Natural history of histologically benign PIRADS 4-5 lesions in multiparametric MRI: Real-life experience in an academic center.

INTRODUCTION: The follow-up findings of patients who underwent prostate biopsy for prostate image reporting and data system (PIRADS) 4 or 5 multiparametric magnetic resonance imaging (mpMRI) findings and had benign histology were retrospectively reviewed. METHODS: There were 190 biopsy-naive patients. Patients with at least 12 months of follow-up between 2012 and 2023 were evaluated. All MRIs were interpreted by two very experienced uroradiologists. Of the patients, 125 had either cognitive or software fusion MR-targeted biopsies with 4 + 8/10 cores. The remaining 65 patients had in-bore biopsies with 4-5 cores. Prostate-specific antigen (PSA) levels below 4 ng/mL were defined as PSA regression following biopsy. PIRADS 1-3 lesions on new MRI images were classified as MRI regression. RESULTS: Median patient age and PSA were 62 (39-82) years and six (0.4-33) ng/mL, respectively, at the initial work-up. During a median follow-up period of 44 months, 37 (19.4%) patients were lost to follow-up. Of the remaining 153 patients, 82 (53.6%) had persistently high PSA. Among them, 72 (87.8%) had repeat mpMRI within 6-24 months which showed regressive findings (PIRADS 1-3) in 53 patients (73.6%) and PIRADS 4-5 index lesion persistence in 19 cases (26.4%). The latter group was recommended to have rebiopsy. Of these 19 patients, 16 underwent MRI-targeted rebiopsy. Prostate cancer was diagnosed in six (37.5%) patients and of these four (25%) were clinically significant (>Grade Group 1). Totally, clinically significant prostate cancer was detected in 4/153 (2.6%) patients followed up. CONCLUSION: Patients should be warned against the relative relaxing effect of a negative biopsy after identification of PIRADS 4-5 index lesion. While PSA decrease was observed in many patients during follow-up, persistent MRI findings were present in nearly a quarter of patients with persistently high PSA. A rebiopsy is warranted in these patients, with significant prostate cancer diagnosed in a quarter of patients with rebiopsy.

The role of PSMA PET/CT in predicting downgrading in patients with Gleason score 4+4 prostate cancer in prostate biopsy.

BACKGROUND: To investigate the predictable parameters associated with downgrading in patients with a Gleason score (GS) 8 (4+4) in prostate biopsy after radical prostatectomy. METHODS: We retrospectively analyzed 62 patients with a GS of 4+4 on prostate biopsy who underwent robotic radical prostatectomy between 2017 and 2022. RESULTS: 38 of 62 (61.2%) were downgraded. In multivariable logistic regression model, Ga-68 prostate-specific membrane antigen (PSMA) positron-emission tomography (PET)/computed tomography (CT) SUV max was independent predictor of downgrading (OR 0.904; p = 0.011) and a Logistic Regression model was constructed using the following formula: Y = 1.465-0.95 (PSMA PET/CT SUV max). The model using this variable correctly predicted the downgrading in 72.6% of patients. The AUC for PSMA PET/CT SUV max was 0.709 the cut off being 8.8. A subgroup analysis was performed in 37 patients who had no other European Association of Urology (EAU) high risk features. 25 out of 37 (67.5%) were downgraded, and 21 of these 25 had organ confined disease. Low PSMA SUV max (<8.1) and percentage of GS 4+4 biopsy cores to cancer bearing cores (45.0%) were independently associated with downgrading to GS 7. CONCLUSION: PSMA PET/CT can be used to predict downgrading in patients with GS 4+4 PCa. Patients with GS 4+4 disease, but no other EAU high risk features, low percentage of GS 4+4 biopsy cores to cancer bearing cores, and a low PSMA PET/CT SUV max are associated with a high likelihood of the cancer reclassification to intermediate risk group.

Postchemotherapy robotic retroperitoneal lymph node dissection for non-seminomatous germ cell tumors in the lateral decubitus position: oncological and functional outcomes.

