Assessment of association between lower ureteric excision technique and oncological outcomes for upper urinary tract urothelial carcinoma: retrospective analysis from the Scottish Renal Cancer Consortium.

PURPOSE: Nephroureterectomy(NU) remains the gold-standard surgical option for the management of upper urinary tract urothelial carcinoma(UTUC). Controversy exists regarding the optimal excision technique of the lower ureter. We sought to compare post-UTUC bladder tumour recurrence across the Scottish Renal Cancer Consortium(SRCC). METHODS: Patients who underwent NU for UTUC across the SRCC 2012-2019 were identified. The impact of lower-end surgical technique along with T-stage, N-stage, tumour location and focality, positive surgical margin, pre-NU ureteroscopy, upper-end technique and adjuvant mitomycin C administration were assessed by Kaplan-Meier and Cox-regression. The primary outcome was intra-vesical recurrence-free survival (B-RFS). RESULTS: In 402 patients, the median follow-up was 29 months. The lower ureter was managed by open transvesical excision in 90 individuals, transurethral and laparoscopic dissection in 76, laparoscopic or open extra-vesical excision in 31 and 42 respectively, and transurethral dissection and pluck in 163. 114(28.4%) patients had a bladder recurrence during follow-up. There was no difference in B-RFS between lower-end techniques by Kaplan-Meier (p = 0.94). When all factors were taken into account by adjusted Cox-regression, preceding ureteroscopy (HR 2.65, p = 0.001), lower ureteric tumour location (HR 2.16, p = 0.02), previous bladder cancer (HR 1.75, p = 0.01) and male gender (HR 1.61, p = 0.03) were associated with B-RFS. CONCLUSION: These data suggest in appropriately selected patients, lower ureteric management technique does not affect B-RFS. Along with lower ureteric tumour location, male gender and previous bladder cancer, preceding ureteroscopy was associated with a higher recurrence rate following NU, and the indication for this should be carefully considered.

Diagnostic Accuracy of Low and Ultra-Low Dose CT for Identification of Urinary Tract Stones: A Systematic Review.

BACKGROUND: Non-contrast computed tomography of the kidneys, ureters, and bladder (CT KUB) is the investigation of choice for renal colic; however, radiation exposure can be a concern. AIMS: The study aimed to investigate the diagnostic accuracy of low dose (LD) and ultra-low dose (ULD) CT of the urinary tract for detection of urinary tract stones in patients with renal colic. METHODS: A Cochrane style systematic review of the literature from 1995 to 2017 was carried out. Literature search and data extraction were conducted by 2 reviewers. Specificity and sensitivity values were calculated for LD (<3.5 mean radiation dose [mSv]) and ULD (<1.9 mSv) CT separately. RESULTS: A total of 12 studies were included following screening. A total of 1,529 patients were included in the review (475 in the LD group and 1,054 in the ULD group). Using standard dose CT KUB as the reference standard, the sensitivity of LD CT KUB ranged from 90 to 98% and specificity from 88 to 100%. The sensitivity of ULD CT KUB ranged from 72 to 99% and the specificity ranged from 86 to 100%. The diagnostic accuracy for LD CT was 94.3% and for ULD CT was 95.5%. CONCLUSIONS: LD and ULD CT KUB provide effective methods of identifying urinary tract stones. High diagnostic accuracy, sensitivity, and specificity are maintained despite significant radiation dose reduction in comparison to standard dose CT.

Creation of a Novel Ex Vivo 3D Printed Ileal Conduit Task Trainer for Teaching Conduitoscopy Skills.

OBJECTIVE: To perform endoscopy in patients with urinary diversions requires specific endoscopic skills, which can currently only be gained in clinical practice. We created a 3D-printed ex vivo ileal conduit model (stoma and conduit with ureters and 2 kidneys) to simulate "conduitoscopy" and evaluated the realism and limitations of the model. METHODS: Accurate anatomical features were represented using an appropriate reusable design, realistic mechanical qualities with several material types, and 3D-printed components. Different models of bowel and ureters were assessed by the subject-matter experts (SME). The final ileal conduit model (Wallace 1 type anastomosis) was evaluated by 18 SMEs. RESULTS: Most experts gave their approval to the view of the stoma, as well as the appearance of the bowel, ureteric, and pelvicalyceal systems. A total of 72.1% of SMEs approved the ureteric endoscopic view compared to about 66% who accepted the endoscopic examination of the bowel. The model's overall appearance was good for 61.1% and excellent for 38.8% of experts. CONCLUSION: Conduitoscopy simulation training can now be facilitated using our novel and unique cutting-edge 3D-printed model. We created a model that is highly anatomically accurate and workable. In our study, anatomical and visual realism was demonstrated. The next step would be increasing the length of the conduit and conduct a validation study.

