Surgical treatment of renal cell carcinoma with tumor thrombosis of the inferior vena cava and the right heart: How we do it.

OBJECTIVE: Renal cell carcinoma with inferior vena cava thrombosis is a rare disease with a poor prognosis without surgical treatment. We report our 11-year experience in the surgical treatment of renal cell carcinoma with extension of the inferior vena cava. METHODS: We conducted a retrospective analysis of patients undergoing surgical treatment for renal cell carcinoma with invasion of the inferior vena cava in two hospitals from May 2010 to March 2021. To assess the spread of the tumor process invasion, we used the Neves and Zincke classification. RESULTS: A total of 25 people underwent surgical treatment. Sixteen patients were men, nine were women. Thirteen patients underwent cardiopulmonary bypass (CBP) surgery. The following postoperative complications were recorded: two cases of disseminate intravascular coagulation (DIC), two cases of acute myocardial infarction (MI) and one case of coma of unknown reason, Takotsubo syndrome and postoperative wound dehiscence. Three patients deceased (16.7%) of DIC syndrome and AMI. After discharge, one of the patients had a recurrence of tumor thrombosis 9 months after surgery, and another patient had the same 16 months later, presumably due to the neoplastic tissue in the adrenal gland on the contralateral side. CONCLUSION: We believe that this problem should be dealt with by an experienced surgeon with a multidisciplinary team in the clinic. The use of CPB provides benefits and reduces blood loss.

Markers of local kidney cancer recurrence: A surgeon's mistake or a pattern? Review.

The influence of various morphological, anatomical, genetic and other factors on the local recurrence-free survival of patients who have undergone different renal cell cancer (RCC) treatment is still a rather complex, ambiguous and controversial issue for practicing oncourologists. This review evaluates the effect of several factors on both recurrence-free survival and local recurrence-free survival. The review includes articles, clinical cases, literature reviews, and meta-analyses highlighting the analysis of independent and interrelated predisposing factors for developing local recurrence of RCC from 1984 to 2020. The PubMed, Web of Science, and Scopus databases were searched in English, Spanish, and German. A review of the literature showed the role of the following indices in the local recurrence RCC: microvascular invasion (p = 0.001), tumor necrosis (p = 0.0001), high malignancy (Fuhrman III or IV) (HR = 38.3, 95% CI 3.1-467, p = 0.004) as histological factors, tumor size as an anatomical factor. Thus, the authors state that every centimeter of the tumor increases the risk of local recurrence (p < 0.05). A group from the Mayo Clinic showed the equivalence of different treatment methods in local RCC recurrence. Thus, in the group of patients with cT1a stage kidney cancer, the 5-year local recurrence-free survival rates were 97.7% (96.7-98.6), 95.9% (92.3-99.6), and 95.9% (92.3-99.6) for renal resection, RFA, and cryoablation, respectively. Surgical margin status is the most studied and controversial marker of local renal cell carcinoma recurrence. Researchers found a direct effect of PSM on the risk of local RCC recurrence (p < 0.01). The personalized approach with the search and evaluation of predisposing factors for the local recurrence, as well as further selection of the most optimal treatment, will allow oncourologists to improve both the effectiveness of primary treatment and the recurrence-free survival of patients.

Emergency versus elective ureteroscopy for the management of ureteral stones.

OBJECTIVE: To assess the safety and efficacy of emergency ureteroscopy (URS) compared with elective URS. METHODS: We conducted a retrospective analysis of patients who underwent URS for isolated ureteral stones in a single center from October 2001 to February 2014. Our patient cohort was divided into two groups: an emergency URS group (Group A), which consisted of patients who underwent URS within the first 24 h of admission, and an elective or planned URS group (Group B). The URS success rate was defined as being the incidence of successful stone fragmentation and whether there was resolution of renal obstruction. RESULTS: A total of 2957 patients' medical records were available for analysis. Of these, 704 (21%) comprised of emergency cases and the remaining 2253 (79%) were elective cases. Patients in Group A were younger, had a smaller BMIs, and had smaller stone sizes (p < 0.001). The URS success rate was found to be 97% in Group A and 96% in Group B (p = 0.35). Intraoperative or postoperative complication rates were not found to vary significantly between the groups (8% vs 7%, respectively, p = 0.50). The incidence of ureteral stenting was nearly twice as high if URS was performed during night hours (85% vs 45%, p < 0.001). However, ureteral stenting was more prevalent in Group B compared to Group A patients (57% vs 25%, p < 0.001), possibly as a result of the number of pre-stented patients (73%). CONCLUSIONS: Emergency URS is an effective and safe option for patients with renal colic. Younger patients without pre-existing obesity and with stone sizes up to 8 mm located in the distal ureter might be a better match for emergency URS.

