Timing, Patterns and Predictors of 90-Day Readmission Rate after Robotic Radical Cystectomy.

PURPOSE: We examine the timing, patterns and predictors of 90-day readmission after robotic radical cystectomy. MATERIALS AND METHODS: From September 2009 to March 2017, 271 consecutive patients undergoing robotic radical cystectomy with intent to cure bladder cancer (intracorporeal diversion 253, 93%) were identified from our prospectively collated institutional database. Readmission was defined as any subsequent inpatient admission or unplanned visit occurring within 90 days from discharge after the index hospitalization. Multiple readmissions were defined as 2 or more readmissions within a 90-day period. Logistic regression analysis was used to identify independent factors related to single and multiple 90-day readmissions. RESULTS: A total of 78 (28.8%) patients were readmitted at least once within 90 days after discharge, of whom 20 (25.6%) reported multiple readmissions. The cumulative duration of readmission was 6.2 (6.17) days with 6 (7.6%) patients having less than 24 hours readmission. Metabolic, infectious, genitourinary and gastrointestinal complications were identified as the primary cause of readmission in 39.5%, 23.5%, 22.3% and 17%, respectively. Fifty percent of readmissions occurred in the first 2 weeks after hospital discharge. On multivariable logistic regression analysis in-hospital infections (OR 2.85, p=0.001) were independent predictors for overall readmission. Male gender (OR 3.5, p=0.02) and in-hospital infections (OR 4.35, p=0.002) were independent predictors for multiple readmissions. CONCLUSIONS: The 90-day readmission rate following robotic radical cystectomy is significant. In-hospital infections and male gender were independent factors for readmission. Most readmissions occurred in the first 2 weeks following discharge, with metabolic derangements and infections being the most common causes.

Radical cystectomy pentafecta: a proposal for standardisation of outcomes reporting following robot-assisted radical cystectomy.

OBJECTIVE: To propose a standardisable composite method for reporting outcomes of radical cystectomy (RC) that incorporates both perioperative morbidity and oncological adequacy. PATIENTS AND METHODS: From July 2010 to December 2017, 277 consecutive patients who underwent robot-assisted RC with intracorporeal urinary diversion (UD) for bladder cancer at our Institution were prospectively analysed. Patients who simultaneously demonstrated negative soft tissue surgical margins (STSMs), ≥16 lymph node (LN) yield, absence of major (grade III-IV) complications at 90 days, absence of UD-related long-term sequelae and absence of clinical recurrence at ≤12 months, were considered as having achieved the RC-pentafecta. A multivariable logistic regression model was assessed to measure predictors for achieving RC-pentafecta. RESULTS AND LIMITATIONS: Since 2010, 270 of 277 patients that had completed at least 12 months of follow-up were included. Over a mean follow-up of 22.3 months, ≥16 LN yield, negative STSMs, absence of major complications at 90 days, and absence of UD-related surgical sequelae and clinical recurrence at ≤12 months were observed in 93.0%, 98.9%, 76.7%, 81.5% and 92.2%, patients, respectively, resulting in a RC-pentafecta rate of 53.3%. Multivariable logistic regression analysis revealed age (odds ratio [OR] 0.95; P = 0.002), type of UD (OR 2.19; P = 0.01) and pN stage (OR 0.48; P = 0.03) as independent predictors for achieving RC-pentafecta. CONCLUSIONS: We present a RC-pentafecta as a standardisable composite endpoint that incorporates perioperative morbidity and oncological adequacy as a potential tool to assess quality of RC. This tool may be useful for assessing the learning curve and calculating cost-effectiveness amongst others but needs to be externally validated in future studies.

Histological Validation of 11Carbon-Acetate Positron Emission Tomography/Computerized Tomography in Detecting Lymph Node Metastases in Prostate Cancer.