PURPOSE: Retroperitoneal lymph node dissection (RPLND) is recommended for residual masses following chemotherapy for non-seminomatous germ cell tumors (NSGCT). Recently, aberrant recurrence patterns were reported in patients who underwent robotic RPLND. We aimed to evaluate perioperative safety in addition to functional and early oncological outcomes of postchemotherapy robotic RPLND (pcR-RPLND) for NSGCT. METHODS: A total of 25 patients with NSGCT who underwent a pcR-RPLND between January 2011 and June 2022 were evaluated retrospectively. Descriptive statistics were provided for demographics, clinical characteristics, intraoperative and postoperative parameters. Functional and oncological outcomes were recorded. RESULTS: The median patient age was 28.9 years (IQR 21.5-32.4). The median retroperitoneal tumor size was 2.6 cm (IQR 1.5-3.5). Intraoperative complications occurred in only one case and the open conversion rate was 12%. There were seven cases with postoperative complications (Clavien grade II: 5 and IIIa: 2). Patients were followed for a median of 33.2 months (IQR 14.8-43.0). Antegrade ejaculation was preserved in 85.7% of the patients. Two patients (8%) relapsed and both had out-of-field recurrences at unusual sites (perinephric fat and omentum). Of those, one patient died (4%) of testicular cancer. CONCLUSION: pcR-RPLND is a feasible and technically reproducible procedure with favorable perioperative morbidity, low rate of complications, and acceptable postoperative ejaculatory function. Although the recurrence rate was low (8%), recurrences were observed at unusual sites. Further studies are required to investigate any association between the robotic approach and aberrant recurrence patterns.

Is elective cancer surgery feasible during the lock-down period of the COVID-19 pandemic? Analysis of a single institutional experience of 404 consecutive patients.

BACKGROUND: We aimed to assess the feasibility and short-term clinical outcomes of surgical procedures for cancer at an institution using a coronavirus disease 2019 (COVID-19)-free surgical pathway during the peak phase of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. MATERIALS AND METHODS: This was a single-center study, including cancer patients from all surgical departments, who underwent elective surgical procedures during the first peak phase between March 10 and June 30, 2020. The primary outcomes were the rate of postoperative SARS-CoV-2 infection and 30-day pulmonary or non-pulmonary related morbidity and mortality associated with SARS-CoV-2 disease. RESULTS: Four hundred and four cancer patients fulfilling inclusion criteria were analyzed. The rate of patients who underwent open and minimally invasive procedures was 61.9% and 38.1%, respectively. Only one (0.2%) patient died during the study period due to postoperative SARS-CoV2 infection because of acute respiratory distress syndrome. The overall non-SARS-CoV2 related 30-day morbidity and mortality rates were 19.3% and 1.7%, respectively; whereas the overall SARS-CoV2 related 30-day morbidity and mortality rates were 0.2% and 0.2%, respectively. CONCLUSIONS: Under strict institutional policies and measures to establish a COVID-19-free surgical pathway, elective and emergency cancer operations can be performed with acceptable perioperative and postoperative morbidity and mortality.

RNA-based markers in biopsy cores with atypical small acinar proliferation: Predictive effect of T2E fusion positivity and MMP-2 upregulation for a subsequent prostate cancer diagnosis.

BACKGROUND: Atypical small acinar proliferation (ASAP) is a precursor lesion of prostate cancer (PC), and PC develops from this suspicious focus or an unsampled malignant gland nearby. However, PC-related molecular alterations that could guide the timing of repeat biopsies and help monitor PC risk in ASAP-diagnosed patients have not been investigated. The purpose of this study was to first investigate the expression of seven different PC-related RNAs that included serine 2 (TMPRSS2): erythroblastosis virus E26 oncogene homolog (ERG) gene (TMPRSS2-ERG, T2E) fusion, alpha-methylacyl-CoA racemase (AMACR), kallikrein related peptidase 3 (KLK3), androgen receptor (AR), prostate cancer specific antigen 3 (PCA3), and matrix metalloproteinases (MMP)-2 and 9. METHODS: PC-related RNAs were evaluated using a real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR) system in pathologically ASAP-diagnosed prostate biopsy cores from 55 patients presenting with a normal digital rectal examination and a PSA level of 4-10 ng/mL. RESULTS: We detected that positive T2E fusion status (P = 0.013) and the expression of AMACR (P = 0.016), AR (P = 0.016) and MMP-2 (P = 0.013) were independently and significantly associated with PC risk in ASAP patients. There were also several statistically significant correlations between expression levels. Additionally, we demonstrated that T2E fusion positive ASAP patients with higher MMP-2 expression were more likely to be diagnosed with PC at a subsequent biopsy during the follow-up period (P = 0.003). CONCLUSIONS: Although, more clinical validations are needed for the stratification of PC risk in ASAP-diagnosed biopsy cores, our current results indicate that the coexistence of T2E fusion positivity with MMP-2 upregulation may help clinicians adjust their biopsy timetable and/or assessment of PC risk in ASAP-diagnosed patients with a PSA level of 4-10 ng/mL.

