Comparison of clamping strategies in minimally invasive partial nephrectomy for cT1 tumors.

OBJECTIVES: To determine whether artery only (AO) clamping promises any advantage over artery and vein (AV) clamping in patients undergoing partial nephrectomy with minimally invasive surgical techniques. MATERIAL AND METHODS: We retrospectively analyzed the data of 68 partial nephrectomy patients who were treated with minimally invasive techniques (robot-assisted laparoscopic or pure laparoscopic) for solitary, unilateral, cT1 renal masses during the period of 2008-2019 in a single institution. Patients were divided into two groups according to clamping strategy (AO and AV). The two groups were compared to each other in terms of perioperative outcomes and long-term functional results. RESULTS: The mean patient age and median follow-up period were 56.8 ± 10.8 years and 13.5 (9-44.5) months, respectively. Warm ischemia time, estimated blood loss, transfusion rate and length of hospital stay were similar between the two groups, while operative time was significantly higher in the AO clamping group (p = .726, p = .604, p = .675, p = .103, and p = .038, respectively). Patients who underwent AV clamping had a significantly lower estimated glomerular filtration rate (eGFR) and higher chronic kidney disease rates six months postoperatively (p = .001 and p = .044, respectively) and at the last follow-up (p = .020 and p = .048, respectively). The percentage of eGFR change at six months and the last follow-up was higher in the AV clamp group but the difference was not statistically significant (p = .056 and p = .082, respectively). CONCLUSIONS: Our findings suggest AO clamping is safe and comparable to AV clamping. In our study, AO clamping was found to be superior to AV in terms of long-term eGFR preservation.

Pathology associated with adherent perirenal fat and its clinical effect.

INTRODUCTION: The dissection of perirenal fat is of critical importance to kidney surgery and ease of dissection is more important when using minimally invasive approaches. This study aimed to determine the clinical, radiological, and pathological significance of adherent perirenal fat (APF). MATERIALS AND METHODS: This prospective study included 22 patients scheduled for partial nephrectomy and 40 patients for donor nephrectomy. Intraoperative fat dissection time was recorded, and the complexity of perirenal fat dissection was surgeon-classified as easy, moderate, and difficult. Perirenal fat and subcutaneous fat thickness were measured. Measurement of perirenal fat depth and the Hounsfield unit (HU) for both perirenal and subcutaneous fields were performed using computed tomography (CT) images. All specimens were submitted for histopatological analysis. Researchers in each arm were blinded to other researchers' data. RESULTS: Mean age of the patients was 51.3 ± 12.7 years. Mean perirenal fat dissection time was 15.0 ± 13.5 minutes. Patient demographics, BMI, nor occupational status differed between the 3 complexity of perirenal fat dissection groups. Radiological findings showed that there was a significant correlation between perirenal fat depth and complexity of perirenal fat dissection (P < .05), but not with HU measurements or subcutaneous fat thickness. Surgeon classification of the complexity of perirenal fat dissection was in accordance with the duration of dissection (P < .05). Perinephric fat contained more fibrous tissue in the patients with histologically proven APF than in those without (P < .05). CONCLUSIONS: APF is a challenge during kidney surgery. Difficult dissection prolongs the duration of perirenal fat dissection and surgery. Perirenal fat thickness measured via preoperative CT might be used to predict APF.

Changes in percutaneous approach to kidney stones in children: A single institute experience over 500 cases.

PURPOSE: The aim of this study is to identify the changes in patient age and stone sizes with technological advancement over time. METHODS: This study was conducted retrospectively with 404 patients (504 renal units) who underwent percutaneous nephrolithotomy (PCNL) between January 1997 and June 2020. Patient characteristics and trends on instrument preferences were investigated. RESULTS: Median age was 7 (1-18) years. Male to female ratio was 1.48:1 (301/203). Median stone burden was 2 cm2 (0.20-25) and median operative time was 90 minutes (20-240). The stone-free rate was 74.6%. Patients were divided into four groups according to the size of the instrument. It was found that the size of sheath used increased significantly with increasing age and stone burden. The micro-PCNL group had the shortest hospitalisation and lowest blood transfusion rate. Chronologically categorised four equal groups were compared to analyse changing patient profiles and trends. Median patient age, stone burden, operation time, sheath size, blood transfusion and complication rates decreased significantly with time. However, the use of tracts smaller than 20F and the number of patients with previous intervention increased significantly. CONCLUSION: Our study demonstrated that the patient's age and stone size at the time of initial diagnosis decrease over time while miniaturisation techniques increase in paediatric urology.