PURPOSE: Conventional imaging cannot definitively detect nodal metastases of prostate cancer. We histologically validated C-acetate positron emission tomography/computerized tomography to identify nodal metastases, examining prostate cancer factors that influence detection rates. MATERIALS AND METHODS: Patients with C-acetate avid positron emission tomography/computerized tomography imaged pelvic/retroperitoneal lymph nodes underwent high extended robotic lymphadenectomy. A standardized mapping template comprising 8 predetermined anatomical regions was dissected during lymphadenectomy, allowing for matched, region based analysis and comparison of imaging and histological data. RESULTS: In 25 patients a total of 2,149 lymph nodes were excised (mean 86 per patient, range 27 to 136) and 528 (22%) harbored metastases (mean 21 positive nodes per patient, range 0 to 109). A total of 174 anatomical regions had matching imaging histological data. C-acetate positron emission tomography/computerized tomography accurately identified 48 node-positive regions and accurately ruled out 88 regions as metastasis-free. C-acetate sensitivity, specificity, and positive and negative predictive values were 67%, 84%, 74% and 79%, respectively. An increasing, histologically measured metastatic lesion size in long axis diameter of 5 or less, 6 to 10, 11 to 15, 16 to 20 and 21 mm or greater correlated with improved C-acetate detection rates of 45%, 62%, 81%, 89% and 100%, respectively. Each standard uptake value unit increase correlated with a 1.9 mm increase in nodal long axis diameter (p <0.001) and a 1.2 mm increase in short axis diameter (p <0.001). Positive C-acetate positron emission tomography/computerized tomography findings correlated with histological lymph node size (long axis diameter 12 mm and short axis diameter 6 mm), metastatic lesion size (long axis diameter 11 mm and short axis diameter 6 mm) and extranodal extension (positive 88% vs false-negative 58%, p = 0.005). CONCLUSIONS: C-acetate positron emission tomography/computerized tomography can identify prostate cancer metastatic nodal disease. However, it underestimates the true cephalad extent of nodal involvement, performing better in the pelvis than in the retroperitoneum. Standard uptake value, histological nodal size, intranodal metastasis size and extranodal extension correlate with cancer bearing nodes.

Use of indocyanine green to minimise uretero-enteric strictures after robotic radical cystectomy.

OBJECTIVE: To evaluate the impact of indocyanine green (ICG) for assessing ureteric vascularity on the rate of uretero-enteric stricture formation after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD). PATIENTS AND METHODS: We identified 179 patients undergoing RARC and ICUD between January 2014 and May 2017, and divided the patients into two groups based on the utilisation of ICG for the assessment of ureteric vascularity (non-ICG group and ICG group). We retrospectively reviewed the medical records to identify the length of ureter excised. Demographic, perioperative outcomes (including 90-day complications and readmissions), and the rate of uretero-enteric stricture were compared between the two groups. The two groups were compared using the t-test for continuous variables and the chi-squared test for categorical variables. A P < 0.05 was considered statistically significant. RESULTS: A total of 132 and 47 patients were in the non-ICG group and the ICG group, respectively. There were no differences in baseline characteristics and perioperative outcomes including operating time, estimated blood loss, and length of stay. The ICG group was associated with a greater length of ureter being excised during the uretero-enteric anastomosis and a greater proportion of patients having long segment (>5 cm) ureteric resection. The median follow-up was 14 and 12 months in the non-ICG and ICG groups, respectively. The ICG group was associated with no uretero-enteric strictures compared to a per-patient stricture rate of 10.6% and a per-ureter stricture rate of 6.6% in the non-ICG group (P = 0.020 and P = 0.013, respectively). CONCLUSION: The use of ICG fluorescence to assess distal ureteric vascularity during RARC and ICUD may reduce the risk of ischaemic uretero-enteric strictures. The technique is simple, safe, and reproducible. Larger studies with longer follow-up are needed to confirm our findings.

Robotic intracorporeal urinary diversion: state of the art.

PURPOSE OF REVIEW: We review historical aspects and current status of the emerging approach of robotic urinary diversion (rUD). Established surgical principles of constructing a low-pressure, large-capacity reservoir are described and the open surgical literature succinctly reviewed to establish the gold standard. Incontinent and continent rUD types [ileal conduit, orthotopic neobladder (all varieties), continent cutaneous diversion, cutaneous ureterostomy] and techniques (extra-corporeal, intra-corporeal) are discussed. Outcomes data (intra-operative, perioperative, intermediate-term, long-term), functional outcomes, complications and learning curve are presented. Outcomes data of open versus robotic urinary diversion are examined. Critiques, improvements, and pros-cons of rUD are discussed. RECENT FINDINGS: Although the majority of centers performing rUD use the extracorporeal technique, use of intra-corporeal rUD is increasing. Although data are yet limited, intra-corporeal rUD may provide some benefits. For rUD, operative times are higher and complication rates comparable with open urinary diversion. SUMMARY: The entire range of urinary diversion surgery has now been replicated robotically. At this writing, extracorporeal urinary diversion techniques still predominate following robotic cystectomy. However, all rUD options can now be performed intra-corporeally with success. As experience increases, the field of robotic urinary diversion is poised to grow.

