Re-salvage focal low-dose rate brachytherapy for local recurrence of prostate cancer after salvage focal low-dose rate brachytherapy.

Introduction: Salvage brachytherapy represents an effective treatment for local recurrence of prostate cancer after prior external beam radiotherapy. However, the optimal therapeutic strategies for local recurrence after salvage brachytherapy have not yet been determined. Case presentation: We describe the case of a 77-year-old man who underwent re-salvage focal low-dose rate brachytherapy for local recurrence after carbon ion radiotherapy and salvage focal low-dose rate brachytherapy. We performed re-salvage focal low-dose rate brachytherapy for the recurrence with a different type of seed, which resulted in a significant reduction in the prostate-specific antigen level. During the 35-month follow-up after re-salvage focal low-dose rate brachytherapy, no recurrence of prostate cancer and no severe radiation-related toxicities were observed. Conclusion: Our patient was successfully treated with re-salvage focal low-dose rate brachytherapy for local recurrence after salvage focal low-dose rate brachytherapy. This treatment strategy might be effective for such patients and is not associated with sexual dysfunction or severe adverse events.

Development and Validation of a Preoperative Nomogram for Endoscopic Management Decision Making in Upper Urinary Tract Urothelial Carcinoma.

OBJECTIVE: We aimed to develop and validate a preoperative nomogram that predicts low-grade, non-muscle invasive upper urinary tract urothelial carcinoma (LG-NMI UTUC), thereby aiding in the accurate selection of endoscopic management (EM) candidates. METHODS: This was a retrospective study that included 454 patients who underwent radical surgery (Cohort 1 and Cohort 2), and 26 patients who received EM (Cohort 3). Utilizing a multivariate logistic regression model, a nomogram predicting LG-NMI UTUC was developed based on data from Cohort 1. The nomogram's accuracy was compared with conventional European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN) models. External validation was performed using Cohort 2 data, and the nomogram's prognostic value was evaluated via disease progression metrics in Cohort 3. RESULTS: In Cohort 1, multivariate analyses highlighted the absence of invasive disease on imaging (odds ratio [OR] 7.04; p = 0.011), absence of hydronephrosis (OR 2.06; p = 0.027), papillary architecture (OR 24.9; p < 0.001), and lack of high-grade urine cytology (OR 0.22; p < 0.001) as independent predictive factors for LG-NMI disease. The nomogram outperformed the two conventional models in predictive accuracy (0.869 vs. 0.759-0.821) and exhibited a higher net benefit in decision curve analysis. The model's clinical efficacy was corroborated in Cohort 2. Moreover, the nomogram stratified disease progression-free survival rates in Cohort 3. CONCLUSION: Our nomogram ( https://kmur.shinyapps.io/UTUC_URS/ ) accurately predicts LG-NMI UTUC, thereby identifying suitable candidates for EM. Additionally, the model serves as a useful tool for prognostic stratification in patients undergoing EM.

Automatic irrigation system with a fiber-optic pressure sensor regulating intrapelvic pressure for flexible ureteroscopy.

Increased intrapelvic pressure (IPP) due to irrigation during flexible ureteroscopy (f-URS) can pose a risk of postoperative severe urinary tract infection associated with pyelovenous backflow. An automatic regulation system for maintaining safe IPP levels could enable surgeons to perform f-URS safely without postoperative complications. This study aimed to assess the measurement accuracy of an ultra-miniature fiber-optic pressure sensor incorporated into a small-caliper ureteroscope for assessing IPP and to develop an automatic irrigation system linked to this sensor. A porcine kidney was used for the ex vivo experiment. The nephrostomy catheter, connected to the conventional pressure transducer, was placed on the renal pelvis to evaluate the actual IPP (a-IPP). For measuring IPP using the fiber-optic pressure sensor (fo-IPP) built into the f-URS, a diaphragm pressure sensor of Φ250 µm was used. To establish an irrigation system, the optimal proportional-integral-derivative (PID) controller was explored to accurately adjust the irrigation pump flow rate. A high correlation between a-IPP and fo-IPP was confirmed across irrigation pressure values of 60-180 mbar (all, r ≥ 0.7, p < 0.001). When performing bolus irrigation, although fo-IPP showed relatively a higher peak value than a-IPP, the response time of fo-IPP was equivalent to that of a-IPP. After PID parameter optimization, our automatic irrigation system based on fo-IPP smoothly and accurately regulated the intended IPP set in the 5-20 mmHg range without overshooting. We successfully developed and demonstrated an automatic irrigation system regulating IPP based on the PID controller for f-URS, utilizing a fiber-optic pressure sensor. Further research, including in vivo studies, will be needed to assess clinical feasibility.

