The Impact of Histologic Subtypes on Clinical Outcomes After Radiation-Based Therapy for Muscle-Invasive Bladder Cancer.

PURPOSE: Outcomes of radiation-based therapy (RT) for muscle-invasive bladder cancer (MIBC) with histologic subtypes of urothelial cancer (HS-UC) are lacking. Our objective was to compare survival outcomes of pure urothelial carcinoma (PUC) to HS-UC after RT. MATERIALS AND METHODS: A multicenter retrospective study of 864 patients with MIBC who underwent curative-intent RT to the bladder for MIBC (clinical T2-T4aN0-2M0) between 2001 and 2018 was conducted. Regression models were used to test the association between HS-UC and complete response (CR) and survival outcomes after RT. RESULTS: In total, 122 patients (14%) had HS-UC. Seventy-five (61%) had HS-UC with squamous and/or glandular differentiation. A CR was confirmed in 69% of patients with PUC and 63% with HS-UC. There were 207 (28%) and 31 (25%) patients who died of metastatic bladder cancer in the PUC and HS-UC groups, respectively. There were 361 (49%) and 58 (48%) patients who died of any cause in the PUC and HS-UC groups, respectively. Survival outcomes were not statistically different between the groups. The HS-UC status was not associated with survival outcomes in multivariable Cox regression analyses. CONCLUSIONS: In our study, HS-UC responded to RT with no significant difference in CR and survival outcomes compared to PUC. The presence of HS-UC in MIBC does not seem to confer resistance to RT, and patients should not be withheld from bladder preservation therapy options. Due to low numbers, definitive conclusions cannot be drawn for particular histologic subtypes.

Complication rate after cystectomy following pelvic radiotherapy: an international, multicenter, retrospective series of 682 cases.

PURPOSE: Conflicting evidence exists on the complication rates after cystectomy following previous radiation (pRTC) with only a few available series. We aim to assess the complication rate of pRTC for abdominal-pelvic malignancies. METHODS: Patients treated with radical cystectomy following any previous history of RT and with available information on complications for a minimum of 1 year were included. Univariable and multivariable logistic regression models were used to assess the relationship between the variable parameters and the risk of any complication. RESULTS: 682 patients underwent pRTC after a previous RT (80.5% EBRT) for prostate, bladder (BC), gynecological or other cancers in 49.1%, 27.4%, 9.8% and 12.9%, respectively. Overall, 512 (75.1%) had at least one post-surgical complication, classified as Clavien ≥ 3 in 29.6% and Clavien V in 2.9%. At least one surgical complication occurred in 350 (51.3%), including bowel leakage in 6.2% and ureteric stricture in 9.4%. A medical complication was observed in 359 (52.6%) patients, with UTI/pyelonephritis being the most common (19%), followed by renal failure (12%). The majority of patients (86%) received an incontinent urinary diversion. In multivariable analysis adjusted for age, gender and type of RT, patients treated with RT for bladder cancer had a 1.7 times increased relative risk of experiencing any complication after RC compared to those with RT for prostate cancer (p = 0.023). The type of diversion (continent vs non-continent) did not influence the risk of complications. CONCLUSION: pRTC carries a high rate of major complications that dramatically exceeds the rates reported in RT-naïve RCs.

Magnetic resonance imaging/transrectal ultrasonography fusion targeted prostate biopsy finds more significant prostate cancer in biopsy-naïve Japanese men compared with the standard biopsy.