Patterns of chemotherapy use in muscle-invasive bladder cancer in a tertiary centre.

Objectives: Although neoadjuvant chemotherapy (NAC) has been demonstrated to have significant benefits to survival in patients with muscle-invasive bladder cancer (MIBC), the current utilization of NAC in Australia is unknown. The aim of this study was to evaluate the patterns of neoadjuvant and adjuvant chemotherapy (AC) use in patients undergoing cystectomy for MIBC at a large tertiary institution in Australia. Methods: A retrospective study was conducted using data of patients who underwent a radical cystectomy (RC) at a high-volume centre for MIBC between 2011 and 2021. Results: Of 69 patients who had a cystectomy for ≥ pT2 bladder cancer, 73.9% were eligible for NAC. However, of those eligible, only five patients received NAC (9.8%). Of the total patients who were eligible for AC, only 44.4% received postoperative chemotherapy. Common reasons for the lack of uptake were due to patients being unfit or declining treatment. There was no difference in progression-free survival or overall survival in those who received NAC and AC. Conclusions: The majority of patients undergoing RC for MIBC received AC compared to NAC, reflecting the real-world challenge of NAC uptake. This highlights the need for ongoing improvements in selection and usage of NAC and less reliance of AC utilization post RC.

Trends in the use of of nephron-sparing surgery (NSS) at an Australian tertiary referral centre: an analysis of surgical decision-making using the R.E.N.A.L. nephrometry scoring system.

UNLABELLED: Study Type--Therapy (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Nephron-sparing surgery (NSS) is increasingly recognised as a preferred form of management for the incidentally detected small renal mass (SRM). Within the context of equivalent oncological outcomes, patients treated by NSS may have a survival advantage over those treated by radical nephrectomy (RN) through a reduced risk of chronic kidney disease and its associated cardiac morbidity. Despite this, according to Medicare data from the USA, a disproportionate number of patients with SRMs continue to be treated with RN instead of NSS. Similar data from Australia are not yet available. The present study explores the evolving management of SRMs at an Australian tertiary centre over a 5-year period. It utilises the R.E.N.A.L. Nephrometry Score to assess how lesion complexity has influenced surgical decision-making and charts the increasing use of NSS in the management of low-complexity renal masses at our centre. OBJECTIVE: • To examine recent trends in the use of nephron-sparing surgery (NSS) at our centre. Specifically, we sought to examine the process of surgical decision-making by applying the R.E.N.A.L. nephrometry scoring system to assess the complexity of lesions for which surgery was undertaken. PATIENTS AND METHODS: • We performed a retrospective review of renal masses treated by surgery from January 2005 to December 2009, including 79 RN and 70 NSS. • CT images were available for analysis in 50 patients within each group. • Lesions were scored on the basis of their complexity using the R.E.N.A.L. nephrometry scoring system developed by Kutikov and Uzzo. RESULTS: • There was no difference in age between patients undergoing RN and NSS (median age 61 vs 60 years). • RN was performed for significantly larger lesions (mean [sd] 68 [9] vs 29 [2] mm, P < 0.05) of predominantly moderate and high complexity (12% low, 56% moderate, 32% high). • NSS was primarily used for low-complexity lesions, but included four (8%) moderate-complexity lesions in the final 2 years of the study. • The use of NSS increased from 28.6% of cases in 2005 to 60.0% of cases in 2009, which mirrored the increase in the proportion of operations performed for low-complexity lesions (22.2% low-complexity in 2005 to 70.6% in 2009, P < 0.01 for trend). CONCLUSIONS: • The increasing use of NSS at our institution mirrored the increasing treatment of low-complexity renal lesions. • This may reflect an increased detection and referral of such lesions, or a shift towards treatment of lesions that in the past would have been under surveillance. • Practice at our centre reflects a shifting paradigm towards preferential use of NSS for the treatment of suitable renal masses.

