Association of patients' sex with treatment outcomes after intravesical bacillus Calmette-Guérin immunotherapy for T1G3/HG bladder cancer.

PURPOSE: To investigate the association of patients' sex with recurrence and disease progression in patients treated with intravesical bacillus Calmette-Guérin (BCG) for T1G3/HG urinary bladder cancer (UBC). MATERIALS AND METHODS: We analyzed the data of 2635 patients treated with adjuvant intravesical BCG for T1 UBC between 1984 and 2019. We accounted for missing data using multiple imputations and adjusted for covariate imbalance between males and females using inverse probability weighting (IPW). Crude and IPW-adjusted Cox regression analyses were used to estimate the hazard ratios (HR) with their 95% confidence intervals (CI) for the association of patients' sex with HG-recurrence and disease progression. RESULTS: A total of 2170 (82%) males and 465 (18%) females were available for analysis. Overall, 1090 (50%) males and 244 (52%) females experienced recurrence, and 391 (18%) males and 104 (22%) females experienced disease progression. On IPW-adjusted Cox regression analyses, female sex was associated with disease progression (HR 1.25, 95%CI 1.01-1.56, p = 0.04) but not with recurrence (HR 1.06, 95%CI 0.92-1.22, p = 0.41). A total of 1056 patients were treated with adequate BCG. In these patients, on IPW-adjusted Cox regression analyses, patients' sex was not associated with recurrence (HR 0.99, 95%CI 0.80-1.24, p = 0.96), HG-recurrence (HR 1.00, 95%CI 0.78-1.29, p = 0.99) or disease progression (HR 1.12, 95%CI 0.78-1.60, p = 0.55). CONCLUSION: Our analysis generates the hypothesis of a differential response to BCG between males and females if not adequately treated. Further studies should focus on sex-based differences in innate and adaptive immune system and their association with BCG response.

Irreversible Electroporation for the Ablation of Prostate Cancer.

PURPOSE OF REVIEW: Although still considered experimental, focal irreversible electroporation (IRE) as a primary treatment for prostate cancer (PCa) is considered one of the most promising ablative technologies for focal therapy. This review provides a description of the principle of IRE for the treatment of PCa, combined with an overview of the recent research. RECENT FINDINGS: It has been almost a decade since the first human studies of focal IRE for PCa were trying to demonstrate its feasibility and safety, and recently new data are emerging regarding the functional and oncological outcomes. It was shown that the expected ablation efficacy of IRE is dependent on increased safety margins of > 9 mm and an uninterrupted IRE procedure, but these findings need further investigation in larger cohorts and randomized control trials (RCT). Recent data from larger cohorts with a longer follow-up of up to 12 months prove that focal IRE as primary treatment for localized PCa is indeed safe, has effective short-term oncological control in selected patients, and it has good functional outcomes by retaining urinary function and causing only mild erectile dysfunction.

Serum testosterone as a biomarker for second prostatic biopsy in men with negative first biopsy for prostatic cancer and PSA>4ng/mL, or with PIN biopsy result.

INTRODUCTION: Data from animal, clinical and prevention studies support the role of androgens in prostate cancer growth, proliferation and progression. Results of serum based epidemiologic studies in humans, however, have been inconclusive. The present study aims to define whether serum testosterone can be used as a predictor of a posi¬tive second biopsy in males considered for re-biopsy. MATERIAL AND METHODS: The study included 320 men who underwent a prostatic biopsy in our department from October 2011 until June 2012. Total testosterone, free testos¬terone, bioavailable testosterone and prostate pathology were evaluated in all cases. Patients undergoing a second biopsy were identified and biopsy results were statistically analyzed. RESULTS: Forty men (12.5%) were assessed with a second biopsy. The diagnosis of the second biopsy was High Grade Intraepithelial Neoplasia in 14 patients (35%) and Prostate Cancer in 12 patients (30%). The comparison of prostatic volume, total testosterone, sex hormone binding globulin, free testosterone, bioavailable testosterone and albumin showed that patients with cancer of the prostate had significantly greater levels of free testosterone (p=0.043) and bioavailable T (p=0.049). CONCLUSION: In our study, higher free testosterone and bioavailable testosterone levels were associated with a cancer diagnosis at re-biopsy. Our results indicate a possible role for free and bioavailable testosterone in predicting the presence of prostate cancer in patients considered for re-biopsy.

