Genitourinary cancer management during a severe pandemic: Utility of rapid communication tools and evidence-based guidelines.

OBJECTIVES: To determine the usefulness of social media for rapid communication with experts to discuss strategies for prioritization and safety of deferred treatment for urologic malignancies during COVID-19 pandemic, and to determine whether the discourse and recommendations made through discussions on social media (Twitter) were consistent with the current peer-reviewed literature regarding the safety of delayed treatment. METHODS: We reviewed and compiled the responses to our questions on Twitter regarding the management and safety of deferred treatment in the setting of COVID-19 related constraints on non-urgent care. We chronicled the guidance published on this subject by various health authorities and professional organizations. Further, we analyzed peerreviewed literature on the safety of deferred treatment (surgery or systemic therapy) to make made evidence-based recommendations. RESULTS: Due to the rapidly changing information about epidemiology and infectious characteristics of COVID-19, the health authorities and professional societies guidance required frequent revisions which by design take days or weeks to produce. Several active discussions on Twitter provided real-time updates on the changing landscape of the restrictions being placed on non-urgent care. For separate discussion threads on prostate cancer and bladder cancer, dozens of specialists with expertise in treating urologic cancers could be engaged in providing their expert opinions as well as share evidence to support their recommendations. Our analysis of published studies addressing the safety and extent to which delayed cancer care does not compromise oncological outcome revealed that most prostate cancer care and certain aspects of the bladder and kidney cancer care can be safely deferred for 2-6 months. Urothelial bladder cancer and advanced kidney cancer require a higher priority for timely surgical care. We did not find evidence to support the idea of using nonsurgical therapies, such as hormone therapy for prostate cancer or chemotherapy for bladder cancer for safer deferment of previously planned surgery. We noted that the comments and recommendations made by the participants in the Twitter discussions were generally consistent with our evidence-based recommendations for safely postponing cancer care for certain types of urologic cancers. CONCLUSION: The use of social media platforms, such as Twitter, where the comments and recommendations are subject to review and critique by other specialists is not only feasible but quite useful in addressing the situations requiring urgent resolution, often supported by published evidence. In circumstances such as natural disasters, this may be a preferable approach than the traditional expert panels due to its ability to harness the collective intellect to available experts to provide responses and solutions in real-time. These real-time communications via Twitter provided sound guidance which was readily available to the public and participants, and was generally in concordance with the peerreviewed data on safety of deferred treatment.

Elevada frequência de Aeromonas spp. e genes de virulência em cultivos de tilápia-do-nilo (Oreochromis niloticus) em tanques-rede, na região semiárida de Pernambuco, Brasil / High frequency of Aeromonas spp. and virulence genes in Nile Tilapia farms (Oreochromis niloticus) in semi-arid regions of Pernambuco, Brazil

Objetivou-se avaliar a ocorrência de Aeromonas spp. em peixes e amostras de água na região semiárida de Pernambuco e avaliar a frequência de aerolissina (aerA), enterotoxina citotóxica (act), enterotoxina citotônica (alt) e serina protease (ahp) nesses isolados. Foram analisados 70 peixes vivos e oito mortos com sinais clínicos de aeromoniose e 16 amostras de água. Aeromonas spp. foram identificadas por análises microbiológicas (provas bioquímicas) e molecular, usando-se primers específicos para a região 16S rRNA, e a distribuição dos quatro fatores de virulência (aerA, alt, act e ahp) foi investigada por ensaio de PCR. Cento e cinquenta e cinco (84,7%) isolados foram confirmados como Aeromonas spp. na análise molecular. Os genes de virulência mais frequentes foram act (53,55%) e aerA (51,61%). De acordo com o tipo de amostra, observou-se maior frequência do gene aerA (87,5% P=0,0474) em isolados de peixes mortos e a menor frequência do gene act (47,73% P=0,0002) em peixes vivos. Este estudo demonstrou a presença de aeromoniose no cultivo de tilápias em tanques-rede, nos municípios de Jatobá e Petrolândia, na região semiárida de Pernambuco. A detecção de aerA, act e alt pode ser utilizada na tipagem de virulência de Aeromonas spp.(AU)