Renal lesions with low R.E.N.A.L nephrometry score are associated with more indolent renal cell carcinomas (RCCs) or benign histology: findings in an Australian cohort.

OBJECTIVE: To validate the relationship of the R.E.N.A.L nephrometry score to histological features of renal lesions treated by surgical excision by radical nephrectomy (RN) or nephron-sparing surgery (NSS) at an Australian tertiary referral centre. PATIENTS AND METHODS: Patients undergoing surgery between 2005 and 2009 with imaging studies available were included. The R.E.N.A.L. nephrometry score is an objective measure of factors important in determining suitability for NSS, e.g. size, exophytic nature, proximity to collecting system and polar location, and R.E.N.A.L scoring was done using the online template at http://www.nephrometry.com. Pathological details were collected by retrospective chart review. Comparisons were made using chi-squared or Fisher's exact tests and trends analysed by linear regression. RESULTS: The rate of benign pathology decreased from 12/58 (20.7%) low-complexity lesions to 1/16 (6.2%) high-complexity lesions (P= 0.09), renal cell carcinomas (RCCs) were stable between 45/58 (77.6%) and 13/16 (81.2%), but other malignancies increased (P= 0.058) from 1/58 (1.7%) to 2/16 (12.5%). Among the RCCs, high vs low R.E.N.A.L score was associated with an increasing risk of clear cell histology (84.6% vs 64.4%, P < 0.05), stage ≥ pT3 (76.9% vs 8.9%, P < 0.001) and grade 4 tumours (15.4% vs 2.2%, P < 0.05), and conversely with a lower risk of papillary histology (0% vs 24.4%, P < 0.02) and stage T1a (0% vs 84.4%, P < 0.001). CONCLUSIONS: Increasing R.E.N.A.L score is associated with histological features of tumour aggressiveness, thus reinforcing the need for RN for lesions with a high score, and conversely the safety of NSS or observation for lesions with a low score.

Accurate lesion localisation facilitates nephron sparing surgery in reninoma patients: case report and discussion.

A 21-year-old female was referred with a suspected juxtaglomerular cell tumour (reninoma) in the superior pole of the left kidney. She underwent renal biopsy and renal vein sampling (RVS) to confirm the diagnosis. Following an uncomplicated laparoscopic partial nephrectomy, antihypertensive medications were ceased. Histopathology confirmed the diagnosis. Reninoma is a rare but reversible cause of secondary hypertension and should be considered along with primary hyperaldosteronism and pheochromocytoma when investigating hypertension in a young person. The subtle appearance of reninoma on imaging can necessitate other investigations to confirm the diagnosis. Definitive localisation is essential to prevent unnecessary loss of nephrons.

Prostate cancer immunology - an update for Urologists.

A better understanding of the immune processes in the pathogenesis and progression of prostate cancer (CaP) may point the way towards improved treatment modalities. The challenge is to amplify immune responses to combat tumour escape mechanisms. Infection and inflammation may have a role in prostate carcinogenesis, including the newly discovered xenotropic murine leukaemia virus (XMRV). These inflammatory states damage defence mechanisms and induce a high proliferative state favouring further mutation and impaired immune surveillance. With this knowledge we are able to explore the use of immunotherapy to rejuvenate the immune system in combating CaP. Recently Sipuleucel-T, an immunotherapeutic agent for metastatic androgen independent CaP, has resulted in improved survival and might be the first immunotherapeutic agent to obtain approval for CaP treatment. This short review will focus on the growing body of evidence suggesting an immunity-based link between CaP and inflammation and infection.

The Use of a Polytetrafluoroethylene Membrane-Covered Stent in the Management of Urine Extravasation After Radical Cystectomy and Ileal Conduit Formation.

Radical cystectomy for urothelial carcinoma is a challenging operation that is associated with significant morbidity and mortality rates. In the literature, the complication rates have been described up to 68%. We describe a unique method of managing a ureteroileal anastomotic leak in a patient with limited ureteral length. The use of polytetrafluoroethylene-covered ureteral stents has been described in the management of ureteral strictures, but this is the first time they have been used in the treatment of a urinary leak after radical cystectomy.

