External validation and comparison of magnetic resonance imaging-based risk prediction models for prostate biopsy stratification.

PURPOSE: Magnetic resonance imaging (MRI) is a promising tool for risk assessment, potentially reducing the burden of unnecessary prostate biopsies. Risk prediction models that incorporate MRI data have gained attention, but their external validation and comparison are essential for guiding clinical practice. The aim is to externally validate and compare risk prediction models for the diagnosis of clinically significant prostate cancer (csPCa). METHODS: A cohort of 4606 patients across fifteen European tertiary referral centers were identified from a prospective maintained database between January 2016 and April 2023. Transrectal or transperineal image-fusion MRI-targeted and systematic biopsies for PI-RADS score of ≥ 3 or ≥ 2 depending on patient characteristics and physician preferences. Probabilities for csPCa, defined as International Society of Urological Pathology (ISUP) grade ≥ 2, were calculated for each patients using eight models. Performance was characterized by area under the receiver operating characteristic curve (AUC), calibration, and net benefit. Subgroup analyses were performed across various clinically relevant subgroups. RESULTS: Overall, csPCa was detected in 2154 (47%) patients. The models exhibited satisfactory performance, demonstrating good discrimination (AUC ranging from 0.75 to 0.78, p < 0.001), adequate calibration, and high net benefit. The model described by Alberts showed the highest clinical utility for threshold probabilities between 10 and 20%. Subgroup analyses highlighted variations in models' performance, particularly when stratified according to PSA level, biopsy technique and PI-RADS version. CONCLUSIONS: We report a comprehensive external validation of risk prediction models for csPCa diagnosis in patients who underwent MRI-targeted and systematic biopsies. The model by Alberts demonstrated superior clinical utility and should be favored when determining the need for a prostate biopsy.

External validation of biochemical recurrence definition to predict oncologic outcomes following focal therapy for localized prostate cancer using high intensity focused ultrasound.

PURPOSE: This is an external validation of several biochemical recurrence definitions based on prostate specific antigen criteria (PSA). The purpose is to predict the need of additional treatment and failure after focal therapy using high intensity focused ultrasound (HIFU) for localized prostate cancer (PCa). MATERIALS AND METHODS: A total of 343 consecutive patients who underwent HIFU with Ablatherm® and Focal One® devices between June 2001 and November 2020 were identified. Treatment failure was defined as clinically significant PCa on postoperative biopsy, the need for salvage radical or systematic treatment, metastasis, or PCa-related death. The biochemical recurrence definitions tested were PSA nadir, time to PSA nadir, percentage of PSA reduction, Huber et al. criteria defined as PSA nadir + 1 ng/mL at 12 months or PSA nadir + 1.5 ng/mL at 24-36 months. Multivariable Cox regression analysis and decision-curve analysis were used to validate and compare criteria. Kaplan-Meier analysis was used to assess criteria associated with the highest accuracy. RESULTS: One hundred seventy-eight patients met the inclusion criteria and were analyzed. Overall, 61 (34%) and 41 (23%) patients had an additional treatment and failure with a median follow-up of 52 months. At multivariable analysis, model including Huber et al. criteria exhibited the highest Harrell's C-index for the prediction of the need of additional treatment (hazard ratio [HR]: 10, p < 0.001, c-index: 84%) and treatment failure (HR: 9.1, p < 0.001, c-index: 82%) as well as higher net benefit. The 60-months need of additional treatment and treatment failure-free survival were 89% and 98% compared to 26% and 49%, respectively, when stratified according to Huber et al. criteria (Log-rank test, p < 0.001). Similar results were found after excluding patient with non-clinically significant PCa at initial biopsy. CONCLUSIONS: We report an external validation of biochemical recurrence definitions predicting the need of additional treatment and failure after focal therapy using HIFU for localized PCa. Huber et al. criteria were identified as the most accurate and could be used to guide clinicians toward further evaluation and salvage treatments.

Transperineal or Transrectal Magnetic Resonance Imaging-targeted Biopsy for Prostate Cancer Detection.

