Optical Coherence Tomography as a Tool for In Vivo Staging and Grading of Upper Urinary Tract Urothelial Carcinoma: A Study of Diagnostic Accuracy.

PURPOSE: Biopsies and cytology are cornerstones in the diagnosis of upper urinary tract urothelial carcinoma. However, a high rate of nondiagnostic biopsies, tumor upgrading and tumor up staging after nephroureterectomy has been observed. In this prospective in vivo study we evaluated the diagnostic accuracy of optical coherence tomography for the grading and staging of upper tract urothelial carcinoma. MATERIALS AND METHODS: A total of 26 patients underwent diagnostic ureterorenoscopy including biopsies and optical coherence tomography, followed by nephroureterectomy or segmental ureter resection. The sensitivity, specificity, negative predictive value and positive predictive value of upper tract urothelial carcinoma grading and staging by optical coherence tomography were evaluated according to the STARD (Standards for Reporting of Diagnostic Accuracy) initiative and the second stage (2a and 2b) of the IDEAL model. For tumor staging a 2×2 table for sensitivity and specificity was calculated. For tumor grading the Wilcoxon rank sum test was used to test µoct in low and high grade lesions followed by ROC analysis for sensitivity and specificity. RESULTS: In 83% the staging of lesions was in accordance with final histopathology. Sensitivity and specificity analysis for tumor invasion was 100% and 92%, respectively. Tumor size greater than 2 mm and inflammation were risks for false-positives. For low and high grade lesions median µoct was 2.1 and 3.0 mm-1, respectively (p <0.01). ROC analysis showed a sensitivity of 87% and a specificity of 90% using a µoct cutoff of 2.4 mm-1. CONCLUSIONS: This report describes optical coherence tomography as a real-time, intraoperatively diagnostic modality in the diagnostic evaluation of upper tract urothelial carcinoma. We confirmed the ability of optical coherence tomography to visualize, grade and stage urothelial carcinoma in the upper urinary tract.

Irreversible electroporation, a new modality in Focal Therapy for prostate cancer.

The extensive use of prostate-specific antigen (PSA) testing and improved imaging technologies have resulted in an increased diagnosis of prostate cancer. Early diagnosis is often accompanied by an increased number of localized (i.e. unifocal or unilateral), small-volume and low-grade prostate cancers. Focal therapy is an emerging treatment option in prostate cancer, targeting individual cancer areas while sparing important functional and anatomical urological structures. Irreversible electroporation is an innovative treatment modality in focal therapy based on the process of cell membrane electroporation limiting damage to adjacent tissue and vital structures. The first phase I-II trials in humans have shown the safety of IRE for focal ablative therapy of prostate cancer and showed encouraging results considering functional preservation. Histological analysis after IRE showed fibrosis without glandular ducts and necrotic tissue with sharp demarcation between unaffected prostatic glandular tissue and the ablation zone. Short-term oncological results are promising; however more data on long-term oncological outcomes are necessary. New studies with IRE and other focal treatment modalities are initiated to explore opportunities for focal therapy in prostate cancer and to optimize current treatment protocols.

Follow-up after focal therapy in renal masses: an international multidisciplinary Delphi consensus project.

PURPOSE: To establish consensus on follow-up (FU) after focal therapy (FT) in renal masses. To formulate recommendations to aid in clinical practice and research. METHODS: Key topics and questions for consensus were identified from a systematic literature research. A Web-based questionnaire was distributed among participants selected based on their contribution to the literature and/or known expertise. Three rounds according to the Delphi method were performed online. Final discussion was conducted during the "8th International Symposium on Focal Therapy and Imaging in Prostate and Kidney Cancer" among an international multidisciplinary expert panel. RESULTS: Sixty-two participants completed all three rounds of the online questionnaire. The panel recommended a minimum follow-up of 5 years, preferably extended to 10 years. The first FU was recommended at 3 months, with at least two imaging studies in the first year. Imaging was recommended biannually during the second year and annually thereafter. The panel recommended FU by means of CT scan with slice thickness ≤3 mm (at least three phases with excretory phase if suspicion of collecting system involvement) or mpMRI. Annual checkup for pulmonary metastasis by CT thorax was advised. Outside study protocols, biopsy during follow-up should only be performed in case of suspicion of residual/persistent disease or radiological recurrence. CONCLUSIONS: The consensus led to clear FU recommendations after FT of renal masses supported by a multidisciplinary expert panel. In spite of the low level of evidence, these recommendations can guide clinicians and create uniformity in the follow-up practice and for clinical research purposes.