Review of the use of prophylactic drain tubes post-robotic radical prostatectomy: Dogma or decent practice?

Objective: To assess the necessity of routine prophylactic drain tube use following robot-assisted radical prostatectomy (RARP). Method: We performed a literature review using the Medline, Scopus, and Web of Science databases with no restriction of language from January 1900 to January 2020. The following terms we used in the literature search: prostatectomy, radical prostatectomy, robot assisted, drainage, and drain tube. Results: We identified six studies that examined the use of routine prophylactic drain tubes following RARP. One of these studies was a randomized study that included 189 patients, with 97 in the pelvic drain (PD) arm and 92 in the no pelvic drain (ND) arm. This non-inferiority showed an early (90-day) complication rate of 17.4% in the ND arm versus 26.8% in the PD arm (P < .001). Another non-inferiority randomized control trial (RCT) showed a complication rate of 28.9% in the PD group versus 20.4% in the ND group (P = .254). Similarly, the other studies found no benefit of routine use of prophylactic drain tube after RARP. Conclusion: Drain tubes play a role during robotic-assisted radical prostatectomy, however, following a review of the current available literature, they can be safely omitted and we suggest that clinicians may be selective in their use.

Computed tomography-based texture analysis of bladder cancer: differentiating urothelial carcinoma from micropapillary carcinoma.

PURPOSE: The purpose of the study is to determine the feasibility of using computed tomography-based texture analysis (CTTA) in differentiating between urothelial carcinomas (UC) of the bladder from micropapillary carcinomas (MPC) of the bladder. METHODS: Regions of interests (ROIs) of computerized tomography (CT) images of 33 MPCs and 33 UCs were manually segmented and saved. Custom MATLAB code was used to extract voxel information corresponding to the ROI. The segmented tumors were input to a pre-existing radiomics platform with a CTTA panel. A total of 58 texture metrics were extracted using four different texture extraction techniques and statistically analyzed using a Wilcoxon rank-sum test to determine the differences between UCs and MPCs. RESULTS: Of the 58 texture metrics extracted using the gray level co-occurrence matrix (GLCM) and gray level difference matrix (GLDM), 28 texture metrics were statistically significant (p < 0.05) for differences in tumor textures and 27 texture metrics were statistically significant (p < 0.05) for peritumoral fat textures. The remaining nine metrics extracted using histogram and fast Fourier transform analyses did not show significant differences between the textures of the tumors and their peritumoral fat. CONCLUSIONS: CTTA shows that MPC have a more heterogeneous texture compared to UC. As visual discrimination of MPC from UC from clinical CT scans are difficult, results from this study suggest that tumor heterogeneity extracted using GLCM and GLDM may be a good imaging aid in segregating MPC from UC. This tool can aid clinicians in further sub-classifying bladder cancers on routine imaging, a process which has potential to alter treatment and patient care.

Robotic intracorporeal ileal conduit: Technical aspects.

OBJECTIVE: To present a review of the technical aspects of robotic intracorporeal ileal conduit  (IC) reconstruction after robot assisted radical cystectomy (RARC). METHODS: A non-systematic review is performed in order  to summarize technical aspects on robot assisted ileal conduit procedure following radical cystectomy in patients with muscle invasive bladder cancer.  RESULTS: Radical cystectomy with pelvic lymph node dissection and urinary diversion is the gold-standard therapy for localized muscle-invasive bladder cancer. IC is the most common diversion utilized by surgeons. Minimally invasive approaches to IC were proposed with the intention of decreasing the morbidity associated to open surgery. Several oncological, and functional factors should be taken into consideration for the selection of patients undergoing this procedure together with surgeons and patients' preferences. The stoma marking of the patient is of critical importance. Identification of the ureters should be done assuring careful handling of the tissue and then isolation of the bowel segments should be performed after confirming proper length of the segment. Side to side anastomosis of the antimesenteric borders of the bowel is performed with linear staplers, and the ureteroileal anastomosis is done. Finally, the ileal conduit is positioned close to the stoma marking site and is fixed to the skin. Urinary diversion and radical cystectomy is a very morbid procedure. Mainly, complications are gastrointestinal, stoma-related, or associated to the ureter-enteric anastomosis.  CONCLUSIONS: The advantages of the robotic platform concerning postoperative outcomes may be more evident if the procedure is done in an intracorporeal fashion. Proper knowledge and mastery of the technical aspects of this procedure are critical.