BACKGROUND AND OBJECTIVE: A notable paradigm shift has emerged in the choice of prostate biopsy approach, with a transition from transrectal biopsy (TRBx) to transperineal biopsy (TPBx) driven by the lower risk of severe urinary tract infections. The impact of this change on detection of clinically significant prostate cancer (csPCa) remains a subject of debate. Our aim was to compare the csPCa detection rate of TRBx and TPBx. METHODS: Patients who underwent magnetic resonance imaging (MRI)-targeted and systematic biopsies for clinically localized PCa at 15 European referral centers from 2016 to 2023 were included. A propensity score matching (PSM) analysis was performed to minimize selection biases. Logistic regression models were used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). KEY FINDINGS AND LIMITATIONS: Of 3949 patients who met the study criteria, 2187 underwent TRBx and 1762 underwent TPBx. PSM resulted in 1301 matched pairs for analysis. Patient demographics and tumor characteristics were comparable in the matched cohorts. TPBx versus TRBx was associated with greater detection of csPCa, whether defined as International Society of Urological Pathology grade group ≥2 (51% vs 45%; OR 1.37, 95% CI 1.15-1.63; p = 0.001) or grade group ≥3 (29% vs 23%; OR 1.38, 95% CI 1.13-1.67; p = 0.001). Similar results were found when considering MRI-targeted biopsy alone and after stratifying patients according to tumor location, Prostate Imaging-Reporting and Data System score, and clinical features. Limitations include the retrospective nature of the study and the absence of centralized MRI review. CONCLUSIONS: Our findings bolster existing understanding of the additional advantages offered by TPBx. Further randomized trials to fully validate these findings are awaited. PATIENT SUMMARY: We compared the rate of detection of clinically significant prostate cancer with magnetic resonance imaging (MRI)-guided biopsies in which the sample needle is passed through the perineum or the rectum. Our results suggest that the perineal approach is associated with better detection of aggressive prostate cancer.

The Added Value of Side-specific Systematic Biopsy in Patients Diagnosed by Magnetic Resonance Imaging-targeted Prostate Biopsy.

BACKGROUND: Systematic biopsy (SB) combined with magnetic resonance imaging (MRI)-targeted biopsy is still recommended considering the risk of missing clinically significant prostate cancer (csPCa). OBJECTIVE: To evaluate the added value in csPCa detection on side-specific SB relative to MRI lesion and to externally validate the Noujeim risk stratification model that predicts the risk of csPCa on distant SB cores relative to the index MRI lesion. DESIGN, SETTING, AND PARTICIPANTS: Overall, 4841 consecutive patients diagnosed by MRI-targeted biopsy and SB for Prostate Imaging Reporting and Data System score ≥3 lesions were identified from a prospectively maintained database between January 2016 and April 2023 at 15 European referral centers. A total of 2387 patients met the inclusion criteria and were included in the analysis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: McNemar's test was used to compare the csPCa detection rate between several biopsy strategies including MRI-targeted biopsy, side-specific SB, and a combination of both. Model performance was evaluated in terms of discrimination using area under the receiver operation characteristic curve (AUC), calibration plots, and decision curve analysis. Clinically significant prostate cancer was defined as International Society of Urological Pathology grade group ≥2. RESULTS AND LIMITATIONS: Overall, the csPCa detection rate was 49%. Considering MRI-targeted biopsy as reference, the added values in terms of csPCa detection were 5.8% (relative increase of 13%), 4.2% (relative increase of 9.8%), and 2.8% (relative increase of 6.1%) for SB, ipsilateral SB, and contralateral SB, respectively. Only 35 patients (1.5%) exclusively had csPCa on contralateral SB (p < 0.001). Considering patients with csPCa on MRI-targeted biopsy and ipsilateral SB, the upgrading rate was 2% (20/961) using contralateral SB (p < 0.001). The Noujeim model exhibited modest performance (AUC of 0.63) when tested using our validation set. CONCLUSIONS: The added value of contralateral SB was negligible in terms of cancer detection and upgrading rates. The Noujeim model could be included in the decision-making process regarding the appropriate prostate biopsy strategy. PATIENT SUMMARY: In the present study, we collected a set of patients who underwent magnetic resonance imaging (MRI)-targeted and systematic biopsies for the detection of prostate cancer. We found that biopsies taken at the opposite side of the MRI suspicious lesion have a negligible impact on cancer detection. We also validate a risk stratification model that predicts the risk of cancer on biopsies beyond 10 mm from the initial lesion, which could be used in daily practice to improve the personalization of the prostate biopsy.

