A Comparison of Globally Applied Prognostic Risk Groups and the Prevalence of Metastatic Disease on Prostate-specific Membrane Antigen Positron Emission Tomography in Patients with Newly Diagnosed Prostate Cancer.

BACKGROUND: Various risk classification systems (RCSs) are used globally to stratify newly diagnosed patients with prostate cancer (PCa) into prognostic groups. OBJECTIVE: To compare the predictive value of different prognostic subgroups (low-, intermediate-, and high-risk disease) within the RCSs for detecting metastatic disease on prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) for primary staging, and to assess whether further subdivision of subgroups would be beneficial. DESIGN, SETTING, AND PARTICIPANTS: Patients with newly diagnosed PCa, in whom PSMA-PET/CT was performed between 2017 and 2022, were studied retrospectively. Patients were stratified into risk groups based on four RCSs: European Association of Urology, National Comprehensive Cancer Network (NCCN), Cambridge Prognostic Group (CPG), and Cancer of the Prostate Risk Assessment. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The prevalence of metastatic disease on PSMA-PET/CT was compared among the subgroups within the four RCSs. RESULTS AND LIMITATIONS: In total, 2630 men with newly diagnosed PCa were studied. Any metastatic disease was observed in 35% (931/2630) of patients. Among patients classified as having intermediate- and high-risk disease, the prevalence of metastases ranged from approximately 12% to 46%. Two RCSs further subdivided these groups. According to the NCCN, metastatic disease was observed in 5.8%, 13%, 22%, and 62% for favorable intermediate-, unfavorable intermediate-, high-, and very-high-risk PCa, respectively. Regarding the CPG, these values were 6.9%, 13%, 21%, and 60% for the corresponding risk groups. CONCLUSIONS: This study underlines the importance of nuanced risk stratification, recommending the further subdivision of intermediate- and high-risk disease given the notable variation in the prevalence of metastatic disease. PSMA-PET/CT for primary staging should be reserved for patients with unfavorable intermediate- or higher-risk disease. PATIENT SUMMARY: The use of various risk classification systems in patients with prostate cancer helps identify those at a higher risk of having metastatic disease on prostate-specific membrane antigen positron emission tomography/computed tomography for primary staging.

The Probability of Metastases Within Different Prostate-specific Antigen Ranges Using Prostate-specific Membrane Antigen Positron Emission Tomography in Patients with Newly Diagnosed Prostate Cancer.

Background and objectives: The association between prostate-specific antigen (PSA) level and probability of metastatic disease on prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) has not yet been established in patients with newly diagnosed prostate cancer (PCa). Our objective was to assess the probability of metastatic disease within different PSA ranges using PSMA PET/CT for initial staging of PCa, and to identify both the anatomical distribution and the predictors of metastases on PSMA PET/CT. Methods: In total, 2193 patients with newly diagnosed PCa were retrospectively studied. PSMA PET/CT was performed for staging purposes between January 2017 and May 2022. The proportion of patients with PSMA-avid metastases, stratified by PSA level, was studied. A vast majority of patients in whom at least one high-risk prognostic factor was present underwent PSMA PET/CT. A multivariable logistic regression analysis was performed to identify the predictors of metastases on PSMA PET/CT using clinical, biochemical, radiological, and pathological variables. Key findings and limitations: The median PSA level at PSMA PET/CT was 14.1 ng/ml. Any metastatic disease (miN1-M1a-c) was observed in 34.7% (763/2193) of all patients and distant metastases (miM1a-c) in 25.4% (557/2193) of patients. The presence of any metastatic disease increased with PSA levels, being 15.4% in men with PSA levels <10 ng/ml and 87.5% in men with PSA levels >100 ng/ml. The multivariable logistic regression analysis found significant associations between the presence of any metastatic disease and PSA subgroups, clinical tumor stage ≥T2, grade group >3, and radiological tumor stage ≥T3b. Conclusions and clinical implications: This is the first large epidemiological study in patients with PCa demonstrating the association between PSA subgroups and metastatic disease on modern imaging PSMA PET/CT. Data from this study can be used to counsel patients on the probability of metastatic disease at the time of PSA screening and to provide guidance on existing guidelines. Patient summary: The prostate-specific antigen level could be used to assess the risk of metastases on prostate-specific membrane antigen positron (PSMA) emission tomography/computed tomography (PET/CT). This knowledge is valuable for selecting patients who will benefit most from metastatic screening with PSMA PET/CT.

The influence of pelvicalyceal system anatomy on minimally invasive treatments of patients with renal calculi.

