Microbiota and the landscape of the prostate tumor microenvironment.

Prostate cancer remains one of the most common causes of cancer-related death in men globally. Progression of prostate cancer to lethal metastatic disease is mediated by multiple contributors. The role of prostate microbiota and their metabolites in metastasis, therapeutic resistance to castration resistant prostate cancer (CRPC), and tumor relapse has yet to be fully investigated. Characterization of microflora can provide new mechanistic insights into the functional significance in the emergence of therapeutic resistance, identification of novel effective targeted therapies, and development of biomarkers during prostate cancer progression. The tumor microenvironment (TME) and its components work concurrently with the prostate microbiota in promoting prostate cancer development and progression to metastasis. In this article, we discuss the growing evidence on the functional contribution of microbiota to the phenotypic landscape of the TME and its effect on prostate cancer therapeutic targeting and recurrent disease.

Mini-Incision Direct Festoon Access, Cauterization, and Excision (MIDFACE): A 12-Year Analysis of a Novel Festoon Surgery.

BACKGROUND: Surgical festoon management often entails aggressive dissection, flaps, unsightly scars, prolonged recovery, and high recurrence rates. The authors present outcomes with subjective and objective evaluation of an office-based, novel, minimally invasive (1-cm incision) festoon repair: mini-incision direct festoon access, cauterization, and excision (MIDFACE). METHODS: Charts of 75 consecutive patients from 2007 to 2019 were evaluated. Photographs of 39 patients who met inclusionary criteria were evaluated by three expert physician graders for festoon and incision visibility (339 randomly scrambled preoperative and postoperative photographs taken with and without flash and from four different views: close-up, profile, full-frontal, and worm's eye) using paired t tests and Kruskal-Wallis tests for statistical evaluation. Surveys returned by 37 of 75 patients were evaluated for patient satisfaction and possible contributing factors to festoon formation or exacerbation. RESULTS: There were no major complications in the 75 patients who underwent MIDFACE. Physician grading of photographs of 39 patients (78 eyes, 35 women; four men; mean age, 58 ± 7.7 years) demonstrated statistically significant sustained improvement in festoon score postoperatively up to 12 years regardless of view or flash. Incision scores were the same preoperatively and postoperatively, indicating incisions could not be detected by photography. Average patient satisfaction score was 9.5 on a Likert scale of 0 to 10. Possible factors for festoon formation or exacerbation included genetics (51%), pets (51%), prior hyaluronic acid fillers (54%), neurotoxin (62%), facial surgery (40%), alcohol (49%), allergies (46%), and sun exposure (59%). CONCLUSION: MIDFACE repair results in sustained improvement of festoons with an office-based, minimally invasive procedure with high patient satisfaction, rapid recovery, and low recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Factors Affecting Patient Radiation Exposure During Prone and Supine Percutaneous Nephrolithotomy.

Purpose: Radiation exposure from fluoroscopy poses risks to patients and surgeons. Percutaneous nephrolithotomy (PCNL) has traditionally required fluoroscopy, however, the use of ultrasound (US) has decreased radiation exposure. US guidance in supine PCNL (S-PCNL) may further reduce radiation exposure. In this study, we investigate patient and operative factors affecting fluoroscopy time (second), total radiation dose (mGy), and effective dose (ED, mSv) in patients undergoing US-guided S-PCNL or prone PCNL (P-PCNL). Methods: We performed a retrospective study of patients undergoing US-guided PCNL in prone and supine positions. Patients with multiple access tracts, pre-existing renal access, or fluoroscopic renal access were excluded. Patient demographic and radiologic and operative data were collected, and compared between the two groups. Results: Ninety-nine patients were included: 45 P-PCNL and 54 S-PCNL. There were no significant demographic differences between the two groups. Operative time, access location, tract length, and total radiation dose (mGy) also did not differ. S-PCNL was associated with lower ED (2.92 ± 0.32 mSv vs 5.3 ± 0.7 mSv, p = 0.0014) despite increased fluoroscopy time (86.32 ± 7.7 seconds vs 51.00 ± 5.1 seconds, p = 0.004), and was more likely a mini-PCNL (35.2% vs 15.9%, p = 0.032). In multivariate analysis, S-PCNL remained associated with reduced ED compared with P-PCNL (p = 0.002), whereas body mass index (p < 0.001) and staghorn calculi (p < 0.001) were independently associated with increased ED. Conclusions: We demonstrated that ED in US-guided PCNL is increased in the prone position compared with supine position, and in overweight patients regardless of position. US-guided S-PCNL may decrease radiation exposure to patients and surgeons compared with US-guided P-PCNL.