Renal cell carcinoma in the pediatric population: A case report and review of the literature.

Renal cell carcinoma is a cancer thought to originate from renal epithelial cells. Commonly seen in patients older than 60 years of age, renal cell carcinoma presents as rare pathological entity seen in urological cancers among the pediatric population. A 17-year-old female patient presented with complaints of intermittency, dysuria, and gross hematuria. Radiological imaging was in favor of a left renal mass. Under general anesthesia, the left kidney was completely laparoscopically resected and sent to pathology, which along with correlating the age group of the patient and the morphology on pathological analysis, was suggestive of microphthalmia family translocation renal cell carcinoma.

The BETTY Score to Predict Perioperative Outcomes in Surgical Patients.

The aim of this study is to evaluate a new user-friendly scoring system, namely the BETTY score, that aims to predict 30-day patient outcomes after surgery. In this first description, we rely on a population of prostate cancer patients undergoing robot-assisted radical prostatectomy. The BETTY score includes the patient's American Society of Anesthesiologists score, the body mass index, and intraoperative data, including operative time, estimated blood loss, any major intraoperative complications, hemodynamic, and/or respiratory instability. There is an inverse relationship between the score and severity. Three clusters assessing the risk of postoperative events were defined: low, intermediate, and high risk of postoperative events. A total of 297 patients was included. The median length of hospital stay was 1 day (IQR1-2). Unplanned visits, readmissions, any complications, and serious complications occurred in 17.2%, 11.8%, 28.3%, and 5% of cases, respectively. We found a statistically significant correlation between the BETTY score and all endpoints analyzed (all p ≤ 0.01). A total of 275, 20, and 2 patients were classified as low-, intermediate-, and high-risk according to the BETTY scoring system, respectively. Compared with low-risk patients, patients at intermediate-risk were associated with worse outcomes for all endpoints analyzed (all p ≤ 0.04). Future studies, in various surgical subspecialties, are ongoing to confirm the usefulness of this easy-to-use score in routine.

Intra-Cavernosal Injection of Botulinum Toxin in the Treatment of Erectile Dysfunction: a Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the role of botulinum toxin in treating erectile dysfunction as a novel treatment strategy avoiding morbid and irreversible surgeries. METHODS: A systematic review of literature was conducted from January 1990 through July 31, 2021. Search engines used included PubMed, Embase and Medline databases, to identify studies investigating botulinum toxin in erectile dysfunction, published in English. Seven studies in total were included in our review including two pre-clinical studies. A meta-analysis was performed on three outcomes included commonly in at least two studies. Among the different parameters assessed were, Erection Hardness Score (EHS), Peak Systolic Velocity in cavernosal artery (PSV) and the Sexual Health Inventory for Men (SHIM) score. RESULTS: A clear benefit was noted for intracavernosal injection (ICI) of botulinum toxin (BoNT-A) on PSV with a mean difference (MD) of 10.82 [4.99, 16.65] and a heterogeneity of I2=61%. EHS results favored BoNT-A as well over placebo with a MD of 0.7 [0.47, 0.93] and heterogeneity of I2=94%. As for SHIM score, with a heterogeneity of I2=85%, no statistically significant difference was found (MD 0.58 [-0.03, 1.20]). CONCLUSION: Our review and meta-analysis have shown statistical significance for the benefit of BoNT-A in terms of EHS and PSV. However, this statistical significance should be interpreted in light of the given limitations: small sample size, heterogeneity in data collection, patient selection bias, and clinical significance of the measured differences. ICI of BoNT-A should currently be limited to clinical studies to further elucidate its clinical benefit.