Minimally invasive approach in the management of upper- urinary-tract tumours.

OBJECTIVE: Nephroureterectomy with bladder cuff excision has been the gold standard treatment for upper tract transitional cell carcinoma (UTTCC) for more than 60 years. However, endoscopic treatment of urothelial tumours of renal pelvis and ureter is gaining acceptance as a conservative treatment modality. MATERIAL AND METHODS: A review in the English language of the Medline and Pub Med databases was performed using the keywords upper urinary tract transitional cell carcinoma and endoscopic management. There was a particular emphasis on treatment outcomes from published series. RESULTS: Endoscopic treatment of UTTCC alone for high-grade tumours is not advised owing to high rates of both local recurrence and disease progression, while many authors do not recommend primary endoscopic management of UTTCC in elective situations if pathological analysis and tumour grade cannot be obtained. CONCLUSION: Endourological management of UTTCC has become an accepted treatment option in highly selected patients, provided long-term close surveillance to detect and treat recurrences is ensured.

Endoscopic treatment of urothelial tumours of the renal pelvis and ureter.

Endoscopic treatment of urothelial tumors of renal pelvis and ureter is gaining acceptance as a conservative treatment modality. Technological advances have increased its applicability. Ureteroscopic and percutaneous tumor ablation have become reasonable treatment options for patients with imperative indications, such as bilateral disease, renal insufficiency or solitary kidney. However, endoscopic tumor ablation is being utilized more frequently for patients with UTTCC even in the setting low grade disease and a normal contralateral kidney, provided long-term close surveillance to detect and treat recurrences is ensured. This paper reviews the current role of endoscopic management of UTTCC.

Xanthogranulomatous pyelonephritis: presentation and management in the era of laparoscopy.

OBJECTIVE: To report a contemporary series of patients with xanthogranulomatous pyelonephritis (XGP, an inflammatory condition of the kidney that has traditionally been treated with open nephrectomy, ON), managed with either ON or laparoscopic nephrectomy (LN), as early reports suggest that the benefits of LN do not extend to patients with XGP. PATIENTS AND METHODS: The medical and procedural records of patients with pathologically confirmed XGP between December 1993 to February 2004 were reviewed retrospectively. During this period, 26 patients (mean age 43.5 years, range 17-85) had surgical management of XGP; information on the mode of presentation, surgical management, hospital course and complications were analysed. RESULTS: Twelve (46%) and 14 (54%) patients had ON and LN, respectively. The LN group had significantly lower blood loss (P = 0.002), transfusion rates (P = 0.02), time to resumption of oral intake (P = 0.002) and length of hospital stay (P = 0.002) than the ON group. One (7%) LN was converted to ON due to failure to progress. The overall complication rates between the ON and LN groups were not significantly different (P = 0.95). CONCLUSIONS: LN in the setting of XGP is often difficult and requires advanced laparoscopic skills. In highly selected patients this approach can be offered, with acceptable morbidity, allowing for lower blood loss and shorter convalesce times.

Case report: laparoscopic ureteropyelostomy and distal ureterectomy for management of duplication with ectopia.

PURPOSE: To evaluate the role of laparoscopic ureteropyelostomy and subtotal ureterectomy for management of an ectopic ureter to the prostatic urethra. CASE REPORT: A 54-year-old man presented with complaints of paravertebral pain and recurrent prostatitis with elevation of the serum prostate specific antigen concentration. Diagnostic evaluation revealed right renal duplication with an ectopic ureter to the prostatic urethra. Using a four-port transperitoneal laparoscopic technique, a laparoscopic ureteropyelostomy and subtotal ureterectomy were performed. Diagnostic follow-up documented successful treatment with the minimally invasive technique. CONCLUSIONS: Laparoscopic ureteropyelostomy and subtotal ureterectomy provide effective treatment for this rare condition. The minimally invasive technique may also have clinical applications in the pediatric population.

The efficacy of BCG TICE and BCG Connaught in a cohort of 2,099 patients with T1G3 non-muscle-invasive bladder cancer.