INTRODUCTION AND OBJECTIVES: Nephrolithiasis has a multifactorial etiology, wherein, besides metabolic factors, the anatomy of the pelvicalyceal system might play a role. Using 3D-reconstructions of CT-urography (CT-U), we studied the morphometric properties of pelvicalyceal anatomy affecting kidney stone formation and compared those with existing literature on their effect on minimally invasive treatment techniques for renal calculi. METHODS: CT-U's were made between 01-01-2017 and 30-09-2018. Patients were chronologically included in two groups: a nephrolithiasis group when ≥ 1 calculus was present on the CT-U and a control group of patients with both the absence of calculi on the CT-U and no medical history of urolithiasis. Patients with a medical history of diseases leading to higher risks on urolithiasis were excluded. In the nephrolithiasis group affected kidneys were measured. In the control group, left and right kidneys were alternately measured. RESULTS: Twenty kidneys were measured in both groups. Mean calyceopelvic tract width was significantly larger in the lower segments of affected kidneys (3.9 vs. 2.7 mm). No significant differences between the groups were found in number of calyces, infundibular length, infundibular width, calyceopelvic angle, upper-lower angle and diameters of the pelvis. Transversal calyceal orientation in hours was significantly smaller in the upper and lower segments of the nephrolithiasis group (7.69 vs. 8.52 and 8.08 vs. 9.09 h), corresponding with more dorsally located calyces in stone-forming kidneys. CONCLUSION: Pelvicalyceal anatomy differs between stone-forming and non-stone-forming kidneys. Understanding the pelvicalyceal system and etiology of stone formation can improve development of endourological techniques.

Lessons from Literature: Nephrostomy Versus Double J Ureteral Catheterization in Patients with Obstructive Urolithiasis-Which Method Is Superior?

Purpose: To review the literature on optimal methods of drainage for obstructive urolithiasis in adult patients, comparing percutaneous nephrostomy (PCN) with retrograde ureteral catheterization (Double J [JJ]) regarding success of procedure, efficacy, complications, quality of life (QoL), and costs. Methods: Web of Science and the Medline, Embase, Emcare, and Cochrane controlled trial databases were searched for all relevant publications until November 2018. A review protocol was created, using the PRISMA statement. Two reviewers independently screened the titles and abstracts in Endnote X8, using criteria as stated in the research protocol. A total of 1108 abstracts were screened of which 9 were included in the qualitative synthesis. Level of evidence of the studied articles varies between 1b and 2c. Results: Both JJ and PCN have high success rates (80%-100% and 99%-100%, respectively). No major complications were reported in both groups. Procedural and fluoroscopy times are significantly shorter for JJ than for PCN (31-33 minutes vs 35-49 minutes and 5 minutes vs 7 minutes, respectively). Time to clinical improvement did not differ. In the JJ group, analgesics were used more frequently than in the PCN group. Data regarding procedural costs were contradictory, but overall the PCN group was associated with higher costs. In pregnant women, PCN placement appears to be significantly more effective than placement of JJ. A significant decrease between pre- and postintervention QoL was found with patients receiving a JJ. Back pain was reported more frequently in the PCN group, urinary symptoms were more common in the patients with a JJ. Conclusions: Both PCN and JJ have comparable success rates for patients with obstructive urolithiasis and procedure-related complications are rare. Overall, higher rates of sepsis, longer hospital stay, and higher costs were found in the PCN group, but that could be explained by patient selection. Patients with JJ experienced a lower QoL and experience more lower urinary tract symptoms.

The Influence of Pain on the Outcome of Extracorporeal Shockwave Lithotripsy.

INTRODUCTION: The aim of this study was to determine the predictive value of pain scores on the efficacy of extracor-poreal shockwave lithotripsy (ESWL) and to identify other predictive risk factors for treatment success. MATERIALS AND METHODS: A total of 476 patients who underwent ESWL (piezoelectric lithotripsy) for urolithiasis between September 2011 and December 2015 were identified. The primary end-point of this study was success rate, which was evaluated 4 months after ESWL. The secondary outcome was the occurrence of complications as a result of ESWL. RESULTS: The average pain perception was reported at 5 on a scale from 0 to 10. The overall success rate of ESWL was found to be 43.9% and the success rate after the first ESWL was 35.1%. Univari-ate analysis showed no significant correlation between pain score and success of ESWL (p = 0.135). The level of intensity was correlated with pain scores (Pearson correlation -0.423, p < 0.001). Univariate analysis identified five predictive factors: sex, stone location, stone size, hydronephrosis and the use of tamsulosin. Multivariate logistic regression analysis showed that sex, stone location and size independently in-fluenced the success of ESWL (p = 0.045, p = 0.001 and p < 0.001). CONCLUSION: No correlation was found between the pain scores and efficacy of ESWL. Despite this absence, pain scores during ESWL sessions remain high and additional analgesia would improve patient satisfaction.