The role of perilesional and multiparametric resonance imaging-targeted biopsies to reduce the risk of upgrading at radical prostatectomy pathology: A retrospective monocentric study.

PURPOSE: To evaluate histopathologic upgrading between biopsy methods and whole-mount prostatectomy specimens in International Society of Urological Pathology grade group. METHODS: Overall, 134 patients, including 175 magnetic resonance imaging (MRI)-suspicious lesions, diagnosed on MRI-targeted (TB) and systematic (SB) biopsies before radical prostatectomy were retrospectively analyzed from a prospectively maintained database. Perilesional (PLB) and "extended" perilesional (ePLB) biopsies were defined as those taken within a circumferential zone of 5 and 10 mm around magnetic resonance imaging (MRI)-suspicious lesion respectively. Proportion of upgrading at prostatectomy pathology were compared between TB, TB + PLB, TP + ePLB and TB + SB. Uni- and multivariable logistic regressions assessed predictors of upgrading for TB + ePLB method. RESULTS: Focusing on index lesion, median (interquartile range) number of cores taken was 4 (3-4) for TB, 5 (4-6) for TB + PLB, 6 (5-8) for TB + ePLB and 12 (12-15) for TB + SB. A higher upgrading proportion was detected upon comparing TB and TB + PLB methods to TB + SB (32 vs. 19%, P = 0.001, 26 vs. 19%, P = 0.04, respectively). Conversely, no significant difference was found between TB + ePLB compared to TB + SB (23 vs. 19%, P = 0.2). Proportion of downgrading was similar regardless of biopsy method (all P > 0.1). At multivariable analysis, Prostate Imaging-Reporting and Data System Steering score, total number of positive ePLB cores and International Society of Urological Pathology Grade Group were independent predictors of upgrading (all P ≤ 0.03). Similar results were found by adding data from non-index lesions. CONCLUSION: Our finding suggest that MRI-targeted biopsies associated with perilesional sampling in a circumferential zone of 10 mm reduced upgrading proportion and showed similar accuracy as the current gold standard combination. Further prospective studies comparing biopsy methods are expected to validate this diagnostic strategy.

A Conservative Approach to Inflammatory Myofibroblastic Tumor of the Bladder: A Case Report and Review of Literature.

Inflammatory myofibroblastic tumors (IMTs) are particularly rare tumors that have been described in various anatomic locations, of which the urinary bladder is the most common. These benign tumors are amendable to conservative therapy but are notoriously difficult to diagnose given their mimicry of malignant sarcomas and sarcomatoid carcinomas, making an accurate diagnosis paramount to spare a patient radical and unnecessary treatment. We hereby present the case of a 37-year-old female patient who was diagnosed with an IMT of the urinary bladder during workup for painless gross hematuria. Patient was successfully managed with a laparoscopic partial cystectomy and is free of recurrence 5 years after surgery. IMTs are rare benign tumors that share the same clinical presentation as malignant bladder tumors. Deep biopsy and experienced pathologist are crucial in establishing diagnosis and avoiding patient radical treatment. This case is a classical demonstration of a remarkably rare tumor that was adequately managed with conservative therapy, achieving excellent clinical outcomes.

Robotic Partial Cystectomy for Urachal Carcinoma: A Case Report and Review of the Literature.

Urachal carcinoma is a very rare tumor, commonly found in the urachal remnant connecting the bladder dome to the umbilicus. Diagnosis is often challenging due to the location of the tumor and its late presentation. We hereby report the case of a 49-year-old female where the diagnosis of urachal carcinoma was made and a robotic partial cystectomy associated with en bloc resection of the umbilicus was performed. We aim to present the clinical aspects, presentation, and diagnosis of this rare entity along with a review of the literature.

Contemporary management of benign uretero-enteric strictures after cystectomy: a systematic review.

