ABSTRACT
BACKGROUND: As the incidence of urological malignancies after renal transplantation (RT) is observed to be greater than in the general population, a better understanding of them is important. We present our experience with urological tumors in RT recipients at our transplant center, and analyze their incidence, management and outcomes. MATERIALS AND METHODS: A retrospective analysis of 2177 RT recipients on follow-up at our center between 1990 and 2022 was conducted for de novo genitourinary malignancy. Patients diagnosed with malignancy before transplantation were excluded. Clinicopathological data at diagnosis and follow-up were collected and analyzed. Kaplan-Meier estimates were used to evaluate overall survival (OS) and cancer-specific survival (CSS). Statistical analysis was performed using IBM SPSS v.24 (IBM Corp., Armonk, NY, USA). RESULTS: The overall incidence of Urological malignancies was 3.9%, with 89 cancers diagnosed in 85 patients. Renal cell carcinoma was most common (n = 61, 68.5%), followed by prostate cancer (n = 10, 11.2%), urothelial carcinoma (n = 10, 11.2%), squamous cell carcinoma of the penis/scrotum (n = 7, 7.9%), and testicular cancer (n = 1, 1.1%). Mean duration between transplantation and diagnosis of malignancy was 9.9 (0.4-20.7) years. At a median follow-up of 4.6 (018.2) years, 27 deaths were seen; 7(25.9%) were due to urological malignancy. CSS rates were 86% and 78% at five and ten years, respectively, after diagnosis. CONCLUSION: We present one of the largest series of de novo urological malignancies observed over an extended 30-year follow-up of RT recipients, demonstrating an elevated risk in line with other studies. Regular surveillance for malignancies is advised, in order to ensure early diagnosis and management.
Subject(s)
Kidney Transplantation , Postoperative Complications , Urologic Neoplasms , Humans , Kidney Transplantation/adverse effects , Male , Female , Retrospective Studies , Middle Aged , Follow-Up Studies , Urologic Neoplasms/etiology , Urologic Neoplasms/epidemiology , Urologic Neoplasms/pathology , Incidence , Prognosis , Adult , Survival Rate , Postoperative Complications/epidemiology , Risk Factors , Kidney Failure, Chronic/surgery , Aged , Young AdultABSTRACT
CONTEXT: Patients with clinically lymph node-positive (cN1) prostate cancer (PCa) are traditionally regarded to have metastatic disease, and the role of local therapy (LT) in their treatment remains unclear. OBJECTIVE: To evaluate the outcomes of cN1 PCa patients treated with LT, and secondarily to compare between different modalities of LT, including radiotherapy (RT) and radical prostatectomy (RP). EVIDENCE ACQUISITION: A bibliographic search was performed using Medline, Embase, and the Cochrane Library to identify studies comparing the survival outcomes of cN1 PCa patients treated with LT (RT or RP) with those who did not receive any form of LT (observation or androgen deprivation therapy alone). The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations were followed. Survival outcomes of the addition of LT were assessed using a random-effect model. EVIDENCE SYNTHESIS: A total of 8522 patients across eight studies were included. LT significantly improved overall survival (OS) across all time points from 2 to 10 yr compared with patients without LT, most notably providing a durable benefit in 10-yr OS (odds ratio [OR]: 1.49, 95% confidence interval [CI] 1.06-2.10). Both RT and RP were associated with benefits to both OS and recurrence-free survival, with no significant difference in OS between both modalities in medium-term follow-up (4-yr OR: 0.76, 95% CI 0.41-1.40, p = 0.19). CONCLUSIONS: Regardless of modality, the use of LT in cN1 patients improved OS. Future studies should aim to identify patients who could benefit from LT and include more comprehensive survival data including biochemical recurrence. PATIENT SUMMARY: In this study, we evaluated the outcomes of clinically lymph node-positive (cN1) prostate cancer (PCa) patients treated with local therapy (LT) and compared between different modalities of LT, including radiotherapy (RT) and radical prostatectomy (RP). We found that the addition of LT for cN1 PCa patients leads to a significant improvement in survival outcomes, most notably for overall survival, with no significant difference between RT and RP.
