Location-Based Oncological Outcomes of Sentinel Node Dissection in Radical Prostatectomy.

PURPOSE: To assess the oncological outcomes of sentinel-node dissection during radical prostatectomy according to nodal location in comparison to extended pelvic lymph node dissection. MATERIALS AND METHODS: Prospectively collected data of clinically node negative patients that underwent prostatectomy and extended lymph node dissection with or without sentinel-node from 2013 to January 2023 was retrospectively analyzed. The primary endpoint was to assess oncological outcomes on the whole population. Kaplan-Meier curves were used to depict biochemical and clinical recurrence free survival. Multivariable Cox regression models assessed the impact of nodal location on SPECT on oncological outcomes. Adjustment for case mix included: pathological T stage, ISUP grade group, initial PSA, nodal burden, age at surgery and surgical margin status. Secondarily, a propensity score match was performed according to age at surgery, PSA, biopsy ISUP, clinical T stage and Briganti risk of nodal invasion. Survival and regression analyses were than performed also in the matched population. RESULTS: 55.8% patients had at least one sentinel node outside of lymph node dissection template at SPECT/CT. Log-rank test showed comparable 36-months biochemical (P = .3) and clinical recurrence-free survival (P = .6) among patients with sentinel-node inside template, outside template or ePLND alone. At Cox regression, sentinel-node location outside template was associated with lower hazard of metastases (HR 0.62; P = .04) in the overall cohort, while in the matched cohort benefits were observed only for biochemical recurrence (HR 0.57; P = .001). CONCLUSIONS: Wider nodal resection boundaries outside "classic" template, driven by sentinel node procedure, have a positive impact on oncological outcomes in selected patient.

The Effect of Reusable Flexible Ureteroscope Aging on the Efficacy and Safety of Retrograde Intrarenal Surgery.

Purpose: Reusable flexible ureteroscopes may lose their mechanical functionality through overuse, which is known as "aging of the flexible ureteroscope." Although mechanical deterioration has been shown in several studies, the data about the effect of this situation on the efficacy and safety of retrograde intrarenal surgery (RIRS) are missing. The aim of our study was to evaluate the effect of the aging of flexible ureteroscopes on the efficacy and safety of RIRS. Methods: Patients who had undergone RIRS between 2017 and 2021 at a single center were retrospectively included in the study. Serial surgeries were performed using the same reusable flexible ureteroscope (Storz X2) until it was broken or malfunctioned because of the aging process. Group 1 was formed by the first 10 cases on whom the flexible ureteroscopes were used, representing the youngest period of the instruments, whereas group 2 was composed of the last 10 cases on whom the flexible ureteroscopes were used, representing the oldest phase of the instruments. The operative and postoperative data-including the operation time, hospitalization time, intraoperative complications, postoperative complications, and stone-free rates-were compared between the two groups. Results: A total of five flexible ureteroscopes were included in the study. The number of cases for each flexible ureteroscope ranged between 87 and 133, with a median number of 107 cases. The demographic and clinical properties of patients in both groups were similar. The operation time, lasering time, and total laser pulse were similar between the groups. The stone-free rates in group 1 and group 2 were 82.0% and 78.0%, respectively (p = 0.304). The complication rates were also similar between the groups (p = 0.591). Conclusion: The aging of reusable flexible ureteroscopes did not negatively affect the efficacy and safety of RIRS. Therefore, surgeons may use the reusable types of flexible ureteroscopes until they are totally broken.

Determining the Stone Free Rate of Retrograde Intrarenal Surgery. Which Radiological Technique? RIRSearch Study Group.