INTRODUCTION: Uretero-enteric stricture (UES) is a common postoperative complication after radical cystectomy with urinary diversion. The aim of this systematic review was to discuss the contemporary management of benign UES after cystectomy and to compare the different surgical approaches. EVIDENCE ACQUISITION: A systematic review was performed from January 2000 to January 2021. Search engines used included PubMed, Embase and Medline databases. Search query were: (["ureteroileal" OR "uretero-ileal" OR "ureteroenteric" OR "uretero-enteric"] AND ["stricture" OR "stenosis"]) AND ("management" OR "treatment"). Study selection followed the PRISMA statement. Studies tackling management of UES, either through open, endoscopic, laparoscopic or robot-assisted approaches, were included in our systematic review. EVIDENCE SYNTHESIS: Forty-one studies were finally included in this systematic review. No prospective studies were found; all included studies were retrospective. Open surgical repair had 78-100% success rate, a significant rate of complications, and a low recurrence rate (6-8%). Endourological management decreased complication rate, length-of-stay, and blood loss, with lower success (15-50%) and higher recurrence rates (62-91%) compared to open surgery. Robotic assisted surgery showed comparable success rates to open surgery (80-100%), while limiting the number of major complications and hospital length-of-stay. CONCLUSIONS: Surgical management of UES remains challenging. Open surgery maintains a role given its high success rate, at the cost of a significant morbidity. On the other hand, endourological procedures offer a favorable and low complication risk, but a low long-term success rate. Robotic-assisted surgery is emerging with a valid resolution of UES as it offers comparable success rates to an open approach, while reducing surgical morbidity. Head-to-head comparisons are awaited to confirm these findings.

Primary Nocturnal Enuresis: A Novel Therapeutic Strategy With Higher Efficacy.

OBJECTIVE: To introduce a new protocol for patients with primary nocturnal enuresis to increase efficacy of treatment and decrease relapse rate. METHODS: A prospective study was done on 185 children diagnosed with nocturnal enuresis between the years 2007 and 2014. Inclusion criteria consisted of age >5 years, monosymptomatic enuresis or non-monosymptomatic enuresis, strict abidance by the protocol, and follow-up >24 months. Exclusion criteria consisted of secondary enuresis, poor compliance to protocol, and neurogenic bladder. Participants were started on combination therapy of desmopressin 120 µg (MELT formula) once per day and propiverine 7.5 mg twice per day, which were then adjusted as per their response to therapy and our designed protocol. Outcome was defined as per the International Children Continence Society (ICCS) latest definitions. RESULTS: One hundred twenty-two patients satisfied the inclusion criteria and were included in the study with a median age of 9 years (range 5-19 years). The mean follow-up time was 62 months (range 25-114 months). Our protocol showed an overall complete success of 87% with failure and relapse of 13%. The success rate of patients needing 120 µg desmopressin as maintenance therapy to achieve dryness was 92.7% as compared to 65% success in patients needing a higher dose of desmopressin to achieve dryness (P < .05). Age, gender, and type of primary nocturnal enuresis had no effect over success (all P > .05). CONCLUSION: Adopting combination therapy along with structured withdrawal as per our protocol showed higher success rates and lower relapses in primary nocturnal enuretic children.

Percutaneous nephrolithotomy in a case of retrorenal colon: A descriptive approach and literature review.

INTRODUCTION: Percutaneous nephrolithotomy procedure is generally used to treat stones resistant to other treatment modalities. Colonic perforation even though rare, is a serious complication that increases patient's morbidity. This case report describes the case of a patient with retrorenal colon who underwent percutaneous nephrolithotomy for management of pelvis/lower calyceal staghorn stone. CASE PRESENTATION: A 63-year-old female patient presented for the management of a staghorn pelvis-lower calyceal stone. The patient had a preoperative computed tomography scan of the abdomen and pelvis that showed an incidental finding of left retrorenal colon. Under computed tomography scan guidance, a nephrostomy tube was successfully placed by an interventional radiologist, and then she underwent percutaneous nephrolithotomy. CONCLUSION: This case report aims to stress on the importance of doing a computed tomography scan whenever a prior abdominal surgery is performed. We strongly believe that gastrointestinal injuries could be avoided by using computed tomography guided access in high risk patients.