Intraoperative prophylactic intravesical chemotherapy to reduce bladder recurrence following radical nephroureterectomy.

PURPOSE: Single, postoperative instillation of prophylactic intravesical chemotherapy (pIVC) is effective in reducing bladder cancer recurrences following radical nephroureterectomy (RNU). Despite high level evidence, pIVC is underutilized. Intraoperative pIVC (I-pIVC) may be easier and safer to implement than postoperative pIVC (P-pIVC). We aimed to evaluate the efficacy of I-pIVC during RNU. MATERIALS AND METHODS: Retrospective analysis of patients undergoing RNU and I-pIVC or postoperative pIVC (P-pVC) with 20 to 40 mg mitomycin-C or 1 to 2 g gemcitabine. Recurrence rates were evaluated using the Kaplan-Meier curves and log rank test. Cox regression was used for univariable and multivariable analysis. RESULTS: One hundred and thirty-seven patients were included in the final analysis. 81% (111/137) had I-pIVC and 19% (26/137) had P-pIVC. In the I-pIVC group higher rates of HG, muscle invasive disease and gemcitabine use were observed. Overall, 74% (101/137) and 26% (36/137) had mitomycin-C and gemcitabine instillations, respectively. Within 12 months 14% (19/137) of the patients experienced bladder recurrence. Median time to bladder recurrence was 7 months (range 3-27). Twelve months bladder recurrence-free survival rates were 82% for the I-pIVC group, and 72% for the P-pIVC group ((log rank P = 0.365). CONCLUSIONS: I-pIVC during RNU may reduce bladder recurrence rates. Bladder recurrence rates are comparable to those reported using postoperative instillations. Intraoperative instillations may be easier to implement and may increase usage rates.

Expression of urokinase-type plasminogen activator system in non-metastatic prostate cancer.

PURPOSE: To investigate the prognostic role of expression of urokinase-type plasminogen activator system members, such as urokinase-type activator (uPA), uPA-receptor (uPAR), and plasminogen activator inhibitor-1 (PAI-1), in patients treated with radical prostatectomy (RP) for prostate cancer (PCa). METHODS: Immunohistochemical staining for uPA system was performed on a tissue microarray of specimens from 3121 patients who underwent RP. Cox regression analyses were performed to investigate the association of overexpression of these markers alone or in combination with biochemical recurrence (BCR). Decision curve analysis was used to assess the clinical impact of these markers. RESULTS: uPA, uPAR, and PAI-1 were overexpressed in 1012 (32.4%), 1271 (40.7%), and 1311 (42%) patients, respectively. uPA overexpression was associated with all clinicopathologic characteristics of biologically aggressive PCa. On multivariable analysis, uPA, uPAR, and PAI-1 overexpression were all three associated with BCR (HR: 1.75, p < 0.01, HR: 1.22, p = 0.01 and HR: 1.20, p = 0.03, respectively). Moreover, the probability of BCR increased incrementally with increasing cumulative number of overexpressed markers. Decision curve analysis showed that addition of uPA, uPAR, and PAI-1 resulted in a net benefit compared to a base model comparing standard clinicopathologic features across the entire threshold probability range. In subgroup analyses, overexpression of all three markers remained associated with BCR in patients with favorable pathologic characteristics. CONCLUSION: Overexpression of uPA, uPAR, and PAI-1 in PCa tissue were each associated with worse BCR. Additionally, overexpression of all three markers is informative even in patients with favorable pathologic characteristics potentially helping clinical decision-making regarding adjuvant therapy and/or intensified follow-up.

PTRF independently predicts progression and survival in multiracial upper tract urothelial carcinoma following radical nephroureterectomy.

