Testicular self-examination for early detection of testicular cancer.

Testicular cancer (TCa) commonly presents as a painless scrotal mass. It has been suggested that testicular self-examination (TSE) can help in early detection and thus potentially improve treatment outcomes and prognosis. While TSE is more well established in guideline recommendations for patients with a known history of TCa, its role in healthy young men is less established and controversial. In this paper, we review contemporary data to provide an updated recommendation.

Wunderlich syndrome secondary to cyst rupture and concurrent anticoagulation.

Wunderlich syndrome (WS) is a rare triad of flank pain, flank mass and hypovolemic shock and is classically attributed to angiomyolipomata or neoplasms. Treatment is guided by clinical severity: conservative, selective arterial embolization, or nephrectomy. We report an atypical case of a 69-year old man with a pre-existing 9 cm left renal tumor who developed WS secondary to anticoagulation and simple cyst rupture from his contralateral kidney, complicated by abdominal compartment syndrome with hemodynamic instability despite inotropic support and robust resuscitation. Early recognition and source control via radical nephrectomy were essential in securing a positive outcome.

Outcomes of Robotic versus Laparoscopic Partial Nephrectomy: an Updated Meta-Analysis of 4,919 Patients.

PURPOSE: We evaluated the current literature comparing outcomes of robotic vs laparoscopic partial nephrectomy. MATERIALS AND METHODS: We performed a literature search according to Cochrane guidelines up to December 2015 including studies comparing robotic and laparoscopic partial nephrectomy, and we compared baseline patient and tumor characteristics. We performed a meta-analysis to evaluate safety, effectiveness and functional outcomes of robotic vs laparoscopic partial nephrectomy using weighted mean difference and inverse variance pooled risk ratios, respectively. RESULTS: A total of 4,919 patients were included from 25 studies (robotic partial nephrectomy 2,681, laparoscopic partial nephrectomy 2,238). There were no significant differences between the 2 groups in terms of age, gender, laterality and final malignant pathology. Patients treated with robotic partial nephrectomy had larger tumors (WMD 0.17 cm, p=0.001) and higher mean R.E.N.A.L. nephrometry scores (WMD 0.59, p=0.002), and were associated with a decreased likelihood of conversion to laparoscopic/open surgery compared to laparoscopic partial nephrectomy (RR 0.36, p <0.001), any (Clavien 1 or greater) (RR 0.84, p=0.007) and major (Clavien 3 or greater) (RR 0.71, p=0.023) complications, positive margins (RR 0.53, p <0.001) and shorter warm ischemia time by 4.3 minutes (p <0.001). Both approaches had similar operative times (WMD -12.2 minutes, p=0.34), estimated blood loss (WMD -24.6 ml, p=0.15) and postoperative change in estimated glomerular filtration rate. CONCLUSIONS: This updated meta-analysis of retrospective cohort studies demonstrated that robotic partial nephrectomy confers a superior morbidity profile compared to laparoscopic partial nephrectomy in most of the examined perioperative outcomes. Despite being the strongest available evidence (Level 2b) for outcomes of robotic vs laparoscopic partial nephrectomy thus far, there have been no completed or ongoing randomized trials to lend Level 1 support for either approach.

A systematic review and meta-analysis on delaying surgery for urothelial carcinoma of bladder and upper tract urothelial carcinoma: Implications for the COVID19 pandemic and beyond.

