The prognostic role of histomorphological subtyping in nonmetastatic papillary renal cell carcinoma after curative surgery: is subtype really irrelevant? A propensity score matching analysis of a multi-institutional real life data.

BACKGROUND AND AIM: The role of histomorphological subtyping is an issue of debate in papillary renal cell carcinoma (papRCC). This multi-institutional study investigated the prognostic role of histomorphological subtyping in patients undergoing curative surgery for nonmetastatic papRCC. PATIENTS AND METHODS: A total of 1,086 patients undergoing curative surgery were included from a retrospectively collected multi-institutional nonmetastatic papRCC database. The patients were divided into 2 groups based on histomorphological subtyping (type 1, n = 669 and type 2, n = 417). Furthermore, a propensity score-matching (PSM) cohort in 1:1 ratio (n = 317 for each subtype) was created to reduce the effect of potential confounding variables. The primary outcome of the study, the predictive role of histomorphological subtyping on the prognosis (recurrence free survival [RFS], cancer specific survival [CSS] and overall survival [OS]) in nonmetastatic papRCC after curative surgery, was investigated in both overall and PSM cohorts. RESULTS: In overall cohort, type 2 group were older (66 vs. 63 years, P = 0.015) and more frequently underwent radical nephrectomy (37.4% vs. 25.6%, P < 0.001) and lymphadenectomy (22.3% vs. 15.1%, P = 0.003). Tumor size (4.5 vs. 3.8 cm, P < 0.001) was greater, and nuclear grade (P < 0.001), pT stage (P < 0.001), pN stage (P < 0.001), VENUSS score (P < 0.001) and VENUSS high risk (P < 0.001) were significantly higher in type 2 group. 5-year RFS (89.6% vs. 74.2%, P < 0.001), CSS (93.9% vs. 84.2%, P < 0.001) and OS (88.5% vs. 78.5%, P < 0.001) were significantly lower in type 2 group. On multivariable analyses, type 2 was a significant predictor for RFS (HR:1.86 [95%CI:1.33-2.61], P < 0.001) and CSS (HR:1.91 [95%CI:1.20-3.04], P = 0.006), but not for OS (HR:1.27 [95%CI:0.92-1.76], P = 0.150). In PSM cohort balanced with age, gender, symptoms at diagnosis, pT and pN stages, tumor grade, surgical margin status, sarcomatoid features, rhabdoid features, and presence of necrosis, type 2 increased recurrence risk (HR:1.75 [95%CI: 1.16-2.65]; P = 0.008), but not cancer specific mortality (HR: 1.57 [95%CI: 0.91-2.68]; P = 0.102) and overall mortality (HR: 1.01 [95%CI: 0.68-1.48]; P = 0.981) CONCLUSIONS: This multiinstitutional study suggested that type 2 was associated with adverse histopathologic outcomes, and predictor of RFS and CSS after surgical treatment of nonmetastatic papRCC, in overall cohort. In propensity score-matching cohort, type 2 remained the predictor of RFS. Eventhough 5th WHO classification for renal tumors eliminated histomorphological subtyping, these findings suggest that subtyping is relevant from the point of prognostic view.

Is varicocoelectomy indicated in infertile men with isolated teratozoospermia? a systematic review and meta-analysis.