Histopathological Outcomes after Irreversible Electroporation for Prostate Cancer: Results of an Ablate and Resect Study.

PURPOSE: Irreversible electroporation is a tissue ablation modality that uses high voltage electric energy to induce an increase in cell membrane permeability. This causes destabilization of the existing cellular transmembrane potential leading to cell death, due to the inability to maintain cellular homeostasis. This phase I-II study was designed to evaluate the histopathological outcomes of irreversible electroporation to prostate and surrounding tissue in radical prostatectomy specimens. MATERIALS AND METHODS: Sixteen patients with prostate cancer underwent an irreversible electroporation ablation without curative intent, followed by radical prostatectomy scheduled 4 weeks later. For histopathological examination of the prostate, whole mounted tissue slices were examined by dedicated genitourinary pathologists. The borders of the ablation zone and residual tumor were outlined on the slides. RESULTS: The irreversible electroporation ablation zones were characterized as areas of fibrosis, necrosis and loss of epithelial tissue in terms of denudation in the glandular structures. The ablation zone was well demarcated, showing trenchant delineations between viable and nonviable tissue. The ablated tissue showed mild to moderate inflammation, with atrophic cells in 1 case. The area was surrounded by hemorrhage at the location of the electrodes. No skip lesions or viable tissue was seen in the ablation zone. Fibrinoid necrosis of the neurovascular bundle was observed in 13 patients and denudation of the urothelium of the prostatic urethra was seen in 9. CONCLUSIONS: Histopathological assessment of the prostate 4 weeks after irreversible electroporation ablation showed sharply demarcated fibrotic and necrotic tissue in the ablation zone. No viable tissue was observed in the irreversible electroporation ablation zone.

MRI and contrast-enhanced ultrasound imaging for evaluation of focal irreversible electroporation treatment: results from a phase I-II study in patients undergoing IRE followed by radical prostatectomy.

OBJECTIVES: Irreversible electroporation (IRE) is an ablative therapy with a low side-effect profile in prostate cancer. The objective was: 1) To compare the volumetric IRE ablation zone on grey-scale transrectal ultrasound (TRUS), contrast-enhanced ultrasound (CEUS) and multiparametric MRI (mpMRI) with histopathology findings; 2) To determine a reliable imaging modality to visualize the IRE ablation effects accurately. METHODS: A prospective phase I-II study was performed in 16 patients scheduled for radical prostatectomy (RP). IRE of the prostate was performed 4 weeks before RP. Prior to, and 4 weeks after the IRE treatment, imaging was performed by TRUS, CEUS, and mpMRI. 3D-analysis of the ablation volumes on imaging and on H&E-stained whole-mount sections was performed. The volumes were compared and the correlation was calculated. RESULTS: Evaluation of the imaging demonstrated that with T2-weighted MRI, dynamic contrast enhanced (DCE) MRI, and CEUS, effects of IRE are visible. T2MRI and CEUS closely match the volumes on histopathology (Pearson correlation r = 0.88 resp. 0.80). However, IRE is not visible with TRUS. CONCLUSIONS: mpMRI and CEUS are appropriate for assessing IRE effects and are the most feasible imaging modalities to visualize IRE ablation zone. The imaging is concordant with results of histopathological examination. KEY POINTS: • mpMRI and contrast-enhanced ultrasound are appropriate imaging modalities for assessing IRE effects • mpMRI and CEUS are the most feasible imaging modalities to visualize IRE ablation zone • The imaging is concordant with results of histopathological examination after IRE • Grey-scale US is insufficient for assessing IRE ablations.