Purpose: The COVID-19 pandemic has led to competing strains on hospital resources and healthcare personnel. Patients with newly diagnosed invasive urothelial carcinomas of bladder (UCB) upper tract (UTUC) may experience delays to definitive radical cystectomy (RC) or radical nephro-ureterectomy (RNU) respectively. We evaluate the impact of delaying definitive surgery on survival outcomes for invasive UCB and UTUC. Methods: We searched for all studies investigating delayed urologic cancer surgery in Medline and Embase up to June 2020. A systematic review and meta-analysis was performed. Results: We identified a total of 30 studies with 32,591 patients. Across 13 studies (n = 12,201), a delay from diagnosis of bladder cancer/TURBT to RC was associated with poorer overall survival (HR 1.25, 95% CI: 1.09-1.45, p = 0.002). For patients who underwent neoadjuvant chemotherapy before RC, across the 5 studies (n = 4,316 patients), a delay between neoadjuvant chemotherapy and radical cystectomy was not found to be significantly associated with overall survival (pooled HR 1.37, 95% CI: 0.96-1.94, p = 0.08). For UTUC, 6 studies (n = 4,629) found that delay between diagnosis of UTUC to RNU was associated with poorer overall survival (pooled HR 1.55, 95% CI: 1.19-2.02, p = 0.001) and cancer-specific survival (pooled HR of 2.56, 95% CI: 1.50-4.37, p = 0.001). Limitations included between-study heterogeneity, particularly in the definitions of delay cut-off periods between diagnosis to surgery. Conclusions: A delay from diagnosis of UCB or UTUC to definitive RC or RNU was associated with poorer survival outcomes. This was not the case for patients who received neoadjuvant chemotherapy.

Neoadjuvant and Adjuvant Chemotherapy for Upper Tract Urothelial Carcinoma: A 2020 Systematic Review and Meta-analysis, and Future Perspectives on Systemic Therapy.

CONTEXT: To improve the prognosis of upper tract urothelial carcinoma (UTUC), clinicians have used neoadjuvant chemotherapy (NAC) or adjuvant chemotherapy (AC) before or after radical nephroureterectomy (RNU). Despite some new data, the evidence remains mixed on their efficacy. OBJECTIVE: To update the current evidence on the role of NAC and AC for UTUC. EVIDENCE ACQUISITION: We searched for all studies investigating NAC or AC for UTUC in Medline, Embase, the Cochrane Central Register of Controlled Trials, and abstracts from the American Society of Clinical Oncology meetings up to February 2020. A systematic review and meta-analysis was performed. EVIDENCE SYNTHESIS: For NAC, the pooled pathologic complete response rate (≤ypT0N0M0) was 11% (n = 811) and pathologic partial response rate (≤ypT1N0M0) was 43% (n = 869), both across 14 studies. Across six studies, the pooled hazard ratios (HRs) were 0.44 (95% confidence interval [CI]: 0.32-0.59, p < 0.001) for overall survival (OS) and 0.38 (95% CI: 0.24-0.61, p < 0.001) for cancer-specific survival (CSS) in favor of NAC. The evidence for NAC is at best level 2. As for AC, there was a benefit in OS (pooled HR 0.77; 95% CI: 0.64-0.92, p = 0.004 across 14 studies and 7983 patients), CSS (pooled HR 0.79; 95% CI: 0.69-0.91, p = 0.001 across 18 studies and 5659 patients), and disease-free survival (DFS; pooled HR 0.52; 95% CI: 0.38-0.70 across four studies and 602 patients). While most studies were retrospective (level 2 evidence), there were two prospective randomized trials providing level 1 evidence. There are currently four phase 2 trials on neoadjuvant immunotherapy and three phase 2 trials on adjuvant immunotherapy for UTUC. CONCLUSIONS: NAC for UTUC confers a favorable pathologic response and tumor downstaging rate, and an OS and CSS benefit compared with RNU alone. AC confers an OS, CSS, and DFS benefit compared with RNU alone. Currently, the evidence for AC appears stronger (with positive level 1 evidence) than that for NAC (at best level 2 evidence). Limited data are available for chemoimmunotherapy approaches, but preliminary data support an active research investment. PATIENT SUMMARY: After a comprehensive search of the latest studies examining the role of neoadjuvant and adjuvant chemotherapy for upper tract urothelial cancer, the pooled evidence shows that perioperative chemotherapy was beneficial for prolonging survival; however, the evidence for adjuvant chemotherapy was stronger than that for neoadjuvant chemotherapy.

Acute idiopathic scrotal edema in the adult: A case report.

