Endoscopic Treatment for Large Multifocal Upper Tract Urothelial Carcinoma.

PURPOSE: We reviewed the oncologic and surgical outcomes of endoscopic treatments for low grade upper tract urothelial carcinoma, and assessed the prognostic significance of tumor size, location and multifocality. MATERIALS AND METHODS: We retrospectively reviewed all patients who underwent endoscopic treatment for low grade upper tract urothelial carcinoma at our institution between 2014 and 2019. Tumors were treated with a dual laser generator, which alternately produces holmium and neodymium lasers. A stringent ureteroscopic followup protocol was conducted. We looked for an association between outcome and tumor size, location or multifocality, and for predictive factors for time to local recurrence and progression. RESULTS: The cohort included 59 patients (62 renal units), 27% of tumors were multifocal and 40% were >2 cm. The median followup time was 22 months (IQR 11-41), and the median number of ureteroscopies was 5.5 (4-9). Local recurrence was observed in 46 renal units (74.1%) at a median of 6.5 months after initial surgery. Four patients (6.4%) developed disease progression and were referred for radical surgery: 2 had pathological progression and 2 had a rapid and high volume local recurrence, and 1 later developed metastatic disease. The progression-free rate was 93.2%. Tumor location in kidney (p=0.03, HR 1.95) and multifocality (p=0.005, HR 3.25) significantly predicted time to local recurrence. No factor predicted time to progression. CONCLUSIONS: Ureteroscopic treatment of large, multifocal, low grade upper tract urothelial carcinoma is feasible, does not involve significant complications and has good short-term oncologic outcomes, with a 93.2% progression-free survival rate. Tumors located in the kidney and multifocality yielded shorter time to local recurrence but not progression.

The urologist's learning curve of "in-bore" magnetic resonance-guided prostate biopsy.

BACKGROUND: The combination of multi-parametric MRI to locate and define suspected lesions together with their being targeted by an MRI-guided prostate biopsy has succeeded in increasing the detection rate of clinically significant disease and lowering the detection rate of non-significant prostate cancer. In this work we investigate the urologist's learning curve of in-bore MRI-guided prostate biopsy which is considered to be a superior biopsy technique. MATERIALS AND METHODS: Following Helsinki approval by The Chaim Sheba Medical Center ethics committee in accordance with The Sheba Medical Center institutional guidelines (5366-28-SMC) we retrospectively reviewed 110 IB-MRGpBs performed from 6/2016 to 1/2019 in a single tertiary center. All patients had a prostate multi-parametric MRI finding of at least 1 target lesion (prostate imaging reporting and data system [PI-RADS] score ≥ 3). We analyzed biopsy duration and clinically significant prostate cancer detection of targeted sampling in 2 groups of 55 patients each, once by a urologist highly trained in IB-MRGpBs and again by a urologist untrained in IB-MRGpBs. These two parameters were compared according to operating urologist and chronologic order. RESULTS: The patients' median age was 68 years (interquartile range 62-72). The mean prostate-specific antigen level and prostate size were 8.6 ± 9.1 ng/d and 53 ± 27 cc, respectively. The mean number of target lesions was 1.47 ± 0.6. Baseline parameters did not differ significantly between the 2 urologists' cohorts. Overall detection rates of clinically significant prostate cancer were 19%, 55%, and 69% for PI-RADS 3, 4 and 5, respectively. Clinically significant cancer detection rates did not differ significantly along the timeline or between the 2 urologists. The average duration of IB-MRGpB targeted sampling was 28 ± 15.8 min, correlating with the number of target lesions (p < 0.0001), and independent of the urologist's expertise. Eighteen cases defined the cutoff for the procedure duration learning curve (p < 0.05). CONCLUSIONS: Our data suggest a very short learning curve for IB-MRGpB-targeted sampling duration, and that clinically significant cancer detection rates are not influenced by the learning curve of this technique.

Oncologic Outcomes Following Robot-Assisted Radical Prostatectomy for Clinical T3 Prostate Disease.

