Oncological outcomes of salvage radical prostatectomy for recurrent prostate cancer in the contemporary era: A multicenter retrospective study.

BACKGROUND: Salvage radical prostatectomy (sRP) historically yields poor functional outcomes and high complication rates. However, recent reports on robotic sRP show improved results. Our objectives were to evaluate sRP oncological outcomes and predictors of positive margins and biochemical recurrence (BCR). METHODS: We retrospectively collected data of sRP for recurrent prostate cancer after local nonsurgical treatment at 18 tertiary referral centers in United States, Australia and Europe, from 2000 to 2016. SM and BCR were evaluated in a univariate and multivariable analysis. Overall and cancer-specific survival were also assessed. RESULTS: We included 414 cases, 63.5% of them performed after radiotherapy. Before sRP the majority of patients had biopsy Gleason score (GS) ≤7 (55.5%) and imaging negative or with prostatic bed involvement only (93.3%). Final pathology showed aggressive histology in 39.7% (GS ≥9 27.6%), with 52.9% having ≥pT3 disease and 16% pN+. SM was positive in 29.7%. Five years BCR-Free, cancer-specific survival and OS were 56.7%, 97.7% and 92.1%, respectively. On multivariable analysis pathological T (pT3a odds ratio [OR] 2.939, 95% confidence interval [CI] 1.469-5.879; ≥pT3b OR 2.428-95% CI 1.333-4.423) and N stage (pN1 OR 2.871, 95% CI 1.503-5.897) were independent predictors of positive margins. Pathological T stage ≥T3b (OR 2.348 95% CI 1.338-4.117) and GS (up to OR 7.183, 95% CI 1.906-27.068 for GS >8) were independent predictors for BCR. Limitations include the retrospective nature of the study and limited follow-up. CONCLUSIONS: In a contemporary series, sRP showed promising oncological control in the medium term despite aggressive pathological features. BCR risk increased in case of locally advanced disease and higher GS. Future studies are needed to confirm our findings.

Renal Papillary Mapping and Quantification of Randall's Plaque in Pediatric Calcium Oxalate Stone Formers.

Introduction: Randall's plaque (RP) with attached stones is recognized as a primary mechanism for stone formation in adult calcium oxalate stone formers (CaOx SFs). The role of RP in pediatric stone pathogenesis is unknown, with no reported studies to date. The purpose of this study is to investigate renal papillary abnormalities and quantify RP in pediatric CaOx SFs. Methods: Eight pediatric CaOx SFs underwent ureteroscopy for symptomatic urolithiasis. The collecting system was mapped using a digital ureteroscope. Video for each patient was then reviewed using a retrograde pyelogram to confirm the location of each papilla. A single investigator (N.L.M.) reviewed the video to quantify RP. Each papilla was graded as having mild, moderate, or severe amount of RP. Patient history was recorded. Results: An average of nine papillae were mapped per patient. RP was present in 100% of patients and in 88.8% (64/72) of all papillae examined. When present, RP was uniformly distributed throughout the kidney without preferential distribution to a region or pole. The amount of RP on the papillae was graded as mild in 60%, moderate in 20.8%, and severe in 8.3%. The mean fractional RP coverage ranged from 0.39% to 9.34%. No correlation was found between the amount of plaque and age at first stone episode or number of prior stone episodes (p = 0.84). Attached stones were rare (1/8 patients). The two patients with severe RP had a small amount of calcium phosphate in their stone analysis. Conclusions: RP is common in pediatric CaOx SFs. Compared with adult CaOx SFs wherein up to 75% of stones are found attached to RP, attached stones were rare. The significance of these findings in the pathogenesis of pediatric stone formation remains unclear and will require longer term follow-up.

Salvage Radical Prostatectomy for Recurrent Prostate Cancer: Morbidity and Functional Outcomes from a Large Multicenter Series of Open versus Robotic Approaches.

PURPOSE: Salvage radical prostatectomy has historically yielded a poor functional outcome and a high complication rate. However, recent reports of robotic salvage radical prostatectomy have demonstrated improved results. In this study we assessed salvage radical prostatectomy functional outcomes and complications when comparing robotic and open approaches. MATERIALS AND METHODS: We retrospectively collected data on salvage radical prostatectomy for recurrent prostate cancer after local nonsurgical treatment at 18 tertiary referral centers from 2000 to 2016. The Clavien-Dindo classification was applied to classify complications. Complications and functional outcomes were evaluated by univariable and multivariable analysis. RESULTS: We included 395 salvage radical prostatectomies, of which 186 were open and 209 were robotic. Robotic salvage radical prostatectomy yielded lower blood loss and a shorter hospital stay (each p <0.0001). No significant difference emerged in the incidence of major and overall complications (10.1%, p=0.16, and 34.9%, p=0.67), including an overall low risk of rectal injury and fistula (1.58% and 2.02%, respectively). However, anastomotic stricture was more frequent for open salvage radical prostatectomy (16.57% vs 7.66%, p <0.01). Overall 24.6% of patients had had severe incontinence, defined as 3 or more pads per day, for 12 or 6 months. On multivariable analysis robotic salvage radical prostatectomy was an independent predictor of continence preservation (OR 0.411, 95% CI 0.232-0.727, p=0.022). Limitations include the retrospective nature of the study and the absence of a standardized surgical technique. CONCLUSIONS: In this contemporary series to our knowledge salvage radical prostatectomy showed a low risk of major complications and better functional outcomes than previously reported. Robotic salvage radical prostatectomy may reduce anastomotic stricture, blood loss and hospital stay, and improve continence outcomes.

