Comparison of MRI, PSMA PET/CT, and Fusion PSMA PET/MRI for Detection of Clinically Significant Prostate Cancer.

PURPOSE: The aim of our study is to compare the efficacy of positron emission tomography (PET) and magnetic resonance imaging (MRI) for detecting intraprostatic lesions in patients with clinically significant prostate cancer who underwent radical prostatectomy; additionally, investigate the benefits of rostate-specific membrane antigen (PSMA) PET-MR software fusion images to the diagnosis. METHODS: Thirty patients, who underwent radical prostatectomy between June 2015 and April 2018, were included in the study. Subjects with gallium PSMA PET-CT and multiparametric prostate MRI performed according to Prostate Imaging Reporting and Data System v2 criteria in our clinic were included in the study. 68Ga-PSMA PET-CT images were fused with MR sequences for analysis. RESULTS: The mean age of cases was 63.2 years (ranged from 45 to 79 years). Index lesions of 29 cases were detected by MRI and 22 of them by PET CT. Both modalities were found to be less sensitive for detection of bilaterality and multifocality (42.85% and 20% for MRI, 28.57% and 20% for PET CT, respectively). There was no statistically significant difference between modalities. It was observed that if a clinically significant tumor focus was not detected by MRI, it was small (6 mm or less) in diameter or had a low Gleason score. CONCLUSIONS: Software fusion PSMA PET-MRI increased the sensitivity of the index lesion identification compared with PSMA PET-CT and also increased the sensitivity of real lesion size identification compared with multiparametric prostate MRI.

The effect of risk factors on surgical and oncological results in high-risk prostate cancer: A multicentre study of the urooncology society, Turkey.

PURPOSE: To evaluate the effect of risk factors and selected surgical methods on operative and oncological results of patients undergoing radical prostatectomy (RP) with high-risk prostate cancer (HRPC). METHODS: Retrospective analysis of patients who underwent RP for HRPC from 13 urology centres between 1990 and 2019 was performed. Groups were created according to the risk factors of D'Amico classification. Patients with one risk factor were included in group 1 where group 2 consisted of patients with two or three risk factors. RESULTS: A total of 1519 patients were included in this study and 1073 (70.6%) patients were assigned to group 1 and 446 (29.4%) patients to group 2. Overall (biochemical and/or clinical and/or radiological) progression rate was 12.4% in group 1 and 26.5% in group 2 (P = .001). Surgical procedure was open RP in 844 (55.6%) patients and minimally invasive RP in 675 (44.4%) patients (laparoscopic and robot-assisted RP in 230 (15.1%) and 445 (29.3%) patients, respectively). Progression rates were similar in different types of operations (P = .22). Progression rate was not significantly different in patients who either underwent pelvic lymph node dissection (PLND) or not in each respective group. CONCLUSION: RP alone is an effective treatment in the majority of patients with HRPC and PLND did not affect the progression rates after RP. According to the number of pre-operative high-risk features, as the number of risk factors increases, there is a need for additional treatment.

Multicenter Multireader Evaluation of an Artificial Intelligence-Based Attention Mapping System for the Detection of Prostate Cancer With Multiparametric MRI.

OBJECTIVE. The purpose of this study was to evaluate in a multicenter dataset the performance of an artificial intelligence (AI) detection system with attention mapping compared with multiparametric MRI (mpMRI) interpretation in the detection of prostate cancer. MATERIALS AND METHODS. MRI examinations from five institutions were included in this study and were evaluated by nine readers. In the first round, readers evaluated mpMRI studies using the Prostate Imaging Reporting and Data System version 2. After 4 weeks, images were again presented to readers along with the AI-based detection system output. Readers accepted or rejected lesions within four AI-generated attention map boxes. Additional lesions outside of boxes were excluded from detection and categorization. The performances of readers using the mpMRI-only and AI-assisted approaches were compared. RESULTS. The study population included 152 case patients and 84 control patients with 274 pathologically proven cancer lesions. The lesion-based AUC was 74.9% for MRI and 77.5% for AI with no significant difference (p = 0.095). The sensitivity for overall detection of cancer lesions was higher for AI than for mpMRI but did not reach statistical significance (57.4% vs 53.6%, p = 0.073). However, for transition zone lesions, sensitivity was higher for AI than for MRI (61.8% vs 50.8%, p = 0.001). Reading time was longer for AI than for MRI (4.66 vs 4.03 minutes, p < 0.001). There was moderate interreader agreement for AI and MRI with no significant difference (58.7% vs 58.5%, p = 0.966). CONCLUSION. Overall sensitivity was only minimally improved by use of the AI system. Significant improvement was achieved, however, in the detection of transition zone lesions with use of the AI system at the cost of a mean of 40 seconds of additional reading time.