OBJECTIVE: To evaluate the sensitivity and specificity of ultrasonography (USG) and kidney ureter bladder radiography (KUB) for the determination of stone-free status of retrograde intrarenal surgery (RIRS) according to different stone-free status definitions. MATERIALS AND METHODS: The patients who underwent RIRS between September 2021 and September 2022 were prospectively included in the study. All patients underwent a KUB radiography, urinary system USG and noncontrast abdominal tomography at the postoperative first month of the surgery. The sensitivity, specificity, negative predictive factor, and positive predictive factor of USG and KUB on evaluating the stone-free rate were analyzed according to different stone-free status definitions. RESULTS: A total of 178 patients were included in the study. The stone-free rates according to stone-free definitions as; residual stone <4 mm, <2 mm and no residual stone were 79.2%, 64.0%, and 56.7%, respectively. According to its definition as a residual stone <4 mm, the sensitivity and specificity of USG were 64.9% and 84.3%, respectively. The sensitivity of USG was 57.1% and 52.5% as the definitions were residual stone <2 mm and no residual stone, respectively. Addition of KUB to USG slightly increased the sensitivity but did not change the specificity. CONCLUSION: USG had high specificity but low sensitivity for evaluating stone-free status after RIRS and addition of KUB did not increase the diagnostic efficacy. Although USG may be used in daily practice, it may overestimate the stone-free status and noncontrast abdominal tomography must be used during the clinical trials to document the exact stone-free rates of RIRS.

Is Psoas Muscle Mass Associated with Failure of Ureteral Access Sheath Insertion and Complications from Retrograde Intrarenal Surgery? A Case-Control Study from RIRSearch group.

Objective: To investigate the association between psoas muscle mass (PMM) and failure of ureteral access sheath (UAS) insertion and complications from retrograde intrarenal surgery (RIRS). Materials and Methods: A multicenter retrospective case-control study was conducted that included patients who underwent RIRS despite failure of UAS insertion (Cohort 1) and confounder-matched control patients who underwent RIRS after successful UAS insertion (Cohort 2). For morphometric analysis of PMM, ipsilateral psoas muscle areas (iPMAs) were measured using the coreslicer.com webkit. After comparing demographic, clinical, and complication rates and iPMAs between cohorts, gender-specific median iPMAs were also determined to further subdivide patients in each cohort as either low iPMAs or high iPMAs. Thereafter, patients were also compared in terms of RIRS complications. Results: Cohort 1 included 86 patients whereas Cohort 2 consisted of 124 matched cases. The median (interquartile range) iPMAs were similar between the cohorts: Cohort 1, 11.05 (6.82-14.44) cm2 versus 11.12 (6.97-13.69) cm2 for Cohort 2 (P ˃ .05). There was a significant inverse relationship between iPMAs with age (r = -0.222) and Charlson comorbidity index (r = -0.180) for all patients (P ˂ .05). Perioperative and postoperative complication rates were 8.1% and 16.3% for Cohort 1 and 6.5% and 21% for Cohort 2, respectively. The complication rates were not statistically different between patients with high iPMAs and those with low iPMAs, in male or female patients (P > .05). Conclusions: These results show that failure of UAS was not associated with PMM. Furthermore, since the complication rates were similar between patients with high PMM and low PMM, RIRS may be a reliable treatment choice for sarcopenic patients as well as in nonsarcopenic patients.

Multi-aspect analysis of ureteral access sheath usage in retrograde intrarenal surgery: A RIRSearch group study.

Objective: To evaluate the effect of ureteral access sheath (UAS) use and calibration change on stone-free rate and complications of retrograde intrarenal surgery (RIRS). Methods: Data from 568 patients undergoing RIRS for kidney or upper ureteral stones were retrospectively included. Firstly, patients were compared after 1:1 propensity score matching, according to UAS usage during RIRS (UAS used [+] 87 and UAS non-used [-] 87 patients). Then all UAS+ patients (n=481) were subdivided according to UAS calibration: 9.5-11.5 Fr, 10-12 Fr, 11-13 Fr, and 13-15 Fr. Primary outcomes of the study were the success and complications of RIRS. Results: Stone-free rate of UAS+ patients (86.2%) was significantly higher than UAS- patients (70.1%) after propensity score matching (p=0.01). Stone-free rate increased with higher caliber UAS (9.5-11.5 Fr: 66.7%; 10-12 Fr: 87.0%; 11-13 Fr: 90.6%; 13-15 Fr: 100%; p<0.001). Postoperative complications of UAS+ patients (11.5%) were significantly lower than UAS- patients (27.6%) (p=0.01). Complications (8.7%) with 9.5-11.5 Fr UAS was lower than thicker UAS (17.2%) but was not statistically significant (p=0.09). UAS usage was an independent factor predicting stone-free status or peri- and post-operative complications (odds ratio [OR] 3.654, 95% confidence interval [CI] 1.314-10.162; OR 4.443, 95% CI 1.350-14.552; OR 4.107, 95% CI 1.366-12.344, respectively). Conclusion: Use of UAS in RIRS may increase stone-free rates, which also increase with higher caliber UAS. UAS usage may reduce complications; however, complications seemingly increase with higher UAS calibration.