BACKGROUND: Clinical palpable varicocoeles in conjunction with isolated teratozoospermia are rarely observed. Therefore, the effects of varicocoelectomy on sperm morphology are not clear. The aim of this meta-analysis is to compile studies that assess the effectiveness of varicocoelectomy in isolated teratozoospermia to reach a more consistent and reliable conclusion. MATERIAL-METHODS: The present meta-analysis was registered to PROSPERO (CRD42023467933). We utilized the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline to report the outcomes. Articles published before 1 October 2023 were included in the study. The search terms used were teratozoospermia, isolated teratozoospermia, varicocoelectomy for isolated teratozoospermia, and semen analysis after varicocoelectomy in isolated teratozoospermia. RESULTS: We identified 1,013 studies in full publications or abstracts using the methodology and the search terms. Five studies were included for systematic review, while four were included for meta-analysis. The five studies (10-14) included 348 patients aged 18-44 years. The pooled analysis revealed a significant improvement in sperm morphology in isolated teratozoospermia patients undergoing varicocoelectomy (Q = 199.42, p < 0.0001; I2  = 98.49%). The pooled analysis revealed no significant improvement in sperm concentration in isolated teratozoospermia patients undergoing varicocoelectomy (Q = 5.69, p = 0.058; I2  = 64.85%). Three of the examined studies provided information regarding pregnancy rate and it was high in all studies. According to the Newcastle-Ottowa scale (NOS) assessment, the total quality score of all studies was 7. The funnel plot test demonstrated a visible asymmetry, and Begg and Mazumdar's rank correlation test confirmed the publication bias (p = 0.04). DISCUSSION: Varicocoelectomy can be an effective and reliable treatment option in patients with isolated morphology abnormalities and clinically palpable varicocoele. CONCLUSION: This meta-analysis reported that varicocoelectomy may increase pregnancy rates by improving semen parameters in infertile men with isolated teratozoospermia, although this conclusion requires further evidence.

Assessing the Performance of Chat Generative Pretrained Transformer (ChatGPT) in Answering Andrology-Related Questions.

OBJECTIVE: The internet and social media have become primary sources of health information, with men frequently turning to these platforms before seeking professional help. Chat generative pretrained transformer (ChatGPT), an artificial intelligence model developed by OpenAI, has gained popularity as a natural language processing program. The present study evaluated the accuracy and reproducibility of ChatGPT's responses to andrology-related questions. METHODS: The study analyzed frequently asked andrology questions from health forums, hospital websites, and social media platforms like YouTube and Instagram. Questions were categorized into topics like male hypogonadism, erectile dysfunction, etc. The European Association of Urology (EAU) guideline recommendations were also included. These questions were input into ChatGPT, and responses were evaluated by 3 experienced urologists who scored them on a scale of 1 to 4. RESULTS: Out of 136 evaluated questions, 108 met the criteria. Of these, 87.9% received correct and adequate answers, 9.3% were correct but insufficient, and 3 responses contained both correct and incorrect information. No question was answered completely wrong. The highest correct answer rates were for disorders of ejaculation, penile curvature, and male hypogonadism. The EAU guideline-based questions achieved a correctness rate of 86.3%. The reproducibility of the answers was over 90%. CONCLUSION: The study found that ChatGPT provided accurate and reliable answers to over 80% of andrology-related questions. While limitations exist, such as potential outdated data and inability to understand emotional aspects, ChatGPT's potential in the health-care sector is promising. Collaborating with health-care professionals during artificial intelligence model development could enhance its reliability.

Technical note: Energy dependence of the Gafchromic EBT4 film: Dose-response curves for 70 kV, 6 MV, 6 MV FFF, 10 MV FFF, and 15 MV x-ray beams.

