Near-infrared fluorescence lymph node template region dissection plus backup lymphadenectomy in open radical cystectomy for bladder cancer using an innovative handheld device: A single center experience.

BACKGROUND: The extent of pelvic lymphadenectomy (PLND) as part of radical cystectomy (RC) for bladder cancer (BC) remains unclear. Sentinel-based and lymphangiographic approaches could lead to reduced morbidity without sacrificing oncologic safety. OBJECTIVE: To evaluate the feasibility and diagnostic value of fluorescence-guided template sentinel region dissection (FTD) using a handheld near-infrared fluorescence (NIRF) camera in open radical cystectomy. DESIGN, SETTING, AND PARTICIPANTS: After peritumoral cystoscopic injection of indocyanine green (ICG) 21 patients underwent open RC with FTD due to BC between June 2019 and June 2021. Intraoperatively, the FIS-00 Hamamatsu Photonics® NIRF camera was used to identify and resect fluorescent template sentinel regions (FTRs) followed by extended pelvic lymphadenectomy (ePLND) as oncological back-up. OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS: Descriptive analysis of positive and negative results per template region. RESULTS AND LIMITATIONS: FTRs were identified in all 21 cases. Median time (range) from ICG injection to fluorescence detection was 75 (55-125) minutes. On average (SD), 33.4 (9.6) lymph nodes were dissected per patient. Considering template regions as the basis of analysis, 67 (38.3%) of 175 resected regions were NIRF-positive, with 13 (7.4%) regions harboring lymph node metastases. We found no metastatic lymph nodes in NIRF-negative template regions. Outside the standard template, two NIRF-positive benign nodes were identified. CONCLUSION: The concept of NIRF-guided FTD proved for this group all lymph node metastases to be found in NIRF-positive template regions. Pending validation in a larger collective, resection of approximately 40% of standard regions may be sufficient and may result in less morbidity.

Diagnosis of female urethral diverticulum using pelvic floor ultrasound and comparison with voiding cystourethrogram (imaging study).

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to evaluate the sensitivity and specificity of pelvic floor ultrasound (PFUS) in the diagnostic work-up of female urethral diverticulum (UD) and to compare results of PFUS with voiding cystourethrogram (VCUG). METHODS: We retrospectively reviewed our database of patients, who received VCUG and PFUS for the diagnosis of UD. A total of 196 consecutive female patients with a minimum of one symptom, such as a lower urinary tract symptom (LUTS), postmicturition dribble, dyspareunia and recurrent urinary tract infection (UTI) who underwent initial diagnostics with VCUG and PFUS were selected. Diagnostic performance of both procedures, which included size, complexity, echogenicity. and content were compared. RESULTS: Recurrent UTI and LUTS were the most common symptoms, which were present in 165 (84%) and 163 patients (83%) respectively. Final diagnosis of UD was based on PFUS and VCUG findings in 69 (35%) and 58 (30%) cases respectively. Based on our study cohort, the sensitivity of PFUS in detecting UD was significantly higher than that of VCUG: 94% (IQR: 89-97) versus 78% (IQR: 73-85, p<0.01), with a trend toward higher specificity: 100% (IQR: 94-100) versus 84% (IQR: 78-84, p=0.05). Enabling direct UD visualisation, PFUS was associated with a positive predictive value (PPV) of 100% (IQR: 97-100) and a negative predictive value (NPV) of 88% (IQR: 78-95), whereas VCUG had an inferior accuracy with a PPV of 84 (IQR: 80-84) and a NPV of 68 (IQR: 62-79). CONCLUSIONS: In clinical practice, VCUG has a lower sensitivity than PFUS. Based on these results, we recommend the usage of dynamic PFUS as part of a non-invasive work-up.

Correlation between symptoms and imaging findings including pelvic floor ultrasound to improve the symptom-based diagnosis of female urethral diverticulum (CHECK-UD study).

INTRODUCTION AND HYPOTHESIS: The objective was to establish a model to predict the presence of a female urethral diverticulum (UD) based on symptoms. METHODS: A prospective CHECK-UD study (check of female urethral diverticulum) was conducted. Female patients presenting with symptoms such as lower urinary tract symptoms (LUTS), postmicturition dribble or urinary incontinence (UI), dyspareunia or pain in the pelvic area, and recurrent urinary tract infection (UTI) treated between 2015 and 2020 were included. The association between each symptom variable and the positive finding of UD was evaluated by multivariate logistic regression adjusting for age, body mass index (BMI), vaginal deliveries, previous surgery for SUI, previous pelvic surgery, and microscopic hematuria. A predictive model for the presence of UD was then created. RESULTS: In total, 189 female patients with a minimum of one symptom were enrolled. Pelvic floor ultrasound revealed the presence of UD in 66 out of 189 (34.92%). Of the four symptoms, the combinations "LUTS + postmicturition dribble + UTI," "postmicturition dribble + LUTS," and "UTI + LUTS" were most significantly related to positive findings and had a higher positive prognostic value for the diagnosis of UD than each individual symptom alone (OR = 13.78 [95% CI: 6.95-16.35], p < 0.001; OR = 9.94 [95% CI: 4.60-12.2], p < 0.05; and OR = 5.78 [95% CI: 1.58-6.98] p = 0.05) respectively. CONCLUSION: Based on our model, the combination "LUTS + postmicturition dribble + UTI" seems to be the most sensitive combination of clinical symptoms predicting the positive finding of UD. This model could be used for patient counseling and for the identification of patients with UD.