The anatomy of the renal pyelocaliceal system studied by CTU.

INTRODUCTION AND OBJECTIVES: Knowledge of the pyelocaliceal system anatomy is essential for the safe and successful performance of endourologic procedures. The purpose of this study was to provide a better understanding of the full three-dimensional pyelocaliceal system anatomy. METHODS: Morphometric parameters of the three-dimensional reconstructions of computed tomography intravenous urography scans (n = 25 scans) were analyzed. Both kidneys were divided into three equal-sized segments (US: upper segment, MS: mid segment, LS: lower segment). Infundibular length (IL), infundibular width (IW), the number of calyces, and the transverse orientation in hours of a clock of each calyx as well as the dimension of the pyelum were determined. RESULTS: The mean upper IL (n = 92) was longer than the middle (n = 154) and lower IL (n = 112) (30.6 ± 7.9 mm vs. 16.4 ± 7.7 mm vs. 16.0 ± 6.0 mm, respectively; P = < 0.0001). IW was significantly smaller in the MS [3.7 ± 1.9 mm], followed by the US [4.6 ± 1.9 mm], and the LS [4.9 ± 2.2] in the increasing order. No correlation was found between IL and IW (Pearson correlation coefficient = 0.1). The US calyces were predominantly orientated lateral (8-10 o'clock: 44.5%) and medial (2-4 o'clock: 30.5%), in the MS lateral (8-10 o'clock: 87.6%) and anterolateral in the LS (9-12 o'clock: 67.9%). 74% of the kidneys consisted of 6-8 calyces (mean 7.2 ± 1.4, range 4-10), with the majority of the calyces in the MS (3.1 ± 0.8) followed by the LS (2.24 ± 0.8), and US (1.8 ± 0.7). There were no statistical differences between the right and left kidneys in terms of IL (P = 0.112) and number of calyces (P = 0.685). CONCLUSION: Anatomic differences between the three segments of the pyelocaliceal system in terms of IL, IW, calyces number, and orientation are seen and should be considered when performing an endourologic procedure.

Antegrade Ureteral Stenting is a Good Alternative for the Retrograde Approach.

BACKGROUND/AIMS: Double J (JJ) stents for treating obstructive ureteral pathology are generally inserted through a retrograde route with cystoscopic guidance. Antegrade percutaneous insertion using fluoroscopy can be performed alternatively but is less known. Indications, success rate and complications of antegrade ureteral stenting were evaluated. METHODS: Data of consecutive patients in which antegrade ureteral stenting was performed were retrospectively analysed using the radiology information system and patient records. Patient characteristics, details of the antegrade JJ stent insertion procedure and registered complications were collected. Furthermore, it was investigated if prior to the antegrade procedure a retrograde attempt for JJ stent insertion was performed. RESULTS: Total 130 attempts for antegrade JJ stent insertion were performed in 100 patients. A percutaneous nephrostomy catheter had already been placed in the majority of kidneys (n = 109) for initial treatment of hydronephrosis. Most prevelant indication for a JJ stent was obstructive ureteral pathology due to malignancy (n = 63). A JJ stent was successfully inserted in 125 of 130 procedures. In 21 cases, previous retrograde ureteral stenting had failed but, subsequent antegrade ureteral stenting was successful. There were 8 procedure related complications; 6 infections, 1 false tract and 1 malposition. CONCLUSION: Antegrade percutaneous insertion of a JJ stent is a good alternative for retrograde insertion.

Considerations in minimally invasive surgery for renal and ureteric calculi: a bicenter quality control study.

BACKGROUND: The use of minimally invasive surgery is increasing. Evaluating the quality of care brings new sights in the optimization of operating techniques. METHODS: We included all procedures performed in two hospitals during 2010 and 2011. A total of 264 patients were included in the ureterorenoscopy (URS) group and 77 patients in the percutaneous nephrolitholapaxy (PCNL) group. Data were gathered by retrospectively reviewing medical records. RESULTS: Mean stone diameter in the URS group was 9 mm. Patients suffered from a single stone in 79% of the cases. Calculi in the distal ureter, defined as the part of the ureter below the lower border of the sacroiliac joint, were most likely to be removed. A stone-free status was reached in 69% of the cases using URS. Mean stone diameter in the PCNL group was 23 mm. PCNL was successful in 70% of the cases in Haga Hospital versus 53% in Medisch Centrum Haaglanden. Incidence of complications was comparable between the hospitals (p = 0.5). Outcome and quality of both PCNL and URS was not influenced by sex, age or body mass index. CONCLUSION: The clinical results were comparable with results in the literature. Further improvement can be made by optimization of technical aspects and centralization of treatment by urologists experienced in minimally invasive techniques.