Challenging risk factors for right and left laparoscopic adrenalectomy: A single centre experience with 272 cases.

PURPOSE: This study aimed to compare perioperative and postoperative results of right and left laparoscopic adrenalectomy (LA), and to evaluate the impact of challenging factors on these outcomes. MATERIALS AND METHODS: A total of 272 patient's medical records that underwent single side LA between October 2006 and September 2017 were retrospectively reviewed. The patients were divided into 2 groups according to operation side. Moreover, pheochromocytoma, metastatic masses and adrenal lesions >5cm in size were considered to be difficult adrenalectomy cases and the outcomes of these cases were compared between two groups. RESULTS: 135 patients (49.6%) underwent right LA and 137 patients (50.4%) underwent left LA. Operation time, estimated blood loss (EBL) and hospitalization time were similar between the groups (p=0.415, p=0.242, p=0.741, respectively). Although EBL was higher on the right side than the left (p=0.038) in the fi rst 20 cases, after this learning period has been completed, there was no significant difference between the groups. In patients with pheochromocytoma, metastatic mass and a mass >5cm in size, despite bleeding complications were clinically higher on the right side, this difference was not statistically significant. CONCLUSIONS: During the learning period of LA, EBL is higher on the right side. Due to the greater risk of bleeding complications on the right side even on the hands of experienced surgeons, extra care and preoperative planning are required in patients with pheochromocytoma, metastatic masses and masses >5cm in size.

Renal Autotransplantation at Three Academic Institutions in Turkey.

OBJECTIVE: The objective of this study is to present the experience of 3 institutions performing renal autotransplantation (RAT) and to discuss surgical techniques employed and the results in the light of the medical literature. MATERIALS AND METHODS: A total of 14 patients (11 male and 3 female) with a mean age of 47 ± 8 years (35-61 years), who underwent RAT procedure at 3 different institutions between October 2006 and November 2014, in Turkey, were evaluated retrospectively. Indications for RAT procedure are ureteral avulsion, renal artery aneurysm and intimal dissection caused by percutaneous transluminal renal artery angioplasty (PTRA). Twelve patients with ureteral avulsion, 1 patient with renal artery aneurysm and 1 patient with intimal dissection caused by PTRA were followed-up for 103 months. Seven (50%) open and 7 (50%) laparoscopic nephrectomies were performed. Nine patients (64.3%) were right-sided and 5 patients (35.7%) were left-sided. Complications of grade III and above as per Clavien-Dindo classification were assessed. RESULTS: Mean time from injury to RAT was 21.2 ± 40.1 days. However, 5 (35.7%) patients were treated on the same day of the injury. As per Clavien-Dindo classification, 2 (14.2%) grade IVa and 1 (7.1%) grade IIIa complications were reported. However, no significant correlation was observed between the complications and graft loss regarding type and side of the nephrectomy performed (p = 0.462 and p = 0.505, respectively) and timing of the intervention (p = 0.692). CONCLUSION: RAT is a safe procedure in combination with minimally invasive laparoscopic technique in carefully selected patients; however, it requires expertise and proficiency in laparoscopy, reconstructive urology and transplantation. Nevertheless RAT should be considered as the last resort, when other modalities fail.

Laparoscopic heminephrectomy for benign and malignant diseases of the horseshoe kidney.

