Diagnostic Performance of Ex Vivo Fluorescence Confocal Microscopy in the Assessment of Diagnostic Biopsies of the Prostate.

BACKGROUND: Fluorescence confocal microscopy (FCM) is a novel micro-imaging technique providing optical sections of examined tissue. The method has been well established for the diagnosis of tumors in dermatological specimens. METHODS: We compare intraoperative diagnoses of the real-time application of FCM in pre-therapeutic prostate biopsies (35 patients, total number of biopsy specimens: n = 438) with the findings of conventional histology. RESULTS: Prostate carcinoma was reliably diagnosed in all patients. Depending on scan quality and experience of the examiner, smaller lesions of well differentiated carcinoma (ISUP1) could not be consistently differentiated from reactive changes. Furthermore, in some cases there was difficulty to distinguish ISUP grade 2 from ISUP grade 1 tumors. ISUP grades 3-5 were reliably detected in FCM. CONCLUSIONS: Despite some limitations, FCM seems to be an effective tool for the timely assessment of prostate biopsies enabling reliable diagnosis of prostate cancer in patients requiring therapy.

A cost analysis of stenting in uncomplicated semirigid ureteroscopic stone removal.

OBJECTIVE: To evaluate the outcome and the costs of stenting in uncomplicated semirigid ureteroscopic stone removal. MATERIALS AND METHODS: A decision tree model was created to evaluate the economic impact of routine stenting versus non-stenting strategies in uncomplicated ureteroscopy (URS). Probabilities of complications were extracted from twelve randomized controlled trials. Stone removal costs, costs for complication management, and total costs were calculated using Treeage Pro (TreeAge Pro Healthcare version 2015, Software, Inc, Williamstown Massachusetts, USA). RESULTS: Stone removal costs were higher in stented URS (€1512.25 vs. €1681.21, respectively). Complication management costs were higher in non-stented procedures. Both for complications treated conservatively (€189.43 vs. €109.67) and surgically (€49.26 vs. €24.83). When stone removal costs, costs for stent removal, and costs for complication management were considered, uncomplicated URS with stent placement yielded an overall cost per patient of €1889.15 compared to €1750.94 without stent placement. The incremental costs of stented URS were €138.25 per procedure. CONCLUSION: Semirigid URS with stent placement leads to higher direct procedural costs. Costs for managing URS-related complications are higher in non-stented procedures. Overall, a standard strategy of deferring routine stenting uncomplicated ureteroscopic stone removal is more cost efficient.

Surgical treatment of neurogenic stress urinary incontinence: A systematic review of quality assessment and surgical outcomes.

BACKGROUND: There are many opinions but little firm knowledge about the optimal treatment of neurogenic stress urinary incontinence (NSUI). OBJECTIVE: To scrutinize the quality and surgical outcomes of the available treatment modalities in the published literature. EVIDENCE ACQUISITION: A systematic review of the published literature from Pub Med and Web of Science was undertaken for studies describing surgical treatment of NSUI between 1990 and 2013. A checklist of criteria of methodological and reporting quality of interventions in urological publications was applied to assess quality of the retrieved publications. Surgical outcomes of success, failure, and reoperation were calculated. Statistical analyses included one-way ANOVA and post-hoc tests to determine significant differences between groups. EVIDENCE SYNTHESIS: Thirty studies were identified with Level 3 evidence. The quality of reporting was 43-81%, with significantly higher quality noted in studies published after 2002 (64% vs. 45%, P < 0.0001). None of the studies followed a randomized controlled trial (RCT) design. Three primary surgical procedures were used in 29 of 30 studies: artificial urinary sphincter (AUS), urethral slings, and urethral bulking agents. One study used a ProACT device. AUS was considered more successful than urethral bulking agents (77 ± 15% vs. 27 ± 20%, P = 0.002). Urethral bulking agents reported higher failures than urethral sling procedures (49 ± 16% vs. 21 ± 19%, P = 0.016) and AUS (21 ± 19% vs. 10 ± 11%, P < 0.002). CONCLUSIONS: The quality of evidence obtained from non-RCTs is modest. Surgeries for NSUI have relatively high success rates but also high complication rates in this highly heterogeneous population. More studies using modern techniques are required to update our knowledge.

Sequential resection of malignant ureteral margins at radical cystectomy: a critical assessment of the value of frozen section analysis.

PURPOSE: The aim of this study was to evaluate the accuracy of frozen section analysis (FSA) for detecting and eliminating malignant ureteral margins at radical cystectomy (RC) and to determine the impact of final margin status obtained by a sequential resectioning strategy on the risk of upper urinary tract recurrence (UUT-R). METHODS: A total of 425 ureteral margins obtained from 218 patients undergoing RC for invasive bladder cancer between 1999 and 2009 were initially examined by FSA. When positive, additional resections were performed. Subsequently, all specimens were reexamined on formalin-fixed, paraffin-embedded (FFPE) sections. Fisher-Exact test/logistic regression were used for uni-/multivariate analysis and log-rank test for the impact of margin status on UUT-R. RESULTS: Of 425 specimens, malignant ureteral margins were found on initial FSA in 17, on FFPE in 23 (sensitivity: 73.9%). FSA results were false-positive in 1/402 margins (specificity: 99.8%) resulting in an overall accuracy of 98.3%. On multivariate analysis (95%-CI), correlations were found between distal ureteral malignancy and FSA (p < 0.0001) and tumor multifocality (p = 0.04). In 10/17 positive initial margins it was not possible to obtain a negative final margin despite multiple reresections, of which one resulted in a UUT recurrence, which was more frequent than in patients with a negative margin (4/208, p = 0.03). Moreover, three of these five recurrences were proximally to the anastomosis. All patients had multifocal disease at RC. CONCLUSIONS: FSA has a high accuracy for detecting malignant ureteral margins. Patients with positive final margins are at increased risk of UUT-R. With sequential resection, however, positive margins cannot reliably be converted to negative ones.