Does Radical Local Treatment in Oligometastatic Prostate Cancer Improve Overall Survival: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine the impact of radical local treatment (RLT) on overall survival (OS) and other survival outcomes in patients with OligoMetastatic Prostate Cancer (OMPC). METHODS: We performed a meta-analysis of randomized controlled trials (RCTs) published in the MEDLINE and CENTRAL databases until May 2023. We included RCTs that randomized patients to RLT (either radical prostatectomy [RP] or external beam radiotherapy [EBRT]) and standard of care and reported on OMPC. Our primary objective was to analyze OS with a minimum median follow-up of 4years (PROSPERO-CRD42023422736). RESULTS: We analyzed 3 RCTs, presenting data across 5 papers. OS was significantly higher in the RLT group (HR - 0.643, 95%CI 0.514-0.8, P-value <.001). The data on EBRT was drawn from 520 patients and that of RP was from 85. The post-hoc power analysis showed 81% power to detect a difference of 10% with an alpha error of 0.01. Pooled prevalence of grade 3-4 bowel and bladder toxicity was 4.5%. Health-Related Quality of Life was similar in both groups (mean difference - 1.54, 95%CI -0.625 -3.705, P-value .163). The risk of bias as per the RoB2 tool was low for all domains and overall bias. As per GRADE criteria, the certainty of evidence was high. CONCLUSION: Our meta-analysis underscores the evidence-based significance of RLT, particularly emphasizing the benefits of EBRT in patients with OMPC. However, the findings should be interpreted with caution due to the limited number of studies and the relatively small sample sizes, especially in the RP subgroup. Future investigations in OMPC should consider incorporating EBRT in their standard treatment approach.

The obstructive index in antenatal unilateral pelviureteric junction obstruction: A novel predictor of the failure of conservative management.

BACKGROUND: To find the impact of the obstructive index (OI) as a predictor of management in antenatal pelviureteric junction obstruction. METHODS: Records of 135 cases of antenatally detected unilateral pelviureteric junction obstruction, selected for initial observation were retrospectively analyzed. All patients who underwent pyeloplasty on follow up were assigned to Group A. Those patients who were still on conservative management were assigned to Group B. The pelvic anteroposterior diameters of the affected (PAPD[A]) and normal kidney (PAPD[N]) of the same patient, along with the cortical thickness of the affected kidneys (CT[A]) and normal kidneys (CT[N]) on postnatal ultrasound scan, the T1/2 of the affected (T1/2 [A]) and normal kidneys (T1/2 [N]), the differential renal function (DRF), and the shape of the curve on a diuretic renogram were noted for each patient at 6 weeks. The OI was defined as (PAPD[A] × T1/2 [A]) / (PAPD[N] × T1/2 [N]). RESULTS: The median duration of follow up was 55 months (36-110). Median age at surgery was 12 months (4-80). Group A had 30 patients with 105 in Group B. On multivariate analysis, OI and shape of curve predicted need for surgery with statistical significance. Median OI in Group A was 18.9 compared to 4.82 in Group B (P < 0.001, Mann-Whitney). Using receiver operating characteristic analysis, the area under curve for the OI was 0.95. A level of 12.2 could predict failure of conservative management with a sensitivity of 93.3% and a specificity of 92.4%. CONCLUSIONS: The OI can reliably predict the need for surgery at a very early stage, thus avoiding repeated tests and saving time.

A Computed Tomography Angiography (CTA): Based score (SGPGI score) to predict level of difficulty, operative, and postoperative outcomes for right-sided radical nephrectomy.

OBJECTIVE: With the advent of laparoscopic approach for the large (T1b-T3a ± N1) right renal masses, higher rates of complications and conversion to open surgery are being reported. The role of preoperative angioembolization (PAE), which has increased cost and inherent morbidity but may help in select circumstances has also not been clearly defined in the literature. We therefore devised a scoring system (SGPGI score) based on pre-operative Computed Tomography Angiography (CTA) to predict the level of difficulty of radical nephrectomy and enhance its safety and efficacy which could also be used for the judicious use of PAE in selected cases. METHODS: In a prospective observational study on 52 patients with right renal masses from January 2014 to July 2018, we calculated a score based on CTA parameters. The patients were stratified for type and duration of surgery, blood loss, postoperative stay, and Clavien-Dindo grade of postoperative complications. RESULTS: Patients were classified into three groups based on our scoring system. Progressively groups with higher score had higher blood loss, operating time, complications and hospital stay, and were more likely to have undergone conversion to open surgery (Area under curve 0.8625 for a cut off score of 10). Intraclass Correlation Coefficient (ICC) was 0.678-1 for the different components of our score. CONCLUSION: The pre-operative CTA based SGPGI score evaluates right renal masses and is able to predict intra-operative difficulties effectively, leading to enhancement of surgery safety and efficacy. It also helps judiciously use PAE.