OBJECTIVE: To assess the clinical benefits of magnetic resonance imaging/transrectal ultrasound fusion-targeted biopsy for biopsy-naïve Japanese men. METHODS: Between February 2017 and August 2018, 131 biopsy-naïve men who underwent targeted biopsy together with 10-core systematic biopsy at Hiroshima University Hospital were retrospectively investigated. Multiparametric magnetic resonance imaging findings were reported based on Prostate Imaging Reporting and Data System version 2. RESULTS: The overall cancer detection rates per patient were 69.5% in systematic biopsy + targeted biopsy cores, 61.1% in systematic biopsy cores and 61.1% in targeted biopsy cores. The detection rates for clinically significant prostate cancer were 43.5% in targeted biopsy cores and 35.9% in systematic biopsy cores (P = 0.04), whereas the detection rates for clinically insignificant prostate cancer were 17.6% and 25.2% respectively (P = 0.04). Lesions in the peripheral zone were diagnosed more with clinically significant prostate cancer (54.8% vs 20.7%, P < 0.001) and International Society of Urological Pathology grade (3.2 vs 2.7, P = 0.02) than that in the inner gland. Just 4.2% (3/71) of Prostate Imaging Reporting and Data System category 2 and 3 lesions in the middle or base of the inner gland were found to have clinically significant prostate cancer. The cancer detection rate per core was 42.3% in targeted biopsy cores, whereas it was 17.9% in systematic biopsy cores (P < 0.001). CONCLUSIONS: Targeted biopsy is able to improve the diagnostic accuracy of biopsy in detection of clinically significant prostate cancer by reducing the number of clinically insignificant prostate cancer detections compared with 10-core systematic biopsy in biopsy-naïve Japanese men. In addition, the present findings suggest that patients with Prostate Imaging Reporting and Data System category 2 or 3 lesions at the middle or base of the inner gland might avoid biopsies.

Is it time to rethink how we page physicians? Understanding paging patterns in a tertiary care hospital.

BACKGROUND: Frequent pages can disrupt workflow, interrupt patient care, and may contribute to physician burnout. We hypothesized that paging volumes followed consistent temporal trends, regardless of the medical or surgical service, reflecting systems based issues present in our hospitals. METHODS: A retrospective review of the hospital paging systems for 4 services at The Ottawa Hospital was performed. Resident paging data from April 1 to July 31, 2018 were collected for services with a single primary pager number including orthopaedic surgery, general surgery, neurology, and neurosurgery. Trends in paging volume during the 4-month period were examined. Variables examined included the location of origin of the page (emergency room vs. inpatient unit), and day/time of the page. RESULTS: During the study period, 25,797 pages were received by the 4 services, averaging 211 (± Standard Deviation (SD) 12) pages per day. 19,371 (75%) pages were from in-patient hospital units, while 6426 (24%) were pages from the emergency room. The median interval between pages across all specialties was 22:30 min. Emergency room pages peaked between 16:30 and 20:00, while in-patient units peaked between 17:30 and 18:30. CONCLUSIONS: Each service experienced frequent paging with similar patterns of marked increases at specific times. This study identifies areas for future study about what the factors are that contribute to the paging patterns observed.

Preoperative risk classification using neutrophil-lymphocyte ratio and hydronephrosis for upper tract urothelial carcinoma.

BACKGROUND: To improve the prediction of outcomes in patients who will undergo radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC), we examined the preoperative prognostic factors and established a risk classification model. METHODS: A total of 148 patients who underwent RNU without history of neo-adjuvant chemotherapy between 1999 and 2016 in Hiroshima University Hospital were retrospectively reviewed. Associations between preoperative/clinicopathological factors and outcomes including cancer-specific survival (CSS) and recurrence-free survival (RFS) were assessed. We specifically looked at neutrophil-lymphocyte ratio (NLR) due to growing evidence on its predictive role in cancer prognosis prediction. RESULTS: Preoperative elevated neutrophil-lymphocyte ratio (pre-op NLR, ≥3.0) and hydronephrosis (≥grade 2) were associated with advanced pathological stage; and were identified as independent predictive factors of shorter CSS and RFS in univariate and multivariate analysis. We classified the patients in three groups using preoperative factors and found that the 5-year CSS was 94.5, 75.9 and 44.7% and the 5-year RFS was 74.3, 57.6 and 28.7% in the low-risk group (neither pre-op NLR nor hydronephrosis), intermediate-risk group (either pre-op NLR or hydronephrosis) and high-risk group (pre-op NLR and hydronephrosis), respectively. High-risk group had significantly worse CSS (P = 0.0172) and RFS (P = 0.0014) than intermediate-risk group and low-risk group (CSS (P < 0.0001) and RFS (P < 0.0001)). CONCLUSIONS: Elevated pre-op NLR and hydronephrosis were identified as independent prognostic factors in patients with UTUC. These simple preoperative factors can stratify three prognostic groups and may help urologists in clinical decision-making before RNU.