Diagnosis and Empirical Treatment of Urinary Tract Infections in Urologic Outpatients.

INTRODUCTION: Due to a continuing increase of bacterial resistance in common uropathogens, we wanted to revisit our standards for the diagnosis and treatment of lower urinary tract infections, in the setting of urological outpatient care in a conurbation in Germany. PATIENTS AND METHODS: All subjects presenting with significant bacteriuria at our urology clinics in Mülheim, Germany, in 2011 were included. Comorbidity, bacterial species, urinary tract symptoms, and empirically prescribed antibiotics were taken from the patients' records. RESULTS: In 2011, a total of 1,324 patients were included (793 female, 531 male). Of the 771 patients with symptomatic bacteriuria, 647 received antibiotic treatment, as well as 116 of 409 patients with asymptomatic bacteriuria. Escherichia coli was identified in 60% of the included patients. In 427 E. coli infections, bacterial resistance was found in 14% of 316 cases treated with quinolone, in 21% of 53 cases treated with co-trimoxazole, and in only 3% of 58 cases treated with nitrofurantoin. CONCLUSIONS: We found a high use of fluoroquinolones for empirical first-line antibiotics in the treatment of lower urinary tract infections. In our regional setting, antibiotic stewardship needs to be promoted, along national and international guidelines, to avoid unnecessary prescription of fluoroquinolones for empirical treatment.

Predictors of Early Continence Recovery Following Radical Prostatectomy, Including Transperineal Ultrasound to Evaluate the Membranous Urethra Length (CHECK-MUL Study).

INTRODUCTION: To predict early continence recovery following radical prostatectomy (RP) using baseline demographic and clinical data, as well as dynamic transperineal ultrasound (TPUS) parameters of membranous urethral length (MUL). PATIENTS AND METHODS: A retrospective CHECK-MUL (check of membranous urethral length) study was conducted. We evaluated 154 patients who underwent RP between August 2018 and April 2023. All patients underwent pre- and postoperative dynamic TPUS to measure MUL. Urinary continence was defined as the use of one safety pad or less 3 months post surgery. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used to assess urinary incontinence (UI). We used logistic regression to assess the association between MUL and early continence recovery. A multivariable logistic regression model was then constructed for the prediction of early continence recovery based on the MUL. RESULTS: The median MUL observed pre- and postoperatively in this study were similar (14.6 mm and 12.9 mm). In the univariable logistic regression analysis, the pre- and postoperative MUL measured by TPUS (odds ratio (OR): 1.12; 95%-CI: 1.02-1.79; p = 0.05 and OR: 1.01; 95%-CI: 1.02-1.12; p < 0.01) directions were independent predictors of early continence recovery 3 months post surgery. In addition, age (OR: 1.23; 95%-CI: 1.11-1.42; p = 0.03), BMI (OR: 1.44; 95%-CI: 1.18-2.92; p = 0.05), and bilateral nerve sparing (OR: 1.24; 95%-CI: 1.02-1.9; p = 0.05) were independent predictors of urinary continence in univariable logistic regression models. Preoperative MUL >15 mm (95% CI 1.28-1.33; p = 0.03) and postoperative MUL >14 mm (95% CI 1.2-1.16; p = 0.05) were significantly associated with early continence recovery at 3 months post surgery. CONCLUSIONS: The likelihood of continence recovery increases with membranous urethral length and decreases with age, BMI, and lack of nerve sparing. Preoperative MUL >15 mm and postoperative MUL >14 mm were significantly associated with early continence recovery at 3 months post surgery.

Retzius Sparing Radical Prostatectomy Versus Robot-assisted Radical Prostatectomy: Which Technique Is More Beneficial for Prostate Cancer Patients (MASTER Study)? A Systematic Review and Meta-analysis.