BACKGROUND: Little is known about oncologic outcomes following robot-assisted-radical-prostatectomy (RALP) for clinical T3 (cT3) prostate cancer. OBJECTIVES: To investigate oncologic outcomes of patients with cT3 prostate cancer treated by RALP. METHODS: Medical records of patients who underwent RALP from 2010 to 2018 were retrieved. cT3 cases were reviewed. Demographic and pre/postoperative pathology data were analyzed. Patients were followed in 3-6 month intervals with repeat PSA analyses. Adjuvant/salvage treatments were monitored. Biochemical recurrence (BCR) meant PSA levels of ≥ 0.2 ng/ml. RESULTS: Seventy-nine patients met inclusion criteria. Median age at surgery was 64 years. Preoperative PSA level was 7.14 ng/dl, median prostate weight was 54 grams, and 23 cases (29.1%) were down-staged to pathological stage T2. Positive surgical margin rate was 42%. Five patients were lost to follow-up. Median follow-up time for the remaining 74 patients was 24 months. Postoperative relapse in PSA levels occurred in 31 patients (42%), and BCR in 28 (38%). Median time to BCR was 9 months. The overall 5-year BCR-free survival rate was 61%. Predicting factors for BCR were age (hazard-ratio [HR] 0.85, 95% confidence interval [95%CI] 0.74-0.97, P = 0.017) and prostate weight (HR 1.04, 95%CI 1.01-1.08, P = 0.021). Twenty-six patients (35%) received adjuvant/salvage treatments. Three patients died from metastatic prostate cancer 31, 52, and 78 months post-surgery. Another patient died 6 months post-surgery of unknown reasons. The 5-year cancer-specific survival rate was 92. CONCLUSIONS: RALP is an oncologic effective procedure for cT3 prostate cancer. Adjuvant/salvage treatment is needed to achieve optimal disease-control.

[ROBOT ASSISTED PYELOPLASTY IN ADULTS WITH URETERO-PELVIC JUNCTION OBSTRUCTION (UPJO)].

BACKGROUND: Robotic-pyeloplasty (RP) for uretero-pelvic-junction-obstruction (UPJO) has been performed in our institution since 2013. OBJECTIVES: To summarize the outcomes of RP in adults over 18 years of age. METHODS: Adult RP cases have been prospectively documented. Analysis included demographic data such as age, sex, American Association of Anesthesiology-ASA Score, surgical-side, pre-operative imaging. Operative time (OT), estimated blood loss (EBL), length of stay (LOS) and short-term complications were also recorded. In all cases a JJ-stent has been left in place and subsequently taken out. Complications were classified in accordance with the Clavien-Dindo classification criteria. Patients were seen periodically with repeat imaging. The renal scan was performed at least once during the post-operative follow-up. Results are given as median (inter-quartile range) or numeric values (%). RESULTS: A total of 32 patients aged 33.5 years (21-45.2) had RP between the years 2013-2020, among which 53% were females and 59% right sided. An ASA score of 1-2 has been observed in 87.5% of all cases. Skin-to-skin OT was 163 min (136-185), and EBL was 5 ml (0-30). Short-term post-operative complications were hematuria (3.1%), urinary leak/urinoma (12.5%), body temperature>38.30C (12.5%). In 2 cases (6.2%) the JJ-stent had been re-positioned in the operating-theater (Clavien-Dindo 3b). LOS was 3 days (2-4) and JJ-stent had been taken out 39 days (31.7-45.2) post-operatively. Median length of follow-up was 19.5 months (9.5-26.7). In 92.3% of cases an improvement in hydronephrosis has been observed in post-operative imaging. The renal scan did not demonstrate renal function deterioration. CONCLUSIONS: Adult robotic pyeloplasty for UPJO is safe and effective. Low complication rates and over 90% success rates have been observed. These findings are in line with those found in previous studies.

[FACTORS PREDICTING FULL URINARY CONTINENCE FOLLOWING ROBOT-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY (RALP)].