The purpose of this study was to evaluate the occurrence of Aeromonas spp. from fishes and tilapia net-cage farm water in semi-arid regions of Pernambuco and to evaluate the frequency of the aerolysin (aerA), cytotoxic enterotoxin (act), cytotonic enterotoxin (alt) and serine protease (ahp) genes in Aeromonas isolates. 70 live and eight dead fish with aeromoniosis clinical signs and 16 water samples were analyzed. Aeromonas spp. isolated were identified by microbiological (biochemical evidence) and molecular analysis using specific primers for 16SrRNA region, while the distribution of four virulence factors, including aerA, alt, act and ahp, was investigated by PCR assay. One hundred fifty-five (84.7%) isolates were confirmed as Aeromonas spp. by molecular analysis. The most frequent virulence genes in isolates were act (53.55%) and aerA (51,61%). According to the kind of sample, the higher frequency of aerA gene (87.5% P= 0.0474) was observed in isolates from dead fish and the lowest frequency of act gene (47.73% P= 0.0002) from live fish. This study found the presence of aeromoniosis on tilapia farming in net-cages on Jatobá and Petrolândia counties in the semiarid Pernambuco region. The detection of aerA, act and alt can be used for virulence typing of Aeromonas spp. isolates.(AU)

Flexible 3D laparoscopic assisted reduction and percutaneous fixation of acetabular fractures: Introduction to a new surgical option.

The gold standard for fractures of the acetabulum is to perform an open reduction and internal fixation in order to achieve anatomical reduction. In a well-defined subset of patients, percutaneous techniques may be employed but achieving reduction by closed means can be challenging especially for fractures with large degrees of displacement. Such patient may include elderly patients who may not have the physiologic reserve to withstand open approaches. In our paper, we present a new option using laparoscopic assisted reduction of the acetabular fracture and percutaneous fixation. The young obese patient refused all forms of blood products transfusion and presented with a displaced transverse posterior wall fracture. While we do not recommend routine use of such technique and recognize its numerous limitations, we present it as an alternative strategy in a small subset of patients.

Focal therapy for prostate cancer: current status and future perspectives.

Focal therapy is a relatively new and extremely attractive option of treatment for prostate cancer. It has been described as the "middle approach" between active surveillance and radical treatment, aiming to destroy the tumor itself or the region containing the tumor in order to preserve surrounding non-cancerous tissue. The goal is to maintain disease control at acceptable levels, while preserving erectile, urinary, and rectal function. While a lot of technologies have been described for delivering targeted therapy to the prostate, such as cryoablation, high intensity focused ultrasound, photodynamic therapy, irreversible electroporation and laser, the key point is the patient selection. Recent advances in mpMRI and the introduction of new biopsy techniques that use MR images as a guidance, have significantly improved localization of the tumor lesions and the detection rate, evolving prostate biopsy toward targeted rather than systematic biopsies. The future challenge to clinicians is to precisely risk-stratify patients to differentiate between those who would profit from focal treatment and who would not. Forthcoming research efforts should pursue to identify molecular, genetic, and imaging characteristics that distinguish aggressive prostate tumors from indolent lesions.

Transperineal versus transrectal prostate biopsy for predicting the final laterality of prostate cancer: are they reliable enough to select patients for focal therapy? Results from a multicenter international study.