Continuous Flow Deformability-Based Separation of Circulating Tumor Cells Using Microfluidic Ratchets.

Circulating tumor cells (CTCs) offer tremendous potential for the detection and characterization of cancer. A key challenge for their isolation and subsequent analysis is the extreme rarity of these cells in circulation. Here, a novel label-free method is described to enrich viable CTCs directly from whole blood based on their distinct deformability relative to hematological cells. This mechanism leverages the deformation of single cells through tapered micrometer scale constrictions using oscillatory flow in order to generate a ratcheting effect that produces distinct flow paths for CTCs, leukocytes, and erythrocytes. A label-free separation of circulating tumor cells from whole blood is demonstrated, where target cells can be separated from background cells based on deformability despite their nearly identical size. In doping experiments, this microfluidic device is able to capture >90% of cancer cells from unprocessed whole blood to achieve 10(4) -fold enrichment of target cells relative to leukocytes. In patients with metastatic castration-resistant prostate cancer, where CTCs are not significantly larger than leukocytes, CTCs can be captured based on deformability at 25× greater yield than with the conventional CellSearch system. Finally, the CTCs separated using this approach are collected in suspension and are available for downstream molecular characterization.

Incidence, Characteristics and Implications of Thromboembolic Events in Patients with Muscle Invasive Urothelial Carcinoma of the Bladder Undergoing Neoadjuvant Chemotherapy.

PURPOSE: Neoadjuvant chemotherapy and pelvic surgery are significant risk factors for thromboembolic events. Our study objectives were to investigate the timing, incidence and characteristics of thromboembolic events during and after neoadjuvant chemotherapy and subsequent radical cystectomy in patients with muscle invasive bladder cancer. MATERIALS AND METHODS: We performed a multi-institutional retrospective analysis of 761 patients who underwent neoadjuvant chemotherapy and radical cystectomy for muscle invasive bladder cancer from 2002 to 2014. Median followup from diagnosis was 21.4 months (range 3 to 272). Patient characteristics included the Khorana score, and the incidence and timing of thromboembolic events (before vs after radical cystectomy). Survival was calculated using the Kaplan-Meier method. The log rank test and multivariable Cox proportional hazards regression were used to compare survival between patients with vs without thromboembolic events. RESULTS: The Khorana score indicated an intermediate thromboembolic event risk in 88% of patients. The overall incidence of thromboembolic events in patients undergoing neoadjuvant chemotherapy was 14% with a wide variation of 5% to 32% among institutions. Patients with thromboembolic events were older (67.6 vs 64.6 years, p = 0.02) and received a longer neoadjuvant chemotherapy course (10.9 vs 9.7 weeks, p = 0.01) compared to patients without a thromboembolic event. Of the thromboembolic events 58% developed preoperatively and 72% were symptomatic. On multivariable regression analysis the development of a thromboembolic event was not significantly associated with decreased overall survival. However, pathological stage and a high Khorana score were adverse risk factors for overall survival. CONCLUSIONS: Thromboembolic events are common in patients with muscle invasive bladder cancer who undergo neoadjuvant chemotherapy before and after radical cystectomy. Our results suggest that a prospective trial of thromboembolic event prophylaxis during neoadjuvant chemotherapy is warranted.

VURD syndrome--does it really preserve long-term renal function?

PURPOSE: VURD (posterior urethral valves, unilateral vesicoureteral reflux and renal dysplasia) syndrome is the combination of persistent unilateral vesicoureteral reflux associated with an ipsilateral dysplastic, poorly functioning kidney in patients with posterior urethral valves. It was postulated that this syndrome may result in preservation of long-term renal function due to a pressure release pop-off mechanism. We determined the effects of VURD long-term renal outcomes. MATERIALS AND METHODS: We retrospectively reviewed the records of boys diagnosed with posterior urethral valves between 1983 and 2009 at a single pediatric tertiary hospital. Patients were divided into those with and those without VURD syndrome. The outcome of interest was renal impairment, defined as stage 3 or greater chronic kidney disease (glomerular filtration rate less than 60 ml/min/1.73 m(2)). RESULTS: We identified 89 patients, of whom 23 (26%) had VURD. Median followup was 77 and 57 months in the VURD and nonVURD groups, respectively. Seven patients (30%) with and 26 (39%) without VURD had significant renal impairment. Survival analysis using a Cox proportional hazard model showed no association between VURD and renal impairment (HR 1.05, 95% CI 0.65-1.70). The main predictors of renal function were the creatinine nadir and patient age at diagnosis. CONCLUSIONS: VURD syndrome does not seem to have a long-term protective effect on renal function.