BACKGROUND: Urinary Incontinence (UI) following Robot-Assisted Laparoscopic-Radical Prostatectomy (RALP) adversely affects patients' quality of life. OBJECTIVES: To find parameters that predict full urinary continence (FUC) following RALP. METHODS: Out of an established prospective RALP database, we retrieved and analyzed parameters that potentially predict FUC: age, Body Mass Index, American Anesthesiology Association (ASA) score, previous abdominal surgeries, pre-operative IPSS (International Prostate-Symptom Score), operative time (OT), estimated blood loss (EBL), peritoneum closure and prostate weight. FUC has been defined as 0 pads/day. Univariate analysis has been executed for comparison between patient groups, whereas multivariate analysis has been implemented for the detection of predicting factors for FUC. Data are presented as median (interquartile range) or numeric value (%). RESULTS: A total of 431 RALP cases were recorded between the years 2010-2019. Final analysis included 364 patients with full medical records; 81% gained FUC within 15 weeks (8-28); 96% gained FUC or used 1 pad/day within 17.5 weeks (8-36). Among those who gained FUC, smaller prostates (p=0.028) and low EBL (p=0.025) have been observed. On multivariate analysis EBL has been associated with UI (OR=0.9). CONCLUSIONS: Most patients gained FUC following RALP. EBL was found as risk factor for UI.

[CLINICAL OUTCOMES FOLLOWING ROBOT-ASSISTED PARTIAL NEPHRECTOMY (RAPN)].

BACKGROUND: Partial nephrectomy is the gold standard treatment for renal tumors less than 7 cm. OBJECTIVES: To describe surgical techniques and trends of treating renal tumors less than 7 cm at our department and present the clinical outcomes of our experience with Robot-Assisted Partial Nephrectomy (RAPN). METHODS: Out of an established prospective RAPN database, we retrieved demographic, clinical, surgical and pathological parameters. Operation length was defined as the time between the first surgical incision and the last suture (skin to skin). Warm ischemia time (WIT) was defined as the time between the renal artery clamping and clamp releasing. Data is presented as mean (range, standard deviation) or numeric value (%). RESULTS: Overall, 250 RAPN cases were recorded between the years 2013-2020. Mean tumor size was 32 mm. Mean operation length was 153 minutes. Mean warm ischemia time was 17.5 minutes. Intra-operative complication rates, including converting the surgery to an open approach or to radical nephrectomy, was low. Mean estimated blood loss was 359 cc. An increase in the utilization of the robotic approach has been recorded throughout the years, with a concurrent decrease in the open and laparoscopic approaches. CONCLUSIONS: RAPN is associated with lower complication rates and superior perioperative outcomes, therefore considered a good alternative to the open and laparoscopic approaches. Thus, RAPN is the gold standard treatment for renal tumors less than 7 cm at our institute.

[FOCAL TREATMENT OF PROSTATE CANCER - LEADING AND FUTURE TECHNIQUES, OUTCOMES AND COMPLICATIONS].

INTRODUCTION: Focal treatment for prostate cancer has been proposed as an innovative strategy that aims to achieve oncological benefit while reducing treatment-related morbidity. This treatment is suitable for patients with low and intermediate risk, organ-confined disease. Focal therapy can be categorized as follows: unifocal index lesion ablation, multifocal ablation, hemi-gland ablation or subtotal gland ablation. Different types of energies are applied in focal therapy including high intensity focal ultrasound (HIFU), cryotherapy, focal laser ablation (FLA), irreversible electroporation (IRE) and Photodynamic therapy (PDT). In this review we will briefly present a summary of leading techniques and the available data regarding their oncological outcomes and adverse events. Whole-gland therapies were excluded from this review.

[UPPER TRACT UROTHELIAL CARCINOMA].

