Immunotherapy-induced adverse events in metastatic renal cell carcinoma: A case of rapid response and complex challenges.

A 55-year-old woman with dyspnea was diagnosed with a 9.5cm left renal clear cell carcinoma and extensive metastatic disease. Initial treatment with Sunitinib was effective but discontinued due to severe dermatitis. Nivolumab therapy led to complete metastasis resolution and consequently nephrectomy was performed at 12 months. Postoperatively, she developed Vogt-Koyanagi-Harada-like disease, necessitating Nivolumab suspension and vision improvement with corticosteroids. After 24 disease-free months, a new contralateral renal lesion and pulmonary metastases were identified, prompting cabozantinib treatment. This resulted in clinical improvement and a partial response at the first follow-up.

A penile fracture hidden behind a urethral bleeding.

Penile fracture with urethral injury is uncommon. Diagnosis is usually based on clinical history and physical examination. Nonetheless, atypical presentation obliges complementary examinations to be performed. We report a case of a 45-years-old man with urethral bleeding after a blunt penile trauma that was ultimately diagnosed as having a cavernous body laceration on top of an urethral rupture.

The Role of Ga-68-PSMA PET/CT in the Initial Staging of Prostate Cancer - A Single Center 4 Year Experience.

BACKGROUND: Recommended imaging modalities for prostate cancer staging have disappointing sensitivities, whereas [68Ga]-PSMA PET/CT (PET-PSMA) shows promising sensitivities and specificities in the initial management of prostate cancer. Recent studies have revealed that a significant change of management when PET-PSMA was used, with favorable negative predictive values. METHODS: In this retrospective study, we analyzed every PET-PSMA performed in our center for initial staging of intermediate and high-risk prostate cancer. Patients were divided into two groups based on whether imaging modalities other than PET-PSMA were performed. In patients submitted to radical prostatectomy, PET-PSMA findings were compared to histological analysis of the specimen. RESULTS: PET-PSMA results of 57 patients were gathered, with 77.2% (n=44) having performed CT scan or bone scan (BS) prior to PET-PSMA. Prostate cancer management strategy was changed in 61.4% (n=27), when PET-PSMA was performed following CT and BS. BS and CT results were consistent with PET-PSMA in 43.2% and 44.8%, respectively. In 30 cases, a curative strategy was used based on PET-PSMA findings. PET-PSMA revealed a negative predictive value of 95.2% in 23 patients submitted to radical prostatectomy with bilateral pelvic lymphadenectomy. Prostate SUV values on preoperative PET-PSMA correlated with initial PSA, ISUP grade, PC risk staging and presence of extraprostatic lesions. CONCLUSIONS: PET-PSMA is a key element for prostate cancer staging and management, with high diagnostic accuracy. More prospective studies need to be implemented to determine its role as a first-line staging tool.

[Consensus on HPV of the Portuguese Society of Andrology, Sexual Medicine and Reproduction: Treatment]. / Consensos em HPV Masculino da Sociedade Portuguesa de Andrologia, Medicina Sexual e Reprodução: Tratamento.

The treatment of condyloma is generally a challenge in clinical practice. Although the spontaneous resolution rate is high, a significant proportion of patients seek treatment, not because of symptomatology, but mainly for aesthetic issues and concerns related to the transmission or worsening of existing lesions. The available treatments should be applied only for clinically evident macroscopic lesions. Ideally, available therapies should have rapid action onset and clearance, resolve symptoms, reduce recurrence rate and viral load, be effective in treating small lesions, and be well tolerated. However, none of the currently available treatments is clearly more effective than the others and there is no ideal treatment for all patients or for all condyloma. Therefore, the therapeutic decision should be based on the clinician's experience, available resources, lesion morphology, size, number and location, primary or recurrent lesions, disease severity, patient preference and expectations, patient's immune competence, convenience, tolerance, cost of treatment and results of previous therapies. The available treatments are divided into three groups: applied by the patient himself (imiquimod 3.75 or 5%, podophyllotoxin .5%, synecatekines 10% or 15%), applied by the health care provider (bi- and tricloacetic acids 80%-90%, intralesional interferon alpha, cryotherapy, surgical removal, electrofulguration, laser ablation) and experimental or alternative therapies (topical cidofovir, intralesional bleomycin, photodynamic therapy). Treatment methodologies can be further divided into their action - ablative or destructive treatment (cryotherapy, electrofulguration, laser ablation, surgical excision), cytotoxic or proapoptotic treatments (podophyllotoxin .5%, 5-fluoruracil, bleomycin) and immunomodulatory treatments (imiquimod 3.75% or 5%, synecatekines 10% or 15%, intralesional interferon alpha). The overall success rate of the various treatments available ranges from 23% to 94%. Only treatments that include cryotherapy or surgical excision are suitable in condyloma with any anatomical location and that have the highest success rate in monotherapy. Recurrences are common regardless of the treatment received. In contrast, immunomodulatory therapies despite having lower initial clearance rates appear to have higher probabilities of cure in the medium term, with low recurrence rates. Some treatments may be combined with each other and the effectiveness of combined therapies appears to be superior to monotherapy (proactive sequential treatment). The consensuses for the treatment of HPV also consider special situations: immunocompromised patients, meatus and intraurethral lesions and treatment of the partner.

Validation of a Novel, Sensitive, and Specific Urine-Based Test for Recurrence Surveillance of Patients With Non-Muscle-Invasive Bladder Cancer in a Comprehensive Multicenter Study.