Benefit of Neoadjuvant Cisplatin-based Chemotherapy for Invasive Bladder Cancer Patients Treated with Radiation-based Therapy in a Real-world Setting: An Inverse Probability Treatment Weighted Analysis.

BACKGROUND: Neoadjuvant chemotherapy (NAC) improves survival for patients with muscle-invasive bladder cancer (MIBC) treated with radical cystectomy. Studies on the potential benefit of NAC before radiation-based therapy (RT) are conflicting. OBJECTIVE: To evaluate the effect of NAC on patients with MIBC treated with curative-intent RT in a real-world setting. DESIGN, SETTING, AND PARTICIPANTS: The study cohort consisted of 785 patients with MIBC (cT2-4aN0-2M0) who underwent RT at academic centers across Canada. Patients were classified into two treatment groups based on the administration of NAC before RT (NAC vs no NAC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The inverse probability of treatment weighting (IPTW) with absolute standardized differences (ASDs) was used to balance covariates across treatment groups. The impact of NAC on complete response, overall, and cancer-specific survival (CSS) after RT in the weighted cohort was analyzed. RESULTS AND LIMITATIONS: After applying the exclusion criteria, 586 patients were included; 102 (17%) received NAC before RT. Patients in the NAC subgroup were younger (mean age 65 vs 77 yr; ASD 1.20); more likely to have Eastern Cooperative Oncology Group performance status 0-1 (87% vs 78%; ASD 0.28), lymphovascular invasion (32% vs 20%; ASD 0.27), higher cT stage (cT3-4 in 29% vs 20%; ASD 0.21), and higher cN stage (cN1-2 in 32% vs 4%; ASD 0.81); and more commonly treated with concurrent chemotherapy (79% vs 67%; ASD 0.28). After IPTW, NAC versus no NAC cohorts were well balanced (ASD <0.20) for all included covariates. NAC was significantly associated with improved CSS (hazard ratio [HR] 0.28; 95% confidence interval [CI] 0.14-0.56; p < 0.001) and overall survival (HR 0.56; 95% CI 0.38-0.84; p = 0.005). This study was limited by potential occult imbalances across treatment groups. CONCLUSIONS: If tolerated, NAC might be associated with improved survival and should be considered for eligible patients with MIBC planning to undergo bladder preservation with RT. Prospective trials are warranted. PATIENT SUMMARY: In this study, we showed that neoadjuvant chemotherapy might be associated with improved survival in patients with muscle-invasive bladder cancer who elect for curative-intent radiation-based therapy.

Effect of Complete Transurethral Resection on Oncologic Outcomes After Radiation Therapy for Muscle-Invasive Bladder Cancer.

PURPOSE: To compare the oncologic outcomes of patients with nonmetastatic muscle-invasive bladder cancer (MIBC) undergoing complete versus incomplete transurethral tumor resection (TURBT) before radiation therapy. METHODS AND MATERIALS: Patients with nonmetastatic MIBC who underwent curative-intent radiation therapy between 2002 and 2018 at 10 Canadian institutions were retrospectively evaluated. Inverse probability of treatment weighting was performed using baseline characteristics. Differences in survival outcomes by complete and incomplete TURBT were analyzed. RESULTS: Of the 757 patients included, 66% (498) had documentation of a complete and 34% (259) an incomplete TURBT. Before adjustment, 121 (47%) and 45 (9%) patients who underwent incomplete and complete TURBT, respectively, were diagnosed with cT3-4 tumor (P <.001). After weight-adjustment, all baseline cohort characteristics were balanced (absolute standardized differences < 0.1). The adjusted median follow-up was 27 months. Adjusted survival analyses showed no significant difference in 5-year overall survival (48% vs 52%, 1.03 [0.82-1.29]; P = .8), cancer-specific survival (64% vs 61%, 0.93 [0.70-1.25]; P = .7), metastasis-free survival (43% vs 46%, 0.97 [0.79-1.19]; P = .8), and disease-free survival (32% vs 35%, 0.95 [0.79-1.15]; P = .7) between the 2 groups. CONCLUSIONS: Complete TURBT may be associated with clinical organ-confined disease. Extent of TURBT was not independently associated with oncologic outcomes in patients with MIBC treated with radiation therapy.