INTRODUCTION: Upper tract urothelial carcinoma is a relatively rare malignancy, but with an increasing prevalence. The main risk factor for the disease is smoking. The most common presentation is hematuria or flank pain. Workup is made by imaging of the upper tract - CTU/MRU (Computed Tomography-Urography/Magnetic resonance (MR) urography) and diagnostic uretero-nephroscopy with biopsy. In the past several years there is major advancement in our understanding of the disease and how to treat it, mainly in nephron-sparing treatments. A risk-stratification is usually conducted according to parameters such as tumor size, distribution, and pathologic diagnosis. The low-risk group is usually offered nephron-sparing treatments such as segmental ureterectomy, endoscopic treatments, and lately - local chemotherapy. The high-risk group is usually offered radical resection of the kidney and ureter, with the possible addition of new-adjuvant and adjuvant treatments. In this article we will review the epidemiology, risk factors, diagnosis, and treatment of this malignancy, with a distinction between the risk groups.

Management of Pancreatic Injuries Following Nephrectomy.

BACKGROUND: Pancreatic injuries during nephrectomy are rare, despite the relatively close anatomic relation between the kidneys and the pancreas. The data regarding the incidence and outcome of pancreatic injuries are scarce. OBJECTIVES: To assess the frequency and the clinical significance of pancreatic injuries during nephrectomy. METHODS: A retrospective analysis was conducted of all patients who underwent nephrectomy over a period of 30 years (1987-2016) in a large tertiary medical center. Demographic, clinical, and surgical data were collected and analyzed. RESULTS: A total of 1674 patients underwent nephrectomy during the study period. Of those, 553 (33%) and 294 patients (17.5%) underwent left nephrectomy and radical left nephrectomy, respectively. Among those, four patients (0.2% of the total group, 0.7% of the left nephrectomy group, and 1.36% of the radical left nephrectomy) experienced iatrogenic injuries to the pancreas. None of the injuries were recognized intraoperatively. All patients were treated with drains in an attempt to control the pancreatic leak and one patient required additional surgical interventions. Average length of stay was 65 days (range 15-190 days). Mean follow-up was 23.3 months (range 7.7-115 months). CONCLUSIONS: Pancreatic injuries during nephrectomy are rare and carry a significant risk for postoperative morbidity.

[THE EFFICACY OF ENDOSCOPIC DUAL LASER TREATMENT FOR LOW GRADE UPPER TRACT UROTHELIAL CARCINOMA].

INTRODUCTION: Until recently, radical nephroureterectomy was considered the gold standard treatment for upper tract urothelial carcinoma (UTUC). Post-operative complications, long-term adverse effects of nephrectomy as well as the risk of contralateral recurrence have led to the development of nephron-sparing techniques. OBJECTIVES: To evaluate the safety, complication rate, and oncologic outcomes of ureteroscopic nephron-sparing treatment for low-grade UTUC utilizing a hybrid laser system that incorporates two types of lasers: Nd:YAG and Ho:YAG. METHODS: We reviewed the files of patients who underwent ureteroscopic treatment for UTUC with the hybrid laser system between the years 2014-2018. Only cases of low-grade UTUC and follow-up time of at least 6 months were included in the present study. The following were analyzed: demographic data, tumor histologic characteristics, peri-operative complications, histologic upgrade, oncologic outcomes (i.e: local recurrence, local spread, metastatic progression). RESULTS: A total of 38 patients, who underwent 74 ureteroscopies, met inclusion criteria. Mean tumor size was 16.2 mm. No intra-operative complications were recorded. Two post-operative complications were recorded in one patient - hematuria and retroperitoneal bleeding - both had been treated conservatively. Mean follow-up time was 21.8 months. Local recurrence rate was 73%. Histologic upgrade has been observed in two patients. Four patients (10.5%) were referred to radical nephroureterectomy. There were no cases of local spread, distant metastases or death during the follow-up period. DISCUSSION: Endoscopic dual-laser treatment for low-grade UTUC is safe, surgically feasible and associated with good short-term oncologic outcome. Patient selection and strict follow-up are mandatory.

Positive surgical margin following radical nephrectomy is an independent predictor of local recurrence and disease-specific survival.