BACKGROUND: Potential differences in efficacy of different bacillus Calmette-Guérin (BCG) strains are of importance for daily practice, especially in the era of BCG shortage. OBJECTIVE: To retrospectively compare the outcome with BCG Connaught and BCG TICE in a large study cohort of pT1 high-grade non-muscle-invasive bladder cancer patients. DESIGN, SETTING, AND PARTICIPANTS: Individual patient data were collected for 2,451 patients with primary T1G3 tumors from 23 centers who were treated with BCG for the first time between 1990 and 2011. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Using Cox multivariable regression and adjusting for the most important prognostic factors in this nonrandomized comparison, BCG Connaught and TICE were compared for time to recurrence, progression, and the duration of cancer specific survival and overall survival. RESULTS AND LIMITATIONS: Information on the BCG strain was available for 2,099 patients: 957 on Connaught and 1,142 on TICE. Overall, 765 (36%) patients received some form of maintenance BCG, 560 (59%) on Connaught and 205 (18%) on TICE. Without maintenance, Connaught was more effective than TICE only for the time to first recurrence (hazard ratio [HR] = 1.48; 95% CI: 1.20-1.82; P<0.001). With maintenance, TICE was more effective than Connaught for the time to first recurrence (HR = 0.66; 95% CI: 0.47-0.93; P = 0.019) with a trend for cancer specific survival (HR = 0.36; 95% CI: 0.14-0.92; P = 0.033). For time to progression and overall survival, Connaught and TICE had a similar efficacy. Compared to no maintenance therapy, maintenance BCG significantly reduced the risk of recurrence, progression and death, both overall, and disease specific, for TICE, but not for Connaught. CONCLUSIONS: We found that BCG Connaught results in a lower recurrence rate as compared with BCG TICE when no maintenance is used. However, the opposite is true when maintenance is given. PATIENT SUMMARY: As there is currently a BCG shortage, information on the efficacy of different BCG strains is important. In this nonrandomized retrospective comparison in over 2,000 patients, we found that BCG Connaught reduces the recurrence rate compared to BCG TICE when no maintenance is used, but the opposite is true when maintenance is given.

Complete daVinci versus laparoscopic pyeloplasty: cost analysis.

BACKGROUND AND PURPOSE: Computer-assisted pyeloplasty with the daVinci system is an emerging technique to treat ureteropelvic junction (UPJ) obstruction. A relative cost analysis was performed assessing this technology in comparison with purely laparoscopic pyeloplasty. PATIENTS AND METHODS: Eight patients underwent computer-assisted (daVinci) dismembered pyeloplasty (CP) via a transperitoneal four-port approach. They were compared with 13 patients who underwent purely laparoscopic pyeloplasty (LP). All patients had a primary UPJ obstruction and were matched for age, sex, and body mass index. The cost of equipment and capital depreciation for both procedures, as well as assessment of room set-up time, takedown time, and personnel were analyzed. Surgeons and nursing staff for both groups were experienced in both laparoscopy and daVinci procedures. One- and two-way financial analysis was performed to assess relative costs. RESULTS: The mean set-up and takedown time was 71 minutes for CP and 49 minutes for LP. The mean length of stay was 2.3 days for CP and 2.5 days for LP. The mean operating room (OR) times for CP and LP were 176 and 210 minutes, respectively. There were no complications in either group. One-way cost analysis with an economic model showed that LP is more cost effective than CP at our hospital if LP OR time is <338 minutes. With adjustment to a volume of 500 daVinci cases/year, CP is still not as cost effective as LP. Two-way sensitivity analysis shows that in-room time must still be <130 minutes and yearly cases must be >500 to obtain cost equivalence for CP. CONCLUSIONS: Perioperative parameters for CP are encouraging. However, the costs are a clear disadvantage. In our hospital, it is more cost effective to teach and perform LP than to perform CP.

Prognostic factors and risk groups in T1G3 non-muscle-invasive bladder cancer patients initially treated with Bacillus Calmette-Guérin: results of a retrospective multicenter study of 2451 patients.