OBJECTIVES: Polymerase I and transcript release factor (PTRF) has been implicated in cancer biology but its role in upper tract urothelial carcinoma (UTUC) is unknown. From a pilot transcriptome, we identified PTRF was significantly upregulated in high stage UTUC. Bladder cancer transcriptome from The Cancer Genome Atlas (TCGA) supported our finding and high PTRF level also predicted poor survival. We, therefore, investigated the correlation of PTRF with patients' clinicopathologic characteristics and outcomes in a multiracial UTUC cohort. MATERIALS AND METHODS: By immunohistochemical staining, PTRF expression was determined using H-score. PTRF expression of 575 UTUCs from 8 institutions, including 118 Asians and 457 Caucasians, was compared with various clinicopathologic parameters. Human urothelial cancer cell lines were used to evaluate the level of PTRF protein and mRNA expression, and PTRF transcript level was assessed in fresh samples from 12 cases of the cohort. The impact of PTRF expression on disease progression, cancer-specific death and overall mortality was also examined. RESULTS: High PTRF expression was significantly associated with multifocality (P = 0.023), high pathologic tumor stage (P < 0.00001), nonurothelial differentiation (P = 0.035), lymphovascular invasion (P = 0.003) and lymph node metastasis (P = 0.031). PTRF mRNA expression was also markedly increased in advanced stage UTUC (P = 0.0003). High PTRF expressing patients had consistently worse outcomes than patients with low PTRF expression regardless of demographic variation (all P < 0.005). In multivariate analysis, high PTRF expression was an independent predictor for progression-free survival (hazard ratio [HR] 1.70, 95% confidence interval [CI] 1.07-2.69, P = 0.025), cancer-specific survival (HR 2.09, 95% CI 1.28-3.42, P = 0.003), and overall survival (HR 2.04, 95% CI 1.33-3.14, P = 0.001). CONCLUSIONS: Results indicate that PTRF is a predictive biomarker for progression and survival and an independent prognosticator of UTUC. Elevated PTRF could probably propel clinically aggressive disease and serve as a potential therapeutic target for UTUC.

Prognostic role of the urokinase plasminogen activator (uPA) system in patients with nonmuscle invasive bladder cancer.

OBJECTIVES: To assess the role of the urokinase plasminogen activator (uPA) system as a prognostic biomarker in patients with nonmuscle invasive bladder cancer (NMIBC) treated with transurethral resection of the bladder (TURB) with or without adjuvant intravesical therapy. MATERIAL AND METHODS: We stained TURB tissue from 827 NMIBC patients with uPA, its receptor (uPAR) and its inhibitor (PAI-1). The status of these markers was categorized as normal vs. overexpressed using the cutoffs of 30% for uPA, 50% for uPAR, and 30% for PAI-1. Multivariable Cox regression analyses were performed to evaluate the prognostic value of these markers. RESULTS: uPA was overexpressed in 37.7% of patients, uPAR in 44.7% and PAI-1 in 44.6%. Overexpression of these markers was associated with high tumor grade. Within a median follow-up was 60 months (interquartile range: 22-109), uPA (hazard ratio [HR]: 1.40; P = 0.006), uPAR (HR: 1.70; P < 0.001), PAI-1 (HR: 1.35; P = 0.014), and the combination of all 3 markers (HR: 3.38; P < 0.001) were associated with recurrence-free survival (RFS); uPA (HR: 1.68; P = 0.035) and the combination of all 3 markers (HR: 8.79; P = 0.005) were associated with progression-free survival (PFS). The addition of the uPA system to a base model improved the discrimination by 1.3% for RFS and 2.1% for PFS. In subgroup analyses, uPA (HR: 2.19; P = 0.018) was associated with PFS in T1G3 patients and its addition to a base model improved the discrimination by 2.5%. uPA (HR: 1.44; P = 0.019), uPAR (HR: 1.54; P = 0.006), PAI-1 (HR: 1.46; P = 0.013) and the combination of all 3 markers (HR: 3.48; P < 0.001) were associated with RFS in TaG1-2 patients and their addition to a base model improved the discrimination by 2.1%. CONCLUSION: uPA, uPAR, and PAI-1 are overexpressed in one-third to half of patients with NMIBC. Their overexpression is an independent prognosticator of RFS and PFS which improved the predictive accuracy of current clinicopathological characteristics. Biomarkers that capture the biological and clinical behavior of individual tumors may help personalize clinical decision-making in patients with NMIBC.