BACKGROUND: EBT4 was newly released for radiotherapy quality assurance to improve the signal-to-noise ratio in radiochromic film dosimetry. It is important to know its dose-response characteristics before its use in the clinic. PURPOSE: This study aims to investigate and compare the dose-response curves of the Gafchromic EBT4 film for megavoltage and kilovoltage x-ray beams with different dose levels, scanning spatial resolutions, and sizes of region of interest (ROI). METHODS: EBT4 film (Lot#07052201) calibration strips (3.5 × 20 cm2 ) were exposed to a 10×10 cm2 open field at doses of 0, 63, 125, 500, 750, 1000 cGy using 6 MV photon beam. EBT4 film strips from the same lot were then exposed to each x-ray beam (6 MV, 6 MV FFF, 10 MV FFF, 15 MV, and 70 kV) at six dose values (50, 100, 300, 600, 800, 1000 cGy). A full sheet (25 × 20 cm2 ) of EBT4 film was irradiated at each energy with 300 cGy for profile comparison with the treatment planning calculation. At two different spatial resolutions of 72 and 300 dpi, each film piece was scanned three consecutive times in the center of an Epson 10000XL flatbed scanner in 48-bit color. The scanned images were analyzed using FilmQA Pro. For each scanned image, an ROI of 2 × 2 cm2 at the field center was selected to obtain the average pixel value with its standard deviation in the ROI. An additional ROI of 1 cm diameter circle was also used to evaluate the impact of ROI shape and size, especially for FFF beams. The dose value, average dose-response value, and associated uncertainty were determined for each energy and relative responses were analyzed. The Student's t-test was performed to evaluate the statistical significance of the dose-response values with different color channels, ROI shapes, and spatial resolutions. RESULTS: The dose-response curves for the five x-ray energies were compared in three color channels. Weak energy dependence was found among the megavoltage beams. No significant differences (average ∼1.1%) were observed for all doses in this study among 6 MV, 6 MV FFF, 10 MV FFF, and 15 MV beams, regardless of spatial resolution and color channel. However, a statistically significant difference in dose-response was observed up to 12% between 70 kV and 6 MV beams. CONCLUSIONS: The dose-response curves for Gafchromic EBT4 films were nearly independent of the energy of the photon beams among 6 MV, 6 MV FFF, 10 MV FFF, and 15 MV. For very low-energy photons (e.g., 70 kV), a separate calibration from the same low-energy x-ray is necessary.

External validation of the VENUSS prognostic model to predict recurrence after surgery in non-metastatic papillary renal cell carcinoma: A multi-institutional analysis.

OBJECTIVE: Recently, VENUSS (VEnous extension, NUclear Grade, Size, Stage), as a prognostic model, was defined to predict disease recurrence (DR) after curative surgery of non-metastatic papillary renal cell carcinoma (papRCC). This study aimed to validate the VENUSS prognostic model in a large multi-institutional European cohort of patients with histopathologically proven papRCC after curative surgery for non-metastatic disease. PATIENTS AND METHODS: Overall, 980 patients undergoing partial or radical nephrectomy for sporadic, unilateral and non-metastatic papRCC between 1987 and 2020 were included from 7 European tertiary institutions. The primary outcome was the prediction of DR by VENUSS score and VENUSS risk groups. Chi-square, Kruskal-Wallis, Cox-regression and Kaplan-Meier survival analyses were used in statistical methods. The Concordance (C) Index was calculated to assess model's discriminatory power. RESULTS: The median age was 64 (IQR:55-70) years and 82.6 % (n = 809) of patients were male. Median VENUSS score was 2 (IQR: 0-4), and 62.9 % (n = 617), 23.9 % (n = 234) and 13.2 % (n = 129) of patients was classified into low, intermediate and high risk according to the VENUSS model, respectively. At a median follow-up of 48 (IQR:23-88) months, the disease recurred in 6.6%, 18.8% and 63.8%, and the 5-year recurrence-free survival was 93.8%, 80.7% and 26.7% in low, intermediate and high-risk groups, respectively. (P < 0.001) Each increase in VENUSS score had 1.52-fold (95%CI:1.45-1.60, P < 0.001) DR risk. Compared with the VENUSS low risk, the intermediate risk had a 2.91-fold increased DR risk (95%CI:1.90-4.46, P < 0.001) and 17.9-fold (95%CI:12.25-26.25, P < 0.001) in high risk, while it was 6.07-fold greater in high risk vs. intermediate risk (95%CI:4.17-8.83, P < 0.001). The discrimination was 81.2% (95%CI:77.5%-84.8%) for the VENUSS score, and 78.6% (95%CI:74.8%-82.4%) for VENUSS risk groups, respectively. Both the VENUSS score and groups were well calibrated. CONCLUSIONS: This contemporary multi-institutional European large dataset validated the use of VENUSS score and VENUSS risk groups on the prediction of DR after curative surgery in patients with non-metastatic papRCC. The VENUSS prognostic model can provide valuable information for patient counselling, follow-up and patient selection for adjuvant trials.