68Ga-labelled PSMA ligand HBED-CC PET/CT imaging in patients with recurrent prostate cancer.

BACKGROUND: 68Ga-PSMA Positron Emission Tomography/Computerized Tomography (PET/CT) has shown promising results for the detection of recurrent prostate cancer (RPCa). However, the diagnostic value of this method is yet to be validated. The aim of this study was to determine the influence of clinical and biochemical variables on the detection rate of 68Ga-PSMA PET/CT in patients with RPCa. METHODS: This is a prospective study of 121 patients who underwent 68Ga-PSMA-PET/CT and conventional imaging (CI) for RPCa. Detection rates were analyzed and correlated with various clinical and biochemical variables such as Gleason score GS), androgen deprivation therapy (ADT), trigger PSA (tPSA), PSA doubling-time (PSAdt) and PSA velocity (PSAv). RESULTS: 68Ga-PSMA-PET/CT showed at least one focus of pathological 68Ga-PSMA uptake in 92/121 (76%) of patients. Nodal metastases (in 47% of patients) were the most common site of recurrent disease followed by bones (36%) and prostate (32%). Out of 121 patients, 57 (47%) had only positive findings on PSMA scan verified by biopsy or follow-up. The majority of these lesion were located in the lymph nodes (31/57, 54,5%), which were below the detection limit of CT. Univariate analysis showed higher detection rate of PET/CT with increasing tPSA, PSAv and short PSAdt. Best cutoff for tPSA, PSAv and PSAdt was 0.5 ng/ml, 2.25 ng/ml/year and 8.65 months, respectively. The detection rate of PSMA-PET/CT was higher in patients with high grade tumors (GS > 7, 23.7% vs 76.3%) and in patients who were on ADT during of PSMA scan (76.3% vs 96%). In multiple logistic regression analysis, PSAdt and concurrent ADT were identified as predictors of positive 68Ga-PSMA-PET/CT. CONCLUSION: 68Ga-PSMA-PET/CT is useful for re-staging patients with RPCa and has improved performance compared with CI for disease detection. Detection rates are improved in patients on ADT and with short PSAdt.

Unusual presentations of Carney Complex in patient with a novel PRKAR1A mutation.

Carney Complex (CNC) is a multiple neoplasia syndrome characterized by skin tumors and pigmented lesions, myxomas, and various endocrine tumors. The aim of this case report was to describe a case of CNC with a novel PRKAR1A mutation. A man aged 46 years with a medical history of surgery for cardiac myxomas at the age of 39 was admitted to our hospital because of four newly-developed heart masses. The histologic examination confirmed cardiac myxomas. He had many presentations of CNC such as growth hormone (GH) and prolactin (PRL)-secreting mixed pituitary adenoma, benign thyroid nodule, large-cell calcifying Sertoli cell tumor (LCCST), and superficial angiomyxoma. A bilateral adrenalectomy was performed because the laboratory findings suggested primary pigmented nodular adrenocortical disease (PPNAD). The pathologic examination revealed a focal unilateral PPNAD, unilateral nonpigmented adrenocortical nodule, and bilateral adrenal medullary hyperplasia. Two years after the second cardiac operation, an interatrial septum-derived tumor was detected. An atrial myxoma was confirmed with histologic studies. Based on these findings, the patient was confirmed to have CNC. A novel insertion mutation in the type 1A regulatory subunit of the cAMP-dependent protein kinase A gene (PRKAR1A) in exon 2 was detected in our patient through genetic analysis. The presence of multiple myxomas and endocrine abnormalities should be an indication to physicians to further investigate for CNC. Herein, we described a case of CNC with a novel mutation in exon 2 of the PRKAR1A gene with typical and atypical clinical features.

The Pathologic Point of View of Laparoscopic Adrenalectomy in the Era of Radiologic Imaging: A Multicenter Retrospective Study.