OBJECTIVES: To compare the concordance of prostate cancer (PCa) laterality between the extended transperineal (TP) or transrectal (TR) prostate biopsy (BP) and radical prostatectomy (RP) specimens. To identify predictors of laterality agreement between BP and RP. MATERIALS AND METHODS: Data from 533 consecutive patients with PCa (278 TP and 255 TR-diagnosed) treated with RP were analyzed. A 12-core technique was used for both TP and TR biopsies. Additional cores were obtained when necessary. RESULTS: Overall, the percentage of agreement of PCa laterality between BP and RP was 60% (K = 0.27, p < 0.001). However, the RP confirmation of unilaterality at BP was obtained in just 33% of the cases. Considering the concordance on bilaterality as the ″target″ of our analysis, the sensitivity and specificity were 54.3% and 98.2% , respectively, with TP and 47.5% and 92.5%, respectively with TR. Focusing on patients with unilaterality at biopsy, none of the evaluated preoperative variables (biopsy technique, age, total positive biopsy cores, PSA, prostate volume, Gleason score on biopsy) were able to predict RP bilaterality in the multivariate analyses. CONCLUSIONS: Most of the patients with unilateral involvement at BP harbored bilateral PCa after RP. TR and TP biopsy showed no difference in their capacity to predict the concordance of tumor laterality at RP. None of the preoperative evaluated variables can predict the tumor laterality at RP. Using BP unilaterality to include patients in focal therapy (FT) protocols may hinder the oncologic efficacy of FT.

The S.T.O.N.E. Score: a new assessment tool to predict stone free rates in ureteroscopy from pre-operative radiological features.

OBJECTIVE: To develop a user friendly system (S.T.O.N.E. Score) to quantify and describe stone characteristics provided by computed axial tomography scan to predict ureteroscopy outcomes and to evaluate the characteristics that are thought to affect stone free rates. MATERIALS AND METHODS: The S.T.O.N.E. score consists of 5 stone characteristics: (S) ize, (T)opography (location of stone), (O)bstruction, (N)umber of stones present, and (E)valuation of Hounsfield Units. Each component is scored on a 1-3 point scale. The S.T.O.N.E. Score was applied to 200 rigid and flexible ureteroscopies performed at our institution. A logistic model was applied to evaluate our data for stone free rates (SFR). RESULTS: SFR were found to be correlated to S.T.O.N.E. Score. As S.T.O.N.E. Score increased, the SFR decreased with a logical regression trend (p < 0.001). The logistic model found was SFR=1/(1+e^(-z)), where z=7.02-0.57•Score with an area under the curve of 0.764. A S.T.O.N.E. Score ≤ 9 points obtains stone free rates > 90% and typically falls off by 10% per point thereafter. CONCLUSIONS: The S.T.O.N.E. Score is a novel assessment tool to predict SFR in patients who require URS for the surgical therapy of ureteral and renal stone disease. The features of S.T.O.N.E. are relevant in predicting SFR with URS. Size, location, and degree of hydronephrosis were statistically significant factors in multivariate analysis. The S.T.O.N.E. Score establishes the framework for future analysis of the treatment of urolithiasis.

Transperineal versus transrectal prostate biopsy for predicting the final laterality of prostate cancer: are they reliable enough to select patients for focal therapy? Results from a multicenter international study

Objectives: To compare the concordance of prostate cancer (PCa) laterality between the extended transperineal (TP) or transrectal (TR) prostate biopsy (BP) and radical prostatectomy (RP) specimens. To identify predictors of laterality agreement between BP and RP. Materials and Methods: Data from 533 consecutive patients with PCa (278 TP and 255 TR-diagnosed) treated with RP were analyzed. A 12-core technique was used for both TP and TR biopsies. Additional cores were obtained when necessary. Results: Overall, the percentage of agreement of PCa laterality between BP and RP was 60% (K = 0.27, p < 0.001). However, the RP confirmation of unilaterality at BP was obtained in just 33% of the cases. Considering the concordance on bilaterality as the “target” of our analysis, the sensitivity and specificity were 54.3% and 98.2%, respectively, with TP and 47.5% and 92.5%, respectively with TR. Focusing on patients with unilaterality at biopsy, none of the evaluated preoperative variables (biopsy technique, age, total positive biopsy cores, PSA, prostate volume, Gleason score on biopsy) were able to predict RP bilaterality in the multivariate analyses. Conclusions: Most of the patients with unilateral involvement at BP harbored bilateral PCa after RP. TR and TP biopsy showed no difference in their capacity to predict the concordance of tumor laterality at RP. None of the preoperative evaluated variables can predict the tumor laterality at RP. Using BP unilaterality to include patients in focal therapy (FT) protocols may hinder the oncologic efficacy of FT. .