BACKGROUND: Positive surgical margins (PSM) are recognized as an adverse prognostic sign and are often associated with higher rates of local and systemic disease recurrence. The data regarding the oncological outcome for PSM following radical nephrectomy (RN) is limited. We examined the predictive factors for PSM and its influence on survival and site of recurrence in patients treated with RN for renal cell carcinoma (RCC). METHODS: Clinical, pathologic and follow-up data on 714 patients undergoing RN for kidney cancer were analyzed. Secondary analysis included 44 patients with metastatic RCC upon diagnosis who underwent cytoreductive nephrectomy (CRN). Univariate and multivariable logistic regression models were fit to determine clinicopathologic features associated with PSM. A Cox proportional-hazards regression model was used to test the independent effects of clinical and pathologic variables on survival. RESULTS: PSM was documented in 17 cases (2.4%). PSM were associated with tumour size, advanced pathologic stage (pT3 vs. ≤ pT2) and presence of necrosis. On multivariate analysis, cancer-specific survival (CSS) was associated with tumour stage, size, presence of necrosis and PSM. PSM was also associated with local recurrence but not distant metastasis or overall survival (OS). CSS and OS were comparable between the PSM and metastatic RCC groups, but significantly lower than the negative margin group. CONCLUSIONS: The prevalence of PSM following RN is rare. Pathological data, including advanced stage (> pT2), tumour necrosis and tumour size, are associated with the presence of PSM. PSM is associated with tumour recurrence and CSS. Patients with PSM are a potential group for adjuvant therapy or for more careful and thorough follow-up following surgery.

Do Urine Cytology and FISH Analysis Have a Role in the Follow-Up Protocol of Upper Tract Urothelial Carcinoma?

BACKGROUND: Current guidelines recommend a stringent follow-up regimen that includes interval cystoureteronephscopy, CT urography, and selective urine cytology sampling for upper tract urothelial carcinoma (UTUC) patients undergoing endoscopic treatment and management. There are no recommendations regarding FISH analysis. Our purpose was to assess the efficacy of cytology and FISH as part of the follow-up protocol and its significance to clinical decision-making in this scenario. METHODS: The medical records of all patients who managed endoscopically for UTUC at our institute between 2014 and 2022 were retrospectively analyzed. Demographic and clinical data, histology, cytology, and FISH results were collected. FISH analysis was considered malignant according to Paris criteria. RESULTS: During the study period, 62 patients underwent 561 ureteroscopies as part of the treatment and follow-up regimen of low-grade UTUC. Urine from the affected upper tract was sampled for cytology in 377 procedures, and FISH analyses were performed in 273. In 75.4% of FISH analyses, the result was different from the cytology results: FISH found malignant aberrations in 15.5% of cases where cytology was benign. Furthermore, FISH classified all the cells defined as atypical via cytology as either benign or malignant. In only one case (0.17%), the urinary cytology report changed the follow-up regimen. CONCLUSION: Cytology may be omitted from the follow-up protocol of low-grade UTUC. In the handful of cases cytology does assist the diagnosis of UTUC, there is an additional benefit to performing FISH analysis, particularly when cellular atypia is reported in the cytology results.

High ambient temperature impact on the pattern of emergency-room visits due to renal colic in the Middle East.

Urolithiasis has a seasonal pattern, with an established increase in incidence during the summer months. This study aims to assess the impact of high ambient temperatures on emergency room (ER) visits related to renal colic (RC) in a Middle Eastern country over the past decade. Population data were extracted using the MDClone Big Data platform. We recorded demographic and clinical data on all RC-associated ER visits from January 2012 to April 2023 and calculated the heat index (HI) that combines daily average coastal plane temperatures and humidity percentages. There was a total of 12,770 ER visits (median age 48 years, 9,236 (72%) males). The number of visits increased during the hottest months (July-October), with the highest numbers recorded during August. The number of visits remained stable throughout the study. We identified a linear association between humidity and the incidence of ER visits (p = 0.002), and a non-linear association between ambient temperature (p < 0.0001) and HI (p < 0.0001). There was a direct relationship between high temperatures and ER visits on the same day (risk ratio [RR]: 1.75, p = 0.036), with a 2-day lag (RR: 1.123, p = 0.024). In Conclusion, there is a significant relationship between temperature, humidity, HI, and the number of ER visits due to RC. Adjusted resource allocation and healthcare workforce availability are essential for managing additional cases during heat waves. Clinical implications: Increased demand is expected during heatwaves and within a 2-day lag, emphasizing the importance of proactive strategies to effectively manage RC patients.