How accurate is 68Gallium-prostate specific membrane antigen positron emission tomography / computed tomography (68Ga-PSMA PET/CT) on primary lymph node staging before radical prostatectomy in intermediate and high risk prostate cancer? A study of patient- and lymph node- based analyses.

BACKGROUND AND AIM: Gallium-68 (68Ga)-Prostate Membrane Specific Antigen Positron Emission Tomography/Computed Tomography (68Ga-PSMA PET/CT) is an emerging diagnostic modality which is gaining importance in individualized prostate cancer (PCa) management era. This study aimed to investigate the diagnostic accuracy of 68Ga-PSMA PET/CT on primary LN staging before radical prostatectomy (RP) in intermediate and high risk PCa. MATERIALS AND METHODS: The retrospectively documented 49 patients with intermediate and high risk non-metastatic PCa who had 68Ga-PSMA PET/CT before RP were enrolled into this study. The histopathology of dissected LNs was used as reference standard to evaluate the accuracy of 68Ga-PSMA PET/CT on primary LN staging, both in per-patient (n = 49) and in per-node (n = 454) analyses. The diagnostic accuracy was investigated using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and by area under the curve (AUC) provided using receiver operating curve (ROC) analysis. RESULTS: Median age was 64 (48-79) years and, median and mean PSA values were 10 (1.31-138) ng/ml and 16.2 (±19.8) ng/ml, respectively. 22 (44.9%) and 27 (55.1%) of patients had intermediate and high risk PCa, respectively. A total of 5 (10.2%) patients had histopathologically proven LN metastasis and 3 (60%) of them was detected in 68Ga-PSMA PET/CT. In per patient analysis, the sensitivity, specifity, PPV and NPV of 68Ga-PSMA PET/CT on primary LN staging were 0.60, 0.96, 0.60 and 0.96, respectively. Among overall 454 LNs, 16 (3.5 %) of them were reported as metastatic in histopathology and, 13 (2.9%) of these metastatic LNs were detected in 68Ga-PSMA PET/CT. In per-node analysis, the sensitivity, specificity, PPV and NPV of 68Ga-PSMA PET/CT on primary LN staging were 0.82, 0.99, 0.87 and 0.99, respectively. The ROC analyses found AUCs for primary LN staging as 0.777 (95%CI:0.508-1.0) in per patient analysis and, as 0.904 (95%CI:0.790 - 1.0) in per node analysis, respectively. CONCLUSION: The use of 68Ga-PSMA PET/CT has promising diagnostic accuracy on primary LN staging before RP in intermediate and high risk PCa. However, the efforts should be taken to increase sensitivity of 68Ga-PSMA PET/CT in individualized treatment era.

The clinical impact of the COVID-19 pandemic on daily urological practice: first 3-month multicenter results from Istanbul

Background/aim: The aim of this paper was to determine the general tendencies of urology patients and effect of COVID-19 pandemic on daily urological practice at tertiary centers located in the most affected area in Turkey. Materials and methods: We retrospectively analyzed the data of 39,677 patients (group 1) that applied to 6 different large-volume tertiary centers in Istanbul for outpatient consultation, surgery, or other procedures in the 3-month period between March 16 and June 14, 2020. The distribution of the number of patients who applied to subspecialty sections of urology outpatient clinics and inpatient services were recorded by weeks. That data was compared to data obtained from 145,247 patients that applied to the same centers in the same period of the previous year (group 2). The reflection of worldwide and Turkish COVID-19 case distribution on the daily urological practice was analyzed. Results: There was a decrease in the number of patients in all subspecialty sections the in group 1 compared to group 2; however, there was a significant proportional increase in urooncology and general urology admissions. A decrease of approximately 75% was observed in the total number of surgeries (p < 0.001). We detected a negative correlation between the numbers of admission to all outpatient clinics and COVID-19 cases or deaths in Turkey (p < 0.05). The same negative correlation was present for all surgical procedures and consultations (p < 0.05). The multivariate linear regression analysis revealed that the number of cases in Turkey, and the number of deaths worldwide affect the number of outpatient clinic admissions (R2 = 0.38, p = 0.028) and urological surgery (R2 = 0.33, p = 0.020) in Turkey negatively. Conclusion: This novel pandemic has implications even for urology practice. Urological surgical procedures were more affected by COVID-19-related deaths in Turkey and worldwide. Outpatient admissions and urological surgeries decreased significantly by increasing COVID-19 case numbers in Turkey and worldwide deaths.