Acute idiopathic scrotal edema (AISE) is a self-limiting disease of uncertain etiology, more common in children. It is characterized by the rapid onset and progression of edema and erythema of the scrotal skin and dartos. Although AISE does not involve the underlying testis and paratesticular structures, on initial presentation it is challenging to differentiate from other causes of acute scrotum. It is a difficult but important diagnosis, as correct identification avoids unnecessary surgical scrotal exploration. We discuss a case of AISE in a 23-year-old patient, and highlight the clinical and sonographic features which, in retrospect, were indicative of the diagnosis.

Optimal Management of Upper Tract Urothelial Carcinoma: Current Perspectives.

INTRODUCTION: Upper tract urothelial carcinoma (UTUC) is a relatively uncommon urologic malignancy for which there has not been significant improvement in survival over the past few decades, highlighting the need for optimal multi-modality management. METHODS: A non-systematic review of the latest literature was performed to include relevant articles up to June 2019. It summarizes the epidemiologic risk factors associated with UTUC, including smoking, carcinogenic aromatic amines, arsenic, aristolochic acid, and Lynch syndrome. Molecular pathways underlying UTUC and potential druggable targets are outlined. RESULTS: Surgical management for UTUC includes kidney-sparing surgery (KSS) for low-risk disease and radical nephroureterectomy (RNU) for high-risk disease. Endoscopic management of UTUC may include ureteroscopic or percutaneous resection. Topical instillation therapy post-KSS aims to reduce recurrence, progression and to treat carcinoma-in-situ; this may be achieved retrogradely (via ureteric catheterization), antegradely (via percutaneous nephrostomy) or via reflux through double-J stent. RNU, which may be performed via open, laparoscopic or robot-assisted approaches, is the gold standard treatment for high-risk UTUC. The distal cuff may be dealt with extravesical, transvesical or endoscopic techniques. Peri-operative chemotherapy and immunotherapy are increasingly utilized; level 1 evidence exists for adjuvant chemotherapy, but neoadjuvant chemotherapy is favored as kidney function is better prior to RNU. Immunotherapy is primarily reserved for metastatic UTUC but is currently being investigated in the perioperative setting. CONCLUSION: The optimal management of UTUC includes a firm understanding of the epidemiological factors and molecular pathways. Surgical management includes KSS for low-risk disease and RNU for high-risk disease. Peri-operative immunotherapy and chemotherapy may be considered as evidence mounts.

Müllerianosis: A Case Report.

Background: Müllerianosis is a rare condition with ∼40 reported cases to date. It presents clinically as hematuria, dysuria, and pelvic pain. It most commonly affects the urinary bladder and affects women of fertile age. Case Presentation: This is a case of a 43-year-old Chinese woman, with a medical history of thyroid cancer post-thyroidectomy. She had no history of gynecologic nor pelvic procedures done. Conclusion: Even though müllerianosis has a benign course, it is important to note that it may also have an atypical presentation such as acute renal colic. Also, malignancy will need to be ruled out as some cases have been associated with malignancy. In this case, the initial CT scan showed adjacent urinary bladder wall thickening near the uterus. This prompted further imaging with MRI to exclude uterine involvement. Fortunately, histology confirmed it to be müllerianosis.

Clinical outcomes of external beam radiotherapy in patients with localized prostate cancer: Does dose escalation matter?

BACKGROUND: To report outcomes of localized prostate cancer treated with radical external beam radiation therapy (EBRT) in our institution over a 14-year period, and to determine the impact of dose escalation of prostate cancer outcomes. METHODS: Patients with T1-T4 N0 M0 prostate cancer who received radical EBRT between January 2002 and December 2015 were reviewed retrospectively. Clinical data were obtained via the institutional electronic medical records. The primary endpoint was 5-year overall survival (OS). The secondary endpoints were 5-year freedom from biochemical failure (FFBF) and treatment toxicities. RESULTS: A total of 200 eligible patients were identified. Median follow-up duration was 48 months. 13%, 36% and 51% of patients had low-, intermediate- and high-risk disease. Median dose was 79.2 Gy. The 5-year OS were 90%, 87% and 78% and FFBF were 94%, 100% and 81% for low-, intermediate- and high-risk patients, respectively. Multivariable analysis showed that Eastern Cooperate Oncology Group performance status 2 and Gleason grade group 5 were independent predictors of worse OS. The incidence of grade ≥2 proctitis was 24.5%. Dose escalation was significantly associated with increased incidence of grade ≥2 proctitis (odd ratio, 4.42; 95% confidence interval, 1.95-10.08; P < 0.01). CONCLUSION: Men with localized prostate cancer treated with EBRT in our population had excellent 5-year OS and biochemical outcomes. Dose escalation did not significantly improve these outcomes but was associated with significantly increased risk of grade ≥2 proctitis in our population. Future studies should be performed to identify patients who will benefit the most from dose-escalated EBRT.

