Ureteral avulsion after ureteroscopy treated with renal auto-transplantation.

Ureteral avulsion can be secondary to blunt or penetrating trauma, or can emerge as a surgical complication. Popularization of minimally invasive interventions has significantly decreased ureteral injuries, ranging from 0% to 28% and varying from minor mucosal injury to perforation, and most catastrophically, avulsion. We present a case of complete ureteral avulsion that was not initially appreciated after undergoing ureteroscopy for stone extraction. Eventual recognition of this injury was managed successfully with a subsequent laparoscopically nephrectomy and renal auto-transplantation preserving renal function.

Rarely Described Renal Malignancies Associated With Venous Tumor Thrombus.

BACKGROUND/AIM: Collecting duct carcinoma, epithelioid angiosarcoma and neuroendocrine/carcinoid tumor are uncommon renal malignancies, and their association with tumor thrombus extending into the inferior vena cava is extremely rare. Owing to the rarity of the above-mentioned malignancies and short follow-up of the cases published in the literature, the prognosis and clinical behavior of these tumors remains unclear. Up to date, the culprit of treatment is surgical management with radical nephrectomy, lymph node dissection, thrombectomy and vascular reconstruction if necessary. PATIENTS AND METHODS: We herein describe in detail the first cases published of the above-mentioned renal malignancies associated with extensive inferior vena cava (IVC) thrombus, in which complex vascular reconstruction was performed. RESULTS: Three male patients were identified as having collecting duct carcinoma, epithelioid angiosarcoma and neuroendocrine/carcinoid tumor with IVC involvement. Tumor thrombus levels were II, I and IIIc respectively. Patient ages were 42, 60 and 47 years and tumor sizes were 9.2, 10.9 and 3.7 cm correspondingly. Patient 2 underwent cavectomy, IVC replacement using polytetrafluoroethylene (Gore-Tex®) vascular graft and IVC filter deployment inside the graft. None of the patients developed any pulmonary emboli postoperatively. At the last follow-up, IVC graft for patient 2 remained patent. CONCLUSION: Owing to the rarity of the aforementioned malignancies and short follow-up of cases published in the literature, the prognosis and clinical behavior of these tumors remains unclear. Up to date, the culprit of treatment is surgical management with radical nephrectomy, lymph node dissection, thrombectomy and vascular reconstruction if necessary. Polytetrafluoroethylene (Gore-Tex) vascular grafts are an excellent and safe option for complex vascular reconstructions in patients with evidence of IVC invasion.

Neoadjuvant versus adjuvant chemotherapy for muscle-invasive bladder cancer: a propensity matched analysis.

BACKGROUND: We compared survival outcomes among patients who received either NAC or AC and RC. METHODS: We identified patients in the National Cancer Data Base (NCDB) diagnosed with clinical T2-T4, N0, M0 urothelial carcinoma who underwent RC. Patients who received NAC were propensity matched by age, race, ethnicity, sex, insurance type, academic/research program, comorbidity, and clinical stage to patients receiving AC within 90 days of RC. Median survival was calculated using Kaplan-Meier analysis. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated from multivariable Cox regression models to compare overall survival (OS), downstaging to non-MIBC (NMIBC), and N upstaging. RESULTS: A total of 417 patients treated with NAC and 272 patients treated with AC were identified from 2004-2013. Patients who received NAC had better 5-year OS (46.2%, 95% CI: 39.2-53.0%) compared to patients who received AC (37.6%, 95% CI: 31.5-43.7%). NAC was a significant predictor of decreased mortality, decreased progression to node positivity, and downstaging to NMIBC (0.76, 0.60-0.96, P=0.023; 0.19, 0.13-0.28, P<0.001; 23.96, 8.91-64.42, P<0.001). CONCLUSIONS: The use of NAC+RC was associated with improved OS compared to RC+AC for patients diagnosed with T2-T4, N0, M0 bladder cancer. The increased survival benefit associated with NAC compared to AC among patients undergoing RC may be due to decreased progression to node positivity and pathological downstaging.

Voiding Cystourethrogram in Children With Unilateral Multicystic Dysplastic Kidney: Is It Still necessary?