The Effect of Ureteral Access Sheath Use/Caliber Change on Outcomes of Retrograde Intrarenal Surgery, Short-Term Kidney Functions, Radiation Exposure, Ureteroscope Lifetime, and Factors Predicting Insertion Failure: A RIRSearch Study.

Background: The aim of this study was (1) to explore effect of ureteral access sheath (UAS) use on primary retrograde intrarenal surgery (RIRS) outcomes, short-term kidney functions, radiation exposure, and ureteroscope lifetime (URS-LT) and (2) to reveal factors that predict UAS insertion failure. Materials and Methods: Patients (n = 1318) who underwent RIRS without UAS (Group 1), those who had operation with a <11-13 Fr (Group 2), and those with a ≥11-13 Fr UAS were matched (1:1:2) and compared. Stone-free rate (SFR), intra- and postoperative complications, acute kidney injury (AKI), fluoroscopy time, URS-LT, and UAS insertion failure were the outcomes. Results: SFR, which was highest in Group 3 (75%, 71% and 87.3%, respectively; P = .001), was significantly associated with use of ≥11-13 Fr (odds ratio [OR]: 4.2, P < .001), but was not with use of <11-13 Fr UAS (OR: 1.3, P = .3). Group 3 had less need for auxiliary procedure (15%, 16%, and 7.4%, respectively; P = .03). Five percent of patients had a risk of AKI, but only 0.3% developed AKI. Although UAS use was protective against creatinine increase (OR: 0.65, P = .02), increased risk of AKI was only associated with female gender (OR: 5.5, P < .001). Fluroscopy times were 5, 15, and 87 sn, respectively (P < .001). Short URS-LT was strongly associated with high frequency of lower calix stones (r = -0.94, P = .005), but URS-LT was not correlated with sheathless case rate (r = 0.59, P = .22). UAS insertion success in first attempt was more likely in younger (OR: 0.99, P = .03), hydronephrotic (OR: 3.4, P < .001), and female cases (OR: 1.5, P = .008). But absolute UAS insertion failure was associated with female gender (OR: 2.7, P = .017). Conclusions: Not any UAS use but a higher caliber UAS use may improve SFR and protect against AKI after RIRS. Although UAS insertion failure is seen mostly in men, it may be more challenging in women owing to less efficacy of preoperative Double-J stent.

Safety and Efficacy of Retrograde Intrarenal Surgery in the Solitary Kidney: A Propensity Score-Matched Analysis of the RIRSearch Study Groups' Results.

Background: The aim of this study was to evaluate the efficacy and safety of retrograde intrarenal surgery (RIRS) in patients with renal calculi with solitary kidneys (SKs). Materials and Methods: In this retrospective, multicenter study, a matched case-control study was carried out using the data from 522 RIRS patients treated between 2014 and 2021. Patients' demographic data, stone characteristics, operative outcomes, perioperative and postoperative complications, and surgical success were analyzed. All patients were evaluated with noncontrast-enhanced computed tomography (NCCT) preoperatively and 1 month after the surgery. Surgical success was defined as no evidence of remaining residual fragments of <3 mm in the first-month postoperative NCCT images. The case group of 29 patients with SKs (Group 1) treated with RIRS were matched with 76 control patients (Group 2) with bilateral kidneys, who underwent unilateral RIRS by propensity score-matched (PSM) analysis. Results: After PSM analysis, the demographic and clinical data did not differ significantly between the groups. The stone burden was similar between the groups: 733.6 mm3 (range: 50.4-7565.9) versus 991.1 mm3 (range: 201.2-4380.6) (P = .09), respectively. The perioperative complication rates were 13.8% (n = 4) in Group 1 and 11.8% (n = 9) in Group 2 (P = .78). There was no statistically significant difference between the groups for postoperative complication rates (minor complications, classified as Clavien 1 or 2), (6.9% [n = 2] versus 13.2% [n = 10; P = .34]), respectively. Surgical success was 82.8% (n = 24) in Group 1 and 83.6% in Group 2 (P = .92). There was no significant difference between preoperative and postoperative glomerular filtration rate and creatinine values (P = .005). Conclusions: Our results support that RIRS is a safe and effective treatment method in SK patients with similar complication and stone-free rates compared to patients who had bilateral functional kidneys and underwent unilateral RIRS.

