Performance of standard systematic biopsy versus MRI/TRUS fusion biopsy using the Navigo® system in contemporary cohort.

INTRODUCTION: The introduction of multi parameter magnetic resonance imaging (mpMRI) of the prostate in combination with MRI/TRUS fusion and systematic biopsy resulted in improved detection of prostate cancer. The aim of the current study was to document the performance of MRI/TRUS fusion biopsy of the prostate using the Navigo™ software in a contemporary cohort of patients from nonreferral centers. MATERIAL AND METHODS: We performed a two centers prospective data collection (2014-2020) for men with clinically suspected Pca and patients on active surveillance for low-risk Pca that were referred for TRUS biopsy after performing mpMRI of the prostate with a visible lesion. The primary outcome was detection of clinically significant cancer (csPca) defined as ISUP grade group ≥2. Patients were stratified according to biopsy technique and PI-RADS category. RESULTS: The study group included 236 patients of whom 129 (54.9%) were diagnosed with Pca and 82 (34.7%) with csPca (GG ≥ 2) on combined biopsy. The overall detection of csPca was 31% for targeted vs. 25.4% for systematic biopsy with an absolute difference of 5.6% in favor of the fusion technique. No significant difference between the two techniques was observed for detection of benign prostate or GG1 disease. The improved performance of the targeted approach was noted only in patients with PI-RADS 4 and 5 lesions. Of the patients with csPca 10 (12%) were diagnosed only by the systematic biopsy while 20 (24%) were detected only in the fusion biopsy. Systematic biopsy of prostate lobe without MRI lesion detected only 2 cases (∼1%) with high grade disease. CONCLUSIONS: Detection of csPca by mpMRI/TRUS fusion biopsy using the 3D Navigo™ system is feasible. The targeted approach outperforms the systematic one, however the later technique also detects high risk disease and should be included in the biopsy procedure. The overall detection rate (34.9%) of clinically significant prostate cancer by both targeted and systematic sampling is relatively low.

A novel approach for a complete laparoscopic nephroureterectomy with bladder cuff excision.

BACKGROUND AND PURPOSE: The dilemma in management of the distal ureter and bladder cuff during nephroureterectomy (NU) for transitional-cell carcinoma (TCC) of the upper urinary tract has delayed the development of a completely minimally invasive approach to NU in cases of TCC. Our aim is to present our technique of a purely laparoscopic nephroureterectomy performed entirely through laparoscopic ports, which mimics established principles of open surgical nephroureterectomy with bladder cuff excision. Precluding the needed for patient repositioning, complex endoscopic procedures either before or after nephrectomy and leaving the bladder cuff defect to heal spontaneously. PATIENTS AND METHODS: Patient positioning and trocar arrangement are similar to those of radical nephrectomy. The simple addition of a 5 mm trocar in the lower abdomen (midline or lateral to the rectus muscle, according to patient build) allows the surgeon to adequately dissect the distal ureter, excise an adequate bladder cuff, and suture the bladder defect in a watertight manner without the need for transurethral and intraureteral instrumentation as well as intraoperative repositioning of the patient. RESULTS: Eight cases were successfully treated. The operative time ranged from 110 to 200 minutes (mean 157 min). The median time for catheter removal was 7 days; in one patient, catheter removal was delayed to 15 days because of bladder extravasation. Average hospital stay was 10.2 days. During a mean follow-up of 12.1 months, three patients had Ta bladder recurrence, and one patient had local recurrence. CONCLUSIONS: A complete NU with bladder cuff excision can be accomplished using this approach, with early results comparable to the gold standard of open surgery with the simple addition of a trocar.

Optimizing the approach for lymph node dissection during laparoscopic radical cystectomy.

BACKGROUND: Lymph node dissection (LND) for muscle-invasive bladder cancer is one of the integral steps of radical cystectomy. In addition to staging, adequate LND has been found to alter both the prognosis for and the course of the disease after radical cystectomy. OBJECTIVE: To point out several essential steps that provide optimal exposure for LND during laparoscopic radical cystectomy for muscle-invasive bladder cancer. DESIGN, SETTING AND PARTICIPANTS: From August 2006 to September 2008, we performed 10 laparoscopic cystectomies with an extended LND using this approach at our institution. Patient and tumor characteristics, the anatomic extent of the LND, the number of lymph nodes examined, and the postoperative complications encountered were evaluated. SURGICAL PROCEDURE: Essential steps include (1) a modified five-trocar arrangement; (2) use of a 30 degrees telescope during LND; (3) prior complete mobilization of the sigmoid colon, allowing its retraction using an umbilical tape; (4) accomplishment of most of the bilateral LND from the right side; and (5) performance of LND after removal of the specimen. MEASUREMENTS: The primary end points were adequate intraoperative exposure of the template and number of lymph nodes retrieved. The secondary end point was evaluation of postoperative lymph node recurrence as an assessment of a complete LND. RESULTS AND LIMITATIONS: Mean total operative time was 512.5 min (range: 420-660), with a mean operative time of 143 min (range: 115-165) for the extended LND. Adequate exposure was successful in all 10 patients. The average number of lymph nodes examined was 25.5 (range: 19-32), with 4 nodes positive for metastasis. No patients had pelvic or lymph node metastasis at a mean follow-up of 14.8 mo (range: 4-30). Limitations included an analysis of a small series of patients. CONCLUSIONS: This new approach provides optimal exposure for an adequate laparoscopic LND during radical cystectomy, without any compromise.