INTRODUCTION/AIM: This study aimed to determine if laparoscopic adrenalectomy (LA) is feasible for the treatment of adrenal malignancies and metastasis, and to review the final pathology findings in order to clarify the indications for surgery. MATERIALS AND METHOD: The medical records of all patients that underwent LA at 3 university hospitals between January 1, 2008, and May 1, 2015, were retrospectively reviewed. RESULTS: In total, 189 laparoscopic adrenalectomies were completed successfully. Mean duration of surgery was 79.3 ± 38.6 min and mean estimated intraoperative blood loss was 39.9 ml. Intraoperatively, 4 patients had major complications: spleen injury (n = 1), renal vein injury (n = 2) and diaphragm injury (n = 2). Histopathological examination showed that there were 20 different types of lesions. Surgical margins (SMs) were tumor free in 95.2% of the patients. Moreover, SMs were tumor free in all patients with adrenocortical carcinomas; however, positive margins were noted in 7 of 23 patients (30.4%) with malignant adrenal tumors. CONCLUSIONS: The present findings support the use of laparoscopy for metastatic adrenal masses, despite a high positive margin rate. LA is a safe, feasible and cost-effective procedure for the management of benign and malignant adrenal masses.

Renal Autotransplantation at Three Academic Institutions in Turkey.

OBJECTIVE: The objective of this study is to present the experience of 3 institutions performing renal autotransplantation (RAT) and to discuss surgical techniques employed and the results in the light of the medical literature. MATERIALS AND METHODS: A total of 14 patients (11 male and 3 female) with a mean age of 47 ± 8 years (35-61 years), who underwent RAT procedure at 3 different institutions between October 2006 and November 2014, in Turkey, were evaluated retrospectively. Indications for RAT procedure are ureteral avulsion, renal artery aneurysm and intimal dissection caused by percutaneous transluminal renal artery angioplasty (PTRA). Twelve patients with ureteral avulsion, 1 patient with renal artery aneurysm and 1 patient with intimal dissection caused by PTRA were followed-up for 103 months. Seven (50%) open and 7 (50%) laparoscopic nephrectomies were performed. Nine patients (64.3%) were right-sided and 5 patients (35.7%) were left-sided. Complications of grade III and above as per Clavien-Dindo classification were assessed. RESULTS: Mean time from injury to RAT was 21.2 ± 40.1 days. However, 5 (35.7%) patients were treated on the same day of the injury. As per Clavien-Dindo classification, 2 (14.2%) grade IVa and 1 (7.1%) grade IIIa complications were reported. However, no significant correlation was observed between the complications and graft loss regarding type and side of the nephrectomy performed (p = 0.462 and p = 0.505, respectively) and timing of the intervention (p = 0.692). CONCLUSION: RAT is a safe procedure in combination with minimally invasive laparoscopic technique in carefully selected patients; however, it requires expertise and proficiency in laparoscopy, reconstructive urology and transplantation. Nevertheless RAT should be considered as the last resort, when other modalities fail.

Local recurrence of renal cell carcinoma that simulated multiple renal arteriovenous fistulas after laparoscopic partial nephrectomy: Report of a rare case.

Herein we report a patient who was initially thought to have renal arteriovenous fistulas 3 months after laparoscopic partial nephrectomy for a small renal mass. After timely intervention using selective renal artery embolization, computed tomography 9 months post-surgery showed persistent renal arteriovenous fistulas and nodular lesions in the perirenal fat. The patient then underwent radical nephrectomy, and histopathological examination showed underlying recurrent clear cell renal cell carcinoma invading the intraparenchymal arteries and veins, which was simulating multiple high-flow renal arteriovenous fistulas.

Congenital megacalycosis with IgA nephropathy: a case report and review of the literature.

Congenital megacalycosis is a rare renal disease characterized by calyceal dilatation without pelvic or ureteral obstruction. If not accompanied by nephrolithiasis and urinary tract infection, this disease is completely benign and does not cause renal dysfunction. We present a case of congenital megacalycosis that was diagnosed at the age of 41 (oldest case in the literature) after admitting with hematuria and acute renal dysfunction. IgA nephropathy was also diagnosed in this patient. Since renal dysfunction is not likely in these patients, if encountered; renal biopsy should be performed although technically difficult to diagnose the cause of this dysfunction.

Safety of Minimally Invasive Surgical Techniques in Large Adrenal Lesions: A Single-Centre Study.

