Drainage of infected kidneys with ureteral stents: does size matter?

PURPOSE: The purpose of our study was to evaluate the ability of ureteral stents with different diameters to drain pus that accumulates in an obstructed kidney using an in vitro model. METHODS: We developed an in vitro model of an obstructed kidney filled with pus. The model included a silicon kidney unit based on computed tomography (CT) data, a 3D printed ureteral stone based on a real extracted ureteral stone, a latex ureter model, a bladder vessel, and a fluid with qualities resembling pus. Identical printed stones were inserted into four ureter models containing stents with varying diameters (4.8F, 6F, 7F, 8F), each of which was connected to the kidney unit and the bladder vessel. The kidney unit was filled with artificial pus to pressures of 30 cmH2O to simulate an infected and obstructed kidney. The obstruction was relieved with stents in place, while artificial urine was pumped into the kidney; pressure in the kidney and remaining pus were measured continuously. RESULTS: The rate of pressure drop and the final pressure measured in the kidney were unaffected by the diameter of the stent. For all stent diameters, the pressure reached non-obstructed levels within 30 s, final pressure was reached within 90-120 s, and minimal amounts of pus remained in the kidney after 120 min. CONCLUSIONS: In vitro experiments demonstrate that all stent diameters drain pus-filled, obstructed kidneys with the same efficacy. The common perception that larger diameter tubes are more effective under such circumstances should be re-examined.

Fascial dehiscence after radical cystectomy: Is abdominal exploration mandatory?

BACKGROUND: Fascial dehiscence after radical cystectomy may have serious clinical implications. To optimize its management, we sought to describe accompanying intraabdominal findings of post-cystectomy dehiscence repair and determine whether a thorough intraabdominal exploration during its operation is mandatory. METHODS: We retrospectively reviewed a multi-institutional cohort of patients who underwent open radical cystectomy between 2005 and 2020. Patients who underwent exploratory surgery due to fascial dehiscence within 30 days post-cystectomy were included in the analysis. Data collected included demographic characteristics, the clinical presentation of dehiscence, associated laboratory findings, imaging results, surgical parameters, operative findings, and clinical implications. Potential predictors of accompanying intraabdominal complications were investigated. RESULTS: Of 1301 consecutive patients that underwent cystectomy, 27 (2%) had dehiscence repair during a median of 7 days post-surgery. Seven patients (26%) had accompanying intraabdominal pathologies, including urine leaks, a fecal leak, and an internal hernia in 5 (19%), 1 (4%), and 1 (4%) patients, respectively. Accompanying intraabdominal findings were associated with longer hospital stay [20 (IQR 17, 23) vs. 41 (IQR 29, 47) days, P = 0.03] and later dehiscence identification (postoperative day 7 [IQR 5, 9] vs. 10 [IQR 6, 15], P = 0.03). However, the rate of post-exploration complications was similar in both groups. A history of ischemic heart disease was the only predictor for accompanying intraabdominal pathologies (67% vs. 24%; P = 0.02). CONCLUSIONS: A substantial proportion of patients undergoing post-cystectomy fascial dehiscence repair may have unrecognized accompanying surgical complications without prior clinical suspicion. While cardiovascular disease is a risk factor for accompanying findings, meticulous abdominal inspection is imperative in all patients during dehiscence repair. Identification and repair during the surgical intervention may prevent further adverse, possibly life-threatening consequences with minimal risk for iatrogenic injury.

Comparative study of renal drainage with different ureteral stents subject to extrinsic ureteral obstruction using an in vitro ureter-stent model.

BACKGROUND: To compare the efficacy of different ureteral stents subject to extrinsic ureteral obstruction (EUO), in a controlled in vitro stented ureter experiment. METHODS: We employ an in vitro ureter-stent experimental set-up, with latex tubing simulating flexible ureters attached to vessels simulating renal units and bladders. The flow behavior of five ureteral stents-polymeric 8F, tandem 6F, tandem 7F, endopyelotomy and metal-was tested under a ureteral deformation configuration of 40°, with 2000 g external force over a 3.5 cm length of the ureter. A constant fluid flow was applied through the ureter-stent configurations, and pressure fluctuations in the renal unit were monitored. We considered a renal unit pressure of 10 cmH2O or flow discontinuation in the bladder as stent failure. Urine containing debris was mimicked by use of a colloidal solution. RESULTS: Of all assessed ureteral stents, under EUO conditions, only the single 8F stents remained patent throughout the length of the experiment. All other stents-tandem 6F and 7F, single 7F, metal and endopyelotomy-displayed limitations. CONCLUSIONS: Tandem and metal stents show no superiority over large luminal polymeric stents for EUO treatment in this in vitro model. Larger luminal stents offer excellent resistance to external pressure and allow adequate colloidal flow. The need for frequent exchange and bladder irritation should also be considered in the choice of stent configuration for treatment of kidney drainage under EUO.