Pathologic Outcomes of Candidates for Active Surveillance Undergoing Radical Prostatectomy: Results from a Contemporary Turkish Patient Cohort.

INTRODUCTION: To evaluate the pathological outcomes of Turkish men meeting the criteria for Active Surveillance (AS), who elected to undergo immediate radical prostatectomy (RP). MATERIAL AND METHODS: Retrospective analysis including 1,212 patients with clinically localized prostate cancer (PCa) who met the eligibility criteria for AS. The primary outcomes were pathological upstaging and pathological upgrading. RESULTS: Nine hundred ninety-one patients were eligible for analysis after the central review of the submitted data. The mean prostate-specific antigen (PSA) level was 6.89 (0.51-15) ng/mL and the mean biopsy core number was 12 (8-47). The mean tumor positive core on final biopsy pathology was 1.95 (1-6) (16.6% [2.1-33.3%]). Overall, 30.6% of the men experienced a Gleason sum (GS) upgrade and 13.2% had pathological upstaging. For GS upgrade, the percentage of tumor-positive cores and free-to-total-PSA ratio were significant both in univariate analysis and multivariate logistic regression analysis. Variables predicting pathological upstaging were percentage of tumor-positive cores and PSA density, which were significant in univariate analysis. However, only PSA density was significant in multivariate logistic regression. Although biochemical recurrence-free survival was longer in patients without GS upgrade, it was not statistically significant between patients with and without any GS upgrade (mean 133.7 vs. 148.2 months, p = 0.243). A similar observation was made for patients with or without pathological upstaging (mean 117.1 vs. 148.3 months, p = 0.190). CONCLUSIONS: Upgrading and upstaging at RP are quite common among Turkish men with clinically low-risk PCa, who are candidates for AS, and a great majority of them experienced long-term PSA control.

Intra-surgical total and re-constructible pathological prostate examination for safer margins and nerve preservation (Istanbul preserve).

PURPOSE: To demonstrate a novel frozen section analysis technique during robot assisted radical prostatectomy with 2 distinct advantages: evaluation of the entire circumference and easier reconstruction for whole mount evaluation. MATERIAL AND METHODS: Istanbul Preserve was performed on patients who underwent robotic prostatectomy with nerve sparing between 10/2014 and 7/2016. Gland was sectioned at 3-4mm intervals from apex to bladder neck. Entire tissue representing margins (except for the most anterior portion) was circumferentially excised and microscopically analyzed. In margin positivity, approach was individualized based on extent of positive margin and Gleason pattern. A matched cohort was established for comparison. Retrospective analysis of a prospectively maintained database was performed. Impact of FSA on PSM rate was primarily assessed. RESULTS: Data on 170 patients was analyzed. Positive surgical margin was reported in 56(33%) on frozen section. Neurovascular bundle was partially or totally resected in 79% and 18%. Conversion of positive margin to negative was achieved in 85%. Overall positive margin rate decreased from 22.5% to 7.5%. Nerve sparing increased from 87% to 93%. Location of positive margin at frozen was at the neurovascular bundle area in 39%; thus Istanbul Preserve detected 61% additional margin positivity compared to other techniques. Reconstruction for whole mount was easy. CONCLUSION: Istanbul Preserve is a novel technique for intraoperative FSA during RARP allowing for microscopic examination of the entire prostate for margin status and easy re-construction for whole mount examination. It guarantees safer margins together with increased rate of nerve sparing.

The accuracy of 68Ga-PSMA PET/CT in primary lymph node staging in high-risk prostate cancer.