Urethroplasty for anterior urethral strictures in a community-based urology practice.

INTRODUCTION: The outcome of urethroplasty for the anterior urethral stricture is superior to internal urethrotomy. However, the excellent results are often reported by tertiary medical centres and most urologists in general urological practice do not offer urethroplasty. We review the results of our institution to ascertain whether equivalent results are achievable in a district hospital urology service. METHODS: Over a 22-month period, 26 urethroplasties were performed. Mean age was 44.2 years (range: 16-83 years) and median follow-up was 14.6 months (range: 0.6-40.2 months). Anastomotic repair was performed in five, substitution urethroplasty in 15 (nine flaps and six grafts) and staged urethroplasty in 6. Length of strictures ranged from less than 0.2 cm to greater than 10 cm. RESULTS: Stricture-free rate of 90.5% at 1 year was observed. Only two cases developed repeat stricture formation. Other minor complications included one epididymo-orchitis and one haematoma. CONCLUSION: Good early outcome for urethroplasty for anterior urethral strictures is achievable in a district hospital practice. Keys to good outcome include having a dedicated team and a wide repertoire of urethral reconstructive techniques.

Xanthogranulomatous pyelonephritis presenting as Proteus preperitoneal abscess.

Xanthogranulomatous pyelonephritis (XGPN) is a rare form of chronic pyelonephritis with progressive loss of renal function. Commonly, obstructing urinary calculi are seen. It is difficult to differentiate between XGPN and malignancy in many cases, and the diagnosis is usually only confirmed post-operatively upon histopathological examination of the specimen. Surgical treatment is often the main treatment modality due to suspicion for malignancy. Here, we present a case of XGPN that presented with abdominal distension, which was eventually discovered to be due to a preperitoneal abscess.

Developing technical expertise in robot-assisted laparoscopic prostatectomy in a moderate-volume center through a proctor-based team approach.

Our aim is to report our preliminary experience of a proctor-based team approach in robot-assisted laparoscopic prostatectomy (RALP) for the treatment of localized prostate cancer. Data was collected between December 2008 and February 2012. RALP was performed on 100 consecutive patients with prostate cancer by a team of five urologists proctored by two fellowship-trained surgeons from a single hospital. Clinical and pathological data of these patients were reviewed. The mean age of the patients was 66 years (range 48-76). Clinical stages were 82 % cT1c, 3 % cT1b, 13 % cT2a and 2 % cT3a disease. Preoperative mean prostate-specific antigen level was 11.33 ng/ml (SD 10.47). Mean operative time was 342 min and mean blood loss was 717 ml (SD 988). Mean hospital stay and duration of the indwelling catheter were 3.2 days (SD 1.8) and 12.6 days (SD 8.5), respectively. Pathological staging showed 65 patients with pT2a (65 %) disease and 33 patients with pT3a (33 %) disease. Thirty-five patients (35 %) had positive surgical margins. Eighteen patients underwent adjuvant radiotherapy. Overall postoperative complication rate was 14 %. There were six Clavien grade 1 complications, seven Clavien grade 2 complications and one Clavien grade 3 complication. At mean follow-up of 36 months, 100 % of patients remained free of biochemical recurrence with continence at 70 %. Our proctor-based team approach will continue to improve each surgeon's technical competency. He or she will continue to improve and gradually move on to achieving his or her outcomes learning curve.