OBJECTIVES: In the current study, we present our pure laparoscopic heminephrectomy experience in 13 patients with horseshoe kidney (HK). MATERIAL AND METHODS: A total of 13 patients with HK underwent pure laparoscopic heminephrectomy (Transperitoneal= 7, Retroperitoneal = 6) due to benign and malign renal conditions (non-functional hydronephrotic and/or infected kidney = 12, kidney mass = 1). RESULTS: The mean age of the patients was 45.8 years. The mean operating time was 140 minutes, and estimated blood loss was 131 ml. The mean hospital stay was 2.3 days. Division of istmus was performed with stapler in 5 patients, ultrasonic scalpel in 3, 15 mm Hem-o-lok clip in 3, 10 mm LigaSure vessel seal system in one and endoscopic suture by 0 polyglactin in one patient without bleeding. Twelve patients underwent pure laparoscopic heminephrectomy due to nonfunctional hydronephrotic and or infected kidney. One patient underwent transperitoneal laparoscopic right heminephrectomy due to kidney mass. According to modifies Clavien classification, Grade I complication (wound infection) occurred in one patient (7.7%) who underwent heminephrectomy due to non-functional kidney. CONCLUSIONS: Laparoscopic heminephrectomy seems to be technically feasible and safe for benign and malignant diseases in patients with HK.

Comparison of ureteroscopic laser lithotripsy with laparoscopic ureterolithotomy for large proximal and mid-ureter stones.

OBJECTIVES: To compare the effectiveness and complications of ureteroscopic laser lithotripsy with laparoscopic ureter laparoscopic ureterolithotomy in mid- or proximal portion of large ureteral stones. MATERIAL AND METHODS: We reviewed patients with large (>15 mm) ureteral stone and those who underwent ureteroscopic laser lithotripsy (URS group) or laparoscopic ureterolithotomy (LU group). The first attempt was considered successful in patients who had residual fragments smaller than 2 mm and no conversion of the primary procedure to another. RESULTS: Sixty patients (URS group 29, LU group 31) met inclusion criteria. FURS was used as an adjunctive procedure in one patient for URS group and in two patients for LU group in the same season. LU had a higher success rate and the first-day stone-free rate when compared with URS. Number of procedures was also significantly higher in URS group. There was no difference in stone-free rates at the first and third months, and length of hospitalization and operation were higher in the LU group. Only two patients in the LU group and one patient in the URS group had major complications. CONCLUSIONS: Laparoscopy is an effective option of large proximal and mid-ureter stone treatment; however, URS provides similar stone-free rates at three months as a minimal invasive procedure.

Prostate-specific Membrane Antigen Positron Emission Tomography as a Biomarker to Assess Treatment Response in Patients with Advanced Prostate Cancer.

CONTEXT: Prostate-specific membrane antigen (PSMA)-targeted positron emission tomography (PET) has superior accuracy for detection of metastatic lesions in patients with prostate cancer (PC). Although PSMA PET has a prominent role in primary and secondary imaging of PC, data on its role in assessing treatment response in advanced PC are limited. OBJECTIVE: To review current data in the literature regarding the impact of antiandrogen therapy on PSMA expression of metastatic sites and the role of serial (baseline and at least 1 follow-up scan) PSMA PET to assess treatment response in patients with metastatic PC. EVIDENCE ACQUISITION: A comprehensive literature search in the PubMed database was performed using the terms "PSMA expression prostate", "PSMA regulation", "PSMA PET response assessment", and "serial PSMA PET". EVIDENCE SYNTHESIS: Serial PSMA PET studies (baseline and at least 1 follow-up scan) provide valuable data regarding PSMA expression changes after systemic treatment in patients with metastatic PC. PSMA PET-detected flare and upregulation of PSMA expression following hormonal intervention seem to be early events resolving after 3 mo of treatment. PSMA PET imaging is essential in selecting patients for 177Lu-PSMA radioligand therapy (RLT). Growing evidence favors its use in assessing treatment responses after RLT. Preliminary evidence indicates the value of PSMA PET for assessment of the treatment response in patients receiving systemic treatment other than RLT for metastatic PC. CONCLUSIONS: PSMA flare following antiandrogen therapy seems to be an early event and thus PET scans should be performed no earlier than 3 mo after the start of treatment. PSMA PET has a promising role in tailoring treatment according to the specific needs of individual patients and assessing responses following systemic treatment in patients with advanced PC. PATIENT SUMMARY: This review describes how a sensitive imaging method can be used to assess the tumor response to treatment for metastatic prostate cancer.

Autophagy regulates sex steroid hormone synthesis through lysosomal degradation of lipid droplets in human ovary and testis.