CONTEXT: Retzius sparing robot-assisted radical prostatectomy (RS-RARP) is increasingly being used, but results of pertinent studies on perioperative, functional, and oncological outcomes comparing the Retzius sparing approach with standard robot-assisted radical prostatectomy (RARP) remain inconsistent. OBJECTIVE: To evaluate the effectiveness of RS-RARP compared with standard RARP, in terms of perioperative, functional, and oncological outcomes. EVIDENCE ACQUISITION: We performed a systematic search using multiple databases (PubMed, MEDLINE, EMBASE, and Cochrane Central) until March 2021. Only randomized controlled trials (RCTs) and prospective studies were eligible for study inclusion. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were respected. Studies were critically appraised for the risk of bias. Primary outcomes were continence/potency recovery, as well as positive surgical margin (PSM) rates. Secondary outcomes included total intra- and perioperative complication rates. EVIDENCE SYNTHESIS: Four RCTs and six prospective observational studies were included in this systematic review. The meta-analysis revealed that PSM rates in ≤pT2 tumors were statistically significantly higher, following RS-RARP as compared with RARP (risk ratio [RR]=1.39; 95% confidence interval [CI]=[1.01-1.91]). PSM rates in ≥pT3 tumors tended to be higher following RS-RARP (RR=1.36; 95% CI=[0.74-2.50]), although statistical significance was not reached. Immediate continence recovery was higher and significantly advantageous for RS-RARP (RR=1.81; 95% CI=[1.26-2.60]). Continence recovery also tended to be higher at 3 and 6 mo in the RS-RARP group (RR=1.57; 95% CI=[0.69-3.58] and RR=1.22; 95% CI=[0.89-1.66], respectively). The urinary continence recovery at 12 mo was similar in both groups (RR=1.14; 95% CI=[0.98-1.32]). A meta-analysis of included studies showed no significant difference concerning the return of erectile function and major complication rates between RS-RARP and RARP (RR=1.05; 95% CI=[0.76-1.45] and (RR=0.79; 95% CI=[0.07-8.74], respectively). CONCLUSIONS: Available data suggest a statistically significant advantage in favor of RS-RARP in terms of immediate urinary continence recovery. PSM rates in localized ≤pT2 tumors are statistically significantly higher following RS-RARP. Potency and serious complication rates appear to be similar. PATIENT SUMMARY: Our meta-analysis of the current evidence shows a significant advantage for Retzius sparing robot-assisted radical prostatectomy (RS-RARP) over robot-assisted radical prostatectomy in terms of immediate urinary continence recovery, but positive cancer margins are higher following RS-RARP. There was no significant difference in the preservation of erectile function and overall postoperative complication rates between both the techniques.

Clinical outcome and quality of life in octogenarian patients with muscle-invasive urothelial carcinoma of the bladder treated with radical cystectomy or transurethral resection of the bladder tumor: a retrospective analysis of 143 patients.

PURPOSE: To compare clinical outcome and quality of life (QoL) in octogenarian patients with muscle-invasive urothelial carcinoma (MIBC) either treated by radical cystectomy (RC) or transurethral resection of the tumor (TURBT). METHODS: We identified octogenarian patients with MIBC in our institutions since 2005. Clinical treatment outcomes and QoL were analyzed. Uni- and multivariable Cox regression analyses, two-tailed Wilcoxon test, Mann-Whitney test and Fisher's exact test were assessed as appropriate. QoL was evaluated using FACT-G (Functional Assessment of Cancer Therapy-General) questionnaire. RESULTS: 143 patients were identified (RC: 51 cases, TURBT: 92 cases). Mean follow-up was 14 months (0-100 months). Median overall survival (OS) was 12 months in the RC group and 7 months in the TURBT group. TURBT and low preoperative hemoglobin were independent risk factors for reduced cancer-specific survival (CSS) (TURBT: p = 0.019, Hb: p = 0.008) and OS (TURBT: p = 0.026, Hb: p = 0.013) in multivariable analyses. Baseline QoL was low throughout the whole cohort. There was no difference in baseline FACT-G scoring comparing RC and TURBT (FACT-G total score (median): RC 43.7/108 vs. TURBT 44.0/108, p = 0.7144). Increased FACT-G questionnaire scoring was assessed for RC patients (median percentage score change RC 22.9%, TURBT 2.3%, p < 0.0001). CONCLUSION: RC and TURBT are feasible treatment options for MIBC in octogenarian patients. In our cohort, RC was associated with increased CSS, OS and QoL. QoL in general was low throughout the whole cohort. Interdisciplinary decision-making has to be improved for these critically ill patients.

Quantitative real-time ARMS-qPCR for mitochondrial DNA enables accurate detection of microchimerism in renal transplant recipients.