ABSTRACT
CONTEXT: Whether prostate-specific membrane antigen positron emission tomography (PSMA-PET) should replace conventional imaging modalities (CIM) for initial staging of intermediate-high risk prostate cancer (PCa) requires definitive evidence on their relative diagnostic abilities. OBJECTIVE: To perform head-to-head comparisons of PSMA-PET and CIM including multiparametric magnetic resonance imaging (mpMRI), computed tomography (CT) and bone scan (BS) for upfront staging of tumour, nodal, and bone metastasis. EVIDENCE ACQUISITION: A search of the PubMed, EMBASE, CENTRAL, and Scopus databases was conducted from inception to December 2021. Only studies in which patients underwent both PSMA-PET and CIM and imaging was referenced against histopathology or composite reference standards were included. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) checklist and its extension for comparative reviews (QUADAS-C). Pairwise comparisons of the sensitivity and specificity of PSMA-PET versus CIM were performed by adding imaging modality as a covariate to bivariate mixed-effects meta-regression models. The likelihood ratio test was applied to determine whether statistically significant differences existed. EVIDENCE SYNTHESIS: A total of 31 studies (2431 patients) were included. PSMA-PET/MRI was more sensitive than mpMRI for detection of extra-prostatic extension (78.7% versus 52.9%) and seminal vesicle invasion (66.7% versus 51.0%). For nodal staging, PSMA-PET was more sensitive and specific than mpMRI (73.7% versus 38.9%, 97.5% versus 82.6%) and CT (73.2% versus 38.5%, 97.8% versus 83.6%). For bone metastasis staging, PSMA-PET was more sensitive and specific than BS with or without single-photon emission computerised tomography (98.0% versus 73.0%, 96.2% versus 79.1%). A time interval between imaging modalities >1 month was identified as a source of heterogeneity across all nodal staging analyses. CONCLUSIONS: Direct comparisons revealed that PSMA-PET significantly outperforms CIM, which suggests that PSMA-PET should be used as a first-line approach for the initial staging of PCa. PATIENT SUMMARY: We reviewed direct comparisons of the ability of a scan method called PSMA-PET (prostate-specific membrane antigen positron emission tomography) and current imaging methods to detect the spread of prostate cancer outside the prostate gland. We found that PSMA-PET is more accurate for detection of the spread of prostate cancer to adjacent tissue, nearby lymph nodes, and bones.
Subject(s)
Prostate , Prostatic Neoplasms , Male , Humans , Prostate/pathology , Positron Emission Tomography Computed Tomography/methods , Positron-Emission Tomography , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/pathology , Magnetic Resonance Imaging , Gallium Radioisotopes , Neoplasm StagingABSTRACT
BACKGROUND: Uroflowmetry remains an important tool for the assessment of patients with lower urinary tract symptoms (LUTS), but accuracy can be limited by within-subject variation of urinary flow rates. Voiding acoustics appear to correlate well with conventional uroflowmetry and show promise as a convenient home-based alternative for the monitoring of urinary flows. OBJECTIVE: To evaluate the ability of a sound-based deep learning algorithm (Audioflow) to predict uroflowmetry parameters and identify abnormal urinary flow patterns. DESIGN, SETTING, AND PARTICIPANTS: In this prospective open-label study, 534 male participants recruited at Singapore General Hospital between December 1, 2017 and July 1, 2019 voided into a uroflowmetry machine, and voiding acoustics were recorded using a smartphone in close proximity. The Audioflow algorithm consisted of two models-the first model for the prediction of flow parameters including maximum flow rate (Qmax), average flow rate (Qave), and voided volume (VV) was trained and validated using leave-one-out cross-validation procedures; the second model for discrimination of normal and abnormal urinary flows was trained based on a reference standard created by three senior urologists. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Lin's correlation coefficient was used to evaluate the agreement between Audioflow predictions and conventional uroflowmetry for Qmax, Qave, and VV. Accuracy of the Audioflow algorithm in the identification of abnormal urinary flows was assessed with sensitivity analyses and the area under the receiver operating curve (AUC); this algorithm was compared with an external panel of graders comprising six urology residents/general practitioners who separately graded flow patterns in the validation dataset. RESULTS AND LIMITATIONS: A total of 331 patients were included for analysis. Agreement between Audioflow and conventional uroflowmetry for Qmax, Qave, and VV was 0.77 (95% confidence interval [CI], 0.72-0.80), 0.85 (95% CI, 0.82-0.88) and 0.84 (95% CI, 0.80-0.87), respectively. For the identification of abnormal flows, Audioflow achieved a high rate of agreement of 83.8% (95% CI, 77.5-90.1%) with the reference standard, and was comparable with an external panel of six residents/general practitioners. AUC was 0.892 (95% CI, 0.834-0.951), with high sensitivity of 87.3% (95% CI, 76.8-93.7%) and specificity of 77.5% (95% CI, 61.1-88.6%). CONCLUSIONS: The results of this study suggest that a deep learning algorithm can predict uroflowmetry parameters and identify abnormal urinary voids based on voiding sounds, and shows promise as a simple home-based alternative to uroflowmetry in the management of patients with LUTS. PATIENT SUMMARY: In this study, we trained a deep learning-based algorithm to measure urinary flow rates and identify abnormal flow patterns based on voiding sounds. This may provide a convenient, home-based alternative to conventional uroflowmetry for the assessment and monitoring of patients with lower urinary tract symptoms.