The correlation between the electrode configuration and histopathology of irreversible electroporation ablations in prostate cancer patients.

PURPOSE: Irreversible electroporation (IRE) is a novel minimally invasive therapy for prostate cancer using short electric pulses to ablate prostate tissue. The purpose of this study is to determine the IRE effects in prostate tissue and correlate electrode configuration with the histology of radical prostatectomy (RP) specimens. We hypothesize that the area within the electrode configuration is completely ablated and that the area within the electrode configuration is predictive for the ablated area after treatment. METHODS: A prospective phase I/II study was conducted in 16 consecutive patients with histopathologically confirmed prostate cancer scheduled for RP. Focal or extended IRE treatment of the prostate was performed 4 weeks prior to RP. The locations of the electrodes were used to calculate the planned ablation zone. Following RP, the specimens were processed into whole-mount sections, histopathology (PA) was assessed and ablation zones were delineated. The area of the tissue alteration was determined by measuring the surface. The planned and the histological ablation zones were compared, analysed per individual patient and per protocol (focal vs. extended). RESULTS: All cells within the electrode configuration were completely ablated and consisted only of necrotic and fibrotic tissue without leaving any viable cells. The histological ablation zone was always larger than the electrodes configuration (2.9 times larger for the 3 electrodes configuration and 2.5 times larger for the ≥4 electrode configuration). These ablation effects extended beyond the prostatic capsule in the neurovascular bundle in 13 out of 15 cases. CONCLUSIONS: IRE in prostate cancer results in completely ablated, sharply demarcated lesions with a histological ablation zone beyond the electrode configuration. No skip lesions were observed within the electrode configuration. CLINICAL TRIALS: ClinicalTrials.gov Identifier: NCT01790451 https://clinicaltrials.gov/ct2/show/NCT01790451.

The safety and efficacy of irreversible electroporation for the ablation of prostate cancer: a multicentre prospective human in vivo pilot study protocol.

INTRODUCTION: Current surgical and ablative treatment options for prostate cancer have a relatively high incidence of side effects, which may diminish the quality of life. The side effects are a consequence of procedure-related damage of the blood vessels, bowel, urethra or neurovascular bundle. Ablation with irreversible electroporation (IRE) has shown to be effective in destroying tumour cells and harbours the advantage of sparing surrounding tissue and vital structures. The aim of the study is to evaluate the safety and efficacy and to acquire data on patient experience of minimally invasive, transperineally image-guided IRE for the focal ablation of prostate cancer. METHODS AND ANALYSIS: In this multicentre pilot study, 16 patients with prostate cancer who are scheduled for a radical prostatectomy will undergo an IRE procedure, approximately 30 days prior to the radical prostatectomy. Data as adverse events, side effects, functional outcomes, pain and quality of life will be collected and patients will be controlled at 1 and 2 weeks post-IRE, 1 day preprostatectomy and postprostatectomy. Prior to the IRE procedure and the radical prostatectomy, all patients will undergo a multiparametric MRI and contrast-enhanced ultrasound of the prostate. The efficacy of ablation will be determined by whole mount histopathological examination, which will be correlated with the imaging of the ablation zone. ETHICS AND DISSEMINATION: The protocol is approved by the ethics committee at the coordinating centre (Academic Medical Center (AMC) Amsterdam) and by the local Institutional Review Board at the participating centres. Data will be presented at international conferences and published in peer-reviewed journals. CONCLUSIONS: This pilot study will determine the safety and efficacy of IRE in the prostate. It will show the radiological and histopathological effects of IRE ablations and it will provide data to construct an accurate treatment planning tool for IRE in prostate tissue. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov database: NCT01790451.

Duplicated ureters and renal transplantation: a case-control study and review of the literature.