Simple Solution to a Difficult Problem: Removal of Large Bladder Calculi Using a Laparoscopic Entrapment Sac.

Introduction and Objectives: Percutaneous management of large bladder calculi with the use of a laparoscopic entrapment sac is a minimally invasive procedure that may have advantages over open cystolithotomy and transurethral cystolithotripsy, as well as standard percutaneous cystolithotomy. We first performed this procedure in 2008, and refined it after our initial publication in 2013 by changing the position from lithotomy to supine by using a urethral catheter postoperatively instead of a suprapubic (SP) catheter, by using ultrasound guidance for access, and by changing the procedure from being inpatient to outpatient. Our objective is to assess the continued feasibility of percutaneous entrapment sac cystolithotomy (PESC) and describe modifications that simplify the technique (mPESC), comparing outcomes and complications. Methods: Forty seven male patients underwent PESC from 2008 to 2019, 16 who had PESC and 31 who had mPESC. After extraction of calculi, either an SP catheter was placed, or the wound was closed and a urethral catheter was placed. Operative and follow-up parameters were compared between the two cohorts. Results: All patients were rendered stone free. Procedure time and length of stay were both significantly shorter in the mPESC cohort. Stone burden and estimated blood loss were equivalent between cohorts. There were no complications of urethral trauma in either cohort. The PESC cohort had higher rates of leakage from the SP site (25% vs 0%), increased need for catheter over 5 days (18.8% vs 0%), and greater likelihood of recurrent retention (12.5% vs 6%). Conclusions: Modifications of PESC, mPESC, leads to fewer complications and reduced length of stay compared with the original PESC procedure. This safe and efficacious technique can reduce morbidity during the management of large bladder calculi and is well suited for an outpatient procedure.

Endoscopic Creation of a Neochimneycystotomy: A Case Report of a Ureteroileal Chimney Stricture.

Background: There are many nonmalignant complications after urinary reconstruction. Anastomotic strictures and redundancy of an ileal chimney are such. A patient with both issues might necessitate an open surgical approach; yet endoscopic techniques are more attractive for these older frail patients. Case Presentation: A 61-year-old woman with a history of bladder cancer who underwent radical cystectomy and neobladder creation now develops left hydronephrosis and a redundant ileal chimney with severe metabolic acidosis. She underwent endoscopic creation of a neochimneycystotomy. Conclusion: The refinement of endoscopic techniques moves the field of surgery away from open surgery, which is beneficial for patients. This endoscopic technique treated the anastomotic stricture as well as redundant ileal chimney in a novel way that has not been reported previously in the literature.

A Novel Technique Using a Thulium Fiber Laser for Simultaneous Percutaneous Nephrolithotomy and Transpelvic Endopyelotomy for High-Insertion Ureteropelvic Junction Obstruction.

Background: Endopyelotomy is a minimally invasive option for treatment of ureteropelvic junction (UPJ) obstruction. Although largely supplanted by laparoscopic or robot-assisted laparoscopic pyeloplasty, it retains efficacy and utility in the absence of a crossing vessel in patients not fit for laparoscopy, patients with secondary obstructions or strictures, or those with stones requiring simultaneous treatment. Antegrade endopyelotomy is most commonly performed with scissors, cold knife, or more recently, using a Holmium laser. Herein we present the first reported case of simultaneous antegrade endopyelotomy and percutaneous nephrolithotomy (PCNL) using a thulium fiber laser (TFL). Case Presentation: A 72-year-old male with surgical history of open abdominal aortic aneurysm repair at age 43 years, colon resection, bilateral popliteal artery aneurysms, 5-vessel coronary artery bypass grafting, recent thoracic endovascular aortic repair, and celiac/superior mesenteric artery/bilateral renal stents on Coumadin was referred for gross hematuria and CT urography demonstrating a high-insertion UPJ obstruction without a crossing vessel and 4 caliceal stones, the largest being 2 cm. Given his multiple comorbidities and prior abdominal and retroperitoneal surgeries, he was offered simultaneous PCNL and endopyelotomy to treat both urological conditions with a single procedure. The procedure was accomplished bloodlessly with TFL PCNL and endopyelotomy as an ambulatory procedure with minimal morbidity, immediate resumption of anticoagulation, and rapid convalescence using a special method to convert the high insertion to a dependent insertion. Conclusion: The TFL provides a new effective and efficient tool for the simultaneous endoscopic management of stones and obstructions with minimal bleeding and rapid recovery in select situations.