Perinephric Hematoma with Active Arterial Hemorrhage following Extracorporeal Shockwave Lithotripsy.

Subcapsular hematoma is an exceedingly rare complication of extracorporeal shockwave lithotripsy (ESWL) for renal stones with cases demonstrating evidence of active arterial bleeding even more so. A 49-year-old male presented with acute onset right flank pain two hours following ESWL. CT scan with contrast revealed active contrast extravasation consistent with arterial bleeding. The patient was managed with arterial embolization and recovered uneventfully following a 4-day hospitalization.

Primary Mature Cystic Teratoma Compressing the Prostate in a 28-Year-Old Male: A Case Report and Literature Review.

Primary mature retroperitoneal teratomas are rare tumors most commonly occurring in adult females. These tumors are usually asymptomatic since they have no attachments to specific organs. We present a rare case of a 28-year-old male with 2-month history of lower urinary tract symptoms, who was found to have a primary mature cystic teratoma abutting the prostate.

A Case of Symptomatic Cowper's Syringocele in an Adult Male: Diagnosis and Management.

Background: Cowper's syringocele is cystic dilation of the excretory bulbourethral gland duct. This entity is common in the pediatric population but is rare or underdiagnosed in the adult population. Syringoceles are usually classified based on the configuration of the duct's orifice to the urethra with symptoms varying between irritative and/or obstructive accordingly. To the best of our knowledge, only few cases were reported in the literature. Case Presentation: We present the case of a 27-year-old male patient presenting with obstructive lower urinary tract symptoms. Pelvis MRI, retrograde urethrography, and flexible cystourethroscopy were performed and a diagnosis of imperforate Cowper's syringocele was made. Endoscopic unroofing with holmium:YAG laser was performed. The patient is free of symptoms 12 months postoperatively. Conclusion: Cowper's syringocele is a rare entity that should be considered in certain adult patients presenting with either storage or voiding symptoms. Ultrasonography is useful in detecting closed cystic lesions; however, antegrade urethrography and retrograde urethrography are gold standards to rule out communication with the urethra. Symptoms tend to resolve spontaneously and initial treatment is conservative. With persistent symptoms, endoscopic unroofing or marsupialization with cold knife or holmium:YAG laser is recommended as standard treatment.

Classic Testicular Seminoma in Men Aged 50 Years or Over: A Case Report and Review of the Literature.

Testicular cancer is the most frequent solid tumor detected in young adult men. Germ cell tumors (GCTs), particularly seminomas, are the most common type of testicular neoplasms seen in that age population. Most publications have reported decreasing incidence of GCTs in patients above forty years of age. Since the biologic activity of seminomas appears similar across ages, recommended management of senior adults involves a multimodal therapy of radical inguinal orchiectomy with radiation or cytotoxic treatment as needed. Attenuating chemotherapy dosages are critical to ensure better tolerability of associated adverse events. Here we report a case series of 2 men older than fifty years of age with metastatic testicular seminoma. We aim to emphasize a rare clinical entity encountered in the senior adult population.

Congenital Bladder Diverticulum in Adults: A Case Report and Review of the Literature.

A 37-year-old male patient presented to the emergency department with fever, gross hematuria, and irritative lower urinary tract symptoms. Investigations revealed the presence of a large left bladder diverticulum superior and lateral to the left ureteral orifice without bladder outlet obstruction. Bladder diverticula in adults almost always present in the setting of bladder outlet obstruction. The finding of a congenital bladder diverticulum in an adult represents a rare clinical entity.

Primary Carcinoid Tumor of the Testis: A Case Report and Review of the Literature.

Carcinoid tumors usually arise in the gastrointestinal tract. Immunocytohistochemical and radiologic studies are important in detecting the primary tumor site. Primary carcinoid tumors of the testis are particularly rare with a high malignant potential warranting long-term follow-up. We present the case of a primary carcinoid tumor of the testis with long-term surveillance.