OBJECTIVE: To compare perioperative outcomes of minimally invasive surgery for ≥5 cm and <5 cm adrenal lesions. STUDY DESIGN: Retrospective cohort study. PLACE AND DURATION OF STUDY: Hacettepe University School of Medicine, Ankara, Turkey, between October 2007 and September 2019. METHODOLOGY: Data of 83 patients operated for adrenal lesions was collected retrospectively. Patients were categorized into two groups based on the size of the adrenal gland as <5 cm and ≥5 cm. The groups were compared in terms of perioperative outcomes. RESULTS: The median age of the patients was 51 (41-60) years, with a female-to-male ratio of 27/56. The median follow-up period was 27 (11.5-91) months. Of 83 adrenal masses, 60 (72.3%) were in the <5 cm group and 23 (27.7%) were in the ≥5 cm group. Fifteen (18.1%) patients underwent adrenalectomy for lung cancer metastasis, whereas three (3.6%) for renal cell carcinoma metastasis. The overall rate of post-operative complications was 10.8%. Post-operative complication rates were similar in each group (p=0.433). Operation time was found to be significantly higher in patients with large adrenal masses (p=0.003). CONCLUSION: Minimally invasive surgical techniques have the same perioperative results in the group with adrenal lesions ≥5 cm compared to <5 cm and may be safely employed in this group of patients. KEY WORDS: Laparoscopy, Robotic assisted laparoscopy, Adrenalectomy, Metastasectomy, Adrenal gland neoplasms.

Can Aortic and Renal Arteries Calcium Scores Be New Factors to Predict Post-Operative Renal Function After Nephron Sparing Surgery?

INTRODUCTION: This study aims to investigate whether the calcification of renal arteries and aorta may be risk factors for developing chronic kidney disease (CKD) after Nephron sparing surgery (NSS). MATERIALS AND METHODS: The patients that underwent either open or laparoscopic NSS from 2000 to 2019 in 4 different centers were retrospectively assessed. Of these patients, 328 had a non-contrast-enhanced computer tomography. Calcium scores of the renal arteries and abdominal aorta were measured in the non-contrast-enhanced images with the calcium score plugin (version 2.0) of Horos™. Univariate and multivariate logistic regression analysis was performed to determine significant risk factors for developing CKD at the last check-up. Roc curve analysis was performed to determine the optimal cut-off values of age and abdominal aorta calcium scores. RESULTS: A total of 302 patients, of which 52 (16,6%) with CKD and 252 (83,4%) without CKD at the last check-up, were included in the analysis. The mean warm ischemia duration was significantly higher in patients with CKD (18,79±6,72 vs 16,38±5,57 minutes, p=0,016). The mean size of the tumor diameter and the number of the patients with ≥stage T1b were higher in the group with CKD (p=0,024 and 0,005, respectively). The median calcium scores of the aorta and renal arteries were higher in the group with CKD (p<0,001 and p<0,001, respectively). In multivariate analysis, age >60 years (OR:3,65, p=0,022), calcium score of the aorta (OR:4,07, p=0,029), tumor diameter (OR:1,03, p=0,026) and pre-operative CKD stage (OR:10,13, p<0,001) found the be significant factors for predicting last check-up CKD. CONCLUSION: The calcium score of the aorta may be used as an additional risk factor to predict post-operative CKD risk after NSS with sensitivity over 80%.

Endovascular management of renal angiomyolipomas: Do coils have a benefit in terms of clinical success rates?

PURPOSE This study evaluated single center results of endovascular treatment in renal angiomyolipoma (AML) to determine whether there is clinical relevance of adding proximal coil embolization to distal particle embolization in terms of safety, efficacy and retreatment rates. METHODS A retrospective analysis was performed to evaluate patients undergoing transarterial embolization for renal AMLs from January 2007 to October 2020. Parameters regarding patient and tumor characteristics, embolization technique, treatment outcome and complications were recorded. Patients were divided into two groups as A (only particle group) and B (particle + coil group) based on the type of embolic agent used for treatment. Comparative analysis was performed between the two groups in terms of tumor size reduction, retreatment and complication rates. RESULT Forty-two patients (37 (88.1%) female, 5 (11.9%) male) harboring 48 AMLs were included in the study. The mean age was 43.46 (range 20 to 78). The technical success rate was 95.8% (46 of 48 procedures). The mean size reduction was 1.94±1 cm (p < 0.001) after treatments however, no significant difference was seen between groups in terms of tumor size reduction. Retreatment rates were 3.1% (1 of 32 cases) in group A and 14.3% (2 of 14 cases) in group B (p = 0.21). No significant difference was found between groups in terms of bleeding and complication rates during the perioperative period. Mean follow-up duration was 26.48±25.71 (range from 2 to 102) months. CONCLUSION In this study, no clear supplementary benefit was observed in terms of safety, and efficacy with the adjunction of coils to distal particle embolization in the management of AMLs.