Spontaneous regression of metastatic renal cancer and improvement in IMDC risk criteria prior to cytoreductive nephrectomy.

A 57-year-old male presented with a 2-month history of a cough, weight loss, chest discomfort and night sweats. He was diagnosed with poor prognosis metastatic Renal Cancer (RCC) according to International Metastatic RCC Database Consortium (IMDC) criteria. We observed spontaneous regression of his metastatic disease and concurrent improvement in his IMDC risk stratification. This changed the initial recommendation of the MDT, and the patient elected to undergo cytoreductive nephrectomy (CRN) with the expectation he would need deferred systemic treatment. He made an uneventful post-operative recovery and at 12 months his follow-up imaging continues to show resolution of his metastatic disease.

The role of hepatic and pancreatic metastatectomy in the management of metastatic renal cell carcinoma: A systematic review.

Surgical resection is feasible in a small proportion of patients with oligometastatic renal cell carcinoma (mRCC) involving the liver or pancreas. The aim of this study was to evaluate the effect of liver and pancreatic resection or ablation for mRCC on survival and to identify factors associated with improved outcomes. A systematic search of the Medline and EMBASE databases was performed to identify studies reporting outcomes following hepatic or pancreatic resection or ablation for mRCC. The study was conducted according to PRISMA guidelines. A total of 35 studies reporting pancreatic resection outcomes and 14 studies reporting hepatic resection for mRCC were identified. There were no randomised controlled trials. Median overall survival (OS) following liver resection ranged from 16 to 142 months and 5-year OS from 14.7 to 62%. Following pancreatic resection, median OS ranged from 6 to 106 months and 5-year OS from 26 to 88%. Metachronous presentation and a longer DFI from resection of the primary tumour were associated with better survival outcomes. Mortality following liver and pancreatic resection was 2.7% and 4.2%, whilst significant morbidity (Clavien-Dindo Grade 3a or above) was reported in 20.9% and 25.4% of cases respectively. Liver or pancreatic resection or ablation for oligometastatic RCC may benefit a very select group of patients and they should be discussed within a hepatopancreatobiliary multidisciplinary tumour board meeting. Further studies are required to further define patients most likely to benefit, including potential utilization of molecular precision oncology strategies.

Real world outcomes of biopsy-proven oncocytic neoplasm of the kidney managed by surveillance.

Objectives: To evaluate outcomes of patients diagnosed with oncocytic renal neoplasms on routine renal mass biopsy and to describe the natural history of these tumours when managed with surveillance as opposed to immediate intervention. To report disease-specific survival. Patients and methods: Patients were identified from a retrospective review of pathology databases from three tertiary referral centres that utilise renal mass biopsy in routine clinical practice. All patients with biopsy-proven oncocytic tumours were included and a retrospective review of online patient records was undertaken. Results: There were 184 biopsy-proven oncocytic renal neoplasms identified in 172 patients. There were two biopsy complications (both pneumothorax, Clavien-Dindo Grade I). Of these lesions, 135 were reported as oncocytomas or oncocytic renal neoplasms that were not further classified and 37 were reported as chromophobe carcinoma (ChRCC). The median age at diagnosis was 70 (33-88). The average tumour diameter at diagnosis was 33 mm. One hundred seven tumours were initially managed with surveillance (including 13 ChRCC) with a minimum follow-up of 6 months and a median of 39 months (6-144) whereas 49 patients underwent immediate treatment. The mean growth rate across all oncocytic renal neoplasms managed by surveillance was 3 mm/year. There was no statistically significant difference in growth rates between oncocytic renal neoplasms and ChRCC. Thirteen patients with oncocytic renal neoplasms initially managed by surveillance moved on to an active management strategy during follow-up. The clinical indication given for a change from surveillance was tumour growth in 12 cases and patient choice in 1 case. Where definitive pathology was available, there was 85% concordance with the biopsy. There were no cases of development of metastatic disease or disease-related morbidity or mortality during the study. Conclusions: This multicentre retrospective cohort study supports the hypothesis that selected biopsy-proven oncocytic renal neoplasms can be safely managed with surveillance in the medium term. Routine renal mass biopsy may reduce surgery for benign or indolent renal tumours and the potential associated morbidity for these patients.