Indication for Y Chromosome Microdeletion Analysis in Infertile Men: Is a New Sperm Concentration Threshold Needed?

OBJECTIVE: To describe the prevalence of Y-chromosome deletions in patients with a sperm concentration of less than 5 million/mL. To also determine a new sperm threshold for Y-chromosome analysis in men with infertility. METHODS: A total of 3023 patients who had a semen concentration of less than 5 million/mL included in this retrospective study. All of these patients had a genetic evaluation, hormonal evaluation, and 2 abnormal semen analyses. RESULTS: Y-chromosome deletions were present in 116 (3.8 %) patients with sperm concentration <5 million/mL. The frequency of a Y-chromosome deletions was 6.8%, 1.0%, 0.15% in azoospermic men, in men with sperm concentrations of 0-1 million /mL, in men with sperm concentrations of 1-5 million/mL. Patients were divided into 2 groups regarding the determined new sperm threshold. The sensitivity and specificity of the Y-chromosome deletions test were 92.2.7% and 49.3 %, 99.1%, and 22.1% in patients with azoospermia and sperm concentrations <1 million/mL, respectively. If the sperm concentration thresholds of azoospermia or <1 million/mL, are applied, the number of tests decreased to 50.5% (1442 tests) and 23.1% (643 tests), respectively. Approximately $108,150 and $48,225 would be saved if the sperm thresholds were azoospermia and <1 million/mL, respectively CONCLUSION: The current threshold of sperm concentration for Y-chromosome deletions is controversial. The new proposed sperm threshold for genetic testing of 1 million/mL would increase sensitivity and more cost-effective compared to the current threshold.

Undescended Testis Does Not Affect the Outcome of Microdissection Testicular Sperm Extraction.

OBJECTIVE: To determine the sperm retrieval rates (SRRs) and predictive factors of patients with a history of undescended testis after testicular sperm extraction (TESE). METHODS: A total of 311 patients were diagnosed with nonobstructive azoospermia (NOA) and underwent TESE were included in this study. These patients were divided into 2 groups: an undescended group consisting of 62 patients who had a history of undescended testes and an idiopathic group consisting of 249 patients. Of the 62 patients with a history of undescended testes, 26 had a history of bilateral orchidopexy, 15 had a history of unilateral orchidopexy, and 21 had no history of surgery. RESULTS: The testicular spermatozoa were found in 134 (53.8%) and 31 (50%) patients in the idiopathic NOA and undescended testes groups, respectively. Similar to patients with idiopathic NOA, the overall SRRs were strongly associated with histopathology for patients with a history of undescended testes. These SRRs were 34.2%, 33.3%, 71.4%, 100%, and 100% for Sertoli Cell Only, late maturation arrest, early maturation arrest, hypospermatogenesis, and normal spermatogenesis, respectively (P <.001). In the undescended group, the SRRs of patients who underwent orchidopexy were not different than patients without a history of orchidopexy. However, patients who underwent unilateral orchidopexy had a higher SRR than those who underwent bilateral orchidopexy (P = .031). CONCLUSION: TESE is a successful treatment modality for men with NOA associated with or without a history of undescended testis. The testicular histopathology and unilateral undescended testis were identified as independent predictors of SRRs for men with a history of undescended testis.