Subject(s)
Deep Learning , Lower Urinary Tract Symptoms , Humans , Male , Lower Urinary Tract Symptoms/diagnosis , Prospective Studies , Rheology/methods , UrodynamicsABSTRACT
BACKGROUND: The optimal number of systematic biopsy cores in the era of multi-parametric MRI targeted biopsy remains unclear, especially on its impact of focal therapy planning. Our objective is to investigate the impact of reducing the number of systematic cores on prostate cancer detection in the era of MRI-US fusion targeted biopsy and as well as its relevance in template planning for focal therapy. MATERIALS AND METHODS: A retrospective analysis of 398 consecutive men who underwent both systematic saturation (~24 cores) and MRI-US fusion targeted biopsy was performed. Four reduced-core systematic biopsy strategies (two-thirds, half, one-third and one-quarter systematic cores) were modelled and the detection rates of clinically-significant prostate cancer (csPCa defined as grade group ≥2) were compared to that of a full systematic biopsy using McNemar's test. Focal therapy treatment plans were made based on positive cores on combined (targeted and systematic) biopsy and the various reduced-cores strategies to compare the proportion who had a change in treatment plan. RESULTS: csPCa was detected in 42% (168/398) of this patient cohort. Non-targeted systematic saturation biopsy had a 21% (83/398) csPCa detection rate. Our four strategies reduced the mean number of non-targeted systematic cores from 21.8 to 14.5, 10.9, 7.3 and 5.4 cores and their csPCa detection rates were significantly decreased to 16%, 13%, 9% and 8% respectively (all p < 0.05). Compared to the reduced-core strategies, a full systematic saturation biopsy resulted in change to the focal therapy treatment plan in 12% (2/3 cores), 19% (1/2 cores), 24% (1/3 cores) and 29% (1/4 cores) of the time (p = 0.0434). CONCLUSIONS: Reducing the number of systematic biopsies when performing an MRI-targeted biopsy leads to reduced detection of csPCa and alter the treatment plans for focal therapy, possibly limiting its oncological efficacy.
Subject(s)
Prostatic Neoplasms , Male , Humans , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/therapy , Image-Guided Biopsy/methods , Retrospective Studies , Prostate/pathology , Magnetic Resonance ImagingABSTRACT
Hematuria is not uncommonly seen among children. We describe the case of a 13-year-old boy who was diagnosed with urothelial carcinoma after presenting with persistent gross hematuria for 2 weeks. We highlight the importance of adequate workup for gross hematuria as it is often associated with an underlying pathology that could lead to significant morbidity if left undiagnosed.
Subject(s)
Carcinoma, Transitional Cell , Urinary Bladder Neoplasms , Adolescent , Carcinoma, Transitional Cell/complications , Carcinoma, Transitional Cell/diagnosis , Child , Cystoscopy , Family , Hematuria/etiology , Humans , Male , Urinary Bladder Neoplasms/complications , Urinary Bladder Neoplasms/diagnosisABSTRACT
Childhood priapism is a rare entity and there is currently no consensus regarding its contemporary management. The use of perioperative anticoagulation and open distal corpora-glandular shunt procedure in the management of childhood priapism has not been reported in the literature. We present a stuttering case of a 13-year-old boy who presented with idiopathic ischaemic priapism lasting 13 h in duration, which recurred despite corporal aspiration and alpha-adrenergic agonist injections, percutaneous distal shunt surgery, and revision of percutaneous distal shunt surgery. He was eventually successfully managed with perioperative subcutaneous enoxaparin, oral aspirin and clopidogrel in conjunction with an Al-Ghorab shunt, which led to sustained detumescence but with spontaneous morning erections. In paediatric patients with sustained childhood priaprism failing stepwise treatments, an Al-Ghorab shunt with perioperative anticoagulation is a viable option.