Do organic substances act as a degradable binding matrix in calcium oxalate kidney stones?

BACKGROUND: Calcium oxalate (CaOx) stones are considered to be highly resistant to chemolysis. While significant organic matter has been identified within these stones, which is presumed to bind (inorganic) CaOx particles and aggregates, most chemolysis efforts have focused on methods to attack the CaOx components of a stone. We examine the feasibility of inducing chemolysis of CaOx kidney stones, within hours, by specifically attacking the organic matrix present in these stones. METHODS: In contrast to previous studies, we focused on the possible "brick and mortar" stone configuration. We systematically tested, via in vitro experiments, the ability of an extensive range of 26 potential chemolysis agents to induce relatively fast disintegration (and/or dissolution) of a large set of natural CaOx stone fragments, extracted during endourological procedures, without regard to immediate clinical application. Each stone fragment was monitored for reduction in weight and other changes over 72 h. RESULTS: We find that agents known to attack organic material have little, if any, effect on stone chemolysis. Similarly, protein and enzymatic agents, and oral additive medical treatments, have little immediate effect. CONCLUSIONS: These findings suggest that the organic and inorganic constituents present in CaOx stones are not structured as "brick and mortar" configurations in terms of inorganic and organic components.

Do patients with ureterolithiasis treated conservatively return to follow up?

INTRODUCTION Distal ureteral stones (DUS) are common in patients presenting to the emergency department (ED) with renal colic. The majority of DUS will pass spontaneously and therefore conservative care is common. Follow up is imperative as some of these stones might not pass and potentially lead to complications. The aim of our study was to evaluate the rate of compliance with follow up and to find predictive variables for it. MATERIALS AND METHODS: We retrospectively surveyed the medical records of all patients who had a non-contrast computed tomography (NCCT) at our ED between 01/03/16 and 31/5/17. We included patients with a DUS smaller than 10 mm that were treated conservatively. We obtained demographic, clinical, laboratory and imaging data. Compliance to follow up was evaluated by surveying the medical records and by calling the patients. We then compared the characteristics of patients who returned for follow up to those who did not. RESULTS: A total of 230 consecutive patients were included in our cohort: 194 (84%) patients were male and the average age was 46 y (21-82); 138 patients (60%) returned for a follow up visit while 92 patients (40%) did not. Univariate analysis revealed stone size and admission to hospital to be predictive of compliance to follow up while multivariate analysis revealed only hospital admission to be predictive of compliance. CONCLUSIONS: Only 60% of the patients with DUS treated conservatively return for a follow up visit. Hospital admission, which likely reflects appropriate patients counseling by a urologist and adequate follow up scheduling, was found to be associated with increased compliance with follow up.

Surgical Outcomes in High-risk Prostate Cancer and Salvage Radical Prostatectomy.

BACKGROUND: Patients with high-risk prostate cancer are at higher risk of treatment failure, development of metastatic disease, and mortality. There is no consensus on the treatment of choice for these patients, and either radical prostatectomy (RP) or external beam radiation therapy (EBRT) is recommended. Surgery is less common as the initial treatment for high-risk patients, possibly reflecting the concerns regarding morbidity as well as oncological and functional outcomes. Another high-risk group includes patients with failure of previous EBRT or focal treatment. For these patients, salvage radical prostatectomy (SRP) can be offered. OBJECTIVES: To describe our experience with surgery of high-risk patients and SRP. METHODS: This cohort included all high-risk patients undergoing RP or SRP at our institution between January 2012 and December 2019. We reviewed the electronic medical charts and collected pathological, functional, and oncological outcomes. RESULTS: Our cohort included 39 patients; average age was 67.8 years, and average follow-up duration was 40.9 months. The most common postoperative morbidity was transfusion of packed cells. There were no life-threatening events or postoperative mortality. Continence was preserved (zero to one pad) in 76% of the patients. Twenty-three patients (59%) had undetectable prostate specific antigen levels following the surgery, 11 (30%) were treated with either adjuvant or salvage EBRT, and 12 patients (31%) were found with no evidence of disease and no additional treatment was needed. CONCLUSIONS: Radical prostatectomy and SRP are safe options for patients presenting with high-risk prostate cancer, with good functional and oncological outcomes.