Safety and Efficacy of Live Retrograde Intrarenal Surgery in Patients with Kindey Stone: Outcomes from a Boutique Course Series Which Complies with the Live Surgery Event Policies.

BACKGROUND: Live surgery events (LSEs) are frequently organized for sharing the surgical experiences with surgeons at the beginning of their learning curves. The aim of this study was to investigate whether the outcomes and complication rates of patients underwent retrograde intrarenal surgery (RIRS) at LSEs are comparable with regular cases. METHODS: Ten courses were organized during 2017-2022. Data of 32 patients who operated in the LSEs were 1:3 matched (for stone burden and surgeon) with the data of patients who underwent regular RIRS within the course periods at the same centers (n = 96). All courses took place in concordance with the latest LSE policies. The primary outcomes were stone-free and complication rates. Fluoroscopy and operation times were the secondary outcomes. RESULTS: Stone-free rates of the groups were similar (84% in LSE and 79% in control group; p = 0.520). Similarly, there were no differences in complication rates (p = 0.428) and fluoroscopy time (p = 0.477). Duration of the LSE cases (82.24 ± 31.12 min) was slightly but insignificantly longer than regular cases (73.77 ± 20.89 min, p = 0.092). Moreover, guest surgeons tend to have longer operation time with statistically insignificant prolongation (74.92 ± 30.43 min for host, 89.52 ± 28.34 min for guest surgeons, p = 0.064). CONCLUSIONS: RIRS can be performed without jeopardizing operation efficiency and patient safety in LSEs. If surgeon is not familiar with operating room set-up or staff, live surgery must be performed by host surgeon to avoid extended operating time.

Retrograde Intrarenal Surgery Learning Curves of Urology Residents Supervised by an Experienced Endourologist: An RIRSearch Study.

INTRODUCTION: Although retrograde intrarenal surgery (RIRS) is being performed with increasing frequency, there are only a limited number of studies about the learning curve (LC). This study aimed to analyze the LC of RIRS for five surgeons who underwent the same training. MATERIALS AND METHODS: The data of the 410 patients who underwent RIRS between April 2017 and 2022 in a single institution, which were performed consecutively by five surgeons, were analyzed. All 50 cases performed by each surgeon were included and numbered consecutively and separately, according to the date of the operation. The combined stone-free rate (SFR) was calculated for each surgeon's cases in the same row, and the LCs were created using moving average and cumulative sum (CUSUM) analyses. Separate multivariable analyses identified each period's (LC vs. beyond) characteristics. RESULTS: The LCs from the combined SFRs reached a plateau after approximately 50 cases for both the CUSUM and the moving average. The effect of stone burden on SFR was more evident in the first 50 cases compared to subsequent cases in the multivariable analyses (p = 0.001 and p = 0.047, respectively). Case order and stone density were independent factors in the first 50 cases (OR: 1.02 [95% CI 1.00-1.04], p = 0.04 and OR: 0.99 [95% CI 0.99-1.00], p = 0.04) but not significant in subsequent cases (OR: 0.97 [95% CI 0.94-1.00], p = 0.1 and OR: 1.00 [95% CI 0.99-1.00], p = 0.7, respectively). Compared to single locations except the lower calyx, the unfavorable effect of the multiple-stone localization on SFR grew in strength after the 50th case (OR: 0.42 [95% CI 0.23-0.78], p = 0.01 and OR: 0.20 [95% CI 0.09-0.46], p < 0.001, respectively). CONCLUSIONS: This is the first study reporting on the RIRS LCs of urology residents. While stone burden, density, and multiple-stone localization were the factors determining SFR in the learning period, after completing the LC, the effect of stone burden weakened and multiple-stone localization became stronger.