[Use of a polymeric gel to prevent retropulsion during intracorporeal lithotripsy]. / Uso de un gel polimérico para evitar retropulsión durante la litotricia intracorpórea.

INTRODUCTION: Stone retropulsion during ureteroscopic lithotripsy may lead to additional procedures needed for residual calculi. Several devices have been introduced in an attempt to reduce retropulsion. We set out to report our initial experience utilizing the new polymeric gel, BackStop. MATERIAL AND METHODS: We prospectively collected data on 7 ureteroscopy procedures with distal ureteral calculi treated with BackStop. Perioperative data including stone size, location, operative time, stone free rate, the presence or absence of retropulsion was collected. Success was defined as no residual fragments, no retropulsion, and no additional procedures required. RESULTS: All of the patients were rendered stone free after URS and no retropulsion occurred. There were no intraoperative complications nor gel migration or problems with dissolving the gel. CONCLUSIONS: BackStop is a new promising therapy to prevent retropulsion during ureteral intracorporeal lithotripsy. It is safe, easy to apply and very effective in preventing stone fragment migration. BackStop has the potential to reduce operative time.

The use of mannitol in partial and live donor nephrectomy: an international survey.

PURPOSE: Animal studies have shown the potential benefits of mannitol as renoprotective during warm ischemia; it may have antioxidant and anti-inflammatory properties and is sometimes used during partial nephrectomy (PN) and live donor nephrectomy (LDN). Despite this, a prospective study on mannitol has never been performed. The aim of this study is to document patterns of mannitol use during PN and LDN. MATERIALS AND METHODS: A survey on the use of mannitol during PN and LDN was sent to 92 high surgical volume urological centers. Questions included use of mannitol, indications for use, physician responsible for administration, dosage, timing and other renoprotective measures. RESULTS: Mannitol was used in 78 and 64 % of centers performing PN and LDN, respectively. The indication for use was as antioxidant (21 %), as diuretic (5 %) and as a combination of the two (74 %). For PN, the most common dosages were 12.5 g (30 %) and 25 g (49 %). For LDN, the most common doses were 12.5 g (36.3 %) and 25 g (63.7 %). Overall, 83 % of centers utilized mannitol, and two (percent or centers??) utilized furosemide for renoprotection. CONCLUSIONS: A large majority of high-volume centers performing PN and LDN use mannitol for renoprotection. Since there are no data proving its value nor standardized indication and usage, this survey may provide information for a randomized prospective study.

Safety and efficacy of the combination of erlotinib and sirolimus for the treatment of metastatic renal cell carcinoma after failure of sunitinib or sorafenib.

BACKGROUND: The mammalian target of rapamycin (mTOR) is an important therapeutic target in the treatment of renal cell carcinoma (RCC). Pre-clinical data indicate that the combined inhibition of both the epidermal growth factor receptor and mTOR results in enhanced anticancer activity. METHODS: All patients had metastatic RCC with progression after treatment with sunitinib and/or sorafenib. Treatment consisted of erlotinib 150 mg orally once a day starting on day 1 and sirolimus 6 mg orally on day 8 followed by 2 mg daily, adjusted according to blood levels. RESULTS: A total of 25 patients were enrolled between July 2006 and March 2008. The median progression-free survival (PFS) was 12 weeks (95% CI 5.9-18.1) and median overall survival (OS) 40 weeks (95% CI 0-85.7). No confirmed complete or partial responses were observed, but stable disease >6 months was noted in 21.8% (95% CI 4.9-38.6) of patients. The most common adverse events were rash and diarrhoea. There was no correlation between erlotinib, OSI-420 (days 8 and 15) or sirolimus (days 15 and 29) blood levels and PFS or OS. CONCLUSIONS: The combination of sirolimus and erlotinib for RCC failed to demonstrate an advantage over available single-agent therapy in the second-line setting.

The role of inflammation and infection in prostate cancer: Importance in prevention, diagnosis and treatment.