Radical Cystectomy after Previous Radiation or Pelvic Surgery: Is It Associated with Increased Morbidity?

BACKGROUND: Radical cystectomy is a complicated surgery with significant risks. Complications of Clavien-Dindo grade 3-4 range from 25% to 40% while risk of mortality is 2%. Pelvic surgery or radiotherapy prior to radical cystectomy increases the challenges of this surgery. OBJECTIVES: To assess whether radical cystectomy performed in patients with prior history of pelvic surgery or radiation was associated with increased frequency of Clavien-Dindo grade 3 or higher complications compared to patients without prior pelvic intervention. METHODS: We retrospectively evaluated all patients who underwent radical cystectomy at our center over a 7-year period. All patients with pelvic radiation or surgery prior to radical cystectomy comprised group 1, while group 2 included the remaining patients. RESULTS: In our study, 65 patients required radical cystectomy at our institution during the study period. Group 1 was comprised of 17 patients and group 2 included 48 patients. Four patients from group 2 received orthotopic neobladder, while an ileal conduit procedure was performed in the remaining patients. Estimated blood loss and the amount of blood transfusions given was the only variable found to be statistically different between the two groups. One patient from group 1 had four pelvic interventions prior to surgery, and her cystectomy was aborted. CONCLUSIONS: Radical cystectomy may be safely performed in patients with a history of pelvic radiotherapy or surgery, with complication rates similar to those of non-irradiated or operated pelvises.

Spermatogenesis in Testicles with Germ Cell Tumors.

BACKGROUND: Almost 50% of patients with germ-cell tumors (GCT) are subfertile, and every step of the treatment may further impair fertility. As a result, sperm banking is often advised prior to radical orchiectomy. However, whether affected testes contribute to fertility is unclear. OBJECTIVES: To determine whether maximal tumor diameter (MTD) is correlated with ipsilateral fertility (IF) in patients treated for GCT. METHODS: We reviewed medical charts for demographic and clinical data of patients with GCT who had undergone orchiectomy at our institution between 1999 and 2015. The extent of spermatogenesis was categorized into three groups: full spermatogenesis, hypospermatogenesis, and absence of spermatogenesis. The presence of mature spermatozoa in the epididymis tail was also assessed. We defined IF as the combination of full spermatogenesis in more than 100 tubules and the presence of mature spermatozoa in the epididymis tail. Mann-Whitney was applied to determine the correlation between MTD and IF. RESULTS: Of 57 patients, IF was present in 28 (49%). Mean patient age was 32.8 years in patients with positive IF and 33.4 years those with negative IF. Seminoma was diagnosed in 46.4% of patients with positive IF and in 65.5% of patients with negative IF. Full spermatogenesis was observed in 33 patients (57.8%). In 48 (82.7%), mature epididymal spermatozoa were found. No correlation was found between MTD and IF. CONCLUSIONS: IF is present in almost half of the patients undergoing radical orchiectomy. Because IF cannot be predicted by MTD, routine pre-orchiectomy sperm banking is suggested.

Self-induced plantar-flexion objectively reduces wave amplitude of detrusor overactivity and subjectively improve urinary urgency: a pilot study.

AIMS: To estimate the effect of plantar-flexion on the wave amplitude of involuntary detrusor contraction and the severity of urinary urgency during filling cystometry in patients with detrusor overactivity (DO). METHODS: Twenty-two consecutive patients with DO were enrolled. During urodynamics, the mean peak detrusor pressures of each contraction were documented and compared. At the beginning of the 2nd or 3rd wave, patients were asked to perform continuous plantar-flexion by pushing their tiptoes against the floor. Following each wave, patients were asked to grade the severity of the urgency by a visual analogue scale (VAS). RESULTS: The mean peak detrusor pressure without plantar-flexion was 58 cmH2 O (95% CI: 46.3-69.7) compared to 31 cmH2 O (95% CI: 23.1-38.9) with plantar-flexion (P < 0.001). All patients reported a reduced degree of urgency during plantar-flexion reflected in a significant reduction in mean VAS score from 9.3 (95% CI: 9-9.5) to 4.7 (95% CI: 3.9-5.4; P < 0.0001). CONCLUSIONS: Self-performed plantar-flexion maneuver might reduce the severity of urinary urgency and the magnitude of overactive detrusor contractions, which may have a role in the conservative therapy of detrusor overactivity.