Safety and Efficacy of Live Retrograde Intrarenal Surgery in Patients with Kindey Stone: Outcomes from a Boutique Course Series Which Complies with the Live Surgery Event Policies

Background: Live surgery events (LSEs) are frequently organized for sharing the surgical experiences with surgeons at the beginning of their learning curves. The aim of this study was to investigate whether the outcomes and complication rates of patients underwent retrograde intrarenal surgery (RIRS) at LSEs are comparable with regular cases. Methods: Ten courses were organized during 2017–2022. Data of 32 patients who operated in the LSEs were 1:3 matched (for stone burden and surgeon) with the data of patients who underwent regular RIRS within the course periods at the same centers (n = 96). All courses took place in concordance with the latest LSE policies. The primary outcomes were stone-free and complication rates. Fluoroscopy and operation times were the secondary outcomes. Results: Stone-free rates of the groups were similar (84% in LSE and 79% in control group; p = 0.520). Similarly, there were no differences in complication rates (p = 0.428) and fluoroscopy time (p = 0.477). Duration of the LSE cases (82.24 ± 31.12 min) was slightly but insignificantly longer than regular cases (73.77 ± 20.89 min, p = 0.092). Moreover, guest surgeons tend to have longer operation time with statistically insignificant prolongation (74.92 ± 30.43 min for host, 89.52 ± 28.34 min for guest surgeons, p = 0.064). Conclusions: RIRS can be performed without jeopardizing operation efficiency and patient safety in LSEs. If surgeon is not familiar with operating room set-up or staff, live surgery must be performed by host surgeon to avoid extended operating time (AU)

Is radiotherapy after radical prostatectomy associated with higher other-cause mortality?

PURPOSE: The aim of this study was to reveal the association between the other-cause mortality (OCM) and post-radical prostatectomy (RP) salvage radiotherapy (sRT) in men with prostate cancer (PCa). METHODS: A retrospective study was carried out with patients who had PCa and underwent RP ± sRT in a high-volume cancer center between 2005 and February 2019. Data from 1955 patients were subjected to a 1:1 matching for age, initial PSA, pathological (p)T/N stages, and ISUP score, which yielding 439 RP + RT (group 1) vs 439 RP-only cases (group 2), without any residual difference. Primary and secondary endpoints of the study were OCM and cancer-specific mortality (CSM). Kaplan-Meier, log-rank, and cox regression tests were used for purpose of the study. RESULTS: The median follow-up time after RP was 5.3 years (interquartile range: 4.0-7.3). After matching, of all deaths that occurred during the study period, 16 in group 1 and 35 in group 2 were attributed to other causes (p = 0.006). 5-year OCM rate of patients who received sRT (1.2%) was significantly lower compared to patients that underwent RP-only (4.4%, p < 0.001). 19 versus 16 patients died of PCa, respectively (p = 0.61). There was no CSM risk difference between groups (p = 0.29). Older patients had an increased risk of OCM (hazard ratio [HR]:1.10 [95%CI 1.05-1.17], p < 0.001) and post-RP RT was associated with lower OCM (HR: 0.28 [95%CI 0.15-0.51], p < 0.001) in multivariable model. pT/N stages and ISUP score were strongly associated with CSM, but not with OCM. CONCLUSION: OCM was not higher in patients who had sRT with or without ADT. Excess OCM in favor of RP-only patients may be cautiously explained with higher-performance status/life expectancy of patients who selected for RT after RP in our cohort.

Why Discovery of PSA was not Granted a Nobel Prize?

This essay draws attention to the prostate-specific antigen (PSA) discovery's lack of Nobel Prize acknowledgement despite its significance for prostate cancer (PCa) clinical practice. The Nobel Prize committee gives more weight to discoveries in basic research than to applications in medicine, which may account for PSA's lack of recognition. The prize has been dominated by the identification of cancer-causing viruses. Considering the subject from our -urologists- side, numerous pioneer researchers have uncovered PSA's presence and function, and its overuse in PCa screening has sparked debates about issues like overdiagnosis and overtreatment. We must concur that the factors contributing to PSA's underappreciation include the lack of a clear pioneer in its discovery and the contradictory opinions around its use. As a conclusion, PSA may have to wait for a better application before it receives recognition in the Nobel Prize.

Is It a Good Strategy to Proceed a Retrograde Intrarenal Surgery Session Sheathless After Ureteral Access Sheath Insertion Failure? A RIRSearch Study.

