily applicable, have complete success rate, few complications, and be well tolerated. Most decisions on upper urinary tract decompression in the daily practice are based on specialists’ opinions, therefore we consider the expert-based survey a suitable method to address this issue. It is well accepted that drainage is mandatory when obstruction of the upper urinary tract occurs in the setting of urinary infection or loss of renal function. Untreated obstruction in patients with infection may lead to serious consequences such as pyonephrosis, sepsis, and death (12). Our results confirmed these indications, with more than 95% of Urologists agreeing on the need of upper urinary tract decompression when facing fever, signs of sepsis, AKI with complications and unilateral functioning kidney. When considering infection, prompt decompression is indicated, with 99% of Urologists considering it should be performed in less than 12 hours in case of fever, and in less than 3h or even 1h hour when clinical signs of sepsis are present. In a previous British study addressing urologists and radiologists, fever and elevated inflammatory parameters were considered non-urgent indications for RUC or PCN, with timing not precisely defined. In case of sepsis, Lynch and colleagues agreed with urgent decompression with PCN (7). In our study, both methods were considered equally effective facing fever and sepsis. In case of septic shock, no agreement was found, but when deciding for one method, most urologists would perform urgent PCN. The surveyed specialists considered that infection complicated with renal abscess or pyonephrosis should likewise be decompressed with PCN. Solitary kidney is an indication for urgent decompression of upper urinary, with most urologist agreeing it should be performed in less than 3 hours. On the other hand, AKI with no complication can safely be addressed within 3 to 12h. These results are consistent with previous studies, that stated it can even be delayed until the next day (7). We also addressed some of the main laboratory findings that may influence clinical decisions. When facing elevated CRP levels and leukocytosis, 81% of urologists would perform decompression of collecting system. No agreement was met in the timing of decompression. When facing leukocytosis with no CRP elevation, no agreement was also assembled. Previous studies demonstrated that both physical and emotional stress increase WBC count on emergency department patients and that this marker can only be transiently elevated with no association with infection (13). Regarding the CRP values that should motivate UUT clearance in the absence of other clinical or laboratory signs, there was clear agreement between Portuguese urologists that a CRP value under 5 mg/dl without other clinical findings is not an indication for decompression. CRP and procalcitonin (PCT) are by far the most widely used and studied biomarkers and both increase transiently during infection and sepsis, but these markers may also be elevated in other conditions (14). In some studies, PCT was considered superior to CRP to diagnose and exclude sepsis. Combination of these two biomarkers may improve their ability to identify or exclude sepsis (14). Ureteric stone disease is the most common cause of UUTO. If uncomplicated, most urologists agree that decompression may be deferred to the following days and that primary URS is an appropriate treatment. We found broad agreement (74%) that patients could wait 3 or more weeks on MET until decompression. There are insufficient studies addressing the function deterioration of the obstructed kidney. We also evaluated the impact of stone dimension on the selection of the best method of decompression. RUC was the method of choice for stones < 10 mm. No agreement was found for stones > 10 mm or steinstrasse. Stent failure occurred more frequently in patients with large ureteral stones (4). According to previous studies, double J stent is the first choice of Urologists when facing patients with uncomplicated benign disease (7). In our study, primary URS was an option for clearance of stones refractory to MET and when AKI is present. When facing fever, signs of sepsis or elevated inflammatory parameters, there was clear consensus not to perform primary URS. These results are at odds with recent studies suggesting that URS can safely manage febrile hydronephrosis when combined with strong antibiotics (10, 11). Our study didn’t reach consensus in UUT decompression during pregnancy. Previous studies have shown that pregnant women with stone disease may undergo definitive treatment with ureteroscopy in specialized referral centers.7 Retrospective studies also concluded that PCN seemed more effective than double J insertion. When choosing double-J placement in this group of patients, rapid encrustation needs to be considered, because during pregnancy, hyperuricosuria, hypercalciuria, and asymptomatic bacteriuria are common (4). PCN was the preferred method in case of locally advanced neoplasia. In previous studies, no significant difference has been reported between the two diverting modalities (5). Archivio Italiano di Urologia e Andrologia 2023; 95(4):12118