OBJECTIVE: To evaluate the value of the voiding cystourethrogram (VCUG) in children with multicystic dysplastic kidney (MCDK) who have a normal versus abnormal contralateral kidney and bladder ultrasound (US), and assess the risk of having vesicoureteral reflux (VUR) or urinary tract infection (UTI) based on the US results. METHODS: A retrospective chart review including children with unilateral MCDK with postnatal US and VCUG available at our institution between January 2008 and September 2017 was performed. Analysis was done to find association between abnormal contralateral US and contralateral VUR and UTI. RESULTS: One hundred and fifty-six children were analyzed; 118(75.6%) patients had a normal contralateral kidney US, while 38(24.4%) had abnormal US. The rate of severe contralateral VUR (grade IV and V) was 2 (1.7%) and 5 (13.2%) in children with normal and abnormal contralateral US, respectively. The risk analysis demonstrated a significant association between severe VUR on the contralateral kidney and an abnormal contralateral US (odds ratio = 7.73; 95%CI: 1.43-41.81; P = 0.018) and no significant association with UTI (odds ratio = 1.58; 95%CI: 0.50-4.94; P = 0.435). CONCLUSION: Our data suggests, the rate of severe contralateral VUR in children with unilateral MCDK and normal contralateral kidney is low. VCUG should be considered for infants with proven MCKD and alterations on the contralateral kidney on US. Following patients with MCDK and normal contralateral kidney without the use of VCUG is a reasonable approach, unless there is development of signs and symptoms of recurrent UTI or deterioration of the renal function. We found that abnormal contralateral kidney US was associated with severe VUR.

Use and Validation of the AUA/SUO Risk Grouping for Nonmuscle Invasive Bladder Cancer in a Contemporary Cohort.

PURPOSE: We applied nonmuscle invasive bladder cancer AUA (American Urological Association)/SUO (Society of Urologic Oncology) guidelines for risk stratification and analyzed predictors of recurrence and progression. MATERIALS AND METHODS: We retrospectively reviewed the records of 398 patients with nonmuscle invasive bladder cancer treated between 2001 and 2017. Descriptive statistics were used to compare AUA/SUO risk groups. Predictors of recurrence and progression were determined by multivariable regression. Kaplan-Meier analysis was done, a Cox proportional hazards regression model was created and time dependent AUCs were calculated to determine progression-free and recurrence-free survival by risk group. RESULTS: Median followup was 37 months (95% CI 35-42). Of the patients 92% underwent bacillus Calmette-Guérin induction and 46% received at least 1 course of maintenance treatment. Of the patients 11.5% were at low, 32.5% were at intermediate and 55.8% were at high risk. In patients at low, intermediate and high risk the 5-year progression-free survival rate was 93%, 74% and 54%, and the 5-year recurrence-free survival rate was 43%, 33% and 23%, respectively. Kaplan-Meier analysis was done to stratify high grade Ta 3 cm or less tumor recurrence-free and progression-free survival in the intermediate vs the high risk group. Relative to low risk, classification as intermediate and as high risk was an independent predictor of progression (HR 9.7, 95% CI 2.23-42.0, p <0.01, and HR 36, 95% CI 8.16-159, p <0.001, respectively). Recurrence was more likely in patients at high risk than in those at low risk (HR 2.03, 95% CI 1.11-3.71, p=0.022). For recurrence and progression the 1-year AUC was 0.60 (95% CI 0.546-0.656) and 0.68 (95% CI 0.622-0.732), respectively. CONCLUSIONS: The AUA/SUO nonmuscle invasive bladder cancer risk classification system appropriately stratifies patients based on the likelihood of recurrence and progression. It should be used at diagnosis to counsel patients and guide therapy.

Pediatric Kidney Transplantation Outcomes in Children with Primary Urological Abnormalities Versus Nonurological Abnormalities: Long-Term Results.

PURPOSE: We assessed renal function, graft survival rates and the risk of graft loss in children based on etiology with a focus on differences between urological causes from congenital anomalies of the kidney and urinary tract vs other causes of end stage kidney disease. MATERIALS AND METHODS: A retrospective chart review was performed including patients younger than 18 years who underwent kidney transplantation at our institution from December 1984 to November 2010 with the last followup recorded in March 2018. Patient clinical characteristics, demographics and end stage kidney disease etiology were recorded. Patients were divided into the 2 groups of urological (congenital anomalies of the kidney and urinary tract) vs nonurological based on end stage kidney disease etiology, and survival analysis was performed. RESULTS: Of 112 kidney transplant cases 90 (80.4%) were associated with nonurological causes and 22 (19.6%) with urological causes. Median (IQR) patient age at transplantation was 12 (7-15) years. Median graft survival time was not statistically different according to end stage kidney disease etiology (nonurological 12 years 95% CI 10.01-13.99 vs urological 16 years 95% CI 7.59-24.41, p=0.532). There was a significant risk of graft loss in patients with urinary tract infections after transplantation (HR 3.15, 95% CI 1.59-6.25, p=0.001). CONCLUSIONS: Children requiring transplantation due to urological causes have no disadvantage in graft survival compared to children with end stage kidney disease with other causes. Patients with urinary tract infection after transplantation had a higher rate of graft loss.