Objectives: To complement our previous findings regarding effect of ureteral access sheath (UAS) use, we checked RIRSearch database for patients who operated without using UAS. The aim of the study was to understand these new data better by comparing outcomes of retrograde intrarenal surgery (RIRS) that continued sheathless after a failed UAS insertion vs those planned and completed sheathless. Materials and Methods: Data of 195 patients who underwent sheathless RIRS for kidney and/or ureteral stones between 2011 and 2021 were retrieved from the database. Patients divided into two groups: cases who were planned and completed sheathless (n = 110, Group 1) and those who proceeded without UAS after insertion failure (n = 85, Group 2). After propensity score matching (PSM), each group consisted of 76 patients. Results: After PSM, stone-free rate for Group 1 (90.8%) was significantly higher than stone-free rate of Group 2 (76.3%) in sheathless RIRS (p = 0.02). Also postoperative complication rate was significantly lower in Group 1 (10.5%) than in Group 2 (27.6%) (p = 0.007). In Group 2, median operating time was longer (60 minutes, interquartile range [IQR]: 40-80) and more unplanned auxilliary procedure (22.4%) was needed than Group 1 (45 minutes, IQR: 40-50 and 3.9%) (both p = 0.001). Stone burden (odds ratio [OR]: 1.002, p = 0.019) and stone density (OR: 1.002, p = 0.003) were associated with high risk of residual stones after RIRS. Higher hydronephrosis grades were associated with increased stone-free rates (OR: 0.588 for residual stone risk, p = 0.024). Cases who completed sheathless by dusting all available stones, as planned preoperatively, were more likely to have stone-free status after RIRS than those who proceeded sheathless after UAS insertion failure (OR: 2.645, p = 0.024). Conclusions: Operation course after UAS insertion failure may be more challenging. In cases who performed without using UAS, surgeons who proceed with procedure sheathless after UAS insertion failure may more frequently run into complications and may fail achieving stone-free status compared with sheathless-planned cases.

Role of Local and/or Metastasis-directed Therapy in Patients with Hormone-sensitive M1a Prostate Cancer-A Systematic Review.

CONTEXT: It remains unclear whether men with hormone-sensitive prostate cancer (PCa) metastasized to nonregional lymph nodes (M1a) benefit from prostate-directed therapy (PDT) and/or metastasis-directed therapy (MDT). OBJECTIVE: To systematically summarize the literature regarding oncological outcomes of de novo and recurrent M1a PCa patients treated with PDT and/or MDT. EVIDENCE ACQUISITION: We searched Medline (Ovid), Embase, and Scopus according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for reports on oncological outcomes of de novo or recurrent hormone-sensitive M1a PCa patients treated with PDT (radical prostatectomy or radiotherapy) and/or MDT (nodal radiotherapy or salvage lymph node dissection) with or without androgen deprivation therapy. A descriptive data synthesis and a methodological quality assessment were performed to evaluate the impact of PDT and/or MDT on survival in M1a PCa patients. EVIDENCE SYNTHESIS: A total of 6136 articles were screened and 24 studies were included in this systematic review. In de novo M1a PCa patients, PDT was associated with improved oncological outcomes compared with no PDT. In recurrent M1a PCa, MDT could delay the need for systemic treatment in a selection of patients, but high-level evidence from prospective phase III randomized controlled trials is still awaited. CONCLUSIONS: This systematic review summarized the limited literature data on the management of M1a PCa. Subgroup analyses suggest a role for PDT plus systemic therapy in de novo M1a PCa. MDT to distant nodal metastases delayed the need for systemic therapy in recurrent disease, but robust data are lacking. The predominantly retrospective nature of the included studies and significant heterogeneity in study designs limit the strength of evidence. PATIENT SUMMARY: We reviewed the treatment of patients with prostate cancer that has spread to lymph nodes outside the pelvis without metastases in other organ systems. There is evidence that treatment of the primary prostate tumor improves outcomes in well-selected patients and that treatment targeting distant lymph node metastases can delay the start of systemic treatment.

A Rare Case of Female Bladder Outlet Obstruction: Severe Introital Stenosis.