PURPOSE: To assess the diagnostic accuracy of 68Ga-PSMA PET in predicting lymph node (LN) metastases in primary N staging in high-risk and very high-risk nonmetastatic prostate cancer in comparison with morphological imaging. METHODS: This was a multicentre trial of the Society of Urologic Oncology in Turkey in conjunction with the Nuclear Medicine Department of Cerrahpasa School of Medicine, Istanbul University. Patients were accrued from eight centres. Patients with high-risk and very high-risk disease scheduled to undergo surgical treatment with extended LN dissection between July 2014 and October 2015 were included. Either MRI or CT was used for morphological imaging. PSMA PET/CT was performed and evaluated at a single centre. Sensitivity, specificity and accuracy were calculated for the detection of lymphatic metastases by PSMA PET/CT and morphological imaging. Kappa values were calculated to evaluate the correlation between the numbers of LN metastases detected by PSMA PET/CT and by histopathology. RESULTS: Data on 51 eligible patients are presented. The sensitivity, specificity and accuracy of PSMA PET in detecting LN metastases in the primary setting were 53%, 86% and 76%, and increased to 67%, 88% and 81% in the subgroup with of patients with ≥15 LN removed. Kappa values for the correlation between imaging and pathology were 0.41 for PSMA PET and 0.18 for morphological imaging. CONCLUSIONS: PSMA PET/CT is superior to morphological imaging for the detection of metastatic LNs in patients with primary prostate cancer. Surgical dissection remains the gold standard for precise lymphatic staging.

The incidence and sequela of lymphocele formation after robot-assisted extended pelvic lymph node dissection.

OBJECTIVE: To determine an accurate incidence of lymphocele formation and its sequela after robot-assisted radical prostatectomy (RARP) and extended lymph node dissection (eLND) in a contemporary prostate cancer cohort. PATIENTS AND METHOD: Consecutive patients who underwent RARP and eLND and had a minimum follow-up of 3 months were included. All surgeries were performed by one surgeon via a transperitoneal approach, with patients uniformly receiving low-molecular-weight heparin. Patients were followed with serial ultrasonography (US) based on a predetermined schedule for lymphocele surveillance. Incidence and sequelae of lymphoceles were retrospectively assessed. RESULTS: In all, 521 patients were analysed. The mean (sd) follow-up was 33.5 (22.8) months. Lymphocele developed in 9% and became symptomatic in 2.5%. All except one were detected at the 1-month postoperative US; however, 76% regressed by the 3-month US. If lymphocele persisted at 3 months, 64% developed symptoms associated with infection and required drainage. Having diabetes mellitus was significantly associated with a higher risk of developing an infected lymphocele. Other symptoms related to lymphocele were rare. Comparisons of patient characteristics between patients with and without lymphoceles did not show any significant prognostic indicators to predict the occurrence of lymphocele in neither univariate nor multivariate analysis in the present cohort. CONCLUSION: The incidence of symptomatic lymphocele after transperitoneal RARP and eLND is rare. However, during follow-up, US imaging at 3 months after surgery appears advisable. If a lymphocele is detected at the 3-month follow-up US discussing percutaneous external drainage with the patient appears to be wise, as it may prevent the development of a symptomatic lymphocele in two-thirds of such patients.

Robot-Assisted Bladder Diverticulectomy with Concurrent Management of Bladder Outlet Obstruction.

INTRODUCTION: Robot-assisted bladder diverticulectomy (RABD) through a technique for easier identification of diverticulum along with concomitant management of bladder outlet obstruction (BOO) utilizing a combination of transurethral prostatectomy (TUR-P) and photoselective vaporization of prostate (PVP) is presented. MATERIALS AND METHODS: Between 2008 and 2015, 9 patients underwent RABD with concurrent treatment of BOO. Diverticula were identified by a technique of catheterizing the diverticulum and the bladder simultaneously and individually. RESULTS: Mean patient age was 62 ± 9.8 and prostate volume was 70 ± 26 ml. Mean time for endourological procedure was 77 ± 35, mean console and total operative times were 108 ± 38 and 186 ± 56 min, respectively. Mean estimated blood loss was 71 ± 37 ml. All diverticula were excised and BOO treated successfully. Bladder irrigation was not necessary in any patient. Mean hospitalization and catheter removal time was 5 ± 3 and 8 ± 3 days, respectively. No complications were observed. CONCLUSIONS: BOO is the main cause of acquired bladder diverticula and is largely due to benign prostatic hyperplasia. Concomitant performance of TUR-P and PVP along with RABD is feasible and safe. Individual catheterization of the diverticulum and bladder facilitates the identification of diverticulum even in the presence of multiple diverticula.

Ischemia modified albumin: does it change during pneumoperitoneum in robotic prostatectomies?

