INTRODUCTION: Retroperitoneal laparoscopic (RPL) urologic surgery offers comparable surgical and functional outcomes to the traditional transperitoneal approach, with the advantage of circumventing the need to enter the intraabdominal space. This precludes the necessity to encounter small intestinal and colonic segments, encounter abdominal adhesions, and mobilize adjacent organs, translating to better peri-operative and post-operative conditions. However, RPL demands a strong knowledge of the retroperitoneal anatomy coupled with a level of laparoscopic dexterity, this results in a steep learning curve. Unfortunately, the evidence on the learning curve for RPL is diverse and scarce. The aim of this systematic review was to consolidate the available literature and determine the minimum required number of cases to efficiently and safely perform RPL. METHODS: This is a systematic review of the literature via PubMed, EBSCO and Science Direct of all studies published since 2000 to 2019. The search was conducted by combining the following terms, “Retroperitoneoscopy”, “Retroperitoneoscopic”, “posterior laparoscopy”, “Learning”, “Nephrectomy”, “Adrenalectomy”, and “Ureterolithotomy”. Outcomes of interest were learning curve, mean operative time, mean intra-operative blood loss and mean hospital stay. RESULTS: After the screening phase and application of the eligibility and exclusion criteria, the review included a total of 6 studies on the learning curve for RPL. The learning curve for retroperitoneoscopic adrenalectomy was 40 cases and 24 to 42 cases, based on the evidence from Uitert, et al. (2016) and Vrielink, et al. (2017), respectively. For retroperitoneoscopic nephrectomy, the minimum required number of cases is 30 – 70, based on the studies by Pal, et al. (2017), Zhu, et al. (2018) and Tokodai, et al. (2013). Ercil, et al. (2014) demonstrated the learning curve for retroperitoneoscpic ureterolithotomy to be at 30 cases. Review of each literature showed that completion of the learning curves translated to better peri-operative and post-operative conditions (i.e. shorter operative time, lesser intra-operative blood loss, shorter hospital stay). Overall, the evidence in this review suggests that for posterior retroperitoneal laparoscopy, a mean learning curve of 31 to 56 cases is required to safely and efficiently perform the procedure. CONCLUSION Retroperitoneal laparoscopic surgery is a valid alternative to the traditional transperitoneal approach. It offers comparable anatomic and functional results, albeit better peri-operative and post-operative outcomes. However, its performance requires a strong knowledge and familiarity of working within the retroperitoneum which can be achieved through progressive experience in RPL. The evidence consolidated by this review suggests a learning curve of 31 to 56 cases prior to effectively performing the procedure.

OBJECTIVE: The purpose of surgical intervention for ureteral duplication is to decrease the risk ofinfections, preserve renal function and avoid bladder dysfunction. The objective of this study was todetermine if there is a difference in outcome between total reconstruction of the urinary tract, anupper tract approach, or a lower tract approach. MATERIALS AND METHODS: The outcomes of partial nephrectomy, common sheath re- implantation, totalreconstruction and transurethral incision of ureterocele were pooled and compared against eachother. Primary outcome criteria included breakthrough infection, voiding dysfunction and need for asecond surgery. Procedural dependence of the primary outcomes for each surgery was analyzed usingChi square test. Odds ratio was then computed for each procedure with total reconstruction as thestandard. Logistic regression analysis of the odds ratio was done to determine statistical significance. RESULTS: A total of 128 patients were included in the study. Breakthrough infection was seen in 18.8%of those who underwent partial nephrectomy, 23.8% of those who underwent re- implantation, 19.4%of those who underwent total reconstruction, and 46.4% of those patients who underwent TUI-U.Only 1 patient from the partial nephrectomy group and 1 patient from the total reconstruction groupexperienced voiding dysfunction. Of the 23 patients who underwent TUI-U, 5 (17.9%) needed asecondary procedure, while 3 from the partial nephrectomy, and none from the re-implantation andtotal reconstruction groups required re-operations. Analysis showed that breakthrough urinary tractinfection is dependent on the type of procedure. Using total reconstruction as the standard, the oddsratio for partial nephrectomy is 0.962, 1.302 for common sheath re-implantation and 3.611 for TUI-U. Logistic regression analysis showed statistical difference in the odds ratio of TUI-U and totalreconstruction. CONCLUSION Breakthrough infection is shown to be dependent on the procedure. TUI-U has a 3.6-foldhigher chance of breakthrough infection compared to total reconstruction, hence up to 18% of patientswho opt for TUI-U should be counseled regarding the need for a secondary operation. The odds ofbreakthrough infection in common sheath re-implantation and partial nephrectomy is not significantlydifferent from total reconstruction. No evidence was established regarding the dependence of re-operations and voiding dysfunction to the primary procedure.

OBJECTIVE: Transrectal ultrasound-guided prostate biopsy (TRUSPBx) is the recommended method for the histopathologic confirmation of prostate cancer. However, the overall cancer detection rate is low; hence, patients are potentially exposed to multiple biopsies and their attendant morbidity. Multiparametric MRI of the prostate followed by MRI-Ultrasound fusion-guided prostate biopsy (FBx) is an emerging diagnostic pathway that has been established and recommended in men with a persistently elevated PSA despite a previous negative biopsy. However, evidence regarding its value in the biopsy-naïve setting is scarce. The objective is to compare the diagnostic accuracy of MRI fusion-guided prostate biopsy against TRUSPBx in biopsy-naïve men. METHODS: This is a retrospective cohort study involving biopsy-naïve men with a PSA of 3 to 20 ng/ml. Primary outcomes of the study include overall cancer detection rate (CDR) and detection of clinically-significant prostate cancer (csPCa). Subgroup analyses were performed based on PSA level and prostate volume. Independent t-test, Mann Whitney U test and Chi square test were used in the statistical analysis. RESULTS: A total of 185 biopsy-naïve men with a PSA level of 3 – 20 ng/mL were included in the study. Median pre-biopsy PSA level was 7.07 ng/mL (5.06 – 11.0) and 9.02 ng/mL (5.8 – 13.8) in the FBx arm and TRUS-guided biopsy arm, respectively. Ninety-nine (n=99; 53%) underwent MP-MRI of the prostate followed by MRI fusion-guided prostate biopsy and eighty-six (n=86; 46%) underwent the standard TRUS-guided prostate biopsy. Compared to TRUSPBx, FBx significantly detected more prostate cancer (CDR: 68% vs 30%, p<0.0001) and csPCa (46% vs 22%, p=0.001). The diagnostic yield of FBx was distinctly superior in the subgroup of men with a PSA of 4 – 10 ng/mL (CDR: 64% vs 7%, p<0.0001; csPCa: 43% vs 2%, p<0.0001) and a prostate volume of <40grams (CDR: 82% vs 36%, p<0.0001; csPCa: 53% vs 21%, p=0.006). CONCLUSION Compared to the current standard, the diagnostic yield of MRI fusion-guided prostate biopsy is significantly better in biopsy-naïve men. FBx detected more men with prostate cancer, with a higher proportion of men having clinically-significant disease. This advantage is strongly evident in men with a PSA level of 4 – 10 ng/mL and an average prostate volume of 40 grams. Hence, Multiparametric MRI of the prostate followed by MRI fusion-guided prostate biopsy is an effective first-line diagnostic modality for prostate cancer in men presenting with elevated PSA levels.
Male ; Image-Guided Biopsy ; Prostatic Neoplasms