Herein, we report a rare case of severe introital stenosis in a 22-year female who presented with obstructive voiding symptoms and inability to have sexual intercourse. Introital stenosis had been caused by the emergency primary closure after major vulvoperineal trauma 15 years ago. To our knowledge, this is the first case report in the literature that describes a very long time from primary closure to dilation and reconstruction. A detailed systematic evaluation and pelvic examination were performed. The dilation procedure was performed and the patient was closely followed up. Reconstructive surgery, which involved the removal of the granulation tissue and approximation of healthy vaginal mucosal edges in several sessions, was performed after the initial dilation procedure. Follow-up was performed with the clinical assessment of the symptoms, physical examination, and uroflowmetry. Our technique was effective and did not lead to any complications. The sexual dysfunction and voiding complaints of the patient completely resolved within a post-operative period of 11 months. Key Words: Introital stenosis, Bladder outlet obstruction, Dilation, Female, Reconstruction.

Financial Toxicity After Robot-Assisted Radical Prostatectomy and Its Relation with Oncologic, Functional Outcomes.

PURPOSE: The aim of the study was to evaluate frequency of financial toxicity among patients who underwent robot-assisted radical prostatectomy for prostate cancer. MATERIALS AND METHODS: Data of 1,479 robot-assisted radical prostatectomy patients between 2006-2021 reporting no financial toxicity in preoperative assessments were included retrospectively. Financial toxicity was measured with financial impact of European Organisation for Research and Treatment of Cancer-quality of life questionnaire-C30. Financial impact scores were collected preoperatively, 6, 12, 18, and 24 months after robot-assisted radical prostatectomy. RESULTS: The frequency of financial toxicity was 8.3% (122/1379; 95% CI 7.0-9.8) at any point in time throughout 2 years of follow-up. Patients reporting financial toxicity (63 [58-68]) were significantly younger than patients who had no financial toxicity (65 [61-69]; P = .001). There was no statistically significant difference between financial toxicity+ and financial toxicity- groups in terms of salvage radiotherapy (P = .8) and positive surgical margin (P = .2) rates. In functional assessments, clinically significant International Prostate Symptom Score and International Consultation on Incontinence Questionnaire-Short Form score increase of financial toxicity+ patients (34% and 62%) were more frequent than financial toxicity- patients (23% and 47%; P = .004 and P = .002, respectively). In multivariable analysis, age at robot-assisted radical prostatectomy, International Prostate Symptom Score, International Consultation on Incontinence Questionnaire-Short Form, and quality of life scores were associated with financial toxicity (P < .001, OR 0.95 [95% CI 0.92-0.98]; P = .015, OR 2.4 [95% CI 1.2-4.7]; P = .032, OR 1.5 [95% CI 1.2-2.5]; P = .01, OR 0.09 [95% CI 0.01-0.57], respectively). Patients who underwent robot-assisted radical prostatectomy before retirement (≤65 years) had a 1.6-fold increased financial toxicity risk (P = .003, 95% CI 1.1-2.3). CONCLUSIONS: Financial toxicity after robot-assisted radical prostatectomy is low in mid-term follow-up. Patients who report urological symptoms after robot-assisted radical prostatectomy should also be evaluated for financial toxicity. Required measures against financial toxicity should be taken especially in the follow-up of younger cancer survivors.

The Effect of Salvage Radiation Therapy on Survival, Functional Outcomes, and Quality of Life in Men with Persistent Prostate-specific Antigen After Robot-Assisted Radical Prostatectomy: Which Patient Benefits More?