ARTICULO SOLO EN INGLES. OBJETIVO: Presentar una revisión de losaspectos técnicos de la reconstrucción con conductoileal (CI) robótico intracorpóreo después de cistectomíaradical asistida por robot (CRAR).MÉTODOS: Realizamos una revisión no sistemática dela literatura para resumir los aspectos técnicos de la técnicade conducto ileal asistido por robot después de la cistectomía radical en pacientes con cáncer vesical  músculo invasivo. RESULTADOS: La cistectomía radical con linfadenectomía pélvica y derivación urinaria es el tratamiento estándar para el cáncer de vejiga músculo invasivo localizado. El conducto ileal es la derivación urinaria másfrecuentemente utilizada por los cirujanos. Los abordajes mínimamente invasivos para el CI fueron propuestos con la intención de disminuir la morbilidad asociada con la cirugía abierta. Para la selección de los pacientesque se van a someter a esta operación se deben considerar algunos factores oncológicos y funcionales, junto con las preferencias de cirujanos y pacientes. Lamarca del estoma del paciente tiene una importancia crítica. La identificación de los uréteres debe realizarse asegurando un manejo cuidadoso de los tejidos y después el aislamiento de los segmentos intestinales debe realizarse tras confirmar la adecuada longitud del segmento.Se realiza una anastomosis latero-lateral de los bordes antimesentéricos del intestino con grapadoras lineales y luego la anastomosis ureteroileal. Finalmente,el conducto ileal se posiciona cerca de la marca del estoma y se fija a la piel. La cistectomía radical con derivación urinaria es un procedimiento muy mórbido.Principalmente, las complicaciones son gastrointestinales, relacionadas con el estoma o asociadas con la anastomosis ureteroentérica. CONCLUSIONES: Las ventajas de la plataforma robótica en relación con los resultados postoperatorios puede ser más evidente si el procedimiento se realiza de forma intracorpórea. Son críticos el conocimiento adecuado y la maestría de los aspectos técnicos de la operación.

Identifying the Optimal Candidate for Salvage Lymph Node Dissection for Nodal Recurrence of Prostate Cancer: Results from a Large, Multi-institutional Analysis.

BACKGROUND: Salvage lymph node dissection (SLND) represents a possible treatment option for prostate cancer patients affected by nodal recurrence after local treatment. However, SLND may be associated with intra- and postoperative complications, and the oncological benefit may be limited to specific groups of patients. OBJECTIVE: To identify the optimal candidates for SLND based on preoperative characteristics. DESIGN, SETTING, AND PARTICIPANTS: The study included 654 patients who experienced prostate-specific antigen (PSA) rise and nodal recurrence after radical prostatectomy (RP) and underwent SLND at nine tertiary referral centers. Lymph node recurrence was documented by positron emission tomography/computed tomography (PET/CT) scan using either 11C-choline or 68Ga-labeled prostate-specific membrane antigen ligand. INTERVENTION: SLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The study outcome was early clinical recurrence (eCR) developed within 1 yr after SLND. Multivariable Cox regression analysis was used to develop a predictive model. Multivariable-derived coefficients were used to develop a novel risk calculator. Decision-curve analysis was used to evaluate the net benefit of the predictive model. RESULTS AND LIMITATIONS: Median follow-up was 30 (interquartile range, 16-50) mo among patients without clinical recurrence (CR), and 334 patients developed CR after SLND. In particular, eCR at 1 yr after SLND was observed in 150 patients, with a Kaplan-Meier probability of eCR equal to 25%. The development of eCR was significantly associated with an increased risk of cancer-specific mortality at 3 yr, being 20% versus 1.4% in patients with and without eCR, respectively (p<0.0001). At multivariable analysis, Gleason grade group 5 (hazard ratio [HR]: 2.04; p<0.0001), time from RP to PSA rising (HR: 0.99; p=0.025), hormonal therapy administration at PSA rising after RP (HR: 1.47; p=0.0005), retroperitoneal uptake at PET/CT scan (HR: 1.24; p=0.038), three or more positive spots at PET/CT scan (HR: 1.26; p=0.019), and PSA level at SLND (HR: 1.05; p<0.0001) were significant predictors of CR after SLND. The coefficients of the predictive model were used to develop a risk calculator for eCR at 1 yr after SLND. The discrimination of the model (Harrel'sC index) was 0.75. At decision-curve analysis, the net benefit of the model was higher than the "treat-all" option at all the threshold probabilities. CONCLUSIONS: We reported the largest available series of patients treated with SLND. Roughly 25% of men developed eCR after surgery. We developed the first risk stratification tool to identify the optimal candidate to SLND based on routinely available preoperative characteristics. This tool can be useful to avoid use of SLND in men more likely to progress despite any imaging-guided approach. PATIENT SUMMARY: The risk of early recurrence after salvage lymph node dissection (SLND) was approximately 25%. In this study, we developed a novel tool to predict the risk of early failure after SLND. This tool will be useful to identify patients who would benefit the most from SLND from other patients who should be spared from surgery.