Holter Monitoring (24-Hour ECG) Parameter Dynamics in Patients with Ischemic Heart Disease and Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia.

INTRODUCTION: This study examined the dynamics of 24-h electrocardiogram (ECG) monitoring parameters (Holter monitoring) in patients with ischemic heart disease (IHD) before and after conservative or surgical treatment of patients with voiding and storage lower urinary tract symptoms (LTS) due to benign prostatic hyperplasia (BPH). METHODS: A total of eighty-three 57 to 81-year-old (mean age 70.4 ± 5.75 years) patients with LUTS/BPH and accompanying IHD were examined and treated at the Institute of Urology and Human Reproductive Health and Clinic of Cardiology of Sechenov University. All patients received recommended cardiac therapy at least 6 months before inclusion in the study. RESULTS: Our study demonstrated that there is correlation between voiding and storage LUTS/BPH and Holter-detected cardiac impairments in patients with IHD/BPH. These data make it possible to consider LUTS/BPH (voiding and storage) as a factor in the additional functional and psychological load on the activity of patients with ischemic heart disease. Improvement of voiding and storage LUTS due to BPH and objective parameters of urination (Qmax) in patients treated with alpha-1 adrenoceptor blocker tamsulosin correlated with improvement of 24-h ECG monitoring parameters (Holter monitoring) in 72% of patients. Improvement of 24-h ECG monitoring parameters (Holter monitoring) 1 month after transurethral resection of the prostate (TURP) in IHD/BPH patients and indications for surgical treatment was observed in 65.7%. Negative dynamics of the Holter-based ECG was not registered in patients who were operated on. CONCLUSION: Holter monitoring helps to identify groups of patients in whom urinary impairments caused by prostatic hyperplasia negatively affect the course of IHD. Restored urination (either conservatively or operatively) in patients with BPH in 72% of cases decreased the number of fits of angina, thus influencing favourably the course of IHD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03856242.

Focal Neuroendocrine Differentiation of Conventional Prostate Adenocarcinoma as a Prognostic Factor after Radical Prostatectomy: A Systematic Review and Meta-Analysis.

The biologic and prognostic value of focal neuroendocrine differentiation (NED) in conventional prostate adenocarcinoma (PC) patients who undergo radical prostatectomy (RP) remains controversial. In this systematic review and meta-analysis, we assessed the association of focal NED in conventional PC with oncological outcomes after RP. A literature search using PubMed, Scopus, Web of Science, and Cochrane Library was conducted on December 2018 to find relevant studies according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We used a fixed-effect model to analyze the impact of focal NED in RP specimen on progression-free survival defined by biochemical recurrence (BCR). A total of 16 studies with the outcomes of disease progression and survival were eligible. No patient in these studies received androgen deprivation therapy prior to RP. Eleven studies found no significant correlation between focal NED and outcomes of interest, while five studies reported a significant association of focal NED assessed by immunohistochemical chromogranin A or serotonin staining with BCR or survival. Focal NED was associated with higher BCR rates after RP with a pooled HR of 1.39 (95% CI 1.07‒1.81) in five studies. No heterogeneity was reported in this analysis (I² = 21.7%, p = 0.276). In conclusion, focal NED in conventional PC is associated with worse prognosis after RP. Its presence should be reported in pathologic reports and its true clinical impact should be assessed in well-designed prospective controlled studies.

Surgical site infections after radical prostatectomy: A comparative study between robot-assisted laparoscopic radical prostatectomy and retropubic radical prostatectomy.

OBJECTIVE: Surgical site infection (SSI) is defined as infection at or near surgical incisions within 30 days of an operative procedure and classified either incisional superficial and deep or organ/space. The aim of the study is to report and compare the incidence and management of SSIs after robot-assisted laparoscopic radical prostatectomy (RALP) and retropubic radical prostatectomy (RRP). MATERIAL AND METHODS: Within the last 4 years, we identified 285 patients that underwent RRP, n=187 (66%) or RALP, n=98 (34%). We reviewed the frequency, types and way of management of SSI complications. RESULTS: A significant difference was found between RALP and RRP (2/98, 2% vs. 27/187, 14.4%; p<0.0001) as for SSIs. The time interval between the time of surgery and diagnosis of SSIs was longer in RALP relative to RRP (median 13.5 vs. 12.9 days, p=0.761). CONCLUSION: All types of SSIs could be developed after RP, however RALP patients only experienced organ or space SSIs and have a lower rate of SSIs and shorter treatment time.