PURPOSE: The aim of this study was to evaluate the effect of salvage radiation therapy (sRT) on survival, functional outcomes, and quality of life in men with persistent prostate-specific antigen (PSA >0.1 ng/mL) after a robot-assisted radical prostatectomy (RARP) and reveal subgroups that benefit more from sRT. METHODS AND MATERIALS: Data of 3409 patients who underwent RARP was retrieved from a high-volume institute database, and 313 patients with persistent PSA were included in further analyses. Patients who received sRT and those who did not were compared after propensity score matching. Progression-free survival (PFS), metastasis-free survival (MFS), androgen deprivation therapy (ADT)-free, cancer-specific survival, and overall survival, as well as patient-reported outcomes were the endpoints. Multivariable Cox regression models were developed to reveal treatment effect sizes for the subgroups. RESULTS: The overall persistent PSA rate was 9.2%, and the median follow-up time after RARP was 4.5 years (interquartile range, 2.7-7.9 years). The sRT was associated with improved PFS (hazard ratio [HR]: 0.29; P < .001), ADT-free survival (HR: 0.34; P < .001), MFS (HR: 0.39; P = .001), cancer-specific survival (HR: 0.34; P = .03), and overall survival (HR: 0.24; P = .001). Positive surgical margins (HR: 0.26; P < .001 for ADT-free survival), advanced pathological T stage (HR: 0.24; P < .001 for PFS) and positive lymph nodes (HR: 0.15; P = .001 for MFS), and lower Gleason score (HR: 0.15; P = .001 for PFS) were associated with marked survival benefits of sRT. Bowel symptoms were observed more frequently in patients who had sRT with or without ADT compared with patients with persistent PSA but no sRT (34.3% vs 19.2%; P = .01). Early sRT (<6 months after surgery) was associated with bothering incontinence (P < .001) and bowel symptoms (P = .03). CONCLUSIONS: Persistent PSA after a radical prostatectomy is still a common challenge in the robotic surgery era. sRT provides clear survival benefits for all endpoints, especially with unfavorable locoregional factors but a low Gleason score.

Mixed Epithelial and Stromal Tumor Family of Kidney (Adult Cystic Nephroma, Mixed Epithelial and Stromal Tumor): Retrospective Clinicopathological Evaluation.

OBJECTIVE: Tumors belonging to the mixed epithelial stromal tumor family (MESTF) are rare; thus clinicopathological experience about them are limited. Each epithelial and stromal component shows different patterns in these tumors. MATERIAL AND METHOD: Clinicopathological features of 11 MESTF cases that were diagnosed between 2000 and 2021 at a single center were evaluated. RESULTS: Ten of the 11 patients were female (F:M = 10:1). The mean age of the females was 47 (31-63) years; the male patient was 45 years old. The mean tumor diameter was 6.7 (3.5-19) cm. All tumors had varying proportions of cystic and solid components. Eight cases were well circumscribed, and the others had distinct but irregular borders. Two of the tumors with irregular borders were bulging into the renal sinus. The epithelial component was dominant in most cases. In the epithelial component, macrocyst, microcyst, and tubules were the most common patterns and the most common types of lining epithelium were flat, cuboidal and hobnail. The stromal component was variable in most cases and included hypocellular (mostly collagenous) and cellular areas. In most cases, the cellular stroma had an ovarian-like appearance. Among the other features observed, hyalinization and dystrophic calcification were common. The positivity for estrogen and progesterone receptor in the stromal component was observed in almost all female cases. CONCLUSION: MESTF, which has distinctive features, should be considered in the differential diagnosis of cystic kidney tumors.

Recent scoring systems predicting stone-free status after retrograde intrarenal surgery; a systematic review and meta-analysis.

Introduction: Several scoring systems and nomograms have been developed to predict the success of retrograde intrarenal surgery. But no meta-analysis for the performance of scoring systems has yet been performed. The aim of this study was to compare predictive ability of recent scoring systems for stone-free rate of retrograde intrarenal surgery. Material and methods: PubMed and Web of Science databases were searched systematically between April and May 2021. The scoring systems which were validated externally or studied at least by two different researcher groups were selected for further analysis. Of 59 records, 14 studies met the inclusion criteria (n = 4137). Area under curve (AUC) values of selected scoring systems were pooled in random or fixed effects. The I2 test was used to quantify heterogeneity. Results: Eight, 5, 8, 4 and 3 studies included in meta-analyses for the modified Seoul National University Renal Stone Complexity Score (S-ReSC), R.I.R.S., Resorlu-Unsal Score (RUS), S.T.O.N.E., and Ito's Nomogram, respectively. We found pooled AUC values 0.709 (95% CI 0.670-0.748), 0.704 (95% CI 0.668-0.739), 0.669 (95% CI 0.646 to 0.692), and 0.771 (95% CI 0.724 to 0.818), for first four of them, respectively. Heterogeneity was very high to pool AUC values for Ito's nomogram. Conclusions: Although S.T.O.N.E. score showed higer pooled AUC value, this systematic review and meta-analysis has not revealed superiority of any scoring system. High heterogeneity between studies and dependencies between scoring systems make it difficult to design a comparative statistical model to generalize the findings. Also, limitations aside, neither scoring system has demonstrated good predictive/discriminative performance.