It is currently estimated that infections and inflammatory responses are linked to 15-20% of all deaths from cancer worldwide. Many studies point to an important role of inflammation in prostate growth, although the contribution of inflammation to benign prostatic hyperplasia and prostate cancer is not completely understood. There is an unmet need for epidemiologic and molecular pathologic approaches to address the issue of inflammation and prostate cancer. Here we review the published evidence with respect to the involvement of inflammation and infection in prostate cancer. We also present an overarching hypothesis that chronic inflammation associated with aging and infection may play an important role in the etiology and progression of prostate cancer. As such, chronic inflammation may represent an important therapeutic target in prostate cancer.

Temperature safety profile of laparoscopic devices: Harmonic ACE (ACE), Ligasure V (LV), and plasma trisector (PT).

BACKGROUND: Reports of iatrogenic thermal injuries during laparoscopic surgery using new generation vessel-sealing devices, as well as anecdotal reports of hand burn injuries during hand-assisted surgeries, have evoked questions about the temperature safety profile and the cooling properties of these instruments. METHODS: This study involved video recording of temperatures generated by different instruments (Harmonic ACE [ACE], Ligasure V [LV], and plasma trisector [PT]) applied according the manufacturers' pre-set settings (ACE setting 3; LV 3 bars, and the PT TR2 50W). The video camera used was the infrared Flex Cam Pro directed to three different types of swine tissue: (1) peritoneum (P), (2) mesenteric vessels (MV), and (3) liver (L). Activation and cooling temperature and time were measured for each instrument. RESULTS: The ACE device produced the highest temperatures (195.9 degrees +/- 14.5 degrees C) when applied against the peritoneum, and they were significantly higher than the other instruments (LV = 96.4 degrees +/- 4.1 degrees C, and PT = 87 degrees +/- 2.2 degrees C). The LV and PT consistently yielded temperatures that were < 100 degrees C independent of type of tissue or "on"/ "off" mode. Conversely, the ACE reached temperatures higher than 200 degrees C, with a surprising surge after the instrument was deactivated. Moreover, temperatures were lower when the ACE was applied against thicker tissue (liver). The LV and PT cooling times were virtually equivalent, but the ACE required almost twice as long to cool. CONCLUSIONS: The ACE increased the peak temperature after deactivation when applied against thick tissue (liver), and the other instruments inconsistently increased peak temperatures after they were turned off, requiring few seconds to cool down. Moreover, the ACE generated very high temperatures (234.5 degrees C) that could harm adjacent tissue or the surgeon's hand on contact immediately after deactivation. With judicious use, burn injury from these instruments can be prevented during laparoscopic procedures. Because of the high temperatures generated by the ACE device, particular care should be taken when it is used during laparoscopy.

Hypotension and acute pulmonary insufficiency following transfusion of autologous red blood cells during surgery: a case report and review of the literature.

Transfusion of autologous blood is associated with fewer complications, although all untoward events of transfusion may not be negated with this strategy. We report a case of acute pulmonary insufficiency and hypotension following transfusion of autologous packed red blood cells (PRBCs) in a patient, who was undergoing major surgery. Anti-HLA class-I and class-II and anti-granulocyte antibodies were measured in the unit and in the recipient. Neutrophil (PMN)-priming activity was measured as the augmentation of the formyl-Met-Leu-Phe-activated respiratory burst. No immunoglobulins were identified; however, significant lipid-priming activity was present in the implicated, autologous PRBC unit that primed PMNs from both healthy people and the recipient. In addition, lipids, identical to those that accumulate during PRBC storage, caused significant hypotension when infused into rats at similar concentrations found in stored PRBCs. We conclude that the observed transfusion-related acute lung injury reaction with significant hypotension may be the result of two independent events: the first is related to inherent host factors, in this case major surgery, and the second is the infusion of lipids that accumulate during the routine storage of PRBCs.

Recurrent bleeding from intercostal arterial pseudoaneurysm after retroperitoneal laparoscopic radical nephrectomy.

We report a case of a 59-year-old man with recurrent bleeding after retroperitoneal laparoscopic nephrectomy. Computed tomography and Doppler ultrasonography confirmed an intercostal artery pseudoaneurysm as the source. Angiography 1 month later demonstrated resolution after conservative management.