BACKGROUND: The impact of prognostic factors in T1G3 non-muscle-invasive bladder cancer (BCa) patients is critical for proper treatment decision making. OBJECTIVE: To assess prognostic factors in patients who received bacillus Calmette-Guérin (BCG) as initial intravesical treatment of T1G3 tumors and to identify a subgroup of high-risk patients who should be considered for more aggressive treatment. DESIGN, SETTING, AND PARTICIPANTS: Individual patient data were collected for 2451 T1G3 patients from 23 centers who received BCG between 1990 and 2011. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Using Cox multivariable regression, the prognostic importance of several clinical variables was assessed for time to recurrence, progression, BCa-specific survival, and overall survival (OS). RESULTS AND LIMITATIONS: With a median follow-up of 5.2 yr, 465 patients (19%) progressed, 509 (21%) underwent cystectomy, and 221 (9%) died because of BCa. In multivariable analyses, the most important prognostic factors for progression were age, tumor size, and concomitant carcinoma in situ (CIS); the most important prognostic factors for BCa-specific survival and OS were age and tumor size. Patients were divided into four risk groups for progression according to the number of adverse factors among age ≥ 70 yr, size ≥ 3 cm, and presence of CIS. Progression rates at 10 yr ranged from 17% to 52%. BCa-specific death rates at 10 yr were 32% in patients ≥ 70 yr with tumor size ≥ 3 cm and 13% otherwise. CONCLUSIONS: T1G3 patients ≥ 70 yr with tumors ≥ 3 cm and concomitant CIS should be treated more aggressively because of the high risk of progression. PATIENT SUMMARY: Although the majority of T1G3 patients can be safely treated with intravesical bacillus Calmette-Guérin, there is a subgroup of T1G3 patients with age ≥ 70 yr, tumor size ≥ 3 cm, and concomitant CIS who have a high risk of progression and thus require aggressive treatment.

Shockwave lithotripsy for urinary stones in patients with urinary diversion after radical cystectomy.

BACKGROUND AND PURPOSE: During recent years, survival of patients with invasive bladder cancer has been improved by early diagnosis and radical treatment. Urinary lithiasis is not rare in patients who have been submitted to radical cystectomy and urinary diversion. We have demonstrated the effectiveness and safety of SWL for these patients. PATIENTS AND METHODS: We studied 11 patients who presented to our lithotripsy department suffering from urinary lithiasis after radical cystectomy. They were all cancer free at the time of treatment, and all underwent SWL on the Dornier HM-3 lithotripter as a first-line treatment. The mean stone burden was 1.85 cm(2), and the stone-to-patient ratio was 1:1. RESULTS: The stone-free rate 1 month after SWL was 63.7%. Patients who were not stone free underwent a second SWL, and the stone-free rate after the second SWL session was 81.8%. We performed percutaneous nephrolithotripsy in one patient after the second SWL session because of the large stone burden remaining (3.2 cm(2)). The remaining patient was submitted to ureterolithotomy. CONCLUSION: Application of SWL gives very good results in the treatment of urinary lithiasis in patients with a urinary diversion. Indeed, the results are equivalent to those achieved in patients without urinary diversion.

Synchronous diagnosis of prostatic adenocarcinoma and sarcoidosis.

Sarcoidosis and prostatic carcinoma in the same patient is a rare clinical entity. This is the third reported case of such pathology. Immunodeficiency caused by sarcoidosis may induce immunity disorientation resulting in the presence of prostatic carcinoma. Sarcoidosis in relation with malignancy may give some answers for the etiopathology of cancer.

Solitary neurofibroma of the spermatic cord.

We report a case of solitary neurofibroma of the spermatic cord. Such benign tumors arise from perineural and Schwann cells and may be located in various parts of the body, but are rarely observed in the spermatic cord. No clinical or laboratorial manifestations of von Recklinghausen disease (Neurofibromatosis) were identified. Distinct criteria have been established for a diagnosis of von Recklinghausen disease, so that a solitary neurofibroma may not represent this complex. Only a little number of solitary neurofibromas of the spermatic cord are reported in the literature.

[Recto-seminal fistula and cancer of the rectum]. / Fistule recto-séminale et cancer du rectum.

The authors present a case of left epididymo-orchitis associated with rectal adenocarcinoma and suspected fistula between the left seminal vesicle and the rectum. This fistula was confirmed by pelvic computed tomography and surgical exploration. Treatment consisted of parenteral antibiotics and surgical drainage of the abscess associated with colorectal resection. This is an original case, as, retrospectively, the cancer of the rectum, diagnosed 4 days previously, was found to be responsible for the recto-seminal fistula and the seminal vesicle abscess.