BACKGROUND: The unique positioning of the patient at steep Trendelenburg with prolonged and increased intra-abdominal pressure (IAP) during robotic radical prostatectomy may increase the risk of splanchnic ischemia. We aimed to investigate the acute effects of IAP and steep Trendelenburg position on the level of ischemia modified albumin (IMA) and to test if serum IMA levels might be used as a surrogate marker for possible covert ischemia during robotic radical prostatectomies. PATIENTS AND METHODS: Fifty ASA I-II patients scheduled for elective robotic radical prostatectomy were included in this investigation. EXCLUSION CRITERIA: The patients were excluded from the study when an arterial cannulation could not be accomplished, if the case had to be converted to open surgery or if the calculated intraoperative bleeding exceeded 300ml. All the patients were placed in steep (45 degrees) Trendelenburg position following trocar placement. Throughout the operation the IAP was maintained between 11-14mmHg. Mean arterial blood pressure (MAP), cardiac output (CO) were continuously monitored before the induction and throughout the surgery. Blood gases, electrolytes, urea, creatinine, alanine transferase (ALT), aspartate transferase (AST) were recorded. Additionally, IMA levels were measured before, during and after surgery. RESULTS: (1) MAP, CO, lactate and hemoglobin (Hb) did not significantly change in any period of surgery (p>0.05); (2) sodium (p<0.01), potassium (p<0.05) and urea (p<0.05) levels decreased at postoperative period, and no significant changes at creatinine, AST, ALT levels were observed in these patients; (3) At the end of surgery (180 min) pCO2, pO2, HCO3 and BE did not change compared to after induction values (p>0.05) but mild acidosis was present in these patients (p<0.01 vs. after induction); (4) IMA levels were found to be comparable before induction (0.34±0.04), after induction (0.31±0.06) and at the end of surgery (0.29±0.05) as well. CONCLUSION: We did not demonstrate any significant mesenteric-splanchnic ischemia which could be detected by serum IMA levels during robotic radical prostatectomies performed under steep Trendelenburg position and when IAP is maintained in between 11-14 mmHg.

Urinary tract infections and post-operative fever in percutaneous nephrolithotomy.

PURPOSE: To review the incidence of UTIs, post-operative fever, and risk factors for post-operative fever in PCNL patients. MATERIALS AND METHODS: Between 2007 and 2009, consecutive PCNL patients were enrolled from 96 centers participating in the PCNL Global Study. Only data from patients with pre-operative urine samples and who received antibiotic prophylaxis were included. Pre-operative bladder urine culture and post-operative fever (>38.5°C) were assessed. Relationship between various patient and operative factors and occurrence of post-operative fever was assessed using logistic regression analyses. RESULTS: Eight hundred and sixty-five (16.2%) patients had a positive urine culture; Escherichia coli was the most common micro-organism found in urine of the 350 patients (6.5%). Of the patients with negative pre-operative urine cultures, 8.8% developed a fever post-PCNL, in contrast to 18.2% of patients with positive urine cultures. Fever developed more often among the patients whose urine cultures consisted of Gram-negative micro-organisms (19.4-23.8%) versus those with Gram-positive micro-organisms (9.7-14.5%). Multivariate analysis indicated that a positive urine culture (odds ratio [OR] = 2.12, CI [1.69-2.65]), staghorn calculus (OR = 1.59, CI [1.28-1.96]), pre-operative nephrostomy (OR = 1.61, CI [1.19-2.17]), lower patient age (OR for each year of 0.99, CI [0.99-1.00]), and diabetes (OR = 1.38, CI [1.05-1.81]) all increased the risk of post-operative fever. Limitations include the use of fever as a predictor of systemic infection. CONCLUSIONS: Approximately 10% of PCNL-treated patients developed fever in the post-operative period despite receiving antibiotic prophylaxis. Risk of post-operative fever increased in the presence of a positive urine bacterial culture, diabetes, staghorn calculi, and a pre-operative nephrostomy.

OPN gene polymorphism (Ala250) and lower serum OPN levels are associated with urolithiasis.