ABSTRACT
OBJECTIVES: To evaluate the clinically-significant prostate cancer (csCaP) detection rate of systematic (SBx) vs. targeted biopsy (TBx), after accounting for the overlapping systematic cores within the MRI regions of interest. MATERIALS AND METHODS: We identified 398 consecutive men who underwent both transperineal systematic and targeted biopsy between January 2015 to January 2019. We reclassified overlapping systematic cores in the MRI regions of interest as target cores. The detection rates of SBx and TBx were compared using McNemar's test. RESULTS: Detection rate of csCaP (grade group ≥2) was 42% (168/398). Median number of systematic and targeted cores were 23 (IQR 19-29) and 9 (IQR 6-12) respectively. A median of 3 (IQR 2-4) overlapping systematic cores were reclassified as targeted cores. After accounting for overlap, csPC detection rate on SBx decreased from 37% and 21% while the csCaP detection rate of TBx increased from 34% to 39% (both P < 0.001), with TBx having a better detection rate (39% vs. 21%, P < 0.001). A previous negative biopsy was associated with a lower risk of having csCaP on non-targeted SBx (OR 0.27, 95% CI: 0.12 - 0.58, Pâ¯=â¯0.001). Only 5% (13/243) of those who had no cancer detected on TBx had csCaP on non-targeted SBx compared to 45% (70/155) of those who had csCaP on TBx (P< 0.001). CONCLUSIONS: The utility of SBx in detecting csCaP decreases after accounting for overlap into the MRI region of interest, especially in men with a prior negative biopsy. Overlapping systematic cores improve the csCaP detection rate on TBx.
Subject(s)
Image-Guided Biopsy/methods , Magnetic Resonance Imaging/methods , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/surgery , Aged , Humans , Male , Middle Aged , Retrospective StudiesABSTRACT
PURPOSE: Several multiparametric magnetic resonance imaging (mpMRI)-based models have been developed with significant improvements in diagnostic accuracy for clinically significant prostate cancer (csCaP), but lack proper external validation. We therefore sought to externally validate and compare all published mpMRI-based csCaP risk prediction models in an independent Asian population. PATIENTS AND METHODS: A total of 449 men undergoing combined transperineal fusion-targeted/systematic prostate biopsy at our specialist center between 2015 to 2019 were retrospectively analyzed. csCaP was defined as lesions with ISUP (International Society of Urological Pathology) grade group ≥2. The performance of 6 mpMRI-based risk models (MRI-ERSPC-3/4, Distler, Radtke, Mehralivand, van Leeuwen and He) were evaluated in terms of discrimination, calibration and clinical utility, using area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analyses. RESULTS: A total of 202 (45%) subjects were diagnosed with csCaP. All models demonstrated excellent accuracy with AUCs ranging from 0.75 to 0.86, and most significantly outperformed mpMRI PIRADSv2.0 (Prostate Imaging Reporting and Data System version 2.0) alone. The models by Mehralivand and He showed good calibration to our validation population, with respective intercepts of -0.08 and -0.84. All models were nevertheless recalibrated to the csCaP prevalence in our population for analysis. Decision curve analysis showed that above a threshold probability of 10%, all mpMRI-based models demonstrated superior net benefit compared to mpMRI PIRADSv2.0 or a biopsy-all-men strategy. The van Leeuwen model had the greatest net benefit, avoiding 39% of unnecessary biopsies while missing only 4% of csCaP, at a threshold probability of 15%. CONCLUSIONS: The mpMRI-based risk models demonstrate excellent discrimination and clinical utility and are easy to apply in practice, suggesting that individualized risk-based approaches can be considered over mpMRI alone to avoid unnecessary biopsies.