Benefit of Whole-Pelvis Radiation for Patients With Muscle-Invasive Bladder Cancer: An Inverse Probability Treatment Weighted Analysis.

PURPOSE: The value of pelvic lymph node irradiation is debated for patients with muscle-invasive bladder cancer (MIBC) undergoing curative-intent radiation therapy (RT). We sought to compare the oncological outcomes between bladder-only (BO)-RT and whole-pelvis (WP)-RT using a large Canadian multicenter collaborative database. PATIENTS AND METHODS: The study cohort consisted of 809 patients with MIBC (cT2-4aN0-2M0) who underwent curative RT at academic centers across Canada. Patients were divided into two groups on the basis of the RT volume: WP-RT versus BO-RT. Inverse probability of treatment weighting (IPTW) and absolute standardized differences (ASDs) were used to balance covariates across treatment groups. Regression models were used to assess the effect of the RT volume on the rates of complete response (CR), cancer-specific survival (CSS), and overall survival (OS). RESULTS: After exclusion criteria, 599 patients were included, of whom 369 (61.6%) underwent WP-RT. Patients receiving WP-RT were younger (ASD, 0.41) and more likely to have an Eastern Cooperative Oncology Group performance status of 0-1 (ASD, 0.21), clinical node-positive disease (ASD, 0.40), and lymphovascular invasion (ASD, 0.25). In addition, WP-RT patients were more commonly treated with neoadjuvant chemotherapy (ASD, 0.29) and concurrent chemotherapy (ASD, 0.44). In the IPTW cohort, BO-RT and WP-RT groups were well balanced (all pretreatment parameters with an ASD <0.10). In multivariable analysis, WP-RT was not associated with CR rates post-RT (odds ratio, 1.14 [95 CI, 0.76 to 1.72]; P = .526) but was associated with both CSS (hazard ratio [HR], 0.66 [95% CI, 0.47 to 0.93]; P = .016) and OS (HR, 0.68 [95% CI, 0.54 to 0.87]; P = .002), independent of other prognostic factors. CONCLUSION: Our study demonstrated that WP radiation was associated with better survival compared with bladder radiation alone after adjusted analysis. Additional randomized controlled trials are needed to confirm our findings.

Imaging in benign prostatic hyperplasia: what is new?

PURPOSE OF REVIEW: This article discusses the new imaging techniques in diagnosis and treatment of benign prostatic hyperplasia by reviewing the most recent publications. RECENT FINDINGS: Imaging study for the evaluation of patients with lower urinary tract symptoms is not suggested by American Urology Association guidelines; however, European Association of Urology recommends the assessment of the upper urinary tract by modalities like ultrasound. Several new imaging indices like resistive index of capsular artery, presumed circle area ratio, prostatic urethral angle, intraprostatic protrusion, and detrusor wall thickness are used to find a noninvasive way for bladder outlet obstruction diagnosis. In addition to them, 3D transrectal ultrasound, near infrared spectroscopy, and MRI are used to add more practical findings in patient management. SUMMARY: Urologists have requested more imaging studies than expected for benign prostatic hyperplasia patients in recent years, and several studies have been done to find a noninvasive way to diagnose bladder outlet obstruction. However, none of them could play the urodynamic studies role in bladder outlet obstruction diagnosis.

Radiation-based Therapy for Muscle-invasive Bladder Cancer: Contemporary Outcomes Across Tertiary Centers.