Osteopontin (OPN) is one of the urinary proteins with an important role in stone formation. Recently, OPN Ala250 (rs1126616) polymorphism and other single nucleotide polymorphisms (SNPs) have been studied to define their role in urolithiasis. This study was conducted to examine the impact of OPN Ala250 polymorphism on the risk of stone formation and their association with serum OPN levels. OPN Ala250 polymorphism was investigated in 127 urolithiasis patients and 92 healthy controls. Stones were analyzed for their chemical composition by using X-Ray diffraction method. Genomic DNA was isolated from peripheral blood leucocytes. The study groups were genotyped by PCR-RFLP and serum OPN levels were measured by ELISA. There was a significant difference between urolithiasis patients and controls concerning genotype and allele frequencies of OPN Ala250 (p < 0.05). Separate analysis by BMI greater or less than 25 kg/m(2) showed that the presence of one mutant T-allele was more frequent in patients with higher BMI than patients with BMI less than 25 kg/m(2) (p < 0.05). Serum OPN concentrations were two-fold higher in the control group compared to urolithiasis patients (p < 0.05). But the mean serum levels did not show any significant difference between OPN Ala250 genotypes in both groups. Moreover, we found an association between higher BMI and stone formation. Our findings suggest that OPN Ala250 polymorphism is associated with the correlation between weight gain and urolithiasis. However, the correlation between urolithiasis and obesity needs to be further studied in larger cohorts.

Enhancing PSMA PET/CT imaging of prostate cancer: investigating the impact of multiple time point evaluation, diuretic administration, cribriform pattern, and intraductal carcinoma.

OBJECTIVE: Our objective was to correlate staging PSMA PET imaging parameters to final histopathology. Second objective was to assess the performance of standard versus delayed PSMA PET to detect primary prostate tumor. METHODS: Thirty-one patients (mean age, 61.4 ± 8.2) who underwent radical prostatectomy and preoperative staging PSMA PET scans were included in the study. After defining dominant lesion in pathology, correlations with PET images were performed. Additionally, two physicians blind to clinical and pathological information retrospectively reviewed staging Ga-68 PSMA PET scans with standard and delayed imaging. RESULTS: Dominant lesion SUV's increased with time 8.2(± 4.5), 10(± 7.1), and 10.2(± 7.8) at 1, 2, and 3 h (P = .03 T1-T3). WHO Grade group 3 had highest SUV (group 3 11.9 ± 5.6 vs. group 2 7.9 ± 1.5, p = .02). Addition of cribriform pattern on intraductal component was associated with higher SUV's (11 ± 2.9 vs. 6.5 ± 2.1, p = .01) and higher Gleason four ratios (64 ± 9% vs. 37 ± 17%, p = .01). Intraductal carcinoma was associated with larger tumors (6.3 ± 2.3 cm3 vs. 2.6 ± 1.7 cm3, p < .001). Physician sensitivities ranged from 61 to 81%. Excluding Gleason 3 + 3 lesions and small lesions (< 1 cm3), sensitivities increased to 80-100%. Differences of sensitivity between different time points were not significant. Combined evaluation of all time points did not increase sensitivity. CONCLUSIONS: Cribriform pattern correlates with higher Gleason 4 ratios and SUVs in PSMA PET. Intraductal carcinoma is associated with larger tumors but not higher Gleason 4 ratios and SUVs. Multiple late imaging times did not enhance tumor detection and may pose tolerability issues for some patients.

Comparing the Diagnostic Performance of Multiparametric Prostate MRI Versus 68Ga-PSMA PET-CT in the Evaluation Lymph Node Involvement and Extraprostatic Extension.

PURPOSE: Our research aims to compare the efficacy of PET and MRI for lymph node metastasis and extraprostatic extension in cases with newly diagnosed prostate cancer undergoing radical prostatectomy with extended pelvic lymph node dissection. METHODS: Thirty-nine cases who underwent radical prostatectomy with pelvic lymph node dissection between June 2015 and January 2020 were included in the study. Patients with gallium (ga-68 Prostate-specific membrane antigen (PSMA) PET) PSMA PET-CT and multiparametric (mp) prostate MRI performed according to PIRADS v2 criteria in our clinic were included. RESULTS: The extraprostatic extension was observed in 16 cases. The sensitivity of MR in detecting extracapsular invasion was calculated as 56.2%, specificity 82.6%, positive predictive value (PPV) 69.2%, negative predictive value (NPV) 73.0%. The sensitivity of PET was 62.5%, specificity 60.8%, PPV 52.6%, NPV 70%. Eleven lymph node metastases were observed in nine cases. The sensitivity, specificity, PPV and NPV of metastatic lymph node detection were; 36.3%, 99.6%, 57.1%, 99.0% for MRI and; 18.1%, 99.4%, 33.3%, 98.8% for PET CT, respectively. CONCLUSION: Mp prostate MRI showed low sensitivity and high specificity compared to PSMA PET CT in extracapsular invasion evaluation. The sensitivity of both modalities in the detection of metastatic lymph nodes was low.