Subject(s)
Multiparametric Magnetic Resonance Imaging/methods , Prostatic Neoplasms/diagnostic imaging , Risk Assessment/methods , Aged , Humans , Male , Middle Aged , Retrospective StudiesSubject(s)
Carcinoma, Renal Cell/secondary , Facial Neoplasms/secondary , Kidney Neoplasms/pathology , Skin Neoplasms/secondary , Aged , Antigens, Neoplasm/analysis , Biomarkers, Tumor/analysis , Biopsy , Carbonic Anhydrase IX/analysis , Carcinoma, Renal Cell/chemistry , Carcinoma, Renal Cell/therapy , Facial Neoplasms/chemistry , Facial Neoplasms/therapy , Female , Humans , Immunohistochemistry , Kidney Neoplasms/chemistry , Kidney Neoplasms/therapy , PAX8 Transcription Factor/analysis , Skin Neoplasms/chemistry , Skin Neoplasms/therapy , Treatment OutcomeABSTRACT
OBJECTIVE: To compare the detection rates of prostate cancer between systematic biopsy and targeted biopsy using a stereotactic robot-assisted transperineal prostate platform. MATERIALS AND METHODS: We identified consecutive patients with suspicious lesion(s) on multiparametric magnetic resonance imaging (mpMRI), who underwent both systematic and MRI-transrectal ultrasonography (US) fusion targeted biopsy using our proprietary transperineal robot-assisted prostate biopsy platform between January 2015 and January 2019 at our institution, for retrospective analysis. Comparative analysis was performed between systematic and targeted biopsy using McNemar's test, and the cohort was further stratified by prior biopsy status and Prostate Imaging Reporting and Data System (PI-RADS) v2.0 score. International Society of Urological Pathology (ISUP) grade group (GG) ≥2 cancers (previously known as Gleason grade ≥7) were considered to be clinically significant. RESULTS: A total of 500 patients were included in our final analysis, of whom 67 (13%) were patients with low-risk cancer on active surveillance. Of the 433 patients without prior diagnosis of cancer, 288 (67%) were biopsy-naïve. A total of 248 (57%) were diagnosed with prostate cancer, with 199 (46%) having clinically significant prostate cancer (ISUP GG ≥2). There were no statistically significant differences in the overall prostate cancer and clinically significant prostate cancer detection rate between systematic and targeted biopsy (51% vs 49% and 40% vs 38% respectively; P = 0.306 and P = 0.609). Of the 248 prostate cancers detected, 75% (187/248) were detected on both systematic and targeted biopsy, 14% (35/248) were detected on systematic biopsy alone and 11% (26/248) were detected on targeted biopsy alone. Of the 199 clinically significant cancers detected, 69% (138/199) were detected on both systematic and targeted biopsy, 17% (33/199) on systematic biopsy alone and 14% (28/199) on targeted biopsy alone. There were no statistically significant differences in the detection rate between systematic and targeted biopsy for both overall and clinically significant prostate cancer, even when the cohort was stratified by prior biopsy status and PI-RADS score. Targeted biopsy has greater sampling efficiency compared to systematic biopsy for both overall and clinically significant prostate cancer (23.2% vs 9.8%, P < 0.001 and 14.8% vs 5.6%, P < 0.001). CONCLUSIONS: Using our robot-assisted transperineal prostate platform, combined MRI-US targeted biopsy with concurrent systematic prostate systematic biopsy probably represents the optimal method for the detection of clinically significant prostate cancer.
Subject(s)
Image-Guided Biopsy/methods , Multiparametric Magnetic Resonance Imaging/methods , Prostate , Robotic Surgical Procedures/methods , Ultrasonography, Interventional/methods , Aged , Humans , Image Interpretation, Computer-Assisted , Male , Middle Aged , Prostate/diagnostic imaging , Prostate/pathology , Prostate/surgery , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/pathology , Prostatic Neoplasms/surgery , Retrospective StudiesABSTRACT
OBJECTIVES: Our objective was to evaluate the effect of the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), lymphocyte/monocyte ratio (LMR), and red blood cell distribution width (RDW) on the survival outcomes of nonmetastatic clear cell renal cell carcinoma (ccRCC). MATERIALS AND METHODS: We accessed our single-center, urologic-oncologic registry to extract the data for patients who had undergone nephrectomy for nonmetastatic ccRCC. The optimal cutoff for these markers was determined using X-tile software, and survival analyses using Cox regression were performed. RESULTS: A total of 687 patients had undergone nephrectomy. The optimal cutoffs for NLR, PLR, LMR, and RDW were 3.3, 210, 2.4, and 14.3%, respectively. The NLR, PLR, LMR, and RDW were significantly associated with a larger pathologic tumor size, and stage, more aggressive Fuhrman grade, and the presence of tumor necrosis. After adjusting for age, baseline Eastern Cooperative Oncology Group, pathologic tumor and nodal stage, and Fuhrman grade, only PLR remained an independent prognostic marker for both cancer-specific survival (hazard ratio, 2.69; 95% confidence interval, 1.36-5.33; P = .004) and overall survival (hazard ratio, 2.19; 95% confidence interval, 1.36-3.50; P = .001). When the PLR was included with the Leibovich score and University of California, Los Angeles, integrated staging system, the Harrell's c-index increased from 0.854 to 0.876 and 0.751 to 0.810, respectively, for cancer-specific survival at 5 years after nephrectomy. When risk stratified by the Leibovich risk group and UCLA integrated staging system, PLR was a significant prognostic factor only within the intermediate- to high-risk groups. CONCLUSIONS: PLR is a robust prognostic marker in nonmetastatic ccRCC that clearly outperforms other inflammatory indexes in those who had undergone nephrectomy. However, its prognostic effect was limited in the low-risk category of ccRCC.