Reconstructing penile supersonic transporter (SST) deformity using glanulopexy (glans fixation).

After penile prosthesis insertion, men may develop a disabling supersonic transporter deformity from any one of several causes. We describe the results of surgical treatment in 10 such patients in whom sexual relations were restored by reconstructive glanulopexy. All procedures were performed on an outpatient basis using local anesthesia.

Image-guided therapy in urology.

Technological breakthroughs have advanced the fields of urology, radiology, and minimally invasive surgery. Today, the various imaging modalities are increasingly applied to guiding therapy. Among the procedures now in use or under development are percutaneous cyst drainage or sclerotherapy; tissue ablation with high-intensity focused ultrasound, cold, heat, or photon radiation; and conformal radiation and brachytherapy. As current limitations are overcome, image-guided therapy will expand.

Renal transplantation: laparoscopic live donor nephrectomy.

Laparoscopic nephrectomy is now performed at many centers worldwide. This technique for organ harvesting offers less postoperative pain, quicker convalescence, and an optimal cosmetic result when compared with the traditional open approach. With experience, the laparoscopic technique is accomplished without compromise to donor safety or allograft function, and complications are comparable with the rates in open historic series. Longer operative times and the need for disposable equipment result in greater hospital costs; however, the quicker convalescence permits patients to resume activity sooner, allowing marked cost savings for patients and employers. The laparoscopic technique is associated with a steep learning curve. Launching a successful laparoscopic living donor program requires a dedicated coordinated effort involving physicians, nurses, and hospital administration. The ultimate impact of this technique on the willingness of individuals to donate has not yet been determined.

Definition of an amino-terminal domain of the human T-cell leukemia virus type 1 envelope surface unit that extends the fusogenic range of an ecotropic murine leukemia virus.

Murine leukemia viruses (MuLV) and human T-cell leukemia viruses (HTLV) are phylogenetically highly divergent retroviruses with distinct envelope fusion properties. The MuLV envelope glycoprotein surface unit (SU) comprises a receptor-binding domain followed by a proline-rich region which modulates envelope conformational changes and fusogenicity. In contrast, the receptor-binding domain and SU organization of HTLV are undefined. Here, we describe an HTLV/MuLV envelope chimera in which the receptor-binding domain and proline-rich region of the ecotropic MuLV were replaced with the potentially corresponding domains of the HTLV-1 SU. This chimeric HTLV/MuLV envelope was processed, specifically interfered with HTLV-1 envelope-mediated fusion, and similar to MuLV envelopes, required cleavage of its cytoplasmic tail to exert significant fusogenic properties. Furthermore, the HTLV domain defined here broadened ecotropic MuLV envelope-induced fusion to human and simian cell lines.

Complications of acucise endopyelotomy.

Endoscopic management of ureteropelvic junction (UPJ) obstruction has a success rate of 80% to 86%. We have been performing a ureteral cutting balloon procedure under fluoroscopic control (Acucise endopyelotomy) for UPJ obstruction at Loyola University Medical Center since 1991. The overall success rate in 77 patients was 78%. All patients had a preoperative intravenous urogram or a retrograde pyelogram, but none had vascular imaging studies. Acucise endopyelotomy consisted of a posterolateral incision of the UPJ and placement of an endopyelotomy or double-J stent. Foley catheter placement at the end of the procedure demonstrated significant gross hematuria in three patients (4%). All three remained hemodynamically stable but with significant drops in postprocedure hemoglobin levels, which necessitated blood transfusion. Aggressive management included angiographic studies and embolization of lower-pole branching arteries in two patients (3%). One patient stopped bleeding after being given two units of blood. None of the patients required an open exploratory procedure. Although the risk of vascular injury is low with Acucise endopyelotomy, prolonged postoperative gross hematuria does mandate investigation and observation. Angiographic embolization appears to be the therapeutic modality of choice for patients with hemorrhagic complications after an Acucise endopyelotomy.