A prospective randomized study to define the role of low dose continuous prophylactic antibiotics and anti-adherence agents in altering the microbial colonization related to indwelling double-J stents.

OBJECTIVE: Despite conflicting evidence, it is common practice to use continuous antibiotic prophylaxis (CAP) in patients with indwelling double-J (DJ) stents. Cranberry extracts and d-mannose have been shown to prevent colonization of the urinary tract. We evaluated their role in this setting. METHODS: We conducted a prospective randomized study to evaluate patients with indwelling DJ stents following urological procedures. They were randomized into three groups. Group A (n=46) received CAP (nitrofurantoin 100 mg once daily [OD]). Group B (n=48) received cranberry extract 300 mg and d-mannose 600 mg twice daily (BD). Group C (n=40) received no prophylaxis. The stents were removed between 15 days and 45 days after surgery. Three groups were compared in terms of colonization of stent and urine, stent related symptoms and febrile urinary tract infections (UTIs) during the period of indwelling stent and until 1 week after removal. RESULTS: In Group A, 9 (19.5%) patients had significant bacterial growth on the stents. This was 8 (16.7%) in the Group B and 5 (12.5%) in Group C (p-value: 0.743). However, the culture positivity rate of urine specimens showed a significant difference (p-value: 0.023) with Group B showing least colonization of urine compared to groups A and C. There was no statistically significant difference in the frequency of stent related symptoms (p-value: 0.242) or febrile UTIs (p-value: 0.399) among the groups. CONCLUSION: Prophylactic agents have no role in altering bacterial growth on temporary indwelling DJ stent, stent related symptoms or febrile UTIs. Cranberry extract may reduce the colonization of urinary tract, but its clinical significance needs further evaluation.

Efficacy and Safety of Supracostal Access for Mini Percutaneous Nephrolithotomy in Pediatric Patients.

OBJECTIVE: To evaluate the efficacy and safety of supracostal percutaneous nephrolithotomy (PCNL) through the 11th intercostal space and compare it with subcostal PCNL in children with renal calculi. MATERIALS AND METHODS: Children with renal calculi who underwent PCNL between January 2010 and December 2017 were divided into 2 groups: supracostal PCNL (group 1) and subcostal PCNL (group 2). Stone location, stone burden, location of the access points, operative time, postoperative visual pain score, success rate, hospital stay, and complications according to the modified Clavien classification were compared. Comparison of medians was done using Mann Whitney U test and the means were compared using t test. RESULTS: Group 1 had 50 patients while group 2 had 60 patients. The stone-free rate was 84.0% and 85.0% in groups 1 and 2, respectively after 1 session of PCNL (P = .885). After auxiliary procedures, it increased to 96.0% and 96.6%, respectively (P = .852). The mean fall in hematocrit was 0.9% in group 1 and 1.5% in group 2 (P = .11) whereas the median pain score was 4 in group 1 and 3 in group 2 (P = .37). In all, 54 complications were recorded the commonest among which were grade I (81.5%). Twenty-nine complications were observed in group 1 while 25 complications were observed in group 2 (P = .088). One patient developed nephropleural fistula while another patient developed hydropneumothorax. Both belonged to group 1. CONCLUSION: Supracostal access for PCNL is an effective and safe alternative to subcostal access for children with renal calculi in terms of stone-free rate and complications.

Technique, complications, and outcomes of pediatric urolithiasis management at a tertiary care hospital: evolving paradigms over the last 15 years.