INTRODUCTION: Complications of the transplant ureter are the most important cause of surgical morbidity after renal transplantation. The presence of ureteral duplication in the renal graft might result in an increased complication rate. We analyzed our data of double-ureter renal transplantations using a case-control study design. Additionally, we performed a review of the literature. METHODS: From January 1995 to April 2012, 12 patients received a donor kidney with a double ureter (0.8%). We created a control group of 24 patients matched in age, sex, donor type, and ureteral stenting. Patient charts and surgical reports were reviewed retrospectively. RESULTS: In 7 patients both ureters were separately anastomosed to the bladder. In 4 patients a common ostium was created. In 1 patient 1 of the 2 ureters was ligated. No postoperative urologic complications occured. In the single-ureter group, the urologic complication rate was 17% (P = .71). Mean creatinine levels after transplantation were comparable between both groups. DISCUSSION: A double-ureter donor kidney is not associated with an increased complication rate after renal transplantation and yields equal outcomes as compared to single-ureter donor kidneys. We conclude that transplantation of a kidney with a duplicated ureter is safe.

Láser y tumores vesicales / Laser and bladder tumors

Los tumores vesicales suponen una de las enfermedades más frecuentes de la urología. La introducción de los láseres en el armamentario terapéutico urológico supuso un gran avance, pero los resultados iniciales con los primeros modelos, no alcanzaron las expectativas. Sin embargo, en la actualidad disponemos de una gran variedad de láseres para uso urológico, con distintas funciones y aplicaciones. Realizamos una revisión e intentamos asentar las indicaciones actuales de su utilización en el tratamiento de los tumores vesicales, así como una visión de futuro de sus posibles aplicaciones (AU)

Bladder cancer is one of the most frequents pathologies in urology. The introduction of the laser among the technical tools supposed a great advance, but the initial results with the first model failed with the expectations. Nevertheless, nowadays we have at our disposal a great variety of laser for urological use, with different functions and applications. We perform a review and try to assess the actual indications for its employment in the treatment of bladder cancer, as well as future applications (AU)

Synchronous esophageal and renal cell carcinoma: incidence and possible treatment strategies.

BACKGROUND: The occurrence of synchronous malignancies in patients suffering from esophageal cancer is a frequent phenomenon, but the reported incidence of synchronous renal cell carcinoma (RCC) is very low. The present study investigated the incidence of synchronously detected RCC since the introduction of preoperative CT scans in a tertiary referral center for esophageal cancer patients. METHODS: The medical records of 392 consecutive patients included in a prospective database of patients scheduled to undergo surgery for esophageal tumors were scrutinized for the presence of renal neoplasms. The coincidence of esophageal cancer and RCC was then estimated by analyzing only those patients who were operated on for an esophageal malignancy after a CT scan was obtained. RESULTS: 192 patients were operated on for an esophageal malignancy after abdominal CT scanning was performed. RCC was diagnosed in 4 of these patients resulting in an incidence of synchronous esophageal and renal malignancies of 2.1%. CONCLUSION: Since the introduction of CT scanning the incidence of synchronous RCC in esophageal cancer patients appears to be much higher than previously reported and suggests a genetic and/or environmental association between these malignancies. Simultaneous treatment of both tumors appeared safe at our institute.

[Laser and bladder tumors]. / Láser y tumores vesicales.

Bladder cancer is one of the most frequents pathologies in urology. The introduction of the laser among the technical tools supposed a great advance, but the initial results with the first model failed with the expectations. Nevertheless, nowadays we have at our disposal a great variety of laser for urological use, with different functions and applications. We perform a review and try to assess the actual indications for its employment in the treatment of bladder cancer, as well as future applications.

[Laparoscopic assisted cryoablation of small renal masses]. / Crioablación laparoscópica de las pequeñas masas renales.

AIMS: To review the current status of cryoablation of small renal masses and to preliminary report our experience at the AMC. MATERIAL AND METHODS: A bibliographic search was conducted (PubMed/Medline/Embase) and the most important series were analyzed. Our series includes 13 patients with a solitary small renal mass treated by Laparoscopic assisted Cryoblation with fine cryoprobes (1,5 cm diameter). Postoperative follow-up was done by means of CT and/or MRI every three months during the first year and every 6 months during the second year. RESULTS: There are no randomized trials comparing Cryoblation of renal masses (<4 cm diameter) with either radical surgery or partial nephrectomy but only case series. Complication rate is low as it is the recurrence or persistence rate in most of the series but one referring to radiologically guided Cryoablation (8%). The maximal diameter of the masses treated in our series were 3,2 cm. Tumors were approached retro or transperitoneally depending on their localization in the kidney. Average surgical time were 208 minutes (108-379) and average time of exposition to temperatures lower than -20 degrees C in the tumor periphery was 10 minutes. AT a mean follow-up of 8 months no tumoral recurrence were objectivated. CONCLUSIONS: Cryoablation of small renal masses may be an acceptable alternative of treatment although mean follow-up is still short in all the series.