Hypoxia-inducible factor 2α protein and mRNA expression correlate with histomorphological features in clear cell renal cell carcinoma.

Hypoxia-inducible factor 2α (HIF2α) has been identified as a potential biomarker and novel target for systemic therapy in clear cell renal cell carcinoma (ccRCC). The present study aims to evaluate the association of HIF2α protein and HIF2A mRNA expression with clinicopathological factors and histomorphological features related to vasculature and inflammation of ccRCC using a localized ccRCC cohort (n = 428) and The Cancer Genome Atlas (TCGA)-KIRC cohort (n = 433). HIF2α protein expression was immunohistochemically assessed using tissue microarrays and HIF2A mRNA expression was assessed using the TCGA RNA-sequencing data. Positive HIF2α protein and high HIF2A mRNA expression were observed in 145 (33.9 %) and 142 (32.8 %) patients, respectively. Positive nuclear HIF2α protein expression was significantly associated with the clear histological phenotype and architectural patterns related to rich vascular networks (p < 0.001), and no tumor-associated immune cells status (p < 0.05) in addition to favorable prognostic factors such as lower TNM stage, lower WHO/ISUP grade, or the absence of necrosis (p < 0.001). The HIF2A mRNA expression profile by the TCGA cohort showed similar trends as the HIF2α protein profile. In addition, positive HIF2α protein and high HIF2A mRNA expression were associated with higher recurrence-free survival and overall survival, respectively (both p < 0.001). In conclusion, we comprehensively demonstrated the association of HIF2α profiles with clinicopathological factors and histomorphological features related to vasculature and inflammation at both protein and mRNA levels. Histomorphological features expressing HIF2α may provide information on HIF2α targeted therapeutic response as well as prognosis in ccRCC patients.

Learning from the past and present to change the future: Endoscopic management of upper urinary tract urothelial carcinoma.

Current guidelines recommend endoscopic management (EM) for patients with low-risk upper urinary tract urothelial carcinoma, as well as those with an imperative indication. However, regardless of the tumor risk, radical nephroureterectomy is still mainly performed worldwide despite the benefits of EM, such as renal function maintenance, no hemodialysis requirement, and treatment cost reduction. This might be explained by the association of EM with a high risk of local recurrence and progression. Furthermore, the need for rigorous patient selection and close surveillance following EM may be relevant. Nevertheless, recent developments in diagnostic modalities, pathological evaluation, surgical devices and techniques, and intracavitary regimens have been reported, which may contribute to improved risk stratification and treatments with superior oncological outcomes. In this review, considering recent advances in endourology and oncology, we propose novel treatment strategies for optimal EM.

Evaluation of sexual function after dutasteride treatment in patients with once-negative prostate biopsy and benign prostate hyperplasia.