Subject(s)
Blood Platelets/pathology , Carcinoma, Renal Cell/pathology , Inflammation Mediators/metabolism , Lymphocytes/pathology , Monocytes/pathology , Nephrectomy/mortality , Neutrophils/pathology , Biomarkers, Tumor/analysis , Carcinoma, Renal Cell/immunology , Carcinoma, Renal Cell/metabolism , Carcinoma, Renal Cell/surgery , Female , Follow-Up Studies , Humans , Kidney Neoplasms/immunology , Kidney Neoplasms/metabolism , Kidney Neoplasms/pathology , Kidney Neoplasms/surgery , Male , Middle Aged , Prognosis , ROC Curve , Retrospective Studies , Survival RateABSTRACT
The treatment of choice for diabetic foot osteomyelitis is surgical debridement and targeted antibiotics with or without revascularization, depending on vascular status. In our society, debridement is done by either a vascular or orthopedic surgeon, and the common teaching is that generous amputation of bone with the accompanying soft tissue envelope is essential for adequate source control and to prevent recurrence (which remains as high as 30% even with this approach). Most of our patients undergo formal ray amputation through the metatarsal neck, while a few get digital amputations through the interphalangeal joints. Many of the resultant wounds cannot be closed and are left to heal by secondary intention. These amputations invariably alter the biomechanics of the foot and leave large and slow-healing open wounds, which have associated adverse psychosocial impacts. We describe 2 cases of patients who had osteomyelitis in the region of the forefoot who underwent complete bony resections of the osteomyelitis but with sparing of the soft tissue envelopes with good outcomes, and we challenge the dogma that maximal debridement of soft tissue must accompany debridement of necrotic and infected bone.
Subject(s)
Debridement/methods , Diabetic Foot/complications , Dissection/methods , Metacarpal Bones , Organ Sparing Treatments/methods , Osteomyelitis/surgery , Toe Phalanges , Forefoot, Human/pathology , Forefoot, Human/surgery , Humans , Male , Metacarpal Bones/diagnostic imaging , Metacarpal Bones/pathology , Metacarpal Bones/surgery , Middle Aged , Osteomyelitis/etiology , Radiography/methods , Plastic Surgery Procedures/methods , Toe Phalanges/diagnostic imaging , Toe Phalanges/pathology , Toe Phalanges/surgery , Treatment OutcomeABSTRACT
BACKGROUND: The use of an endovascular approach for treatment of abdominal aortic aneurysms has gained traction over the past 2 decades. One of the major drawbacks of the endovascular approach is the increased rates of reintervention, with the majority arising from endoleaks that occur up to 20% of the time. Although type II endoleak is the most common subtype (25-45% of all endoleaks), it is associated with the greatest dilemma and debate with regard to indications and modalities of treatment. The open surgical approach to management of type II endoleak has gained interest and popularity over the years because of issues associated with the endovascular approach. METHODS: We present a case of a patient with type II endoleak undergoing transperitoneal sacotomy, endoaneurysmorrhaphy, and stent-graft preservation, after having failed endovascular intervention. In addition, we describe the difficulties associated with posteriorly located backbleeding lumbar arteries and a unique case of iatrogenically created type III endoleak intraoperatively. RESULTS: A literature review was performed with regard to the risk factors, indications for intervention, and modalities of treatment for type II endoleaks. In addition, suggestions are provided for future improvements in surgical technique. CONCLUSIONS: Type II endoleak is a common complication of endovascular aortic repair. In spite of this, management strategies are poorly standardized with no definitive gold standard. More collective data and pooled experience will be needed to further refine the open surgical technique and objectively assess its benefits and shortcomings vis-à-vis other alternatives.