Early Surgical Intervention is Beneficial in Avoiding Complications in Patients with Male Lower Urinary Tract Symptoms.

In 2018, owing to the variety of true minimally invasive and effective treatment modalities available, early surgery in patients suffering from lower urinary tract symptoms due to benign prostatic enlargement is a valid, safe, and effective option compared to long-term less effective medical treatment.

Prognostic Value of PD-1 and PD-L1 Expression in Patients with High Grade Upper Tract Urothelial Carcinoma.

PURPOSE: We investigated the prognostic value of PD-1 and PD-L1 expression in patients with high grade upper tract urothelial carcinoma. MATERIALS AND METHODS: Tissue microarrays of 423 patients treated with extirpative surgery for high grade upper tract urothelial carcinoma from the International Upper Tract Urothelial Carcinoma collaboration were stained for PD-1 and PD-L1 using antibodies, including Cell Marque™ NAT105 diluted 1:250 and prediluted E1L3N® via immunohistochemistry. A 1% or greater staining rate of tumor infiltrating lymphocytes (PD-1) and tumor cells (PD-L1) was considered positive. Univariate and multivariate analyses were performed to assess independent prognosticators of survival outcomes. RESULTS: Median patient age was 70.0 years and median followup was 37.0 months. PD-1 and PD-L1 were positive in 37.2% and 26.2% of patients, respectively. PD-1 positivity was significantly associated with adverse pathological characteristics while PD-L1 positivity was associated with favorable pT stage. On univariate analysis PD-1 expression was associated with worse recurrence-free, cancer specific and overall survival. On multivariate analysis PD-1 expression was an independent prognosticator of cancer specific survival (HR 1.7, 95% CI 1.03-2.66, p = 0.039) and overall survival (HR 1.5, 95% CI 1.05-2.24, p = 0.029) but not recurrence-free survival (HR 1.4, 95% CI 0.9-2.16, p = 0.139). On univariate analysis PD-L1 expression was not significantly associated with survival outcomes. However, on multivariate analysis in patients with organ confined disease (pT2 or less, pN0/x and cM0), PD-L1 positivity was an independent prognosticator of recurrence-free survival (HR 0.2, 95% CI 0.06-0.98, p = 0.046) and overall survival (HR 0.3, 95% CI 0.11-0.63, p = 0.003). CONCLUSIONS: PD-1 positivity of tumor-infiltrating lymphocytes was associated with adverse pathological criteria and independent prognostication of worse survival outcomes. PD-L1 positivity of tumor cells was an independent prognosticator of favorable survival outcomes in cases of organ confined disease.

Near-infrared fluorescence with indocyanine green for diagnostics in urology: initial experience.

INTRODUCTION: Fluorescence imaging with indocyanine green is used in urology for the detection of sentinel lymph nodes and identification of prostate margins in radical prostatectomy for delineation of resection zone and selective clamping of vessels in partial nephrectomy; for identification and evaluation of length of ureteral strictures; for assessment of perfusion and viability of anastomoses during reconstructive stage of cystectomy. Safety of this technique is proven, while its diagnostic value and usefulness is still controversial. METHODS: This pilot study of using the SPY Elite Fluorescence Imaging System for diagnostics was performed in the I.M. Sechenov First Moscow State Medical University. Ten patients were enrolled: four patients underwent retropubic RP and lymph node dissection, five patients underwent partial nephrectomy, and one patient underwent ureteroplasty. Fluorophore was injected transrectally with TRUS guidance during RP in order to assess the lymph nodes. During partial nephrectomy, the compound was injected intravenously to differentiate the tumor from parenchyma by its blood supply. During ureteroplasty, the indocyanine green solution was injected into the renal pelvis to dye the ureter and locate the stricture. RESULTS: Sensitivity of this technique for visualization of sentinel lymph nodes was 100%, and specificity was 73.3%. In patients who underwent partial nephrectomy, all lesions were malignant and hypofluorescent when compared with healthy parenchyma. SPY allowed us to determine the location and extension of the stricture during ureteroplasty. No hypersensitivity reactions or complications were observed during injection of the compound.