BACKGROUND: Radiation therapy (RT) is an alternative to radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). OBJECTIVE: To analyze predictors of complete response (CR) and survival after RT for MIBC. DESIGN, SETTING, AND PARTICIPANTS: This was a multicenter retrospective study of 864 patients with nonmetastatic MIBC who underwent curative-intent RT from 2002 to 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Regression models were used to explore prognostic factors associated with CR, cancer-specific survival (CSS), and overall survival (OS). RESULTS AND LIMITATIONS: The median patient age was 77 yr and median follow-up was 34 mo. Disease stage was cT2 in 675 patients (78%) and cN0 in 766 (89%). Neoadjuvant chemotherapy (NAC) was given to 147 patients (17%) and concurrent chemotherapy to 542 (63%). A CR was experienced by 592 patients (78%). cT3-4 stage (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.29-0.63; p < 0.001) and hydronephrosis (OR 0.50, 95% CI 034-0.74; p = 0.001) were significantly associated with lower CR. The 5-yr survival rates were 63% for CSS and 49% for OS. Higher cT stage (HR 1.93, 95% CI 1.46-2.56; p < 0.001), carcinoma in situ (HR 2.10, 95% CI 1.25-3.53; p = 0.005), hydronephrosis (HR 2.36, 95% CI 1.79-3.10; p < 0.001), NAC use (HR 0.66, 95% CI 0.46-0.95; p = 0.025), and whole-pelvis RT (HR 0.66, 95% CI 0.51-0.86; p = 0.002) were independently associated with CSS; advanced age (HR 1.03, 95% CI 1.01-1.05; p = 0.001), worse performance status (HR 1.73, 95% CI 1.34-2.22; p < 0.001), hydronephrosis (HR 1.50, 95% CI 1.17-1.91; p = 0.001), NAC use (HR 0.69, 95% CI 0.49-0.97; p = 0.033), whole-pelvis RT (HR 0.64, 95% CI 0.51-0.80; p < 0.001), and being surgically unfit (HR 1.42, 95% CI 1.12-1.80; p = 0.004) were associated with OS. The study is limited by the heterogeneity of different treatment protocols. CONCLUSIONS: RT for MIBC yields a CR in most patients who elect for curative-intent bladder preservation. The benefit of NAC and whole-pelvis RT require prospective trial validation. PATIENT SUMMARY: We investigated outcomes for patients with muscle-invasive bladder cancer treated with curative-intent radiation therapy as an alternative to surgical removal of the bladder. The benefit of chemotherapy before radiotherapy and whole-pelvis radiation (bladder plus the pelvis lymph nodes) needs further study.

Lack of visual endoscopic appearance of ureteropelvic urothelial cancer; is it a deterrence for nephroureterectomy? A case study and literature review.

Two case reports are presented with an important question what should be done when an endoscopic appearance of the urotherial lesion is unavailable. As seen in clinical practice, many patients choose nephroureterectomy with frequent follow up procedures. The other question raised is that what should be done when the lesions are ureteroscopically inaccessible. These patients can avail the advantages of radical treatment without accepting the probable as initial form of treatment to evade the risk and detriments of unnecessary additional endoscopic procedures.

Successful treatment of recurrent small cell carcinoma of urinary bladder with pembrolizumab.

INTRODUCTION: Small cell carcinoma of urinary bladder is rare and has an aggressive malignant behavior and poor prognosis. Advanced bladder cancers are treated with immune checkpoint inhibitors, however, its efficacy for small cell carcinoma of urinary bladder is unclear. CASE PRESENTATION: A 54-year-old female, diagnosed with clinical stage T2N0M0 small cell carcinoma of urinary bladder, underwent radical cystectomy after three cycles of etoposide-cisplatin neoadjuvant chemotherapy. Despite the fact that pathological examination revealed no residual carcinoma in bladder in her cystectomy specimen, local recurrence of a 60-mm mass detected in the follow-up investigation 7.5 months later. This was completely treated by pembrolizumab without any adverse effects. Immunohistochemical staining revealed that the tumor had no programmed death ligand 1 expression but it showed CD8-positive T-lymphocyte infiltration into the tumor. CONCLUSION: Immune checkpoint inhibitors might have curative potentials for treatment of small cell carcinoma of urinary bladder.