INTRODUCTION: Patients with benign prostatic hyperplasia are usually treated with 5α-reduced inhibitors (5ARIs) such as finasteride and dutasteride. However, studies on the influence of 5ARIs on sexual function have been controversial. In this study, we evaluated the impact of dutasteride treatment for erectile function in patients with once-negative prostate biopsy and benign prostate hyperplasia. PATIENTS AND METHODS: 81 patients with benign prostate hyperplasia were enrolled in a one-armed prospective study. They were administrated 0.5 mg/day of dutasteride for 12 months. Patient characteristics and changes of International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF)-15 scores at baseline and 12 months after dutasteride administration were examined. RESULTS: The mean ± standard deviation (SD) age of the patients was 69.4 ± 4.9 years and the prostate volume was 56.6 ± 21.3 mL, respectively. The mean ± SD prostate volume and PSA levels were decreased 25.0 and 50.9%, respectively, after 12 months of dutasteride administration. IPSS total, voiding subscore, storage subscore, and quality of life score significantly improved after 12 months of dutasteride administration. No statistically significant change in IIEF-total score from 16.3 ± 13.5 to 18.8 ± 16.0 (p = 0.14), IIEF-EF score from 5.1 ± 6.9 to 6.4 ± 8.3 (p = 0.13) were observed. There was no decrease in erectile function severity. CONCLUSION: Twelve months administration of dutasteride for patients with BPH improved urinary function and did not increase the risk of sexual dysfunction.

Evaluation of ureteral injuries caused by ureteral access sheath insertion during ureteroscopic lithotripsy.

OBJECTIVE: To evaluate ureteral injuries caused by insertion of a 13-Fr ureteral access sheath and identify factors (other than pre-stenting) that are predictive of ureteral injury. METHODS: We enrolled 201 patients who underwent ureteroscopic lithotripsy (URSL). We excluded 80 patients who underwent ureteral stent insertion before URSL, 10 patients who did not use a ureteral access sheath, and 2 patients in whom a ureteral access sheath could not be inserted. In total, 109 patients were analyzed; all underwent insertion of a 13-Fr ureteral access sheath. We investigated ureteral injuries using the Traxer ureteral injury scale. RESULTS: There were 21 (19.3%) cases of ureteral access sheath-related ureteral injury, including 11 (10.1%) grade 2 cases and 10 (9.2%) grade 3 cases. The ureteral injury location was the proximal ureter in 20 cases (18.3%), middle ureter in one case (0.9%), and distal ureter in zero cases. Multiple logistic regression analysis showed that male sex and smaller stone diameter were significant predictive factors for ureteral injury (p = 0.037, odds ratio [OR]: 5.19, 95% confidence interval [CI]: 1.11-24.3 and p = 0.02, OR: 0.83, 95% CI: 0.71-0.97, respectively). Postoperative ureteral stricture did not occur in any cases. CONCLUSIONS: The rate of ureteral injury caused by a 13-Fr ureteral access sheath was considerable, and most ureteral injuries occurred in the proximal ureter. Male sex and smaller stone diameter were significant predictive factors for ureteral injury. The proximal ureter should be confirmed when using a 13-Fr ureteral access sheath, particularly in male patients and patients with small stones.

Comparison of Empower and M-arm for One-surgeon Basketing in Ureteroscopic Lithotripsy: A Simulator Study by Non-doctors.

OBJECTIVE: To compare the Empower and M-arm for stone retrieval during ureteroscopic lithotripsy in a simulator. METHODS: We used flexible ureteroscopy to compare use of the Empower and use of the M-arm, both of which are one-surgeon basketing techniques. LithoVue and ZeroTip stone extraction devices were used. All participants were nurses who had never handled a ureteroscope. They retrieved 3 stones in the simulator using the Empower or M-arm. We compared the stone retrieval time, number of times the retrieval device was opened and closed, number of times the line of sight was removed from the endoscope monitor, number of times the participant lost sight of a stone, and participants' subjective evaluations. RESULTS: The stone retrieval time was significantly shorter with the Empower than M-arm (10.0 vs. 19.9 min, respectively; P = .02). The mean number of times the retrieval device was opened and closed and the mean number of times the line of sight was removed from the endoscope monitor were significantly lower with the Empower (24 vs. 53 times, P = .01 and 3.1 vs. 51.5 times, P < .001, respectively). The mean number of times the participant lost sight of a stone tended to be lower with the Empower (9.4 vs. 25.3, P = .06). All participants indicated that the Empower is better for stone retrieval by beginners. CONCLUSION: The Empower reduces the stone retrieval time compared with the M-arm. We consider that the Empower has the potential to be useful in ureteroscopic lithotripsy.