The role of water-jet dissection in improving erectile function and urinary continence after nerve-sparing prostatectomy.

OBJECTIVES: The aim of this study was to assess erectile function (EF) and urinary continence (UC) recovery after nerve-sparing retropubic radical prostatectomy (NS-RRPE) and nerve-sparing laparoscopic radical prostatectomy (NS-LRPE) depending on the neurovascular bundle (NVB) dissection technique used. METHODS: Twenty-four hour pad test was used to assess the degree of postoperative UC 1, 6 and 12 months after the surgery. For the purpose of EF assessment, International Index of Erectile Function-5 (IIEF-5) questionnaire was used. In addition, EF recovery assessment included the time needed to achieve a successful sexual intercourse with or without Inhibitors Phosphodiesterase 5 (IPDE5). A successful sexual intercourse was defined as an ability to achieve a strong erection enough for penetration and maintain erection for a long time, throughout the intercourse. Assessment was performed before the surgery and 8 and 6 months after the surgery. RESULTS: In the patient group with BNS + water jet dissection (WJD), the IIEF-5 score was considerably higher 8 weeks after the surgery (by 2.8 points) (р = 0.02). In 6 months, the difference between the group become more significant and reached 3.5 points (p = 0.01). Three months after urethral catheter removal, majority (95%) of patients in the NS-RPE + WJD group had no urinary incontinence (UI). For standard NS-RPE, that figure was 87%. Mild stress UI was observed in 5% of patients after NS-RPE + WJD and in 13% of patients after NS-RPE. Six months after urethral catheter removal, no significant differences in UC assessment were observed in the two groups. CONCLUSIONS: The implementation of WJD of NVB in clinical practice has made it possible to considerably improve the quality of life for postoperative patients due to good outcomes in terms of early UC and EF recovery.

Holmium laser enucleation of the prostate (HoLEP) for small, large and giant prostatic hyperplasia: tips and tricks.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) allows to treat extremely large prostates (>200 cm3). The aim of the study was to compare the efficiency of HoLEP for prostates of different sizes. METHODS: Four hundred and fifty-nine patients were divided into three groups: group 1 included 278 patients (<100 cm3); group 2 included 169 patients (100-200 cm3); group 3 included 12 patients (>200 cm3). RESULTS: The duration of enucleation in group 1 was 56.5 ± 10.7 min; in group 2 was 96.4 ± 24.9 min; in group 3 was 120.9 ± 35 min. The duration of morcellation in group 1 was 37.5 ± 7.3 min; in group 2 was 63.3 ± 11.2 min; in group 3 was 84.0 ± 25.6 min. The enucleation efficiency in group 3 (1.70 g/min) was higher (p<0.05) than in group 1 (1.05 g/min) and group 2 (1.23 g/min). Morcelation efficiency was lower in groups 1 and 2 (1.58 and 1.87 g/min, respectively) than in group 3 (2.45 g/min) (p<0.05).Follow-up period lasted 18 months. There were no significant differences (p>0.05) in International Prostate Symptom Score, Qmax, quality of life and postvoid residual volume for 1, 3, 6, 12 and 18 months after surgery. CONCLUSIONS: HoLEP is a safe, highly efficacious and a size-independent procedure.

Percutaneous US-guided renal cryoablation using 3D modeling.