Bladder neck preservation during classic laparoscopic radical prostatectomy - point of technique and preliminary results.

INTRODUCTION: Stress urinary incontinence after radical prostatectomy for prostate cancer organ-confined patients can significantly affect quality of life. The article presents a technique of bladder neck preservation, because it is believed that this point is one of many crucial points responsible for fast recovery of continence after laparoscopic radical prostatectomy (LRP). MATERIAL AND METHODS: Laparoscopic radical prostatectomy with the intention of bladder neck preservation was performed in 194 patients of clinically organ-confined prostate cancer (cT2 ≤ N0M0). The working space was done by tissues-fingers dissections and insufflation of the cavity under full visual control, without the Gaur-balloon device. We insert two 10 mm trocars, three trocars of 5 mm and both 0° and 30° laparoscopes. The most important points of technique include: identification of landmarks of bladder neck and prostate base; dissection of muscle fibres of the very superficial bladder wall; mobilization of the posterior part of the urethra and simultaneous seminal vesicles release; neuro-vascular bundles preservation. This procedure resulted in a long bladder neck which can be easily anastomosed with the urethra. Tension-free and end-to-end (bladder neck-urethra) anastomosis are the results. RESULTS: In all cases radical prostatectomy was performed laparoscopically in the extraperitoneal space. There were no complications of bladder neck preservation during laparoscopic radical prostatectomy (LRP) apart from 22 cases with a large medium lobe. The mean time of operation was 150 min (110-210 min). The mean blood loss during LRP was 150 ml (110-350 ml). Blood transfusion was not necessary. There were no postoperative complications. Mean hospitalization time was 5 days. Pathological result of the postoperative specimens was pT2a in 30%, pT2b in 60%, pT3a in 6%, and pT3b in 4% of patients. In 7% of patients a positive surgical margin was affirmed, but the bladder neck was not affected in any case. Full continence after 3, 6, and 12 months was observed in 75%, 85%, and 92% of analysed patients, respectively. CONCLUSIONS: Bladder neck preservation during LRP is an effective, safe procedure that offers good functional results based on fast recovery of continence. Bladder neck preservation offers full tight anastomosis, especially in cases with no large median lobe of prostatic adenoma. Continence of patients who underwent bladder neck preservation was improved during short-term follow-up. Long-term results are still not conclusive. We think that this technique applied to laparoscopy will finally result in real progress of continence preservation after radical prostatectomy, but larger groups of patients have to be compared.

Serum testosterone as a biomarker for second prostatic biopsy in men with negative first biopsy for prostatic cancer and PSA>4ng/mL, or with PIN biopsy result

Abstract Introduction: Data from animal, clinical and prevention studies support the role of androgens in prostate cancer growth, proliferation and progression. Results of serum based epidemiologic studies in humans, however, have been inconclusive. The present study aims to define whether serum testosterone can be used as a predictor of a positive second biopsy in males considered for re-biopsy. Material and Methods: The study included 320 men who underwent a prostatic biopsy in our department from October 2011 until June 2012. Total testosterone, free testosterone, bioavailable testosterone and prostate pathology were evaluated in all cases. Patients undergoing a second biopsy were identified and biopsy results were statistically analyzed. Results: Forty men (12.5%) were assessed with a second biopsy. The diagnosis of the second biopsy was High Grade Intraepithelial Neoplasia in 14 patients (35%) and Prostate Cancer in 12 patients (30%). The comparison of prostatic volume, total testosterone, sex hormone binding globulin, free testosterone, bioavailable testosterone and albumin showed that patients with cancer of the prostate had significantly greater levels of free testosterone (p=0.043) and bioavailable T (p=0.049). Conclusion: In our study, higher free testosterone and bioavailable testosterone levels were associated with a cancer diagnosis at re-biopsy. Our results indicate a possible role for free and bioavailable testosterone in predicting the presence of prostate cancer in patients considered for re-biopsy.

A comparison of one-stage procedures for post-traumatic urethral stricture repair.