Minimally Invasive Partial Nephrectomy in the Era of Robotic Surgery.

OBJECTIVES: The objectives of the study were to compare the operative features, complication rates, functional, and pathological outcomes of laparoscopic partial nephrectomy (LPN) and robotic-assisted partial nephrectomy (RPN). METHODS: The demographics, perioperative, and follow-up data of patients who underwent partial nephrectomy between January 2007 and April 2020 with minimally invasive methods were retrospectively analyzed. Patients with minimum 3 months follow-up were enrolled in the present study. Perioperative and pathological outcomes were compared between the patients underwent LPN and RPN. RESULTS: A total of 85 patients (65 LPN and 20 RPN) were included in the present study. The mean patient age at the time of surgery was 56.31±10.48 years. Female-to-male ratio was 30/55. Patients in the RPN group had higher R.E.N.A.L. and PADUA scores (p=0.039 and p=0.030, respectively). Median warm ischemia time, median operation time, median intraoperative estimated blood loss, mean post-operative hemoglobin change, and median hospitalization time were similar between groups (p=0.133, p=0.753, p=0.079, p=0.882, and p=0.473, respectively). Artery-only clamping rate was significantly higher in RPN group (p=0.033). The cost of RPN was significantly greater than LPN (p<0.001). Transfusion rates, post-operative complication rates, percent of estimated glomerular filtration rate change at the last follow-up, and trifecta achievement were similar between the groups (p=0.622, p=0.238, p=0.428, and p=0.349, respectively). CONCLUSION: In this series, similar perioperative and functional outcomes were achieved by RPN compared to LPN in more complex renal masses.

Percutaneous Nephrolithotomy in Young-Old, Old-Old, and Oldest-Old Patients: A Multicenter Study.

Introduction: To compare percutaneous nephrolithotomy (PCNL) outcomes between the elderly and young age groups and examined differences between young-old, old-old, and oldest-old patients. Methods: A retrospective analysis was conducted on 8191 renal units that underwent PCNL between September 1997 and March 2020 at three Turkish academic institutions. Patients were classified into young (18-64 years) and elderly (65+ years) age groups. The elderly age group was classified into young-old (65-69 years), old-old (70-79 years), and oldest-old (80+ years). Demographics, stone features, and perioperative and postoperative outcomes were compared between groups. The factors affecting stone-free rates and complications were determined in the elderly age group. Results: The patients' median age was 47 years (18-100) and the female to male ratio was 1:1.72. The stone-free and complication rates were 78.9% and 16.4%, respectively. General complications, blood transfusion, postoperative urinary tract infections, and major complications rate were similar between the young and elderly age groups (P = .902, P = .740, P = .659, P = .219, respectively). The stone-free rate was higher in the elderly age group (P = .002). Presence of partial or complete staghorn stones and number of stones were independently associated with stone-free rates for elderly age group patients (P = .006, P < .001, respectively). Stone burden (≥400 mm2) and presence of partial or complete staghorn stones were significantly associated with complications for the elderly age group patients (P = .038, P = .014, respectively). Conclusions: In the young-old, old-old, and oldest-old age group, PCNL appears like the preferred treatment with high stone-free rates but similar complication rates compared to their younger counterpart.

Outcomes of Percutaneous Nephrolithotomy in Preschool Age Group: A Single-Center Study.

Objective: To determine the factors affecting the outcomes of percutaneous nephrolithotomy (PCNL) in patients in infantile/toddler and preschool age group. Materials and Methods: The data of 186 renal units from 152 patients who underwent PCNL were retrospectively analyzed. Patients under ≤72 months of age were included in the study. The patients were divided into two groups according to their age: infantile/toddler and preschool group. Demographics and stone features were compared between infantile/toddler and preschool age groups. Effects of different factors on complications and stone-free rates were investigated. Comparisons in the study were done using SPSS 24.0 software for Windows. Results: The mean age of the patients was 40.5 ± 16.5 months, and the female/male ratio was 87/99. The median stone burden was 1.92 cm2 (0.12-20). Stone-free rates were 75.3% and 84.4% when cases with Clinically Insignificant Residual Fragments were also included. The numbers of patients with Clavien grade 1, grade 2, and grade 3b complications were 7 (3.8%), 39 (21%), and 9 (4.8%), respectively. There was no difference between infantile/toddler and preschool children in terms of stone-free and complication rates (p = 0.082, p = 0.088, respectively). Mini PCNL and tubeless-totally tubeless- urinary diversion techniques were more frequently performed in the infantile/toddler group compared to the preschool group (p = 0.001, p = 0.028, respectively). Presence of staghorn stone was the only significant factor for complications, while the number of stones was significant for stone-free rates for patients ≤72 months (p = 0.012, p = 0.001, respectively). Stone burden was the only predictive factor for complications in patients aged ≤36 months, while number of stones was predictive for success in patients aged between 37 and 72 months (p = 0.034, p = 0.006, respectively). Conclusion: PCNL is a feasible and effective method in preschool age group with acceptable complications and high success rates. Presence of staghorn stone is predictive for complications, while number of stones is predictive for success in the preschool age group.