INTRODUCTION: The article describes the first experience of performing percutaneous ultrasound (US)-guided cryoablation of renal tumor and assesses the safety and short-term results of treatment. MATERIALS AND METHODS: Twelve patients were subjected to US-guided cryoablation of renal tumor in 2015. The tumor size in 11 patients was up to 3.0 cm (T1а); in one female patient, 4.5 cm (T1b). Tumors were assessed according to the PADUA score. In eight patients, it was 6-7 (low); in three patients, 8-9 (average); in one, 10 (high). All the patients underwent US examination using a FlexFocus 800 apparatus with convex abdominal transducers. Before surgery and 6 months later, all the patients underwent renal Doppler US and contrast-enhanced computed tomography. RESULTS: The average cryoablation time was 60 min. Seven operations were performed under spinal anesthesia and five operations under local anesthesia. The follow-up period lasted 8 months on average. According to the ultrasonography and Doppler findings, after 6 months, the tumor (T1a) in 11 patients reduced in size by an average of 7-8 mm and had no blood supply.T1b patient's mass size reduces from 4.5 to 3.7 cm; however, a 1.5 cm area with a high attenuation gradient of the contrast medium was visualized. Later, the patient was subjected to laparoscopic renal resection. Histological finding revealed clear-cell carcinoma. CONCLUSIONS: We consider percutaneous US-guided cryoablation as a method of choice for patients with stage T1a renal tumor localized on the posterior or lateral surface in the inferior or middle segment without sinus involvement and PADUA <9.

Transurethral contact ureterolithotripsy in gas (СО2) medium.

BACKGROUND: Transurethral intracorporeal lithotripsy is the modality of choice for the endoscopic disintegration of large, long-standing, radiolucent or high-density stones. Despite several advantages and proven benefits of contact ureterolithotripsy/ureterolithoextraction (CULT), the application of irrigation carries significant risks of untoward perioperative events including retrograde stone migration and postoperative pyelonephritis. METHODS: We describe a new technique - endoscopic intracorporeal lithotripsy in the gas (СО2) medium. It is a prospective randomized, single blinded pilot study that included total of (n = 60) patients with urolithiasis who were allocated to either experimental or control group. Out of the total pool of patients, 30 underwent treatment with the new approach (experimental group) and other 30 (control group) had contact ureterolithotripsy in a standard of care 0.9% NaCL medium. We included patients >18 years old, with known symptomatic renal calculi disease who were eligible and scheduled for CULT and free from significant coexisting pathologies of urinary tract. RESULTS: No retrograde migration of the stone fragments into the kidney was reported in the experimental group [complications rate 0%, confidence interval (CI): 0-11.6%]. In the control group, complications were observed in eight cases (complications rate 26.7%, CI: 14.7-42.3%); retrograde migration was in five patients (16.6%), and acute pyelonephritis/exacerbation of chronic pyelonephritis was seen in three (10%) patients. There was not any acute pyelonephritis in the experimental group. Reliability of frequency differences - p = 0.0023 (χ2). CONCLUSIONS: The novel method of contact ureterolithotripsy is a safe and promising alternative to the conventional contact ureterolithotripsy in a fluid medium in a carefully selected patient population.

Postoperative Nomogram for Relapse-Free Survival in Patients with High Grade Upper Tract Urothelial Carcinoma.

PURPOSE: We developed a prognostic nomogram for patients with high grade urothelial carcinoma of the upper urinary tract after extirpative surgery. MATERIALS AND METHODS: Clinical data were available for 2,926 patients diagnosed with high grade urothelial carcinoma of the upper urinary tract who underwent extirpative surgery. Cox proportional hazard regression models identified independent prognosticators of relapse in the development cohort (838). A backward step-down selection process was applied to achieve the most informative nomogram with the least number of variables. The L2-regularized logistic regression was applied to generate the novel nomogram. Harrell's concordance indices were calculated to estimate the discriminative accuracy of the model. Internal validation processes were performed using bootstrapping, random sampling, tenfold cross-validation, LOOCV, Brier score, information score and F1 score. External validation was performed on an external cohort (2,088). Decision tree analysis was used to develop a risk classification model. Kaplan-Meier curves were applied to estimate the relapse rate for each category. RESULTS: Overall 35.3% and 30.7% of patients experienced relapse in the development and external validation cohort. The final nomogram included age, pT stage, pN stage and architecture. It achieved a discriminative accuracy of 0.71 and 0.76, and the AUC was 0.78 and 0.77 in the development and external validation cohort, respectively. Rigorous testing showed constant results. The 5-year relapse-free survival rates were 88.6%, 68.1%, 40.2% and 12.5% for the patients with low risk, intermediate risk, high risk and very high risk disease, respectively. CONCLUSIONS: The current nomogram, consisting of only 4 variables, shows high prognostic accuracy and risk stratification for patients with high grade urothelial carcinoma of the upper urinary tract following extirpative surgery, thereby adding meaningful information for clinical decision making.