Validation of dominant and secondary sequence utilization in PI-RADS v2 for classifying prostatic lesions.

INTRODUCTION: To assess the secondary sequence rule in The Prostate Imaging Reporting Data System (PI-RADS) version 2 by comparing the detection of Grade group 1+ (GG1+) and 2+ (GG2+) cancers in PI-RADS 3, an upgraded PI-RADS 4, and true (non-upgraded) PI-RADS 4 targets. MATERIALS AND METHODS: We analyzed a total of 589 lesions scored as PI-RADS 3 or 4 obtained from 434 men who underwent mpMRI-US fusion biopsy from September 2015 to November 2017 for evaluation of GG1+ and GG2+ prostate cancer. PI-RADS 4 lesions were differentiated into those that were 'upgraded' to PI-RADS 4 based on the secondary sequence and those that were 'true' PI-RADS 4 based on the dominant sequence. RESULTS: The odds of detecting a GG2+ cancer was significantly higher for an upgraded 4 (peripheral zone (PZ): OR 5.06, 95%CI 2.04-12.54, p < 0.001, transitional zone (TZ): OR 3.08, 95%CI 1.04-9.08, p = 0.042) and true 4 (PZ: OR 5.82, 95%CI 3.10-10.94, p < 0.0001, TZ: OR 2.43, 95%CI 1.14-5.18, p = 0.022) lesions compared to PI-RADS 3 lesions. Additionally, we found no difference in the odds of detecting a GG2+ prostate cancer between a true PI-RADS 4 (OR 1.15, 95%CI 0.49-2.71 p = 0.746) and upgraded 4 (referent) in the PZ. Similar non-significance was noted between true 4 (OR 0.79, 95%CI 0.26-2.38 p = 0.674) and upgraded 4 lesions in the TZ for detection of GG2+ cancers. CONCLUSIONS: Upgraded PI-RADS 4 and true 4 targets have a higher odds of detecting GG1+ and GG2+ compared to PI-RADS 3 in the PZ and TZ. Our findings validate the revised scoring system for PI-RADS.

Entering an era of radiogenomics in prostate cancer risk stratification.

Radiogenomics is a field that amalgamates data from genomics and imaging techniques in order to derive clinically meaningful trends. In this article, we discuss the importance of prostate cancer risk classification and how data derived from genomic testing and multi-parametric magnetic resonance imaging (mpMRI) can be integrated into clinical decision-making processes with a focus on active surveillance (AS). Finally, we describe an ongoing prospective trial (Miami MAST trial) which incorporates imaging (mpMRI) and radiomics data in patients who are on AS for prostate cancer.

Imaging for the selection and monitoring of men on active surveillance for prostate cancer.

Traditional prostate imaging is fairly limited, and only a few imaging modalities have been used for this purpose. Until today, grey scale ultrasound was the most widely used method for the characterization of the prostatic gland, however its limitations for prostate cancer (PCa) detection are well known and hence ultrasound is primarily used to localize the prostate and facilitate template prostate biopsies. In the past decade, multiparametric magnetic resonance imaging (mpMRI) of the prostate has emerged as a promising tool for the detection of PCa. Evidence has shown the value of mpMRI in the active surveillance (AS) population, given its ability to detect more aggressive disease, with data building up and supporting its use for the selection of patients suitable for surveillance. Additionally, mpMRI targeted biopsies have shown an improved detection rate of aggressive PCa when compared to regular transrectal ultrasound (TRUS) guided biopsies. Current data supports the use of mpMRI in patients considered for AS for reclassification purposes; with a negative mpMRI indicating a decreased risk of reclassification. However, a percentage of patients with negative imaging or low suspicion lesions can experience reclassification, highlighting the importance of repeat confirmatory biopsy regardless of mpMRI findings. At present, no robust data is available to recommend the substitution of regular biopsies with mpMRI in the follow-up of patients on AS and efforts are being made to determine the role of integrating genomic markers with imaging with the objective of minimizing the need of biopsies during the follow up period.

The Influence of Ethnic Heterogeneity on Prostate Cancer Mortality After Radical Prostatectomy in Hispanic or Latino Men: A Population-based Analysis.