Comparison of lower urinary tract symptoms between women with detrusor overactivity and impaired contractility, and detrusor overactivity and preserved contractility.

PURPOSE: We compared symptoms in women with detrusor overactivity with impaired contractility and women with detrusor overactivity who had preserved contractility. MATERIALS AND METHODS: The study included 359 consecutive women with detrusor overactivity who underwent multichannel urodynamics at our department between 2009 and 2011. The women were divided into 2 groups, including 151 (42%) with detrusor overactivity and impaired contractility, and 208 (58%) with detrusor overactivity and preserved contractility. We compared the 2 groups. RESULTS: Women with detrusor overactivity and impaired contractility were older (mean ± SD age 73.2 ± 17.3 vs 54.1 ± 20.7 years) with a higher frequency of diabetes mellitus (49% vs 31%, each p <0.001). The prevalence of previous urinary retention and recurrent cystitis was significantly higher in women with impaired contractility (7% vs 1%, p <0.01 and 22% vs 7%, p <0.001, respectively). Mean post-void residual urine was greater in the group with impaired contractility (89 ± 42 vs 21 ± 18 ml) and the mean maximal flow rate was lower (11 ± 6 vs 23 ± 5 ml per second, each p <0.001). The frequency of storage symptoms was similar in the 2 groups. However, voiding symptoms were more common in women with impaired contractility, including a slow stream in 69% vs 42%, an intermittent stream in 72% vs 26%, hesitancy in 35% vs 22%, straining in 84% vs 26%, terminal dribbling in 73% vs 42% and incomplete emptying in 71% vs 49% (p <0.001). CONCLUSIONS: Women with detrusor overactivity and impaired contractility are older than women with detrusor overactivity and preserved detrusor contractility. Urinary retention and recurrent cystitis are more frequent in women with detrusor overactivity and impaired contractility, and voiding symptoms are significantly more common.

How accurate is our clinical prediction of "minimal prostate cancer"?

BACKGROUND: Recommendations for active surveillance versus immediate treatment for low risk prostate cancer are based on biopsy and clinical data, assuming that a low volume of well-differentiated carcinoma will be associated with a low progression risk. However, the accuracy of clinical prediction of minimal prostate cancer (MPC) is unclear. OBJECTIVES: To define preoperative predictors for MPC in prostatectomy specimens and to examine the accuracy of such prediction. METHODS: Data collected on 1526 consecutive radical prostatectomy patients operated in a single center between 2003 and 2008 included: age, body mass index, preoperative prostate-specific antigen level, biopsy Gleason score, clinical stage, percentage of positive biopsy cores, and maximal core length (MCL) involvement. MPC was defined as < 5% of prostate volume involvement with organ-confined Gleason score < or = 6. Univariate and multivariate logistic regression analyses were used to define independent predictors of minimal disease. Classification and Regression Tree (CART) analysis was used to define cutoff values for the predictors and measure the accuracy of prediction. RESULTS: MPC was found in 241 patients (15.8%). Clinical stage, biopsy Gleason's score, percent of positive biopsy cores, and maximal involved core length were associated with minimal disease (OR 0.42, 0.1, 0.92, and 0.9, respectively). Independent predictors of MPC included: biopsy Gleason score, percent of positive cores and MCL (OR 0.21, 095 and 0.95, respectively). CART showed that when the MCL exceeded 11.5%, the likelihood of MPC was 3.8%. Conversely, when applying the most favorable preoperative conditions (Gleason < or = 6, < 20% positive cores, MCL < or = 11.5%) the chance of minimal disease was 41%. CONCLUSIONS: Biopsy Gleason score, the percent of positive cores and MCL are independently associated with MPC. While preoperative prediction of significant prostate cancer was accurate, clinical prediction of MPC was incorrect 59% of the time. Caution is necessary when implementing clinical data as selection criteria for active surveillance.

Hyperbaric oxygen therapy for hemorrhagic radiation cystitis.