Urinary Viral Shedding of COVID-19 and its Clinical Associations: A Systematic Review and Meta-analysis of Observational Studies.

OBJECTIVES: To review the current literature on the presence of COVID-19 virus in the urine of infected patients and to explore the clinical features that can predict the presence of COVID-19 in urine. MATERIALS AND METHODS: A systematic review of published literature between 30th December 2019 and 21st June 2020 was conducted on Pubmed, Google Scholar, Ovid, Scopus, and ISI web of science. Studies investigating urinary viral shedding of COVID-19 in infected patients were included. Two reviewers selected relative studies and performed quality assessment of individual studies. Meta-analysis was performed on the pooled case reports and cohort with a sample size of ≥ 9. RESULTS: Thirty-nine studies were finally included in the systematic review; 12 case reports, 26 case series, and one cohort study. Urinary samples from 533 patients were investigated. Fourteen studies reported the presence of COVID-19 in the urinary samples from 24 patients. The crude overall rate of COVID-19 detection in urinary samples was 4.5%. Considering case series and cohorts with a sample size of ≥ 9, the estimated viral shedding frequency was 1.18 % (CI 95%: 0.14 - 2.87) in the meta-analysis. Urinary viral load in most reports were lower than rectal or oropharyngeal samples. In adult patients, urinary shedding of COVID-19 was commonly detected in patients with moderate to severe disease (16 adult patients with moderate or severe disease versus two adult patients with mild disease). In children, urinary viral shedding of COVID-19 was reported in 4 children who all suffered from mild disease. Urinary viral shedding of COVID-19 was detected from day 1 to day 52 after disease onset. The pathogenicity of virus isolated from urine has been demonstrated in cell culture media in one study while another study failed to reveal replication of isolated viral RNA in cell cultures. Urinary symptoms were not attributed to urinary viral shedding. CONCLUSION: While COVID-19 is rarely detected in urine of infected individuals, infection transmission through urine still remains possible. In adult patients, infected urine is more likely in the presence of moderate or severe disease. Therefore, caution should be exerted when dealing with COVID-19 infected patients during medical interventions like endoscopy and urethral catheterization especially in symptomatic adult patients while in children caution should be exerted regardless of symptoms.

Renal cell carcinoma in presacral pelvic kidney.

Renal pelvic ectopia has been estimated to occur in 1 of 2100 to 3000 autopsies. Renal cell carcinoma (RCC) is a very rare phenomenon in an ectopic kidney. According to our review of literature, there are only seven reports of RCC occurrence in pelvic kidneys. We describe a patient with RCC of presacral ectopic kidney who underwent radical nephrectomy at our medical center.

Natural history of prostatic lesions on serial multiparametric magnetic resonance imaging.

INTRODUCTION: The natural history of prostatic lesions identified on multiparametric magnetic resonance imaging (mpMRI) is largely unknown. We aimed to describe changes observed over time on serial MRI. METHODS: All patients with ≥2 MRI studies between 2008 and 2015 at our institution were identified. MRI progression was defined as an increase in Prostate Imaging Reporting and Data System (PI-RADS; version 2) or size of existing lesions, or the appearance of a new lesion PIRADS ≥4. Patients on active surveillance (AS) were analyzed for correlation of MRI progression to biopsy reclassification. RESULTS: A total of 83 patients (54 on AS and 29 for diagnostic purposes) underwent serial MRI, with a mean interval of 1.9 years between scans. At baseline, 115 lesions (66 index, 49 non-index) were identified. Index lesions were more likely than non-index lesions to increase in size ≥2 mm (36.2 vs. 7.3 %; p=0.002). Overall progression was more likely to be seen among the index cohort (34.8 vs. 7.6%; p<0.001). New lesions with PIRADS ≥4 were seen on second imaging in 13 (16.5%) men, and became the index lesion in 29 cases (34.9%). Eighteen men on AS showed evidence of MRI progression (five with new lesions, 13 with progression of a previous lesion). Biopsy reclassification was present in three men (16.7%) with and seven men without MRI progression (19.4%). CONCLUSIONS: Overall changes in size and PIRADS scores of index lesions on MRI were small. New lesions were common, but usually did not alter management.