Autophagy is an evolutionarily conserved process that aims to maintain the energy homeostasis of the cell by recycling long-lived proteins and organelles. Previous studies documented the role of autophagy in sex steroid hormone biosynthesis in different animal models and human testis. Here we demonstrate in this study that sex steroid hormones estrogen and progesterone are produced through the same autophagy-mediated mechanism in the human ovary in addition to the human testis. In brief, pharmacological inhibition and genetic interruption of autophagy through silencing of autophagy genes (Beclin1 and ATG5) via siRNA and shRNA technologies significantly reduced basal and gonadotropin-stimulated estradiol (E2), progesterone (P4) and testosterone (T) production in the ex vivo explant tissue culture of ovary and testis and primary and immortalized granulosa cells. Consistent with the findings of the previous works, we observed that lipophagy, a special form of autophagy, mediates the association of the lipid droplets (LD)s with lysosome to deliver the lipid cargo within the LDs to lysosomes for degradation in order to release free cholesterol required for steroid synthesis. Gonadotropin hormones are likely to augment the production of sex steroid hormones by upregulating the expression of autophagy genes, accelerating autophagic flux and promoting the association of LDs with autophagosome and lysosome. Moreover, we detected some aberrations at different steps of lipophagy-mediated P4 production in the luteinized GCs of women with defective ovarian luteal function. The progression of autophagy and the fusion of the LDs with lysosome are markedly defective, along with reduced P4 production in these patients. Our data, together with the findings of the previous works, may have significant clinical implications by opening a new avenue in understanding and treatment of a wide range of diseases, from reproductive disorders to sex steroid-producing neoplasms, sex steroid-dependent malignancies (breast, endometrium, prostate) and benign disorders (endometriosis).

Fluorescence-guided extended pelvic lymphadenectomy during robotic radical prostatectomy.

We evaluated and described the impact of prostatic indocyanine green (ICG) injection on extended pelvic lymph node (LN) dissection (ePLND) in robotic-assisted radical prostatectomy (RARP). Between January 2019 and December 2021, we included consecutive 50 PCa patients who underwent ePLND during RARP with (n = 25) or without (n = 25) prostatic ICG injection. ICG injection was performed during abdominal port placement and robot docking. Pelvic LNs reflecting green color were initially excised and then the template was completed. The outcomes of two groups were compared. Overall, nine (36%) and five (20%) of the patients had metastatic LN involvement in the ICG and non-ICG groups, respectively. Of the 509 dissected LNs in the ICG group, 122 (23.9%) were fluorescence active. 20 LNs (3.9%) were metastatic in this group, 9 (45%) of which were ICG+. 408 LNs were resected on the non-ICG group with 8(1.9%) being metastatic. Eight (88.9%) of nine pN+ patients were florescent positive in the ICG group. Out of six patients with pN+ disease, Ga68 PSMA-PET/CT detected positive LNs preoperatively. In addition to preoperative Ga68 PSMA-PET/CT investigation, ICG-guided ePLND might increase identification and removal of metastatic LNs duirng RARP. Improvements in staging and oncologic outcomes may also be seen in intermediate- and high-risk patients.

Diagnostic Performance of 68Ga-PSMA-11 Positron Emission Tomography/Computed Tomography to Monitor Treatment Response in Patients with Metastatic Prostate Cancer: The Concordance Between Biochemical Response and Prostate-specific Membrane Antigen Results.