[Clinical usefulness of free PSA/total PSA ratio in the early diagnosis of prostatic cancer]. / Utilidad clínica de la ratio PSA libre/PSA total en el diagnóstico precoz del cáncer de próstata.

OBJECTIVES: To determine the clinical utility of free/total PSA ratio and PSA density in the early diagnosis of prostate cancer (patients with serum PSA between 4 and 10 ng/ml) and to determine the differences, if any, in the free/total PSA ratio in patients with cancer and those with benign prostatic hyperplasia (BPH). METHODS: A prospective and descriptive study was conducted on 61 patients with low grade obstructive symptoms and total serum PSA between 4 and 10 ng/ml (group 1), and 42 patients who underwent prostate surgery and had an anatomopathologically confirmed diagnosis of BPH (group 2). Free and total PSA were determined, as well as prostate volume by transrectal US, in all cases. Prostate biopsy was performed in all patients with a total PSA value between 4-10 ng/ml. The sensitivity, specificity, positive and negative prognostic values of free/total PSA ratio and PSA density were analyzed. RESULTS: The mean age of the patients in group 1 was 67.7 years and 68.3 years in group 2. The mean prostate volume by US was 55.2 and 47.1, respectively (n.s.). The mean total PSA was 6.39 ng/ml for group 1 and 5.73 ng/ml for group 2 (n.s.). No significant difference was found between the mean free PSA values of both groups. However, the free/total PSA ratio and PSA density were significantly different (p < 0.000). In group 1 (total PSA 4-10 ng/ml), prostate biopsy was positive in 32.8% of the patients. In this group of patients, there were no significant differences in the parameters analyzed. Application of different cutoffs for both tests showed a higher clinical utility for the 0.24-0.30 range. CONCLUSIONS: At similar mean prostate volume and mean total PSA, significant differences were found in the free/total PSA ratio and PSA density of patients submitted to surgery for BPH and those with a total PSA value of 4-10 ng/ml. However, these results were not observed when patients with PSA of 4-10 ng/ml were analyzed for presence or absence of evidence of malignancy in the prostate biopsy.

[Transvesical repair of non-complicated vesicovaginal fistula]. / Reparación transvesical de fístulas vesicovaginales no complicadas.

OBJECTIVE: The management of vesicovaginal fistula still remains controversial in regard to the timing of repair and type of approach. We review the relevant literature and describe our experience with the transvesical management of uncomplicated vesicovaginal fistulas after gynecological surgery. MATERIAL AND METHODS: We reviewed retrospectively 6 consecutive women who presented with uncomplicated vesicovaginal fistula, repaired at our institution between 1995 and 1998. Four cases underwent early repair after a trial of conservative management. One case underwent intraoperative repair and another case after 19 months because of delayed diagnosis. Postoperative follow up ranges from 4 to 35 months. RESULTS: All patients were cure. The fistula tract was excised totally in all patients. There were no postoperative complications. CONCLUSIONS: Early repair of uncomplicated vesicovaginal fistulas after gynecological surgery offers reliable success, according with literature records and our own experience. On the other hand, transvesical repair offers an easy operative approach, with a high successful rate.