Deep learning-based predictions of clear and eosinophilic phenotypes in clear cell renal cell carcinoma.

We have recently shown that histological phenotypes focusing on clear and eosinophilic cytoplasm in clear cell renal cell carcinoma (ccRCC) correlated with prognosis and the response to angiogenesis inhibition and checkpoint blockade. This study aims to objectively show the diagnostic utility of clear or eosinophilic phenotypes of ccRCC by developing an artificial intelligence (AI) model using the TCGA-ccRCC dataset and to demonstrate if the clear or eosinophilic predicted phenotypes correlate with pathological factors and gene signatures associated with angiogenesis and cancer immunity. Before the development of the AI model, histological evaluation using hematoxylin and eosin whole-slide images of the TCGA-ccRCC cohort (n = 435) was performed by a urologic pathologist. The AI model was developed as follows. First, the highest-grade area on each whole slide image was captured for image processing. Second, the selected regions were cropped into tiles. Third, the AI model was trained using transfer learning on a deep convolutional neural network, and clear or eosinophilic predictions were scaled as AI scores. Next, we verified the AI model using a validation cohort (n = 95). Finally, we evaluated the accuracy of the prognostic predictions of the AI model and revealed that the AI model detected clear and eosinophilic phenotypes with high accuracy. The AI model stratified the patients' outcomes, and the predicted eosinophilic phenotypes correlated with adverse clinicopathological characteristics and high immune-related gene signatures. In conclusion, the AI-based histologic subclassification accurately predicted clear or eosinophilic phenotypes of ccRCC, allowing for consistently reproducible stratification for prognostic and therapeutic stratification.

Clinical outcomes of intraductal carcinoma or cribriform in radical prostatectomy specimens of men opting for active surveillance: data from the PRIAS-JAPAN study.

BACKGROUND: Among early stage prostate cancer patients, intraductal carcinoma of the prostate (IDC-P) and invasive cribriform are key prognostic factors; however, their presence and clinical significance following active surveillance (AS) are unknown. In men who opted for AS, we aimed to examine the presence and impact of IDC-P or cribriform, utilizing radical prostatectomy (RP) specimens. METHODS: We re-reviewed 137 RP specimens available in the PRIAS-JAPAN prospective cohort between January 2010 and September 2020. We assessed the presence of IDC-P or cribriform, and compared the patients' characteristics and prostate-specific antigen (PSA) recurrence-free survival after RP between groups with and without IDC-P or cribriform. In addition, we examined the predictive factors associated with IDC-P or cribriform. RESULTS: The percentage of patients with IDC-P or cribriform presence was 34.3% (47 patients). IDC-P or cribriform pattern was more abundant in the higher Gleason grade group in RP specimens (P < 0.001). The rates of PSA recurrence-free survival were significantly lower in the IDC-P or cribriform groups than in those without them (log rank P = 0.0211). There was no association between IDC-P or cribriform on RP with the Prostate Imaging-Reporting and Data System (PI-RADS) 4,5 score on magnetic resonance imaging (MRI) before RP even with adjustments for other covariates (OR, 1.43; 95% confidence interval [CI] 0.511-3.980, P = 0.497). CONCLUSIONS: IDC-P or cribriform comprised approximately one-third of all RP specimens in men who underwent RP following AS, confirming their prognostic significance.

Preoperative Factors Associated with Intraoperative Maximum Arterial Pressures in Patients with Pheochromocytoma and Paraganglioma.