BACKGROUND: Hemorrhagic radiation cystitis (HRC) is a significant clinical problem that occurs after pelvic radiation therapy and is often refractory. OBJECTIVES: To evaluate the efficacy and safety of hyperbaric oxygen therapy (HBO) for HRC. METHODS: Daily 90 minute sessions of HBO at 2 ATM 100% oxygen were given to 32 HRC patients with ASTRO grades 3-4 hematuria. RESULTS: The median age was 72.5 (48-88 years). The median time interval between radiation therapy and HBO was 4 years (1-26 years). The patients received a median of 30 HBO sessions (3-53). Hematuria resolved in 27 patients (84%) and persisted in 5. Cystectomy was required in two, and ileal-conduit and bilateral percutaneous nephrostomies were performed in one and two patients, respectively. With a median follow-up of 12 months (5-74 months), the hematuria cleared completely in 16 patients (59%) and mild hematuria requiring no further treatment recurred in 10 others. Another patient with ASTRO grade 4 hematuria needed bladder irrigation and blood transfusions. Complications included eardrum perforation in four patients and transient vertigo and mild hemoptysis in one case each. None of them required HBO discontinuation. CONCLUSIONS: HBO controlled bleeding in 84% of the patients. A durable freedom from significant hematuria was achieved in 96% of the patients. HBO seems to be an effective and safe modality in patients with HRC.

Adjuvant chemotherapy after radical cystectomy: Do all patients who need chemotherapy after surgery actually receive it?

Background: Compliance with the guideline recommendations for neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer is incomplete. The adjuvant chemotherapy approach has the advantage of pathology-based decision-making, allowing for patient selection. In addition, radical surgery is not delayed and treatment-related toxicity does not impair surgical fitness. The proportion of patients who completed chemotherapy after cystectomy among those who were fit and in need of treatment were evaluated. The reasons for not completing adjuvant chemotherapy were determined. Materials and methods: We retrospectively evaluated all patients who had undergone radical cystectomy at our center over the last 7 years. Indications for adjuvant chemotherapy included pathological T > 2, any node+, or surgical margin involvement. Only patients who were fit for chemotherapy before surgery were included in the study. Results: Of the 52 patients with muscle-invasive bladder cancer, 14 received neoadjuvant chemotherapy or unfit for chemotherapy were excluded. Of the remaining 38 patients, 14 (37%) had bladder-confined cancers and did not require additional chemotherapy. Of the 24 patients who needed chemotherapy and were fit to receive it, 8 patients completed treatment (33%), and 3 discontinued treatment due to toxicity. Twelve patients (50%) declined chemotherapy, whereas 1 patient became unfit for chemotherapy after surgery. Conclusions: While the adjuvant chemotherapy approach could save unnecessary treatment in 37% of patients, two-thirds of those who needed chemotherapy did not complete it. Patient refusal was the primary reason for not receiving treatment.

A clinical evaluation of an ex vivo organ culture system to predict patient response to cancer therapy.

Introduction: Ex vivo organ cultures (EVOC) were recently optimized to sustain cancer tissue for 5 days with its complete microenvironment. We examined the ability of an EVOC platform to predict patient response to cancer therapy. Methods: A multicenter, prospective, single-arm observational trial. Samples were obtained from patients with newly diagnosed bladder cancer who underwent transurethral resection of bladder tumor and from core needle biopsies of patients with metastatic cancer. The tumors were cut into 250 µM slices and cultured within 24 h, then incubated for 96 h with vehicle or intended to treat drug. The cultures were then fixed and stained to analyze their morphology and cell viability. Each EVOC was given a score based on cell viability, level of damage, and Ki67 proliferation, and the scores were correlated with the patients' clinical response assessed by pathology or Response Evaluation Criteria in Solid Tumors (RECIST). Results: The cancer tissue and microenvironment, including endothelial and immune cells, were preserved at high viability with continued cell division for 5 days, demonstrating active cell signaling dynamics. A total of 34 cancer samples were tested by the platform and were correlated with clinical results. A higher EVOC score was correlated with better clinical response. The EVOC system showed a predictive specificity of 77.7% (7/9, 95% CI 0.4-0.97) and a sensitivity of 96% (24/25, 95% CI 0.80-0.99). Conclusion: EVOC cultured for 5 days showed high sensitivity and specificity for predicting clinical response to therapy among patients with muscle-invasive bladder cancer and other solid tumors.