Extracorporeal shock wave lithotripsy in the management of a 14-year-old girl with chronic calcific pancreatitis.

BACKGROUND: Chronic pancreatitis is very rare in childhood and causes chronic/relapsing abdominal pain, frequent hospitalizations, malnutrition, growth retardation, and stone formation in the main duct. Although pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is commonly used in the treatment of pancreatic stones (PS) in adults, the use in children is still controversial. An adolescent girl with multiple PS is presented to discuss the use of ESWL as a treatment alternative in children with PS. CASE: A 14-year-old girl was admitted with abdominal pain and elevated pancreatic enzyme levels. Abdominal US showed irregularity and rough echogenicity in pancreas revealing pancreatitis. Multiple stones were seen in main pancreatic duct on Magnetic resonance cholangiopancreatography (MRCP). Endoscopic retrograde cholangiopancreatography (ERCP) was performed and dilated pancreatic duct, thickened pancreatic secretion were detected. Endoscopic sphincterotomy was performed. Endoscopic removal of stones could not be achieved since the largest stone was 17x8 mm. Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) was performed using electromagnetic lithotripter under general anesthesia. Following ESWL, fragmentation of stones in the main duct was confirmed with ERCP. After 3 sessions of ESWL, no ESWL-related complication was observed. Pain relief was achieved. The patient is still under follow-up regarding endocrine and exocrine function of pancreas. CONCLUSION: ESWL may be an effective and safe management option in pediatric PS which could not be removed by ERCP. The patients managed with ESWL should be followed-up for a long time regarding the endocrine and exocrine functions of the pancreas. As in management of adult pancreatitis, clinical guidelines are needed regarding the management of pediatric PS.

Incidental diagnosis of transitional cell carcinoma during percutaneous nephrolithotomy.

INTRODUCTION: The aim of this study was to investigate the characteristics of patients who were incidentally diagnosed with transitional cell carcinoma (TCC) during percutaneous nephrolithotomy (PCNL) surgery. PATIENTS AND METHODS: We retrospectively analyzed the data of 1,406 patients who underwent PCNL for the removal of renal calculi. Tumoral lesions detected during diagnostic cystourethroscopy and nephroscopy were endoscopically resected and the resected specimens were sent to the pathology laboratory for definitive diagnosis. RESULTS: Tumoral lesions were detected with cystoscopic examination in 6 patients and with nephroscopy in 4. Pathological examination of the lesions in the kidneys revealed stage T1G1 TCC in 2 patients, T1G3 TCC with carcinoma in situ in 1, and high-grade TCC with sarcomatoid features in 1 patient. The patient with sarcomatoid features died 2 months after surgery and all the other patients survived with no evidence of disease at the end of 26.67 +/- 18.58 months of follow-up. CONCLUSIONS: Since early diagnosis and management of urothelial lesions significantly improves the prognosis, a careful examination of urothelial mucosa during PCNL surgery is important. Instant diagnosis of a sarcomatoid component and imperative surgical intervention may be life-saving.

Feasibility of Boari Bladder Flap Procedure in Patients With Heterotrophic Renal Transplant.