Subject(s)
Aortic Aneurysm, Abdominal/surgery , Blood Vessel Prosthesis Implantation , Blood Vessel Prosthesis , Endoleak/surgery , Endovascular Procedures , Iatrogenic Disease , Stents , Aged, 80 and over , Aortic Aneurysm, Abdominal/diagnostic imaging , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/instrumentation , Endoleak/diagnostic imaging , Endoleak/etiology , Endovascular Procedures/adverse effects , Endovascular Procedures/instrumentation , Humans , Male , Prosthesis Design , Reoperation , Treatment OutcomeABSTRACT
PURPOSE: The Leibovich model was updated to prognosticate oncological outcomes in postnephrectomy nonmetastatic renal cell carcinoma (RCC) for each major histological subtype including clear cell (ccRCC), papillary (papRCC), and chromophobe RCC. We evaluated its performance in an independent population of predominantly Asian patients from Singapore. MATERIALS AND METHODS: Nine hundred and forty two binephric patients with nonmetastatic unilateral RCC treated with radical/partial nephrectomy from 1990 to 2015 from Singapore were retrospectively reviewed. Based on the Leibovich model, ccRCC patients were scored from 0 to 25 and papRCC patients divided into 3 risk groups. Primary outcomes of progression-free survival (PFS) and cancer-specific survival (CSS) were assessed with the Kaplan-Meier method. Receiver operating characteristic curves and calibration plots were obtained to determine discrimination and calibration respectively. RESULTS: Eight hundred and twenty nine patients (88%) had ccRCC where 16.2% experienced disease progression while 11.9% died of RCC over a median follow-up of 76 (42-117) months. There was good discrimination (c-index 0.81 for PFS, 0.83 for CSS) and calibration (PFS calibration-in-the-large 0.002 and calibration slope 0.99, CSS calibration-in-the-large 0.005 and calibration slope 0.96). One hundred and thirteen patients (12%) had papRCC, where 18.6% progressed while 14.2% died from RCC over a median follow-up of 69.5 (36.0-112.0) months. Discrimination was slightly weaker (c-index 0.72 for PFS, 0.74 for CSS), and the model was only calibrated for CSS (calibration-in-the-large 0.002, calibration slope 0.98), not for PFS (calibration-in-the-large 0.09, calibration slope 1.93). CONCLUSIONS: The updated Leibovich score is applicable for prognostication of progression and death in both ccRCC and papRCC, even when applied to an independent population of Asian patients. Further validation is required to ensure accuracy in prognosticating PFS for papRCC.
Subject(s)
Carcinoma, Renal Cell/mortality , Carcinoma, Renal Cell/surgery , Kidney Neoplasms/mortality , Kidney Neoplasms/surgery , Models, Statistical , Nephrectomy , Aged , Asian People , Disease Progression , Disease-Free Survival , Female , Humans , Male , Middle Aged , Prognosis , Retrospective Studies , Singapore , Survival RateABSTRACT
OBJECTIVE: To validate the significance of the entity of "very-low-risk" bladder cancer by analyzing the clinical outcomes of low-risk bladder cancer when further stratified by tumor size. METHODS: We accessed our prospectively maintained, single-institution, electronic bladder cancer registry to extract the clinicopathological data of patients who were diagnosed with primary, solitary, Ta, low-grade tumors that were <3 cm. Patients were divided into two prognostic groups based on tumor size (≤1.0 cm vs >1.0 cm). The survival data of the two groups were compared for recurrence, progression and mortality. RESULTS: A total of 165 patients were followed up for a median period of 79 months (interquartile range 47-118 months). A total of 45% (75/165) of the study cohort had tumors that were ≤1.0 cm. Recurrences were found in 40% (66/165) of the study cohort. On Kaplan-Meier analysis, patients with tumor size ≤1.0 cm had significantly longer time to recurrence (P < 0.001, log-rank test). Using multivariate Cox modeling, only tumor size >1.0 cm was significantly associated with shorter time to recurrence (HR 2.54, 95% CI 1.35-4.77, P = 0.004). Tumor size was not significantly associated with any differences in time to overall progression, muscle-invasive progression or overall mortality (P = 0.108, P = 0.362 and P = 0.225, respectively, log-rank test). CONCLUSIONS: Low-risk bladder cancer can be further stratified based on tumor size. Larger tumors (>1.0 cm) are significantly associated with shorter time to recurrence compared with smaller tumors (≤1.0 cm). However, there were no significant differences in the probability of developing disease progression or overall mortality between larger and smaller tumors.