BACKGROUND: Treatment response is traditionally monitored using prostate-specific antigen (PSA) and conventional imaging in patients with metastatic prostate cancer (mPCa). OBJECTIVE: To assess the diagnostic performance of prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) when monitoring mPCa patients receiving systemic treatment and also to investigate the concordance between PSMA PET response according to the PSMA PET progression (PPP) criteria and biochemical response. DESIGN, SETTING, AND PARTICIPANTS: A total of 96 patients with 68Ga-PSMA-11 PET/CT-detected mPCa at baseline PSMA PET/CT (bPSMA) who underwent at least one follow-up scan after receiving systemic treatment were included in the study. PSA levels at bPSMA and follow-up PSMA PET (fPSMA) scans were recorded. The PPP criteria were used to define PSMA progression. Biochemical progression was defined as ≥25% increase in PSA. PSMA PET and PSA responses were dichotomized into progressive disease (PD) versus non-PD, and the concordance between PSA and PSMA responses was evaluated. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The concordance between PSA and PSMA PET responses was presented using frequencies, percentages, and Cohen's kappa test. RESULTS AND LIMITATIONS: A total of 345 serial PSMA PET/CT (96 bPSMA and 249 fPSMA) scans were evaluated. The positivity rates of PSMA PET scans for PSA levels of <0.01, 0.01-0.2, 0.2-4, and >4 ng/ml were 55.6%, 75.0%, 100%, and 98.8%, respectively. PSA and PSMA responses showed moderate-to-high concordance (Cohen's κ = 0.623, p < 0.001). PSA-PSMA discordance was detected in 39 scans (17%). The most common cause of discordance was the discordant results between different metastatic lesions (16/28, 57.1%) in patients with PPP without PSA progression and local progression in prostate (n = 7/11, 63.6%) in patients with PSA progression without PPP. CONCLUSIONS: PSMA PET/CT showed very high detection rates of malignant lesions even at very low PSA values and showed significant concordance with PSA response when monitoring treatment response in patients receiving systemic treatment for mPCa. PATIENT SUMMARY: This study describes that prostate-specific membrane antigen positron emission tomography (PSMA PET), a new sensitive imaging tool, can detect malignant lesions even at very low prostate-specific antigen values when monitoring metastatic prostate cancer. The PSMA PET response and biochemical response showed significant concordance, and the reason for discordant results seems to be the different responses of metastatic lesions and prostatic lesions to systemic treatment.

Intraoperative Frozen Section via Neurosafe During Robotic Radical Prostatectomy in the Era of Preoperative Risk Stratifications and Primary Staging With mpMRI and PSMA-PET CT: Is There a Perfect Candidate?

BACKGROUND: We aimed to analyze the effect of preoperative risk assessment including Ga-68 PSMA PET and multiparametric magnetic resonance imaging (mpMRI) on nerve sparing practices, positive surgical margin (PSM) rates and oncological outcomes based on a comparison between patients underwent RARP with and without Neurosafe (NS). METHODS: Patients underwent RARP with NS (RARP-NS) or without (RARP-only) NS retrospectively evaluated. Suspicion for extracapsular extension on mpMRI and/or Ga-68 PSMA PET was recorded as i(imaging)T3. NS was performed according to the Martini-Klinik technique. PSM at preserved bundle side were called PSM at region of interest (ROI) while the others were elsewhere. RESULTS: A total of 208 patients (90 in RARP-NS, 118 in RARP-only groups) were included. Preoperatively the RARP-only group showed significantly higher mean PSA (p = .01) and PIRADS 5 (p = .002) findings and had more D'Amico high risk (DAHR) patients (p = .08). The overall PSM rates for pT2 versus pT3 disease were 7.5% versus 21.6 and 15.6% versus 55% in RARP-NS and RARP-only groups, respectively. NS resulted in more bilaterally preserved bundles (81.1% vs. 66.3%) and less PSM at the ROI (3.3% vs. 23.4%) than RARP-only group. NS outperformed RARP-only in all clinical settings had its highest differential benefit in more bilateral nerve sparing and less PSM at ROI in patients with both DAHR and iT3 disease. BCR rates were 2.2% and 2.5% for RARP-NS and RARP only groups, respectively (p = .4). One patient in RARP-NS and 9 in RARP-only groups had PSA persistence (p = .02). CONCLUSION: RARP-NS led to more preserved bundles with less PSM. It was especially useful in DAHR patients with preoperative extracapsular extension suspicion in imaging simultaneously.

Factors Influencing Lymphocele Development After Kidney Transplant: Single Center Experience.