Robotic partial nephrectomy is associated with a significantly decreased rate of postoperative pseudoaneurysm compared to open and laparoscopic partial nephrectomy.

While partial nephrectomy offers oncologic efficacy and preserves renal function for T1 renal tumors, renal artery pseudoaneurysm (RAP) remains a rare but potentially life-threatening complication. This study compared RAP incidence across robotic-assisted (RAPN), laparoscopic (LPN), and open (OPN) partial nephrectomies in a large tertiary oncological center. This retrospective study analyzed 785 patients undergoing partial nephrectomy between 2012 and 2022 (398 RAPN, 122 LPN, 265 OPN). Data included demographics, tumor size/location, surgical type, clinical presentation, treatment, and post-operative outcomes. The primary outcome was RAP incidence, with secondary outcomes including presentation, treatment efficacy, and renal function. Seventeen patients (2.1%) developed RAP, presenting with massive hematuria (100%), hemorrhagic shock (5.8%), and clot retention (23%). The median onset was 12 days postoperatively. RAP occurred in 4 (1%), 4 (3.3%), and 9 (3.4%) patients following RAPN, LPN, and OPN, respectively (p = 0.04). Only operative length and surgical approach were independently associated with RAP. Selective embolization achieved immediate bleeding control in 94%, with one patient requiring a second embolization. No additional surgery or nephrectomy was needed. Estimated GFR at one year was similar across both groups (p = 0.53). RAPN demonstrated a significantly lower RAP incidence compared to LPN and OPN (p = 0.04). Emergency angiographic embolization proved effective, with no long-term renal function impact. This retrospective study lacked randomization and long-term follow-up. Further research with larger datasets and longer follow-ups is warranted. This study suggests that robotic-assisted partial nephrectomy is associated with a significantly lower risk of RAP compared to traditional approaches. Emergency embolization effectively treats RAP without compromising long-term renal function.

Unveiling the Challenges in Tandem Ureteral Stent Management for Malignant Ureteral Obstruction: Failure Rate, Risk Factors, and Durability of Their Replacement.

BACKGROUND: Malignant ureteral obstruction (MUO) is a sequela of advanced malignant disease that requires renal drainage, with tandem ureteral stents (TUSs) being a viable option. This study aimed to evaluate the TUS failure rate, associated risk factors, and the feasibility of replacing failed TUSs with a new pair of stents. METHODS: A retrospective analysis of MUO patients treated with TUS insertion from 2014 to 2022 was conducted. TUS failure was defined as urosepsis, recurrent urinary tract infections, acute kidney failure, or new hydronephrosis on imaging. Cox proportional hazard regression analysis identified the independent predictors of TUS failure. RESULTS: A total of 240 procedures were performed on 186 patients, with TUS drainage failing in 67 patients (36%). The median time to failure was 7 months. Multivariate analysis revealed female gender (OR = 3.46, p = 0.002), pelvic mass (OR = 1.75, p = 0.001), and distal ureteral obstruction (OR = 2.27, p = 0.04) as significant risk factors for TUS failure. Of the failure group, 42 patients (22.6%) underwent TUS replacement for a new pair. Yet, 24 (57.2%) experienced a second failure, with a median time of 4.5 months. The risk factors for TUS second failure included a stricture longer than 30 mm (OR = 11.8, p = 0.04), replacement with TUSs of the same diameter (OR = 43, p = 0.003), and initial TUS failure within 6 months (OR = 19.2, p = 0.006). CONCLUSIONS: TUS insertion for the treatment of MUO is feasible and has good outcomes with a relatively low failure rate. Primary pelvic mass and distal ureteral obstruction pose higher risks for TUS failure. Replacing failed TUSs with a new pair has a success rate of 42.8%. Consideration should be given to placing larger diameter stents when replacing failed TUS.