Performance of apparent diffusion coefficient values and ratios for the prediction of prostate cancer aggressiveness across different MRI acquisition settings.

PURPOSE: In this study, we assessed the performance of apparent diffusion coefficient (ADC) and diffusion-weighted imaging (DWI) metrics and their ratios across different magnetic resonance imaging (MRI) acquisition settings, with or without an endorectal coil (ERC), for the evaluation of prostate cancer (PCa) aggressiveness using whole-mount specimens as a reference. METHODS: We retrospectively reviewed the data of prostate carcinoma patients with a Gleason score (GS) of 3+4 or higher who underwent prostate MRI using a 3T unit at our institution. They were divided into two groups based on the use of ERC for MRI acquisition, and patients who underwent prostate MRI with an ERC constituted the ERC (n = 55) data set, while the remaining patients accounted for the non-ERC data set (n = 41). DWI was performed with b-values of 50, 500, 1000, and 1,400 s/mm2, and ADC maps were automatically calculated. Additionally, computed DWI (cDWI) was performed with a b-value of 2000 s/mm2. Six ADC and two cDWI parameters were evaluated. In the ERC data set, receiver operating characteristic (ROC) curves were plotted for each metric to determine the best cutoff threshold values for differentiating GS 3+4 PCa from that with a higher GS. The performance of these cutoff values was assessed in non-ERC dataset. The diagnostic accuracies and area under the curves (AUCs) of the metrics were compared using Fisher's exact test and De Long's method, respectively. RESULTS: Among all metrics, the ADCmean-ratio yielded the highest AUC, 0.84, for differing GS 3+4 PCa from that with a higher GS. The best threshold cutoff values of ADCmean-ratio (£0.51) for discriminating GS 3+4 PCa from that with a higher GS classified 48 patients out of 55 with an accuracy of 87.27%. However, there was no significant difference between each metric in terms of accuracy and AUC (p = 0.163 and 0.214). Similarly, in the non-ERC data set, the ADCmean-ratio provided the highest diagnostic accuracy (82.92%) by classifying 34 patients out of 41. However, Fisher's exact test yielded no significant difference between DWI and ADC metrics in terms of diagnostic accuracy in non-ERC data (p = 0.561). CONCLUSION: The mean ADC ratio of the tumor to the normal prostate showed the highest accuracy and AUC in differentiating GS 3+4 PCa and PCa with a higher GS across different MRI acquisition settings; however, the performance of different ADC and DWI metrics did not differ significantly.

Cribriform Pattern of The Prostate Adenocarcinoma: Sensitivity of Multiparametric MRI.

BACKGROUND: The aim of this study was to investigate the diagnostic performance of mpMRI for detecting cribriform pattern prostate cancer. MATERIALS AND METHODS: This study retrospectively enrolled 33 patients who were reported cribriform pattern prostate cancer at final pathology. The localization, grade and volumetric properties of the dominant tumors and areas with cribriform pattern at the final pathological specimens were recorded and the diagnostic value of mpMRI was evaluated on the basis of the cribriform morphology detection rate. It was analyzed using Wilcoxon test, the Chi-square test and Fisher's Exact test. The significance level (P-value) was set at .05 in all statistical analyses. RESULTS: A total of 58 prostate cancer foci were (38 cribriform, 20 non-cribriform foci) identified on the final pathology. mpMRI identified 36 of the 38 cribriform morphology harboring tumor foci with a sensitivity of 94.7% (95% confidence interval 82.7-98.5%). In 17 of the 33 patients mpMRI detected single lesion and for these lesions; mpMRI identified cribriform morphology positive areas precisely in 15 patients with significantly low ADCmean and ADCmin values compared to the non-cribriform cancer areas within the primary index lesion (P < .001). For the remaining 16 patients with multiple lesions; all of the tumor foci that harboring cribriform morphology were identified by mpMRI but in none of them any ADCmean and ADCmin value divergence were detected between the cribriform and non-cribriform pattern tumor foci within the primary index lesion. CONCLUSION: Cribiform pattern should be considered in single lesions with an area of lower ADC value on mpMRI.