Background: Surgery for pheochromocytoma and paraganglioma (PPGL) can lead to life-threatening complications, such as intraoperative hypertensive crises, even when adequate doses of preoperative α-receptor blockades are administered. Objectives: The aim of this study was to identify preoperative factors associated with intraoperative maximum arterial pressure (AP) in patients with PPGL. Methods: We retrospectively reviewed the cases of 61 PPGL patients who underwent surgical resection in our hospital between 2006 and 2020. The primary outcome was intraoperative maximum AP as a single index for continuous variables. Simple and multiple linear regression model were used for statistical analysis. Results: The median maximum systolic AP during surgery was 165 mmHg (interquartile range: 150 - 180 mmHg). Log24-h urinary-fractionated metanephrine (MN) and normetanephrine (NMN) was correlated with intraoperative maximum AP (R-squared = 0.218, P < 0.001). Multiple regression analyses showed that diabetes mellitus, one or more of the classic triad, and log24-h urinary-fractionated MN and NMN were independent factors associated with intraoperative maximum AP. Conclusions: Patients with PPGL accompanied by diabetes mellitus, one or more of the classic triad, and high log 24-h urinary-fractionated MN and NMN values may be at risk for hypertensive crises during surgery regardless of whether preoperative α-receptor blockades are used. Clinicians should manage these patients more carefully and effectively.

CD155 immunohistochemical expression in upper tract urothelial carcinoma predicts poor prognosis.

A novel immune checkpoint, CD155/T-cell immunoreceptor with Ig and ITIM domains, has been recognized as a new therapeutic target in addition to conventional immune checkpoints, such as anti-programmed cell death protein 1/programmed cell death ligand 1 (PD-L1), for urothelial carcinoma (UC). Fibroblast growth factor receptor (FGFR) is considered another new therapeutic target for UC. As FGFR3-mutant UC may be associated with decreased T-cell infiltration, FGFR3 inhibition may facilitate lymphocyte invasion into the tumor microenvironment. Although a combined effect of immune checkpoint inhibitors and FGFR inhibition is expected, the combined expression profiles of CD155, PD-L1 and FGFR3 have not been evaluated in upper tract UC (UTUC). The present study aimed to investigate the association between CD155 expression and clinicopathological factors in 208 patients with UTUC undergoing radical nephroureterectomy. Furthermore, the expression profiles of CD155, PD-L1 and FGFR3 were compared. Immunohistochemical analysis was performed using tissue microarray specimens and survival analyses were performed using the Kaplan-Meier method and the Cox proportional hazards model. High immunohistochemical expression of CD155 was observed in 177 patients (85.1%) and it was associated with advanced pathological stage and lymphovascular invasion. The survival rate was lower among patients with tumors exhibiting high CD155 expression than among those with tumors with low CD155 expression. In addition, multivariate survival analysis revealed that high CD155 expression was an independent prognostic factor for recurrence (hazard ratio=7.32, 95% CI=1.01-53.35, P=0.049). FGFR3 and immune checkpoint signaling molecules, such as CD155 and PD-L1, had a weak negative correlation. The present results indicated that the expression of CD155 is a useful marker for predicting the recurrence of UTUC. In addition, the immunohistochemical expression profiles of CD155, PD-L1 and FGFR3 may further the understanding of the role of FGFR-targeted therapies in immunotherapy for UTUC.

Comparison of the medical costs between active surveillance and other treatments for early prostate cancer in Japan using data from the PRIAS-JAPAN study.