The Added Value of Systematic Sampling in In-Bore Magnetic Resonance Imaging-Guided Prostate Biopsy.

We sought to quantify the additive value of systematic biopsy (SB) using in-bore magnetic resonance (MR)-guided prostate biopsy (IBMRGpB) by retrospectively reviewing the records of 189 patients who underwent IBMRGpB for suspected prostate cancer or as part of the surveillance protocol for previously diagnosed prostate cancer. The endpoints included clinically significant and non-clinically significant cancer diagnosis. SB detected clinically significant disease in 67 (35.5%) patients. Five (2.65%) patients whose targeted biopsies indicated benign or non-clinically significant disease had clinically significant disease based on SB. SB from the lobe contralateral to the lesion detected clinically significant disease in 15 (12%) patients. The size of the prostate was larger and the percentage of lesions located in the peripheral zone of the prostate was higher in patients with SB-detected clinically significant disease. The location of the main lesion in the peripheral zone of the prostate was a predictor for clinically significant disease in the multivariate analysis (OR = 8.26, p = 0.04), a finding supported by a subgroup analysis of biopsy-naïve patients (OR = 10.52, p = 0.034). The addition of SB during IBMRGpB increased the diagnosis of clinically significant as well as non-clinically significant prostate cancer. The location of the main lesion in the peripheral zone emerged as a positive predictive factor for clinically significant disease based on SB. These findings may enhance patient-tailored management.

Primary Ureteroscopy without Pre-Stenting for Proximal Ureteral Stones-Is It Feasible?

BACKGROUND: Primary ureteroscopy with laser lithotripsy is the treatment of choice for distal ureteral stones. However, in cases of proximal ureteral stones, some urologists recommend the preliminary insertion of a ureteral stent and deferred ureteroscopy. We aimed to evaluate the necessity of preliminary ureteral stent insertion in the management of proximal ureteral stones by comparing the surgical outcomes of patients undergoing primary ureteroscopy with laser lithotripsy for proximal vs. distal ureteral stones. METHODS: Medical records of patients who underwent ureteroscopy between 2016 and 2017 in our institution were retrospectively reviewed. Data collected included demographic data, stone size, renal function, intra- and post-operative complications, and stone-free rate (SFR). Patients were divided into two groups: proximal ureteral stones and distal ureteral stones. RESULTS: The cohort included 241 patients who underwent ureteroscopy. Among them, 106 had a proximal ureteral stone. The median age was 51 (IQR 41-65) years. Patients who underwent ureteroscopy for proximal ureteral stones were significantly older (p = 0.007). The median stone's maximal diameter was 7 (5-10) mm. The complication rate and stone-free rate (SFR) were similar in both groups (p = 0.657 and p = 1, respectively). The prevalence of post-procedural ureteral stent insertion was higher among patients who underwent ureteroscopy for proximal ureteral stones: 92.5% vs. 79.3% (p = 0.004). CONCLUSIONS: Our study concludes that primary ureteroscopy with laser lithotripsy for proximal ureteral stones is a valid and feasible treatment with a similar surgical outcome compared to distal ureteral stones. Preliminary ureteral stent insertion seems to be unnecessary.

Strategies of Endoscopic Management of Upper Tract Urothelial Carcinoma among Endourologists: A Global Survey.