One step nucleic acid amplification (OSNA) for detection of lymph node metastasis during robotic radical prostatectomy for prostate cancer: A pilot study.

INTRODUCTION: The OSNA technique is based on reverse transcription loop-mediated DNA amplification for the detection of cytokeratin 19 (CK19) messen-ger RNA (mRNA). The purpose of our paper, which represents the first study in the literature, is to test the accuracy of this method in the detection of lymph node metastases in patients undergoing robotic radical prostatectomy with lymph node dis-section. METHODS: Our cohort consisted of patients that have undergone robotic radical prostatectomy with extended lymph node dissec-tion. Lymph nodes were evaluated with imprint technique and then with frozen section examination. The remaining tissue was evaluated by OSNA method. Lymph nodes were defined as 'neg-ative' or 'positive' according to mRNA copy number. RESULTS: 7 patients and 25 lymph nodes were included in our cohort. Two patients were found negative with all pathology methods. In one patient the standard stains revealed a suspi-cious outcome but it was positive for micrometastasis with OSNA. In another patient the outcome was positive for standard stains and negative for OSNA. Finally, 2 patients were found positive for OSNA and negative for imprint methods. CONCLUSIONS: One Step Nucleic Acid Amplification (OSNA) method using CK19 seems to fail in detection of lymph node metastases in prostate cancer patients undergoing radical prostatectomy and lymph node dissection.

Effect of simple malrotation on percutaneous nephrolithotomy: a matched pair multicenter analysis.

PURPOSE: In this multicenter study we compared the outcome of percutaneous nephrolithotomy in patients with and without malrotated kidneys. MATERIALS AND METHODS: A total of 44 patients (group 1) at 6 institutions who underwent percutaneous nephrolithotomy for kidneys with simple malrotation were enrolled in our study. Attending physicians in our group also provided the same number of cases of percutaneous nephrolithotomy done for nonmalrotated (normal) kidneys (group 2). Group 2 patients were selected by match pairing. Operative and postoperative data on the 2 groups were compared using the chi-square, Student t and Fisher exact tests. RESULTS: As a result of match pairing, the 2 groups were similar in age, gender, body mass index, and stone size and site. Mean ± SD stone size was 5.9 ± 3.5 cm(2) in group 1. Multiple access attempts were required in 9 (20.5%) and 7 cases (15.9%) in groups 1 and 2, respectively (p >0.05). Mean fluoroscopy time was 7.0 ± 3.9 minutes in the malrotated kidney group and 7.3 ± 4.5 minutes in the nonmalrotated kidney group (p >0.05). The mean hemoglobin decrease after percutaneous nephrolithotomy was significantly higher in group 1 (-1.9 vs -1.3 gm/dl, p = 0.008) but the blood transfusion rate was similar in the 2 groups. The procedure success rate in groups 1 and 2 was 77.3% and 79.5%, respectively (p >0.05). CONCLUSIONS: Percutaneous nephrolithotomy is safe and effective even in patients with larger kidney stones and malrotated kidneys.

The visibility of prostate cancer concerning underlying histopathological variances: A single-center multiparametric magnetic resonance imaging study.

PURPOSE: To investigate whether prostate cancer (PCa) lesions regarding histopathological composition exhibit different morphological features on multiparametric prostate MRI (mpMRI). METHODS: We investigated men with PCa with available mpMRI and whole-mount specimens between June 2015 to December 2020.The acquisition protocol consistent with the Prostate Imaging Reporting and Data System (PI-RADS). Two observers evaluated the images following the PI-RADS v2.1. guideline before biopsy and radical prostatectomy. The discrepancies were resolved in a joint meeting. A genitourinary pathologist reviewed the whole-digitalized mount specimens, and the lesions with Gleason score of 7 and above (3 + 4 and above), and/or cancers with a maximum diameter of 6 mm and more, and/or extraprostatic extension were accepted as clinically significant PCa. The PI-RADS scores and the diameter of the clinically significant PCa on mpMRI concerning histopathological components (i.e., cribriform component, intraductal pattern, or without cribriform component or intraductal pattern) were investigated. The clinically significant PCa foci with PI-RADS score <3 was accepted as an invisible lesion on mpMRI. RESULTS: In all, 58 men with a total of 112 clinically significant PCa foci, were enrolled in the study. The intraductal pattern, cribriform pattern, or none of these patterns were observed in 28/112 (25 %), 43/112 (38.05 %), and 41/112 (36.60 %) tumor foci. Six out of 28 (21.42 %), 17/43 (39.53 %), and 18/41 (42.8 %) foci with an intraductal pattern, cribriform component, or without any of them, respectively, were invisible on mpMRI (P = 0.111). CONCLUSION: Though it was not reached a statistical significance, clinically significant PCa with the cribriform component and without any intraductal or cribriform component are more likely to manifests mpMRI invisible foci than the intraductal pattern. Further multi-center studies are warranted to precisely elucidate mpMRI features of PCa regarding histopathological composition.