OBJECTIVES: To compare the medical costs of active surveillance with those of robot-assisted laparoscopic prostatectomy, brachytherapy, intensity-modulated radiation therapy, and hormone therapy for low-risk prostate cancer. METHODS: The costs of protocol biopsies performed in the first year of surveillance (between January 2010 and June 2020) and those of brachytherapy and radiation therapy performed between May 2019 and June 2020 at the Kagawa University Hospital were analyzed. Hormone therapy costs were assumed to be the costs of luteinizing hormone-releasing hormone analogs for over 5 years. Active surveillance-eligible patients were defined based on the following: age <74 years, ≤T2, Gleason score ≤6, prostate-specific antigen level ≤10 ng/ml, and 1-2 positive cores. We estimated the total number of active surveillance-eligible patients in Japan based on the Japan Study Group of Prostate Cancer (J-CAP) study and the 2017 cancer statistical data. We then calculated the 5-year treatment costs of active surveillance-eligible patients using the J-CAP and PRIAS-JAPAN study data. RESULTS: In 2017, number of active surveillance-eligible patients in Japan was estimated to be 2808. The 5-year total costs of surveillance, prostatectomy, brachytherapy, radiation therapy, and hormone therapy were 1.65, 14.0, 4.61, 4.04, and 5.87 million United States dollar (USD), respectively. If 50% and 100% of the patients in each treatment group had opted for active surveillance as the initial treatment, the total treatment cost would have been reduced by USD 6.89 million (JPY 889 million) and USD 13.8 million (JPY 1.78 billion), respectively. CONCLUSION: Expanding active surveillance to eligible patients with prostate cancer helps save medical costs.

Use of ileal bypass in the surgical management of two rare cases of ileal-neobladder fistula in patients who underwent radical cystectomy.

PURPOSE: An entero-neovesical fistula (ENF) is a rare troublesome complication of an orthotopic ileal bladder substitution. We report on a novel, safe technique to close ileal neovesical fistulas without extensive adhesiolysis using an NK-stapler (ENDOPATH® ENDOCUTTER ETS; Johnson & Johnson, Cincinnati, OH, USA). PATIENTS: We treated two cases of postoperative ENF after orthotopic ileal bladder substitution for radical cystectomy. Case 1 was a 63-year-old male with occasional fecaluria, and Case 2 was a 73-year-old male who experienced continuous fecaluria.Surgical procedureAfter laparotomy, we mobilized the ascending colon to bypass the anastomosis of the primary surgery by an ileo-ileal, ileo-ascending colon anastomosis. The distance between the fistula and bypass was about 10 cm. We made tunnels in the mesentery between the bypass and fistula, without damaging blood vessels, to insert the jaw of the NK-stapler. We closed the afferent and efferent loops using NK-staplers (45 mm ×2), followed by a Lembert anastomosis covering the stapler's suture lines. RESULTS: They were discharged on the ninth and seventh postoperative days, respectively. In Case 1, we experienced recanalization of the fistula after three postoperative months and required second closure with the same procedure was needed. They have not experienced any symptoms of ENF since. CONCLUSIONS: This technique is worth considering for the surgical treatment of ENF because it does not require unnecessary dissection and can ultimately achieve fistula closure.

Site-specific Risk Stratification Models for Postoperative Recurrence and Survival Prediction in Patients with Upper Tract Urothelial Carcinoma Undergoing Radical Nephroureterectomy: Better Stratification for Adjuvant Therapy.

Background: Site-specific postoperative risk models for localized upper tract urothelial carcinoma (UTUC) are unavailable. Objective: To create specific risk models for renal pelvic urothelial carcinoma (RPUC) and ureteral urothelial carcinoma (UUC), and to compare the predictive accuracy with the overall UTUC risk model. Design setting and participants: A multi-institutional database retrospective study of 1917 UTUC patients who underwent radical nephroureterectomy (RNU) between 2000 and 2018 was conducted. Outcome measurements and statistical analysis: A multivariate hazard model was used to identify the prognostic factors for extraurinary tract recurrence (EUTR), cancer-specific death (CSD), and intravesical recurrence (IVR) after RNU. Patients were stratified into low-, intermediate-, high-, and highest-risk groups. External validation was performed to estimate a concordance index of the created risk models. We investigated whether our risk models could aid decision-making regarding adjuvant chemotherapy (AC) after RNU. Results and limitations: The UTUC risk models could stratify the risk of cumulative incidence of three endpoints. The RPUC- and UUC-specific risk models showed better stratification than the overall UTUC risk model for all the three endpoints, EUTR, CSD, and IVR (RPUC: concordance index, 0.719 vs 0.770, 0.714 vs 0.794, and 0.538 vs 0.569, respectively; UUC: 0.716 vs 0.767, 0.766 vs 0.809, and 0.553 vs 0.594, respectively). The UUC-specific risk model can identify the high- and highest-risk patients likely to benefit from AC after RNU. A major limitation was the potential selection bias owing to the retrospective nature of this study. Conclusions: We recommend using site-specific risk models instead of the overall UTUC risk model for better risk stratification and decision-making for AC after RNU. Patient summary: Upper tract urothelial carcinoma comprises renal pelvic and ureteral carcinomas. We recommend using site-specific risk models instead of the overall upper tract urothelial carcinoma risk model in risk prediction and decision-making for adjuvant therapy after radical surgery.