OBJECTIVES: Lymphocele is a well-known postoperative surgical complication after kidney transplant. In this study, our aim was to analyze incidence, risk factors, and outcomes of posttransplant lymphocele in a large cohort. MATERIALS AND METHODS: This observational study included 395 consecutive patients (219 males and 176 females) who underwent kidney transplant procedures from 183 living and 212 deceased donors in our center between January 2007 and 2014. A lymphocele was diagnosed with ultrasonography. RESULTS: The incidence of lymphoceles in our cohort was 31.9% (n = 126). There were no significant dif-ferences with regard to body mass indexes, age of donors, deceased donor ratios, acute rejection episodes, and history of abdominal surgery between those with and without lymphoceles. The pre-transplant serum albumin levels (3.29 ± 0.67 vs 3.48 ± 0.69 g/dL; P = .009) in the lymphocele group and diabetes mellitus ratios (15.9% vs 4.5%; P < .001) in the nonlymphocele group were lower than levels shown in the other group. The lymphocele ratio in patients who received cyclosporine was higher than that shown in patients who did not received it (37.5% vs. 27.4%; P = .032). There was no difference in lymphocele incidence between patients who were taking and those who were not taking mammalian target of rapamycin inhibitors, mycophenolate mofetil, or mycophenolate sodium. In regression analysis, presence of diabetes mellitus, transplant from deceased donors, older age of donors, and lower albumin levels were independent risk factors for posttransplant lymphocele occurrence. CONCLUSIONS: Posttransplant lymphocele was a relatively common surgical complication in our cohort. We concluded that diabetes mellitus, use of kidneys from deceased donors, older donor age, and hypoalbuminemia were independent risk factors for lymphocele development.

Pathological Accuracy in Prostate Cancer: Single-Center Outcomes of 3 Different Magnetic Resonance Imaging-Targeted Biopsy Techniques and Random Systematic Biopsy.

OBJECTIVE: The aim of this study is to compare systematic, cognitive fusion, in-bore, and software fusion prostate biopsies regarding rates of and risk factors for pathological upgrading. MATERIAL AND METHODS: Charts of 291 patients with systematic biopsy (n = 105), magnetic resonance imaging- targeted cognitive fusion (n = 58), in-bore (n = 68), and software fusion biopsy (n = 60), and who subsequently underwent radical prostatectomy were retrospectively evaluated. The degree of similarity between the grade groups reported in the biopsy and radical prostatectomy pathology results was recorded. Analyses of the associated factors for concordance and discordance were performed with univariate and multivariate methods. RESULTS: The concordance rates were as follows: systematic biopsy = 42.8%, cognitive fusion-targeted biopsy = 50%, in-bore fusion-targeted biopsy = 61.8, and software fusion biopsy = 58.4%. The upgrade rate of systematic biopsy (46.6%) was higher than cognitive fusion-targeted biopsy (27.6%), in-bore fusiontargeted biopsy (26.4%), and software fusion-targeted biopsy (18.3%). The number of positive cores was significantly associated with grade group concordance for the systematic biopsy group (P = .040). Within the cognitive fusion-targeted biopsy cohort, number of positive cores was the only parameter that exhibited a significant association with grade group concordance in multivariate analysis (P = .044). Considering the in-bore fusion-targeted biopsy group, maximum tumor length was statistically significant (P = .021). In the software fusion-targeted biopsy group, low prostate volume was found to be the only significant predictor for grade group accordance (P = .021). CONCLUSION: Magnetic resonance imaging-targeted biopsy techniques showed higher concordance and lower upgrade rates compared to systematic biopsy. For systematic biopsy and cognitive fusion-targeted biopsy, the number of positive cores was associated with grade group concordance, while maximum tumor length in in-bore fusion-targeted biopsy and low prostate volume for in-bore fusion-targeted biopsy were associated with grade group concordance. Among the MRI-targeted biopsy methods, in-bore fusion-targeted biopsy and software fusion-targeted biopsy were more accurate than cognitive fusion-targeted biopsy in terms of grade group.

The Impact of Visible Tumor (PI-RADS ≥ 3) on Upgrading and Adverse Pathology at Radical Prostatectomy in Low Risk Prostate Cancer Patients: A Biopsy Core Based Analysis.