Quantitative Contour Analysis as an Image-based Discriminator Between Benign and Malignant Renal Tumors.

OBJECTIVE: To investigate whether morphologic analysis can differentiate between benign and malignant renal tumors on clinically acquired imaging. MATERIALS AND METHODS: Between 2009 and 2014, 3-dimensional tumor volumes were manually segmented from contrast-enhanced computerized tomography (CT) images from 150 patients with predominantly solid, nonmacroscopic fat-containing renal tumors: 100 renal cell carcinomas and 50 benign lesions (eg, oncocytoma and lipid-poor angiomyolipoma). Tessellated 3-dimensional tumor models were created from segmented voxels using MATLAB code. Eleven shape descriptors were calculated: sphericity, compactness, mean radial distance, standard deviation of the radial distance, radial distance area ratio, zero crossing, entropy, Feret ratio, convex hull area and convex hull perimeter ratios, and elliptic compactness. Morphometric parameters were compared using the Wilcoxon rank-sum test to investigate whether malignant renal masses demonstrate more morphologic irregularity than benign ones. RESULTS: Only CHP in sagittal orientation (median 0.96 vs 0.97) and EC in coronal orientation (median 0.92 vs 0.93) differed significantly between malignant and benign masses (P = .04). When comparing these 2 metrics between coronal and sagittal orientations, similar but nonsignificant trends emerged (P = .07). Other metrics tested were not significantly different in any imaging plane. CONCLUSION: Computerized image analysis is feasible using shape descriptors that otherwise cannot be visually assessed and used without quantification. Shape analysis via the transverse orientation may be reasonable, but encompassing all 3 planar dimensions to characterize tumor contour can achieve a more comprehensive evaluation. Two shape metrics (CHP and EC) may help distinguish benign from malignant renal tumors, an often challenging goal to achieve on imaging and biopsy.

Plasmacytoma of the testis in a patient with relapsed and refractory multiple myeloma: Case report and review of the literature.

Testicular plasmacytoma, whether occurring as a primary lesion or as a reflection of underlying multiple myeloma (MM), is a rare disease. We report the case of a 38-year-old male with multiply relapsed MM, who was found to have a testicular plasmacytoma. He presented with a gradually enlarging scrotal mass. Following orchidectomy, pathologic examination of the specimen demonstrated a plasmacytoma. In the context of active MM, the specimen was also sent for cytogenetic analysis but this was unhelpful in guiding a chemotherapy regime, which still continues at time of reporting. Although a rare lesion, there remains no definitive treatment protocol for the management of testicular plasmacytoma representing an extramedullary manifestation of MM.

Rare synchronous metastases of renal cell carcinoma.

Renal cell carcinoma can metastasize to any region of the body. We review a patient who presents fourteen years after initial resection of the primary tumor with distant metastatic disease. This included spread to the bladder and penis that manifested as frank haematuria and malignant priapism respectively. We discuss the mechanism of spread and the management options available.