The presence of microchimerism in peripheral blood of solid organ transplant recipients has been postulated to be beneficial for allograft acceptance. Kinetics of donor cell trafficking and accumulation in pediatric allograft recipients are largely unknown. In this study, we implemented SNPs of the HVRs I and II of mitochondrial DNA to serve as molecular genetic markers to detect donor-specific cell chimerism after pediatric renal transplantation. Serial dilution of artificial chimeric DNA samples showed a linear correlation coefficient of R > 0.98 and a detection sensitivity of 0.01% with high reproducibility. Longitudinal semiquantitative analysis of donor-specific SNPs was then performed in peripheral blood mononuclear cells samples up to two yr post-transplant. Quantity of donor-specific cell chimerism in peripheral blood was highest in the early post-transplant period reaching values of ~10% after liver-kidney and 2.8% after renal transplantation. From one wk after transplantation, renal transplant patients exhibited an amount of donor-specific mtDNA ranging from 0.01% to 0.1%. We developed a highly accurate, sensitive, and rapid real-time quantitative PCR method using sequence-specific primers and fluorescent hydrolysis probes for the detection of at least 0.01% donor-specific cells in the recipient's peripheral blood after renal transplantation.

[Cystic nephroma in a 15-month-old boy with DICER1 mutation]. / Zystisches Nephrom bei einem 15 Monate alten Patienten mit DICER1-Mutation.

Cystic nephroma is a rare tumor in childhood. Seventy percent of all cases are associated with DICER1-anomaly and therefore cystic nephroma represents the second most common tumor of all patients with DICER1 mutation. We present a case of a 15-month-old boy with a DICER1 mutation and cystic nephroma. Organ-sparing surgery was not possible. Due to higher prevalence of germ cell tumors, follow-up after nephrectomy is necessary until adulthood.

Stone extraction with loop ureteral catheter versus ureteroscopy in small distal ureteral stones-retrospective comparison of 547 consecutive patients.

BACKGROUND: To evaluate whether stone extraction with a loop ureteral catheter (LUC) in distal ureteral stones is associated with a higher frequency of ureteral strictures compared to treatment with primary ureteroscopic stone removal (p-URS) or ureteroscopic laser lithotripsy (l-URS). METHODS: Five hundred and forty-seven consecutive patients were primarily endourologically treated for distal ureteral stones in our department between 2005 and 2019 and included in the study protocol. Data was retrospectively obtained from the patients' charts and medical reports as well as from office-based urologists. Data analysis was performed using Fisher's exact test, Mann-Whitney test or Student's t-test as appropriate. A level of P<0.05 was assigned statistical significance. RESULTS: Four hundred and twelve patients were treated by URS (p-URS n=304, l-URS n=108) and another 135 by LUC stone extraction. Median follow-up was 41 [2-159] months. There was no difference between the groups concerning age, gender, proportion of patients with ureteral stenting, operating time, hospitalization or readmission rates. The number of ureteric strictures was small in all procedures [n=3 (1.0%) in p-URS, n=2 (1.9%) in l-URS and n=2 (1.5%) in LUC] and there was no difference between the groups concerning this serious complication (p-URS vs. LUC: P=0.6465; l-URS vs. LUC: P=0.9999). CONCLUSIONS: In small distal stones, LUC stone extraction still is an alternative to URS procedures in stone management with comparable results concerning postinterventional ureteral strictures. In experienced hands, it still has its value in accurately selected patients.

Serum and tissue syndecan-1 levels in renal cell carcinoma.

BACKGROUND: The proteoglycan syndecan-1 is involved in cell proliferation, adhesion and angiogenesis. It was shown to be involved in cancer progression in different tumor entities. So far, the role of syndecan-1 in renal cell carcinoma (RCC), one of the most common diseases in urologic oncology, was little described. Purpose of the present study was to obtain serum concentrations and tissue expression levels of syndecan-1 in a cohort of patients diagnosed with RCC. METHODS: Clinical and follow-up data were obtained from 413 RCC patients. SDC1 levels were determined in serum samples of 100 patients by enzyme-linked immunosorbent assay and tissue SDC1 expression was measured by immunohistochemistry (IHC) in 343 cases. Results were correlated with clinicopathological and follow-up data. RESULTS: Five and ten years overall and cancer specific survival were 67% and 56% [overall survival (OS)] and 79% and 76% [cancer-specific survival (CSS)]. In female patients and locally advanced disease (≥T3), tissue SDC1 expression was decreased (female 85.6% vs. male 71.1% low tissue SDC1 expression, P=0.0153 and ≤T2 70.0% vs. ≥T3 87.2% low tissue SDC1 expression, P=0.0055) compared to male patients and organ confined disease. Locally advanced tumor stage, presence of lymph node or distant metastases, high Fuhrman grading and clear cell carcinoma as histopathological subtype were independent prognostic factors for reduced CSS and OS. There was no impact of serum SDC1 (sSDC1) serum concentration or SDC1 tissue protein expression on OS, CSS or recurrence free survival (RFS) in uni- or multivariable analysis. CONCLUSIONS: sSDC1 concentration or SDC1 tissue protein expression levels had no influence on patients' prognosis in the present cohort of patients diagnosed with RCC.