Is robotic radical nephroureterectomy a safe alternative to open approach: The first prospective analysis.

PURPOSE: To test the efficacy and safety profile of robotic radical nephroureterectomy compared to the open approach. METHODS: We enrolled 45 consecutive patients who suffered from non-metastatic, upper urinary tract urothelial carcinoma from September 2019 to March 2021 and underwent radical nephroureterectomy. Patients were divided in two groups: group A consisted of 29 patients (open approach) and group B consisted of 16 patients (robotic approach). The factors which were taken into consideration were age, sex, body mass index, tumour size, side and grade, cancer stage, ASA score, operation time, drain removal time, foley time, hospitalization time, estimated blood loss, surgical margins, preoperative and postoperative creatinine, Hct and bladder recurrences. Statistical analysis was performed with the use of SPSS version 26 and p < 0.05 was the cut-off for reaching statistical significance. RESULTS: The mean age in group 1 was 67.12 years and in group 2 68.12 years, whereas the mean body mass index (BMI) in group 1 was 26.54 kg/m2 and in group 2 25.20 kg/m2. Operative time was better in group A (124 vs 186 mins p < 0.001) and estimated blood loss were better in group B compared to group A (137 vs 316 ml p < 0.001). Length of stay (LOS) was significantly less in the robotic group (5.75 vs 4.3 days p = 0.003) and the same applied for time required for drain removal (4.5 vs 3.3 days p = 0.006). CONCLUSIONS: Robotic radical nephroureterectomy is a safe and efficient alternative to open approach. It provides a favorable perioperative profile in patients suffering from upper urinary tract carcinoma without metastasis.

Off-Clamp Robot-Assisted Partial Nephrectomy: Is There Something More to Achieve Optimal Trifecta Outcomes?

Objectives: To report trifecta outcomes of our "off-clamp" partial nephrectomy (PN) patients operated without main renal artery and/or any selective/superselective clamping. Materials and Methods: Between April 2008 and March 2020, 52 patients received "off-clamp" robot-assisted partial nephrectomy. Postoperative sixth month estimated glomerular filtration rate (eGFR) and eGFR decrease were considered for renal function evaluation. Patients with negative surgical margins, <15% postoperative eGFR decrease and absence of grade ≥2 Clavien-Dindo complications were reported to achieve trifecta outcomes. Results: Mean age and body mass index of the patients were 57.51 ± 12.99 years and 27.23 ± 4.35 kg/m2, respectively. Mean preoperative hematocrit, serum creatinine, and eGFR were 42.01 ± 3.86%, 0.92 ± 0.28 mg/dL, and 85.26 ± 21.27 mL/min/1.73 m2, respectively. Mean tumor size was 30.32 ± 13.64 mm. Mean PADUA and RENAL scores were 7.63 ± 1.46 and 6.21 ± 1.63, respectively. One patient had focal surgical margin positivity. Mean console time and estimated blood loss was 82.11 ± 38.51 minutes and 280.76 ± 278.98 mL, respectively. Complications were observed in two (4%) patients (one Clavien I, one Clavien IIIB). At postoperative sixth month, serum creatinine and eGFR were 0.95 ± 0.32 mg/dL and 83.65 ± 22.44 mL/min/1.73 m2, respectively. Eventually seven patients had ≥15% postoperative eGFR decrease, one patient had grade ≥2 complication and one patient had positive surgical margin. Forty-three (83%) patients fulfilled trifecta outcomes. Conclusion: Off-clamp PN is important for optimal renal function preservation. Patient selection and additional operative measures along with experience in robotic procedure can contribute achievement of optimal trifecta outcomes.