BACKGROUND: The objective of this study was to investigate the impact of the characteristics of a single visible tumor (Prostate Imaging-Reporting and Data System [PI-RADS]≥3) on upgrading and adverse pathology at radical prostatectomy (RP) in biopsy naïve low risk prostate cancer (PCa) patients. MATERIALS AND METHODS: We retrospectively reviewed 64 biopsy naïve patients from 3 different referral centers between 2018 and 2020 with a PSA<10, cT1c disease, a single PI-RADS≥ 3 index lesion in multiparametric-MRI (mp-MRI), all bearing a GG 1 tumor sampled software fusion biopsy, who underwent RP. Preoperative clinical variables including the localization, number and tumor burden of positive cores for each PI-RADS category were related to upgrading and adverse pathology (GG>2 and/or pT3 and/or lymph node positive disease) at RP. RESULTS: Overall 37 patients (57.8%) were upgraded with a significant difference of upgrading in PI-RADS3 (30.0%) versus PI-RADS 4 (67.6%) (P = .007) and PI-RADS 4-5 (70.5%) lesions (P = .002). Thirty-three of 37 GG1 tumors were upgraded to GG2, while 6 of these 33 (18.2%) had adverse pathology as well. Overall 9 patients (14.1%) had adverse pathology at RP all harboring PI-RADS4-5 lesions. The number of positive cores differed significantly between the upgraded and nonupgraded patients. Adverse pathology group had significantly higher tumor volume at RP. CONCLUSION: PI-RADS4-5 lesions are the independent predictors of upgrading and adverse pathology in low risk PCa with visible tumors. Upgrading and adverse pathology were closely related to the number of positive combined cores reflecting the role of tumor volume. This should be kept in mind in shared decision making of an individual patient with low risk disease and a visible tumor.

Percutaneous nephrolithotomy in children: does age matter?

PURPOSE: To compare the outcomes of percutaneous nephrolithotomy (PCNL) in 2 age groups. METHODS: Fifty-one renal units (RU) of 45 patients were operated between January 2006 and December 2010. In all patients, PCNL was performed by pediatric nephroscope of 17F size through a 20F Amplatz sheath. Patients were examined in 2 groups (Group1: ≤5 years, Group 2: >5 years) and outcomes were compared accordingly. RESULTS: The mean age was 5.95 ± 3.63 years and male-to-female ratio was 23/22. The mean stone burden, operative time, and postoperative hospital stay were 4.24 ± 2.03 cm(2), 94.30 ± 37.28 min, and 5.18 ± 2.97 days, respectively. In the postoperative period, 44 renal units (86.2%) were stone-free. Two age groups were similar regarding the postoperative hospital stay, gender distribution, stone location, stone composition, and complication rates. However, stone burden and number of access was less and stone-free rate was higher in younger age group. CONCLUSION: The stone-free rate in preschool children is at least as good as older children without an increase in complication rates. The older children (>5 years) have a higher stone burden and need multiple accesses more frequently. The complications are mostly low grade and can be managed conservatively. Our results showed that PCNL in younger children as safe and effective as in the older children and age should not be considered as a limiting factor.

Tumor volume as a predictor of adverse pathologic features and biochemical recurrence (BCR) in radical prostatectomy specimens: a tale of two methods.

PURPOSE: The prognostic value of tumor volume in predicting biochemical recurrence after prostatectomy has been debated. Our aim in this study was to (a) evaluate tumor volume as an independent predictor of adverse pathologic outcomes and BCR and (b) determine the effect of two different methods of tumor volume estimation. METHODS: We reviewed the charts of 3,087 patients who underwent radical prostatectomy at Vanderbilt University Medical Center between 2000 and 2008; of which 1,747 patients had data sufficient for analysis. Prostate specimens were processed as whole mount between 2000 and 2003 and then via systematic sampling from 2003 to 2008, with tumor volume measured by planimetry in the whole-mount group and tumor volume estimated by percent tumor involvement in the systematic sampling group. RESULTS: Tumor volume estimates were higher with SS than with WM. There were significant associations between larger tumor volume and adverse pathological outcomes, regardless of pathologic method (all with P<0.001). Controlling for other pathologic parameters, tumor volume was an independent predictor of PGS, EPE, and SM in logistic regression models (P<0.001 for TV in all models). Tumor volume was demonstrated to be an independent predictor of BCR in the WM group (1.06, 95% CI 1.01-1.11, P=0.013), though tumor volume was not a significant predictor of BCR in the SS group. CONCLUSIONS: Though the prognostic value of tumor volume is debated, our data demonstrate that tumor volume, when calculated via planimetry on whole-mount pathologic sectioning, is a significant predictor of biochemical recurrence after prostatectomy.