Single Session Bilateral Vs Staged Bilateral Ureteroscopy for Nephrolithiasis: An Assessment of Safety and Efficacy.

OBJECTIVE: To compare outcomes of patients undergoing single session bilateral ureteroscopy (SSBU) to those undergoing planned staged ureteroscopy (URS) for bilateral nephrolithiasis. While SSBU has the advantage of 1 anesthetic procedure, some may pursue a staged approach due to the potential higher risk of complications and patient discomfort with 2 ureteral stents. METHODS: We retrospectively identified patients undergoing SSBU and planned staged URS for nephrolithiasis between December 2007 and December 2014. Preoperative characteristics, intraoperative techniques, and postoperative outcomes were compared. Stone burden was calculated as cumulative stone diameter. Residual stone fragments were defined as any stone visible on postoperative imaging. RESULTS: Sixty-three patients underwent SSBU and 37 underwent planned staged URS. Both cohorts had a relatively large cumulative stone burden (30.9 mm vs 32.4 mm, P = .71). Total operative time was significantly longer for planned staged URS (139 vs 86 minutes, P <.0001). There were no significant differences in complications or emergency room visits between the 2 cohorts despite bilateral ureteral stents being placed in the majority of the SSBU cohort (73%). There were no differences in stone-free rates or the need for additional procedures. CONCLUSION: SSBU is safe and effective with overall shorter operative times and similar stone-free rates compared to planned staged URS. Bilateral ureteral stent placement did not increase the rate of unplanned emergency visits. For patients with bilateral nephrolithiasis, urologists should strongly consider SSBU to limit anesthetic exposure, overall operative time, and health care costs.

The utility of abdominal ultrasound during percutaneous suprapubic catheter placement.

INTRODUCTION: To evaluate the use of ultrasound (US) at the time of percutaneous suprapubic catheter (SPC) placement. US has been recommended as a way to minimize complications, such as bowel injury, during percutaneous SPC placement, yet there is limited data supporting this recommendation. MATERIALS AND METHODS: A retrospective chart review was performed on patients undergoing percutaneous SPC placement from 2002 to 2011. The method of percutaneous SPC placement (cystoscopic and/or ultrasound guidance, blind) was recorded and patients were subdivided into groups based on the use of US. The need to modify the approach based on US findings and complications such as bleeding or bowel injury were noted and compared between groups. RESULTS: A total of 307 percutaneous SPCs were placed: cystoscopy alone was used in 190 (62%) patients, cystoscopy + US in 86 (28%) patients, US alone in 6 (2%) patients, and 25 (8%) patients had the SPC placed blindly. Previous lower abdominal surgery was noted in 41/92 (45%) of patients with and 32/215 (15%) of patients without US usage. US identified intervening loops of bowel in 5/92 cases (5%), all of whom had a history of lower abdominal surgery. The approach was modified in 2/5 and abandoned in 3/5 based on US findings. Postoperative bleeding occurred in 1/215 (0.5%) of patients with and 1/92 (1%) of patients without US usage. No bowel injuries occurred. CONCLUSIONS: While US may not be needed in most patients, particularly when cystoscopy is used, it may help to avoid bowel injury in patients with a history of lower abdominal surgery.

Urinary proteome analysis in patients with stable SFU grade 4 ureteropelvic junction obstruction differs from normal.

OBJECTIVE: To evaluate and analyze the urinary proteome in infants with stable grade 4 ureteropelvic junction obstruction (UPJO) and compare to age-matched normal controls. METHODS: Bladder urine specimens were obtained from 21 healthy infants with normal maternal/fetal ultrasound and 25 infants with grade 4 unilateral UPJO. All patients had >40% ipsilateral individual kidney function by renal scanning and the anteroposterior (AP) diameter of the hydronephrotic kidney ranged from 1.6-3.9 cms at presentation. Over a 5-year follow-up period, the disease progressed in 7 infants (28%), resolved in 4 (16%), and remains stable in the majority (56%). The urinary specimens were prepared using standard methods and subjected to LC/MS/MS analysis. The normalized data were annotated utilizing the Ingenuity Pathways Analysis (IPA; www.Ingenuity.com) knowledge platform. RESULTS: In the stable UPJO group, the urinary proteomes obtained in infancy differed significantly from the age-matched controls. Analysis revealed important differences in a number of biologic functions including inflammation, apoptosis, tubular injury and fibrosis, and reactive oxygen species response. CONCLUSION: The urinary proteomes from the bladder in patients with stable grade 4 UPJO (by imaging criteria) are significantly different at birth and during the first year of life and seem to indicate the presence of an ongoing active renal response to UPJO. The imminent discovery of surrogate urinary biomarkers may result in reconsideration of the watchful waiting strategy during this critical period of renal maturation and development in infancy.