Subject(s)
Neoplasm Recurrence, Local/epidemiology , Tumor Burden , Urinary Bladder Neoplasms/diagnosis , Urinary Bladder/pathology , Aged , Cystectomy , Disease Progression , Disease-Free Survival , Female , Follow-Up Studies , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Neoplasm Grading , Neoplasm Invasiveness/diagnosis , Neoplasm Recurrence, Local/pathology , Prognosis , Progression-Free Survival , Prospective Studies , Registries/statistics & numerical data , Retrospective Studies , Risk Assessment , Time Factors , Tomography, X-Ray Computed , Urinary Bladder/diagnostic imaging , Urinary Bladder/surgery , Urinary Bladder Neoplasms/mortality , Urinary Bladder Neoplasms/pathology , Urinary Bladder Neoplasms/surgery , UrographyABSTRACT
PURPOSE: Primary ADT (pADT) monotherapy is used significantly for patients with clinically localised disease in Asia and is acceptable even by guidelines, especially in intermediate- and high-risk disease. This occurs despite controversy in the West and data suggesting association with adverse effects, notably cardiovascular events. We therefore sought to assess the impact of pADT on all-cause mortality and prostate cancer-specific mortality (PCSM) in Asian men with high-risk and unfavourable intermediate-risk PCa. METHODS: With cancer registry data, men from a single centre in Singapore with clinically localised high-risk/unfavourable intermediate-risk PCa diagnosed between 2004 and 2014 and either treated conservatively with no therapy or started on pADT within 1 year of diagnosis were followed up through January 2017. Patients with non-localised PCa (clinical stage T4, regional/distant lymph node involvement, metastases), or receipt of local therapy (radical prostatectomy/radiotherapy) were excluded. The primary outcomes of all-cause mortality and PCSM were analysed with Cox proportional hazards regression models. RESULTS: Three hundred and forty Asian men were analysed, and 177 (52.1%) were started on pADT, with mean age of 77 (49-98) years. There were 119 deaths in the cohort, and 68 (38.4%) occurred in patients treated with pADT (median follow-up, 4.4 years). After adjusting for comorbidities and clinical characteristics, pADT did not provide benefit to all-cause mortality, PCSM or cardiovascular mortality. CONCLUSION: For clinically localised unfavourable intermediate-risk and high-risk PCa, starting pADT within 12 months of diagnosis is not associated with improved 5-year all-cause mortality or PCSM compared to patients treated conservatively with no therapy and should be discouraged due to lack of mortality benefit.
Subject(s)
Androgen Antagonists/therapeutic use , Prostatic Neoplasms/pathology , Prostatic Neoplasms/therapy , Aged , Aged, 80 and over , Asian People , Cause of Death , Gonadotropin-Releasing Hormone/analogs & derivatives , Gonadotropin-Releasing Hormone/antagonists & inhibitors , Humans , Male , Middle Aged , Orchiectomy , Proportional Hazards Models , Prostatic Neoplasms/mortality , Registries , Risk Factors , Singapore , Survival RateSubject(s)
Kidney Neoplasms/diagnostic imaging , Kidney Neoplasms/surgery , Kidney/diagnostic imaging , Nephrectomy/methods , Renal Artery/diagnostic imaging , Constriction , Feasibility Studies , Fluorescence , Humans , Indocyanine Green , Infrared Rays , Kidney/blood supply , Kidney/surgery , Laparoscopy , Optical Imaging , Renal Artery/surgeryABSTRACT
PURPOSE: To analyze the long-term clinical outcomes of men with large prostate sizes of 80 mL and greater who were managed conservatively. MATERIALS AND METHODS: We retrospectively analyzed men with prostate sizes of 80 mL and greater from our electronic hospital database. Clinical parameters such as age, International Prostate Symptom Score (IPSS), quality of life (QoL) scoring, serum prostate-specific antigen (PSA), uroflowmetry variables, and transabdominal ultrasound findings were evaluated. These parameters were compared at entry to our study and at the patient's latest follow-up visit. RESULTS: For the 50 men included in our analysis, mean age was 68 years, median PSA was 9.9 ng/mL, and median prostate volume was 94 mL. Seven men underwent upfront prostate surgery, whereas the other 43 were managed conservatively, predominantly with pharmacotherapy (98%). Only serum PSA, QoL scores, and postvoid residual urine demonstrated a significant reduction at the end of a median follow-up period of 62 months. Fourteen men (33%) were considered to have progressed clinically, with 8 experiencing retention of urine and 6 having symptomatic deterioration. Of the 35 men who were still receiving conservative treatment at the end of the follow-up period, 24 men (69%) had a peak flow rate of 10 mL/s or greater, a QoL score of 3 or less, and mild to moderate (IPSS, 0-19) symptoms. CONCLUSIONS: Although the incidence of clinical progression in men with prostate sizes of 80 mL and greater is high, there is still a role for conservative management with pharmacotherapy.