Potentiation of 2-methoxyestradiol-induced cytotoxicity by blocking endothelin A receptor in prostate cancer cells.

BACKGROUND: 2-Methoxyestradiol (2ME2) is an antitumoral and antiangiogenic compound that inhibits hypoxia-inducible factor (HIF)-1, a key regulator of the hypoxic response that promotes tumor progression. HIF-1alpha, the regulated subunit of HIF-1, is overexpressed in premalignant, cancerous and metastatic lesions of prostate. Endothelin (ET)-1 is a HIF target gene and one that plays an important role during prostate bone metastasis via its interaction with endothelin A (ET(A)) receptor. We reasoned that 2ME2 combined with an ET(A) receptor antagonist would induce potent cytotoxic effects in prostate cancer cells. METHODS: PC-3 and LNCaP cells were grown alone or cocultured with human osteoblasts. The cells were treated with 2ME2, with an ET(A) receptor antagonist (BQ-123) or with combinations of both compounds. The cells were then evaluated for cytotoxicity, HIF-1alpha protein expression and HIF-1 transcriptional activity. RESULTS: The combination of 2ME2 with BQ-123 induced synergistic cytotoxic effects in prostate cancer cells and in their cocultures with osteoblasts. No synergism was observed when 2ME2 was combined with the ET(B) selective antagonist, BQ-788. These results correlated with inhibition of HIF-1alpha protein expression, HIF-1 transcriptional activity, and PSA mRNA expression. CONCLUSIONS: The ET(A) receptor antagonist was capable of potentiating the cytotoxic effects of 2ME2 in prostate cancer cells. These effects were apparently mediated through the inhibition of the HIF-1 pathway. Our in vitro data strengthen the rationale for using 2ME2 in combination with ET(A) receptor antagonists for the treatment of metastatic prostate cancer.

[The role of nonoperative management of penetrating renal trauma].

INTRODUCTION: Penetrating renal trauma has been treated traditionally by renal exploration. In view of the successful outcome of nonoperative treatment of major blunt renal trauma, there has been a gradual shift in the approach to penetrating renal injuries, in selected cases. This study reviews the local experience with the conservative approach to penetrating renal injuries. PATIENTS AND METHODS: The researchers retrospectively reviewed the medical records of patients with penetrating renal injuries during a period of 10 years at two medical centers (Meir in Kfar Saba and Hillel Yaffe in Hadera). The data included mechanisms of injury, grading of the injury, homodynamic stability presence of hematuria, associated injuries, management conservative versus operative, complications and outcome. RESULTS: The study group consisted of 18 patients, with mean age of 22.5 years (15-40 years). The mechanisms of injury were stab wounds (10 patients) and gunshot injuries (8 patients). Nine patients (50%) required surgical intervention for associated injuries. Nonoperative treatment of the urological injury was selected in 10 patients (55.5%), 4 of them required surgery for associated abdominal injuries but did not undergo renal or retroperitoneal exploration, 8 patients (44.5%), were managed primarily by renal exploration. Grade I-II renal injuries were treated conservatively while all grade V injuries were explored. Of grade III injuries, 3 were treated conservatively and renal exploration was performed in 2. Half of grade IV injuries (4 patients) were treated conservatively. Follow-up of conservatively treated patients, demonstrated a viable kidney in all cases. Nephrectomy was performed in 3/8 patients who were treated primarily by renal exploration. These patients had grade IV or V injuries. Renorrhaphy was performed in the remaining 5 patients of whom one required delayed nephrectomy. Overall, the injured renal unit was lost in half of the operated patients. CONCLUSIONS: The present study presents a successful conservative approach to penetrating renal injuries in 10 out of 18 cases. All renal units in the nonoperated patients were preserved in comparison to only half in the surgically treated patients. Hence, nonoperative treatment is a reasonable option for the majority of minor penetrating renal injuries as well as in many selected high-grade injuries. This approach provides maximal preservation of the injured kidney with manageable complications.