Impact of adherence to criteria on oncological outcomes of radical prostatectomy in patients opting for active surveillance: data from the PRIAS-JAPAN study.

OBJECTIVES: This study aimed to evaluate whether oncological outcomes of radical prostatectomy differ depending on adherence to the criteria in patients who opt for active surveillance. MATERIALS AND METHODS: We retrospectively reviewed the data of 1035 patients enrolled in a prospective cohort of the PRIAS-JAPAN study. After applying the exclusion criteria, 136 of 162 patients were analyzed. Triggers for radical prostatectomy due to pathological reclassification on repeat biopsy were defined as on-criteria. Off-criteria triggers were defined as those other than on-criteria triggers. Unfavorable pathology on radical prostatectomy was defined as pathological ≥T3, ≥GS 4 + 3 and pathological N positivity. We compared the pathological findings on radical prostatectomy and prostate-specific antigen recurrence-free survival between the two groups. The off-criteria group included 35 patients (25.7%), half of whom received radical prostatectomy within 35 months. RESULTS: There were significant differences in median prostate-specific antigen before radical prostatectomy between the on-criteria and off-criteria groups (6.1 vs. 8.3 ng/ml, P = 0.007). The percentage of unfavorable pathologies on radical prostatectomy was lower in the off-criteria group than that in the on-criteria group (40.6 vs. 31.4%); however, the differences were not statistically significant (P = 0.421). No significant difference in prostate-specific antigen recurrence-free survival was observed between the groups during the postoperative follow-up period (median: 36 months) (log-rank P = 0.828). CONCLUSIONS: Half of the off-criteria patients underwent radical prostatectomy within 3 years of beginning active surveillance, and their pathological findings were not worse than those of the on-criteria patients.

Successful endoscopic treatment using thulium YAG laser for multiple ureteral fibroepithelial polyps in a pediatric patient.

Introduction: Ureteral fibroepithelial polyps are extremely rare and cause ureteropelvic junction obstruction in the pediatric population. Recent advancements in endoscopic treatment, such as holmium:yttrium-aluminum-garnet laser, have created more options for practitioners to treat multiple ureteral fibroepithelial polyps cases. However, the use of holmium:yttrium-aluminum-garnet laser multilobulated ureteral fibroepithelial polyps may have technical difficulties. Case presentation: An 11-year-old boy with intermittent right flank pain revealed multiple ureteral fibroepithelial polyps approximately 3 cm long at the right ureteropelvic junction. The ureteral fibroepithelial polyps were resected using flexible ureteroscopy using thulium:YAG laser. A second-look ureteroscopy revealed no recurrence, residual polyps, or ureteral stricture. At 1-year follow-up, ultrasonography showed no hydronephrosis on the affected side. Conclusion: Thulium:YAG laser provides clear visibility due to its high hemostatic and evaporation effects. To the best of our knowledge, this is the first pediatric case of multiple ureteral fibroepithelial polyps successfully treated with endoscopic resection using thulium:YAG laser, with a favorable clinical outcome.