Reparación transvesical de fístulas vesicovaginales no complicadas / Transvesical repair of uncomplicated vesicovaginal fistulas

OBJETIVO: El manejo de las fístulas vesicovaginales es objeto de controversia. Principios fundamentales como la vía de abordaje o el momento adecuado para la reparación quirúrgica varían ampliamente según los distintos autores. Realizamos una revisión de la literatura y aportamos nuestra experiencia en el abordaje transvesical para la reparación de las fístulas vesicovaginales no complicadas de causa ginecológica. MATERIAL Y MÉTODOS: Analizamos retrospectivamente una serie de 6 pacientes con fístulas vesicovaginales no complicadas sometidas a reparación quirúrgica en nuestro centro entre 1995 y 1998. En cuatro casos se realizó corrección quirúrgica precoz, tras un intento de cierre espontáneo con medidas conservadoras. En un caso la reparación se realizó intraoperatoriamente. En otro caso la reparación se realizó a los 19 meses por retraso en el diagnóstico. El seguimiento medio fue de 21 meses (límites: 4-35 meses). RESULTADOS: El tratamiento definitivo de la fístula fue quirúrgico en todos los casos, con un porcentaje de éxitos en un solo tiempo del 100 por ciento. El trayecto fistuloso fue escindido totalmente en todos los casos. No hubo complicaciones postoperatorias. CONCLUSIONES: La reparación precoz de las fístulas vesicovaginales no complicadas de causa ginecológica ofrece buenos resultados de acuerdo con los datos aportados por la literatura y nuestra propia experiencia. Por otra parte, el abordaje abdominal proporciona un acceso fácil y cómodo para la corrección de la fístula, con un alto porcentaje de éxitos (AU)

[Retroperitoneal germinal tumor: extragonadal or burned out phenomenon of testicular primary? Presentation of a clinical case]. / Tumor germinal retroperitoneal: estragonadal o fenómeno de burned-out del primario testicular? Presentación de un caso clínico.

Clinical record case of a retroperitoneal seminoma with "burned-out" phenomenon in the testicular primary, in a 38 year old male with no background of interest who consults for a picture of left nephritic colic. The ipsilateral testis study detects a fibrotic area with hyalinosis and hemosiderin deposits, although there are no tumoral debris, compatible with the "burned-out" phenomenon. Management is through surgery plus a chemotherapy protocol. Discussion of the diagnostic algorithm of retroperitoneal tumours and the literature on extragonadal germinal tumours.

[Perineal radical prostatectomy in the age of laparoscopy]. / La prostatectomía radical perineal en la era de la laparoscopia.

With the advent of laparoscopic lymphadenectomy, attention has been focussed again to the perineal approach for cancer of the prostate. The high rate of postoperative impotence and the abdominal incision required had made radical perineal prostatectomy unpopular. From August 1990 to July 1991, 76 patients with localized prostate cancer were surgically treated at the University of St. Louis. These patients were divided into three groups; group A comprised 26 patients who were submitted to laparoscopic lymphadenectomy and radical perineal prostatectomy, group B comprised patients treated by laparoscopic lymphadenectomy and radical retropubic prostatectomy, and group C or controls underwent open lymphadenectomy and radical retropubic prostatectomy. Fifty-three patients were sexually potent preoperatively but only 20 (7 from group A, 5 from group B and 8 from group C) were considered for preservation of the neurovascular bands. All the patients were followed for a minimum of one year. Comparison of these three groups revealed significant differences for perioperative bleeding and postoperative hospital stay in favor of Group A. The overall stress incontinence rate was 5.3% and the complications ranged from 4.1% for group C and 29.1% for group B. The postoperative sexual potency ranged from 57% for group A to 75% for group C, the differences not being statistically significant. Radical perineal prostatectomy is as valid as radical retropubic prostatectomy for localized prostatic cancer and has the advantages of less bleeding and a faster recovery, particularly if combined with laparoscopic lymphadenectomy.

[The apical meatus in surgical treatment of hypospadias]. / Le méat apical dans le traitement chirurgical de l'hypospadias.

We present a surgical technique for the correction of hypospadias which has the major advantage of locating the new meatus at the apex of the glans. The prepuce is opened out and fashioned into a pediculated strip which is used to form the new penile and distal portion of the urethra. This pediculated strip is placed longitudinally along a deep cleft created by an incision along the glans. The five surgical stages are described together with the sutures and diversions employed. The results and complications obtained in 132 boys are then analysed.