Autonomic response during bladder hydrodistention in patients with bladder pain syndrome.

PURPOSE: We determined whether patients with bladder pain syndrome who have typical interstitial cystitis endoscopic findings, including glomerulations and/or Hunner ulcer, have a distinct autonomic response during bladder hydrodistention. MATERIALS AND METHODS: Included in the study were 50 consecutive patients (40 females and 10 males) who met International Society for the Study of BPS recommendations. All patients underwent the same clinical evaluation, consisting of medical history, physical examination, urine and blood tests, urine cytology and culture, urinary tract ultrasound and urodynamics. Bladder hydrodistention and biopsies were performed using general anesthesia. Systolic and diastolic blood pressure, and heart rate were recorded after the induction of general anesthesia and at the end of the filling phase. Patients were divided into 2 groups, including patients with and without typical endoscopic findings, respectively. Clinical, histological and urodynamic variables, and autonomic parameters were compared between the 2 groups. RESULTS: No significant differences in demographics, symptoms, pain severity, comorbidities, previous surgery, urodynamic variables, anesthetic bladder capacity or histological findings were found between the 2 groups. In patients with endoscopic findings average ± SD systolic and diastolic blood pressure increased by 25 ± 19 and 21 ± 12 mm Hg, respectively, and average heart rate increased by 12 ± 11 beats per minute. All hemodynamic changes were statistically significant (p <0.001). In patients without endoscopic findings a minor decrease in hemodynamic parameters was observed. CONCLUSIONS: Patients with bladder pain syndrome who have typical interstitial cystitis findings on endoscopy show a marked autonomic response during bladder hydrodistention, consisting of an increase in heart rate, and systolic and diastolic blood pressure.

Decreased amplitude of detrusor overactivity by repetitive swallowing.

PURPOSE: We determined whether swallowing has an effect on the degree of urinary urgency and on the amplitude of detrusor contraction during filling cystometry in patients with detrusor overactivity. MATERIALS AND METHODS: Included in study were 20 consecutive patients with detrusor overactivity. During urodynamics the mean peak pressure of each contraction was documented and compared. At the beginning of wave 2 patients were asked to perform 5 repetitive swallows. After each wave patients were asked to grade the severity of urgency on a visual analog scale. RESULTS: The mean ± SD peak of the detrusor contraction was 39 ± 15 vs 95 ± 26 cm H(2)O with vs without swallowing (p <0.01). All patients reported that during swallowing the degree of urgency decreased. The mean visual analog scale score for urgency was significantly lower during repetitive swallowing than without swallowing (mean 3.4 ± 1.5 vs 7.7 ± 2.2, p <0.01). CONCLUSIONS: The repetitive swallowing maneuver inhibits urinary urgency and detrusor overactivity. The maneuver can be used during bladder training program or when micturition is not desirable.

Pathological characteristics of prostate cancer recurrence after radiation therapy: implications for focal salvage therapy.

PURPOSE: Focal therapy is currently under investigation as an alternative to salvage radical prostatectomy for locally recurrent prostate cancer after primary radiation therapy. If patients can be selected properly, focal therapy could enable tumor eradication without the morbidity associated with salvage radical prostatectomy. We describe the pathological features of recurrent prostate cancer in salvage radical prostatectomy specimens and the implications of these results for focal therapy. MATERIALS AND METHODS: We gathered data on 50 consecutive patients who had recurrence after primary radiation therapy and underwent salvage radical prostatectomy between 1993 and 2008. Preoperatively prostate specific antigen was less than 10 ng/ml in 49 patients (98%) and biopsy Gleason score was 7 or less in 18 (36%). Salvage radical prostatectomy specimens were analyzed for tumor zonal origin, site and volume, Gleason score and pathological stage. RESULTS: Median preoperative prostate specific antigen was 3.4 ng/ml. Pathological stage was T2 in 23 patients (46%). The salvage radical prostatectomy Gleason score was 7 or less in 17 patients (34%) and surgical margins were negative in 43 (86%). A single cancer focus was found in 33 cases (66%) while there was bilateral involvement in 37 (74%). The base and apex were involved in 23 cases (46%) and 37 tumors (74%) were located within 5.0 mm of the urethra. Median tumor volume was 1.27 cm(3) (range 0.05 to 12.96). CONCLUSIONS: Prostate cancer recurrence after radiation therapy is often bilateral and involves multiple zones. It is often high grade, bulky and close to the urethra. These findings suggest that planning salvage focal therapy after radiation failure will be difficult.