Management of upper urinary tract obstruction

Double J stent was the method of choice in case of coagulopathy and patients on antiaggregant or anticoagulant therapy. These findings confirmed previous studies that similarly recommended stent as first line of treatment (7). Conclusions on pain and QoL are contradictory. Portuguese specialists considered RUC as the method that better preserves quality of life, preferring this option for young patients and professionally active population. Patient sex did not influence the choice, both methods were considered equally appropriate. Patient and disease characteristics like obesity and slight hydronephrosis influenced the choice of method, probably due to technical difficulties. Urologists opted for RUC in these patients. Our results need confirmation from other studies and have several limitations. National representativity was limited to 35% of urologists and possible bias are present when addressing patient characteristics independently. We aim to amplify our survey respondents by expanding to other countries. Our future aim is to assemble Portuguese experts in the next Portuguese Urology Association meeting to define the expert-based consensus national guidelines for UUT decompression using Delphi method consensus.

CONCLUSIONS

We successfully identified consensus among expert Portuguese urologists regarding upper urinary tract decompression. These conclusions serve as a solid foundation for the subsequent formulation of specific guidelines.

REFERENCES

1. Chávez-Iñiguez JS, Navarro-Gallardo GJ, Medina-González R, et al. Acute Kidney Injury Caused by Obstructive Nephropathy. Int J Nephrol. 2020; 2020. 2. Pearle MS, Pierce HL, Miller GL, et al. Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi. J Urol. 1998; 160:1260-4. 3. Ramsey S, Robertson A, Ablett MJ, et al. Evidence-Based Drainage of Infected Hydronephrosis Secondary to Ureteric Calculi. J Endourol. 2010; 24:185-89. 4. Weltings S, Schout BMA, Roshani H, et al. Lessons from Literature: Nephrostomy Versus Double J Ureteral Catheterization in Patients with Obstructive Urolithiasis-Which Method Is Superior? J Endourol. 2019; 33:777-786. 5. Hsu L, Li H, Pucheril D, et al. Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction. World J Nephrol. 2016; 5:172. 6. Mokhmalji H, Braun PM, Martinez Portillo FJ, et al. Percutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective, randomized clinical trial. J Urol. 2001; 165:1088-92. 7. Lynch MF, Anson KM, Patel U. Current opinion amongst radiologists and urologists in the UK on percutaneous nephrostomy and ureteric stent insertion for acute renal unobstruction: Results of a postal survey. BJU Int. 2006; 98:1143-1144. 8. Mottet N, Cornford P, Briers E, et al. EAU - Guidelines on Prostate Cancer Update 2022. European Association of Urology 2022; pp.1-182. 9. Mckay A, Somani BK, Pietropaolo A, et al. Comparison of Primary and Delayed Ureteroscopy for Ureteric Stones: A Prospective NonRandomized Comparative Study. Urol Int. 2021; 105:90-94. 10. Shoshany O, Erlich T, Golan S, et al. Ureteric stent versus percutaneous nephrostomy for acute ureteral obstruction - clinical outcome and quality of life: a bi-center prospective study. BMC Urol. 2019; 19:79. 11. Wang C-J, Hsu C-S, Chen H-W, et al. Percutaneous nephrostomy versus ureteroscopic management of sepsis associated with ureteral stone impaction: a randomized controlled trial. Urolithiasis. 2016; 44:415-419. 12. Wein AJ, Kavoussi LR, Partin AW PC. Campbell-Walsh Urology. 12th ed. Philadelphia: 2020. 13. Bertolino G, Quaglia F, Scudeller L, et al. Transient leukocytosis in Emergency Room: an overlooked issue. Italian Journal of Medicine. 2017; 11:41. 14. Pierrakos C, Velissaris D, Bisdorff M, et al. Biomarkers of sepsis: time for a reappraisal. Crit Care. 2020; 24:287. Correspondence Vasco Pedro Duarte Quaresma, MD (Corresponding Author) vpdquaresma@gmail.com Urology Department, Centro Hospitalar e Universitário de Coimbra - Rua António Manso Cunhavaz, Lote 2, 5ºB, 3030-779, Coimbra Francisca Magalhães, MD - mfranciscacspmagalhaes@gmail.com Lorenzo Marconi, MD - lorenzooliveiramarconi@gmail.com João Lima, MD - joaopedrosolima@gmail.com Manuel Lopes, MD - manuel11070@gmail.com Ana-Marta Ferreira, MD - anamartaferreira0@gmail.com Pedro Nunes, MD - ptnunes@gmail.com Arnaldo Figueiredo, MD - ajcfigueiredo@gmail.com Conflict of interest: The authors declare no potential conflict of interest. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12118

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