Up-to-date guidelines on the management of upper tract urothelial carcinoma (UTUC) are continuously published. We aim to assess the variability of diagnosis and treatment strategies in the endoscopic management of UTUC and adherence to European Association of Urology and National Comprehensive Cancer Network guidelines. A 15-question survey was designed to query practitioners on approaches to clinical practice and knowledge about endoscopic treatment indications and techniques. It was emailed to all members of the Endourologic Society through the society's office, and to all Israeli non-member endourologists. Eighty-eight urologists participated in the survey. Adherence to guidelines on indications for endoscopic management was only 51%. Most of the survey respondents (87.5%) use holmium laser for tumor ablation, and ~50% use forceps for biopsy while the other half use baskets. Only 50% stated that they would use Jelmyto® for specific indications. Most (80%) indicated that they repeat the ureteroscopy 3 months after the first one, and 52.3% continue with follow-up ureteroscopy every 3 months during the first year after diagnosis. There is vast variability among endourologists in the technical aspects of UTUC, the indications for endoscopic management, and adherence to the available guidelines for managing UTUC.

Laparoscopic Versus Robot-Assisted Pyeloplasty in Adults-A Single-Center Experience.

Background: Laparoscopic (LP) and robot-assisted pyeloplasty (RAP) are minimally invasive techniques for correcting uretero-pelvic junction obstruction (UPJO). We retrospectively compared the clinical outcomes of all adults who underwent RAP (n = 41) to those who underwent LP (n = 24) for UPJO at our institution between 2003−2022. Methods: Age, sex, body mass index, surgical side, past abdominal/endoscopic surgeries, pre- and postoperative renal scans, pre- and postoperative serum creatinine levels, operative time (OT), presence of crossing vessels, estimated blood loss, postoperative complications, length of hospital stay, time to JJ stent removal, follow-up length, and postoperative hydronephrosis were analyzed. Results: The groups were demographically comparable. The mean total and skin-to-skin OTs (minutes) were significantly longer in the RAP group than in the LP group (242.4 ± 55 vs. 161.4 ± 40 p < 0.001; 163.7 ± 41.8 vs. 124.3 ± 30.3 p = 0.006, respectively). Hospital stay (days) was shorter in the RAP group (3.3 ± 2.1 vs. 7.3 ± 2.5 p < 0.001). Postoperative complication rates were identical for both groups. The LP group had a significantly longer follow-up period (85.2 ± 73 vs. 19 ± 14 months p < 0.001). The success rates for the LP and RAP groups were 87.5% and 90.6% (p = 0.708). Conclusions: RAP achieves equivalent results to LP, in adult patients. A longer OT may be expected with the robotic system since it can handle more complicated cases.

Diagnosing Oncocytoma by Core Needle Biopsy: A Single-Center Experience.

Background: Oncocytoma is one of the most common benign kidney tumors, accounting for 3-7% of all solid renal masses. Diagnosing oncocytomas using renal biopsy remains a controversy in the uro-pathologic community. With the increasing use of biopsies for assessment of renal lesions, reaching this pathologically benign diagnosis may prevent further surgical measures and have significant clinical benefit. Objective: To demonstrate our center's results using renal biopsy to diagnose oncocytomas and to suggest that this diagnosis can be made with high success rates. Design: , Setting, and Participants. From our center's database, we retrospectively identified and retrieved all cases of oncocytoma diagnosed between the years 2011 and 2020 by renal biopsy. Medical records of those patients were then reviewed to view follow-up meetings and imaging of the lesions biopsied. Outcome Measurements and Statistical Analysis. In 21 biopsies performed on 19 patients, diagnosis was supported by subsequent follow-up averaging at 3.44 years per patient. Results and Limitations. The lesions exhibited benign behavior during follow-up after biopsy, consistent with the diagnosis of oncocytoma. Conclusions: Our study demonstrates that with good patient selection and proficient cooperation between urologists, radiologists and dedicated uro-pathologists, correctly diagnosing oncocytomas using RCB is a viable task. Patient Summary. Oncocytomas are benign lesions of the kidney. In our study, we reviewed all cases of oncocytomas pathologically diagnosed using renal biopsy from our center's database. We found that in subsequent follow-up later to biopsy, the lesions displayed benign behavior consistent with oncocytoma. The use of percutaneous biopsies to reach this diagnosis could save patients more extensive surgeries.