Is transureteroureterostomy performed during multi-organ resection for non-urothelial malignancy safe and effective?

BACKGROUND: Multi-organ resection in patients with non-urothelial cancer may include segmental ureteral resection. The resulting ureteral defect can be reconstructed with a transureteroureterostomy (TUU); however, whether TUU is safe and effective in this patient group remains unclear. OBJECTIVES: In the current retrospective analysis, we evaluated renal function before and after complex multi-organ resection that included TUU to determine whether TUU is safe and effective. METHODS: We retrospectively reviewed the charts of patients who underwent TUU between 1995 and 2011. Renal imaging studies performed before and after TUU were used to determine whether hydronephrosis was present in either kidney. Kidney function was assessed by measuring serum creatinine levels and calculating the estimated glomerular filtration rate (eGFR) before and after TUU. RESULTS: Twelve patients underwent TUU during multiorgan resection. Median follow-up time was 15 months. Three patients with cancer recurrence involving the TUU developed progressive hydronephrosis. Serum creatinine levels did not increase more than 0.5 mg/dl in any patient. Kidney function as assessed by eGFR was maintained in all patients (until the time of recurrence in the three patients with recurrence affecting the TUU). CONCLUSIONS: TUU during multi-organ resection for non-urothelial malignancy is safe and effective. Long-term renal function is maintained in the majority of patients.

When should we give up on expectant management for patients with proximal ureteral stones?

Background: Proximal ureteral stones (PUS) have relatively low rates of spontaneous expulsion. However, some patients do well on expectant management. Our aim was to compare risk factors for surgical intervention in patients with PUS who underwent primary intervention to those subjected to expectant management. Materials and methods: We retrospectively reviewed the medical charts of patients presented to the emergency room with symptoms of renal colic and underwent computerized tomography between August 2016 and August 2017. A total of 97 consecutive patients were identified with up to 10mm PUS. We collected patient demographics, clinical, and imaging data, and performed binary regression analysis for risk of intervention. Results: The average age was 49years (range 17-97) and average stone size was 7.1mm (range 3-10). Forty-one patients underwent immediate intervention while the remaining 56 patients were treated conservatively. Of the 56 patients treated conservatively, 26 underwent delayed intervention while 30 reported spontaneous stone expulsion. On univariate analysis of all 97 patients, statistically significant risk factors for intervention were found based on stone size, age, serum lymphocyte, platelet counts, and stone density. Of these risk factors, stone size ≥ 7mm (p = 0.012, odds ratio = 5.4) and platelet count ≤ 230K/µL (p = 0.027, odds ratio = 4.9) remained statistically significant on multivariate analysis. Conclusion: Stone size and platelet count were found to be risk factors for surgical intervention in patients with up to 10mm PUS. These findings may assist in identifying patients who are more suitable for conservative approach.

Potential Markers to Reduce Non-Contrast Computed Tomography Use for Symptomatic Patients with Suspected Ureterolithiasis.

Most patients with ureterolithiasis are managed successfully with conservative treatment. In this context, delineation of clinical risk factors that identify patients with low risk for surgical intervention may reduce use of Non-Contrast Computed Tomography (NCCT). Here, emergency department patient files from a 14-month period were reviewed retrospectively, to identify patients who underwent NCCT and showed a ureteral stone. Demographic, clinical and laboratory information was collected. Patients were grouped to either requiring surgical intervention (Group 1) or having successful conservative management (Group 2). The cohort included 368 patients; 36.1% ultimately required surgical intervention (Group 1) and 63.9% were successfully treated conservatively (Group 2). On univariate analysis, patients who required surgical intervention were older, had longer duration of symptoms, had history of urolithiasis and surgical intervention for urolithiasis and had higher serum creatinine levels. Multivariate analysis identified the following risk factors associated with surgical intervention: creatinine >1.5 mg/dL, duration of symptoms ≥ 1.5 days and age > 45 years. Patients with 0, 1, 2 or 3 of the identified risk factors had 19%, 32%, 53% and 73% likelihood, respectively, of surgical intervention. Incorporating these data may reduce the use of NCCT scans in patients who are likely to pass a stone via conservative management.