OBJECTIVE: To determine if recently found disparities in prostate cancer-specific mortality (PCSM) among Mexican and Puerto Rican men remained true in patients undergoing radical prostatectomy (RP), where the true grade and extent of cancer are known and can be accounted for. MATERIALS AND METHODS: Men diagnosed with localized-regional prostate cancer who had undergone RP as primary treatment were identified (N = 180,794). Patients were divided into the following racial and ethnic groups: non-Hispanic white (NHW) (n = 135,358), non-Hispanic black (NHB) (n = 21,882), Hispanic or Latino (n = 15,559), and Asian American or Pacific Islander (n = 7995). Hispanic or Latino men were further categorized into the following subgroups: Mexican (n = 3323) and South or Central American, excluding Brazilian (n = 1296), Puerto Rican (n = 409), and Cuban (n = 218). A multivariable analysis was conducted using competing risk regression in the prediction of PCSM. RESULTS: This analysis revealed hidden disparities in surgical outcomes for prostate cancer. In the multivariable analysis, Hispanic or Latino men (hazard ratio [HR] = 0.88, P = .207) did not show a significant difference in PCSM compared with NHW men. When breaking Hispanic or Latino men into their country of origin or ancestry, Puerto Rican men were found to have significantly worse PCSM than NHW men (HR = 2.55, P = .004) and NHB men (HR = 2.33, P = .016). CONCLUSION: Our findings reveal higher rates of PCSM for Puerto Rican men after RP than for both NHW and NHB men. At a minimum, these findings need further validation and should be considered in the screening and management of these men.

Determinación de los niveles de procalcitonina para el diagnóstico de sepsis neonatal / Determination of the procalcitonin levels for the diagnosis of neonatal sepsis

Introducción: la sepsis es la principal causa de morbi-mortalidad en neonatos; sin embargo, debido a la poca especificidad de los signos clínicos en esta población el diagnóstico clínico precoz se considera difícil. Objetivos: evaluar la utilidad de la procalcitonina para el diagnóstico de sepsis en neonatos con diagnóstico presuntivo de esta. Materiales y métodos: se realizó un estudio descriptivoprospectivo en pacientes entre cero y 30 días de nacidos que ingresaron a las Unidades de Cuidados Neonatales de la Clínica El Rosario, sede Centro y sede El Tesoro (Medellín, Colombia), durante septiembre de 2010 y septiembre de 2011, con sospecha de sepsis neonatal o que presentaron un cuadro compatible durante su permanencia. Resultados: de los 65 neonatos captadosse confirmó el diagnóstico clínico de sepsis en 39 (60%). No se encontraron diferencias significativasentre los grupos de neonatos con y sin sepsis respecto a los signos clínicos, parámetros hematológicos o la presencia de alteraciones morfológicas en los eritrocitos. La mediana de los marcadores de infección evaluados, procalcitonina y proteína C reactiva, fueron significativamente superiores en los neonatos con sepsis, así como la proporción de los resultados de procalcitonina y proteína C reactiva interpretados como anormales de acuerdo a los valores de referencia que, en el caso de la procalcitonina, fueron ajustados de acuerdo a las horas transcurridas desde el nacimiento.Conclusiones: los resultados de este estudio demuestran que los reactantes de fase aguda como la procalcitonina y proteína C reactiva son los mejores indicadores de sepsis en neonatos.

Introduction: sepsis is the leading cause of morbidity and mortality in neonates; however, due to the low specificity of signs and symptoms in this population the early clinical diagnosis is considered difficult. Objectives:to evaluate the usefulness of procalcitonin for the diagnosis of sepsis in neonates with presumptive diagnosis of sepsis. Materials and methods: A descriptive prospective study was made in patients from zero to 30 days of born that were admitted to the Neonatal Care Unit from Clínica El Rosario (Medellin, Colombia), headquarters Centro and headquarters El Tesoro, between September 2010 and September 2011, with suspicious of neonatal sepsis or that presented a compatible clinical with sepsis during their permanence. Results: From 65 captured neonates, it was confirmed a clinical diagnosis of sepsis in 39 (60%). No significant differences were observed between neonates with and without sepsis related to clinical and haematological parameters or morphological abnormalities in erythrocytes. The median values of the infection markers evaluated, C-reactive protein and procalcitonin, were significantly higher in neonateswith sepsis, as well as the proportion of procalcitonin and C-reactive protein results interpreted as abnormal according to the reference values, that in the case of procalcitonin were adjusted according with the hours since birth. Conclusions: The results of this study demonstrate that acute.