OBJECTIVE: To compare the results and complication rates of various one-stage treatments for repairing a post-traumatic urethral stricture. PATIENTS AND METHODS: The medical records of 153 patients who had a post-traumatic urethral stricture repaired between 1977 and 2003 were evaluated retrospectively, and analysed for the different types of urethral reconstruction. RESULTS: The procedures included direct end-to-end anastomosis in 86 (56%) patients, free dorsal onlay graft urethroplasty using preputial or inguinal skin in 40 (26%), ventral onlay urethroplasty using buccal mucosa in seven (5%) and ventral fasciocutaneous flaps on a vascular pedicle in 20 (13%). At a mean (median, range) follow-up of 75.2 (38, 12-322) months, 121 (79%) patients had no evidence of recurrent stricture, while in 32 men (21%) they were detected at a mean follow-up of 30.47 (1-96) months. Patients having a dorsal onlay urethroplasty had the longest strictures. The re-stricture rate was lowest after a dorsal onlay urethroplasty (5% vs 27% when treated with end-to-end anastomosis, 15% after fasciocutaneous flaps and 57% after a ventral buccal mucosal graft). The surgical technique used had no effect on postoperative incontinence or erectile dysfunction rates. CONCLUSION: In patients with strictures which are too long to be excised and re-anastomosed, tension-free dorsal onlay urethroplasty is better than ventral graft or flap techniques. In patients with short urethral strictures direct end-to-end anastomosis remains an option for the one-stage repair of urethral stricture.

Laparoscopic retroperitoneal lymph node dissection: duplication of open technique.

Laparoscopic retroperitoneal lymph node dissection has been used to stage germ cell testicular cancer. Since its initial description, this minimally invasive procedure has evolved into a therapeutic operation that adheres to established strict oncologic principles. A modified template dissection that fully duplicates the open technique is now routinely performed at our institution. We describe and show in the accompanying video segments a laparoscopic modified template dissection.

Long-term morbidity and mortality of transurethral prostatectomy: a 10-year follow-up.

BACKGROUND: Long-term complication and reoperation rates in 1,211 patients undergoing TURP for symptomatic BPH between 1988 and 1991 were evaluated after a follow-up of at least 10 years. METHODS: Of the 1,211 patients who underwent TURP, 577 (47.6%) were available for follow-up. Long-term complications as well as reoperation rates were evaluated on the basis of a patient questionnaire or a physician interview. RESULTS: Repeat operation had to be performed in 35 patients (6%). TUR for bladder neck contracture had to be done in 14 patients (2.4%), while repeat TURP for BPH obstruction was required in 11 patients (1.9%). Finally, urethral strictures mandating surgical correction were present in 10 patients (1.7%). CONCLUSIONS: TURP is associated with low reoperation rates and therefore remains the gold standard in BPH therapy. Nevertheless, follow-up of these patients must be continued, as late complications requiring intervention may occur even after 10 years postoperatively.

Extracorporeal shock wave lithotripsy produces a lower stone-free rate in patients with stones and renal cysts.

BACKGROUND: Renal cysts have a space-occupying effect and therefore can distort the pelvicalyceal anatomy. This distortion often produces abnormalities in normal urinary drainage. In the same way, it may effect the ability of the kidneys to become stone free after extracorporeal shock wave lithotripsy (ESWL). The purpose of the current study is to evaluate the effect of renal cysts on the outcome of ESWL. METHODS: We studied 15 patients who had renal stones and coexistent renal cysts. Four patients had polycystic disease, five patients had multiple cysts and six patients has solitary ones. All cysts produced a distortion to the calyceal system of the kidneys, a fact confirmed by intravenous urography (IVU) and computed tomography (CT). All patients underwent ESWL and their stone-free status was evaluated 1 month later by ultrasound and plain kidney ureter bladder (KUB) X-ray. RESULTS: We had a total 60% (9/15) stone-free patients in our study group and a stone fragmentation rate of 100%. Patients with more cysts had lower stone-free rates. Patients with polycystic kidneys had a 25% (1/4) stone-free rate, while patients with multiple cysts and solitary cysts had, 60% (3/5) and 83.3% (5/6), respectively. These results are lower than the rates reported in patients without renal cysts. CONCLUSIONS: We believe that renal cysts may interfere with the passage of stone fragments, due to the impediment of drainage and urinary stasis from the stretching and distortion of the calyceal system by the renal cysts.