Bladder cancer (BC), the most frequent malignancy of the urinary system, is ranked the sixth most prevalent cancer worldwide. Of all newly diagnosed patients with BC, 70-75% will present disease confined to the mucosa or submucosa, the non-muscle-invasive BC (NMIBC) subtype. Of those, approximately 70% will recur after transurethral resection (TUR). Due to high rate of recurrence, patients are submitted to an intensive follow-up program maintained throughout many years, or even throughout life, resulting in an expensive follow-up, with cystoscopy being the most cost-effective procedure for NMIBC screening. Currently, the gold standard procedure for detection and follow-up of NMIBC is based on the association of cystoscopy and urine cytology. As cystoscopy is a very invasive approach, over the years, many different noninvasive assays (both based in serum and urine samples) have been developed in order to search genetic and protein alterations related to the development, progression, and recurrence of BC. TERT promoter mutations and FGFR3 hotspot mutations are the most frequent somatic alterations in BC and constitute the most reliable biomarkers for BC. Based on these, we developed an ultra-sensitive, urine-based assay called Uromonitor®, capable of detecting trace amounts of TERT promoter (c.1-124C > T and c.1-146C > T) and FGFR3 (p.R248C and p.S249C) hotspot mutations, in tumor cells exfoliated to urine samples. Cells present in urine were concentrated by the filtration of urine through filters where tumor cells are trapped and stored until analysis, presenting long-term stability. Detection of the alterations was achieved through a custom-made, robust, and highly sensitive multiplex competitive allele-specific discrimination PCR allowing clear interpretation of results. In this study, we validate a test for NMIBC recurrence detection, using for technical validation a total of 331 urine samples and 41 formalin-fixed paraffin-embedded tissues of the primary tumor and recurrence lesions from a large cluster of urology centers. In the clinical validation, we used 185 samples to assess sensitivity/specificity in the detection of NMIBC recurrence vs. cystoscopy/cytology and in a smaller cohort its potential as a primary diagnostic tool for NMIBC. Our results show this test to be highly sensitive (73.5%) and specific (93.2%) in detecting recurrence of BC in patients under surveillance of NMIBC.

Arterioureteral fistula: an unusual clinical case.

Arterioureteral fistulas (AUFs) are abnormal communications between a major artery and the mid to distal ureter. It is a rare but potentially life-threatening condition that is seldom recognised. We present a case of a 66-year-old man who was admitted to the surgical ward owing to infection of an aortic bifemoral bypass graft. During admission, the patient developed persistent haematuria with considerable loss of haemoglobin. He was submitted to urgent surgical exploration of the graft. An ascending pyelography performed at the beginning of the surgery clearly shows a communication between the left ureter and the vascular graft. Open surgical exploration was undertaken, the fistulised section of the ureter resected and an end-to-end ureteroplasty was performed. The vascular graft was removed and the patient later submitted to left supracondylar amputation. Urinary drainage remained intact.

Coagulum pyelolithotomy "revisited" by laparoscopy: technique modification.

OBJECTIVE: Laparoscopic ureteropyeloplasty is a widely accepted treatment option for the obstructed ureteropelvic junction (UPJ). Although it is often a straightforward surgical procedure, there may be technical difficulties in the case of concomitant stone burden, with multiple calicial, small, mobile stones. The authors describe a modification to the classic coagulum pyelolitothomy, using a mixture based on commercially available fibrin sealant, first used in the laparoscopic era. METHODS: During a laparoscopic transperitoneal dismembered ureteropyeloplasty complemented with coagulum pyelolithotomy, the following steps are suggested: (1) Exposure of the UPJ; (2) ureter clamping with a vessel loop 2 cm distal to the UPJ (to allow pelvis filling); (3) transabdominal puncture of the pelvis with an 18-G, 20-cm needle (under laparoscopic vision) and urine aspiration; (4) recording the volume of urine aspirated; (5) preparing an equal volume of fibrin sealant (to avoid overdistention of the pelvis); (6) injecting the sealer protein solution through that needle + 1 mL of methylene blue (color the coagulum and facilitate its identification in the removal procedure); (7) insertion of another needle to inject the thrombin solution; (8) wait 5 minutes to allow coagulum cast formation; (9) circumferential excision of the UPJ; (10) coagulum removal; (11) pelvis plastic reduction (if needed) and ureter spatulation; (12) double-J stent placement; and (13) tension-free anastomosis completion. RESULTS: The procedure results in the extraction of a tenacious coagulum containing more stones than normally anticipated from the x-ray studies. CONCLUSIONS: This technique modification reduces the incidence of incomplete stone removal, when there are small, free stones lying in a large renal pelvis.

Metabolic syndrome and sexual (dys)function.

INTRODUCTION: The general worldwide increase in metabolic syndrome (MS) among most populations may result in more individuals with sexual dysfunction. AIM: To provide an update on clinical and experimental evidence regarding sexual dysfunction in patients with MS from both sexes and treatment modalities. METHODS: A comprehensive literature review was performed using MEDLINE with the MeSH terms and keywords for "metabolic syndrome,""obesity,""female sexual dysfunction,""erectile dysfunction,""androgen deficiency,""weight loss," and "bariatric surgery." MAIN OUTCOME MEASURES: To examine the data relating to sexual function in both men and women with MS, its relationship and the impact of treatment. RESULTS: The MS is strongly correlated with erectile dysfunction, hypogonadism (predictors of future development of MS), and female sexual dysfunction. Few studies have been addressed in the treatment of these dysfunctions in the special setting of MS, other than the observational effects on sexual function of individual risk factors correction. This can be a result of their understudied etiopathogeny. Nonsurgical weight loss has been shown to improve sexual function (with the mainstay on sedentarism prevention), whereas the efficacy of bariatric surgery in this respect, which has been suggested by some preliminary evidence, needs to be further confirmed by adequate clinical trials. CONCLUSION: As the global incidence of MS increases, more individuals may experience sexual dysfunction and a systematic evaluation should be emphasized in this patient population, in order to identify those who are in need of intervention.