BACKGROUND: Despite technological advancements, there is lack of consensus for the standard treatment modalities for pediatric urolithiasis. OBJECTIVE: The primary objective was to review the management of pediatric urolithiasis over the last 15 years in terms of technical modifications, surgical outcomes, and complications. The secondary objective was to compare the efficacy and outcomes of standard percutaneous nephrolithotomy (PCNL) and mini-PCNL for renal and upper ureteric calculi. STUDY DESIGN: Medical records of all patients aged <18 years who presented to the authors' tertiary care hospital in northern India between August 2003 and December 2018 were reviewed retrospectively. Before 2010, all PCNLs performed were standard PCNL, whereas after 2010, most PCNLs performed were mini-PCNL. Thus, the patients were divided into two groups: group A (patients up to 2010) and group B (patients after 2010). These were compared for the type of treatment, success rate, and complications. The outcomes of surgical management of lower ureteric and vesical calculi were also reviewed. RESULTS: During this period, there were 580 children with urolithiasis (677 stone sites). There were 265 patients (321 stone sites) in group A and 315 patients (356 stone sites) in group B. The median age was seven years (range: 3-18 years). The most common location of calculus was the collecting system of the kidney (n = 398, 58.8%). A total of 175 stone sites (25.8%) were located in the ureter. Urinary bladder calculi were seen in 43 (6.4%) patients. Multiple stones were seen in 61 sites (9.0%). A total of 115 patients in group A underwent standard PCNL, whereas in group B, nine patients underwent standard PCNL and 129 underwent mini-PCNL. Group B had a significantly higher stone clearance rate for mini-PCNL (P < 0.001). Minor complications (grades 1 and 2) accounted for a majority of overall complications in both groups (87.5% in group A and 94.9% in group B). DISCUSSION: Mini-PCNL is an excellent option for renal calculi in children as it offers dual advantages of improved stone clearance and reduced major complications such as bleeding. Ureteroscopic lithotripsy has been established as the standard for small lower ureteric calculi. CONCLUSION: For renal and upper ureteric calculi, mini-PCNL has evolved as standard technique with a high stone-free rate and minimum complications compared with standard PCNL. Extracorporeal shockwave lithotripsy and ureteroscopic lithotripsy (URSL)/retrograde intrarenal surgery are acceptable alternatives for smaller stone burden. For lower ureteric and vesical calculi, retrograde approaches such as cystolithotripsy and URSL have now become the standard of care.

Radical cystectomy and W-shaped ileal orthotopic neobladder reconstruction with serosa-lined tunneled ureteroileal anastomoses: A critical analysis of the short-term voiding patterns and urodynamic and functional outcomes.

INTRODUCTION: We present the short-term voiding patterns and functional and urodynamic outcomes of W-shaped ileal orthotopic neobladder (ONB) following radical cystectomy (RC). MATERIALS AND METHODS: Forty-one patients who underwent RC and W-shaped ONB creation between July 2015 and January 2018 were enrolled. Data were analyzed in terms of voiding patterns, urodynamic findings, and functional outcomes at 6 months after surgery. Pouch-related quality of life (QoL) was assessed using European Organization for Research and Treatment of Cancer (EORTC) Generic (QLQ C30), Bladder Cancer-Specific Instruments (QLQ BM30), and IONB-Patient-Reported Outcome (IONB-PRO). RESULTS: The mean length of follow-up was 19.4 months. At first follow-up, three patients had developed acidosis and rising serum creatinine, and one of them required temporary hemodialysis. One patient developed urethral-pouch anastomotic stricture, which required bladder neck incision. Balloon dilatation was performed for ureteroileal anastomotic stricture and mesh repair for incisional hernia was required in one patient each. Upper tract changes were observed in two patients. During the first and second follow-up, maximum flow rate, voided volume, and postvoid residual urine were 12 ± 4.7 mL/s, 212 ± 120 mL, and 72 + 81 mL and 14.7 ± 5.3 mL/s, 254 ± 168 mL, and 123.7 ± 42.5 mL, respectively. The mean pouch capacity and compliance were 436 ± 103.5 mL and 50.6 ± 17.8 mL/cm H2O. No patient required clean intermittent catheterization for bladder emptying. In EORTC QLQ-C30 questionnaire, the "Cognitive" domain had the highest and "global QoL" domain had the lowest level of functional scores. "Nausea and vomiting and abdominal bloating and flatulence" domain had the lowest level and "financial difficulties and urinary symptoms" had the highest level of symptomatology in EORTC QLQ questionnaire. The IONB-PRO questionnaire showed the highest level of functioning in "relation life" and the lowest level in "emotional life" domain. CONCLUSION: The Ghoneim pouch has a low complication rate with near-normal voiding patterns with an acceptable QoL impairment.