OBJECTIVES: Our goal was to investigate the safety and efficacy of the Boari bladder flap procedure in patients who received either allogeneic or autotransplant of kidneys. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients with either allogeneic or autotransplant of kidneys who also underwent Boari bladder flap procedures between January 2007 and January 2018. Boari bladder flap was preferred in management of ureteral com-plications after allogeneic renal transplant or it was combined with renal autotransplant when ureteral length was not sufficient to allow ureterovesical anastomosis in patients with ureteral injury. RESULTS: Boari bladder flap procedures were performed in 14 patients who had undergone heterotrophic renal transplant. Nine patients had undergone allogeneic renal transplant, and 5 patients had renal auto-transplant. The mean age of patients was 41.7 ± 13.4 years. The 5 patients with renal autotransplant procedures had simultaneous Boari flap procedures due to ureteral avulsion during retrograde ureter-orenoscopic surgery for urolithiasis. For the entire cohort, mean preoperative and postoperative (at month 1) serum creatinine levels were 1.42 ± 0.71 and 1.13 ± 0.43 mg/dL, respectively. At last visit, the mean creatinine level was 1.94 ± 1.88 mg/dL. CONCLUSIONS: The Boari bladder flap procedure can be a safe and relevant choice in the management of challenging complications after heterotrophic (either allogeneic or autotransplant) renal transplant, allowing minimally invasive urologic surgery, no need for use of bowel segments, and no potential risk for the contralateral kidney.

Clinicopathological predictors of positive 68Ga-PSMA-11 PET/CT in PSA-only recurrence of localized prostate cancer following definitive therapy.

OBJECTIVE: To demonstrate the effect of clinicopathological factors on 68Ga-PSMA-11 PET/CT positivity at the time of biochemical recurrence (BCR) of localized prostate cancer (PCa) following definitive therapy. METHODS: We retrospectively reviewed our institutional database for PCa patients who had BCR and subsequently underwent 68Ga-PSMA-11 PET/CT between April 2014 and February 2018. A total of 51 patients who were metastasis-free before PSMA imaging and previously treated with definitive therapy (radical prostatectomy or external beam radiotherapy) for localized disease (pT1c-T3b pN0-1 cM0) were included. RESULTS: 37 out of 51 patients (72.5%) had positive 68Ga-PSMA-11 PET/CT scans. Age at diagnosis, Gleason score (GS), D'Amico risk status of PCa, initial PSA level before treatment and PSA doubling time were not associated with PSMA positivity. Pre-scan PSA levels of > 0.2 ng/ml and PSA velocity of ≥ 1 ng/ml/year were significantly associated with increased PSMA positivity, whereas history of androgen deprivation therapy showed a trend towards significance. The optimal cutoffs for distinguishing between positive and negative scans were ≥ 0.71 ng/ml for pre-scan PSA and ≥ 1.22 ng/ml/yr for PSA velocity. In multivariable analysis, log pre-scan PSA and pre-scan PSA level > 0.2 ng/ml remained significant predictors for PSMA positivity, whereas the association of PSA velocity and of ADT was lost. CONCLUSIONS: In BCR of localized PCa following definitive therapy, pre-scan PSA was strongly associated with positive 68Ga-PSMA-11 scan, even at PSA levels ranging from 0.2 to 1.0 ng/ml. Therefore, clinical and pathological predictors of positive 68Ga-PSMA-11 PET/CT in PSA-only recurrence of localized prostate cancer need to be further elucidated.

A new device for the treatment of post-prostatectomy incontinence: adjustable perineal male sling.

PURPOSE: We describe a novel male sling device for the treatment of post-prostatectomy incontinence that allows tension adjustment over the urethra postoperatively. We report the short-term results in patients with severe incontinence who were treated with this device. MATERIALS AND METHODS: An adjustable male sling procedure was performed in 19 patients with a mean age of 67.5 years (range 59 to 80) who had severe post-prostatectomy incontinence. A tissue expander, including a silicone balloon expander, a small tube and a self-sealing valve that allowed the expander to gradually fill with saline solution, was used for this procedure. A pocket was created to anchor the balloon expander in its position by suturing 2 polypropylene meshes to each other around the filled balloon expander. The empty silicone balloon expander was inserted into this pocket and the sling was placed over the urethra. The injection port was secured inside the scrotum and connected to the balloon expander. RESULTS: Average operative time was 63 minutes (range 45 to 90). A total of 11 patients required injections. The average number of adjustments was 2 (range 1 to 3) and average injected volume was 6.3 cc (range 5 to 10). Of the patients 15 (78.9%) were completely dry and 2 (10.5%) improved significantly to 1 to 2 pads per day at a mean followup of 17.3 months (range 12 to 25). CONCLUSIONS: Our short-term results suggest that a tissue expander makes the male sling procedure more effective. However, since it is a new device, long-term results are needed to evaluate durability.