Effect of stone composition on surgical stone recurrence: single center longitudinal analysis.

INTRODUCTION The objective of this study is to explore the association between urinary stone composition and surgical recurrence. MATERIALS AND METHODS: Patients who underwent kidney stone surgeries (between 2009-2017), were followed for > 1 year, and had ≥ 1 stone composition analyses were included in our analysis. Surgical stone recurrence (repeat surgery) was defined as the second surgery on the same kidney unit. Recurrence-free survival analysis was used. RESULTS: A total number of 1051 patients were included (52.7% men, average age 59.1 +/- 15.1 years). Over 4.7 +/- 2.5 years follow up, 26.7% of patients required repeat surgery. Patients' stone compositions were calcium oxalate (66.0%), uric acid (12.2%), struvite (10.0%), brushite (5.7%), apatite (5.1%) and cystine (1.0%). Results suggested that patients with cystine stones had the highest surgical recurrence risk; brushite had the second-highest surgical recurrence risk. Struvite, uric acid, and apatite stones were at higher risk compared with calcium oxalate stones (lowest risk in our cohort). When pre and postoperative stone size was controlled, patients with a history of uric acid, brushite, and cystine stones were at higher surgical risk. After controlling clinical and demographic factors, only brushite and cystine stones were associated with higher surgical recurrence. CONCLUSIONS: Patients with cystine stones had the highest surgical recurrence risk; brushite stones had the second highest surgical recurrence risk. Struvite, uric acid, and apatite stones were at higher risk compared with calcium oxalate stones. When pre and postoperative stone size, clinical and demographic factors were controlled, only those with brushite or cystine stones were at significantly higher risk of surgical recurrence.

Development and validation a task-specific checklist for a microsurgical varicocelectomy simulation model.

PURPOSE: To develop and validate a new test of specific technical skills required for microsurgical varicocelectomy. MATERIALS AND METHODS: An electronic questionnaire was sent to 558 members of the Brazilian Society of Urology for the validation of the task-specific checklist (TSC) for assessment of microsurgical varicocelectomy. Participants who had experience in this procedure were selected as judges. For construct validation, 12 participants including attending urologists and urological residents in training were recruited for voluntary participation. We formed a group of three experts and a group of nine novices, who had to perform the steps of microsurgical varicocelectomy on a simulation model using human placenta. Each participant was filmed and two blinded raters would then evaluate their performance using the TSC of microsurgical varicocelectomy. RESULTS: 14 judges were recruited. The assessment tool was reformulated, according to the judges suggestions and had the content validity achieved. The final version of the TSC was comprised of the task-specific score, a series of 4 items scored in a binary fashion designed for microscopic sub-inguinal varicocelectomy. The differences between the performance of participants with different levels of experience reflected the construct validity. The reliability between the raters was high. The mean time required to complete the training of microsurgical varicocelectomy in simulation model was significantly shorter for experts compared to novices (201 vs. 496 seconds, p=0.01). CONCLUSIONS: This preliminary study suggests that the task-specific checklist of microsurgical varicocelectomy is reliable and valid in assessing microsurgical skills.

Role of Residual Fragments on the Risk of Repeat Surgery after Flexible Ureteroscopy and Laser Lithotripsy: Single Center Study.

PURPOSE: We analyzed the impact of residual stone fragments seen on abdominal x-ray after ureteroscopy and laser lithotripsy on the risk of repeat surgical intervention. MATERIALS AND METHODS: Our study included 781 patients (802 renal units) who underwent ureteroscopy and laser lithotripsy with abdominal x-ray within 3 months postoperatively and who had at least 1 year of followup. Ureteroscopy and laser lithotripsy were performed using the dusting technique. We analyzed the association between surgical recurrence-free survival and the size of the largest residual fragment. RESULTS: During a median followup of 4.2 years repeat surgery was performed on 161 renal units (20%). Of the repeat interventions 75% were done for symptomatic nephrolithiasis. Postoperative imaging showed residual stone fragments in 42% of cases. In the entire group the risk of repeat surgery was increased in renal units with residual fragments greater than 2 mm. The effect of the size of residual fragments on the risk of surgical recurrence varied by patient body mass index. It was much larger in nonobese subjects, who were at increased risk for repeat surgery with residual fragments of any size. In the obese subgroup only fragments greater than 2 mm increased the risk of surgical recurrence. CONCLUSIONS: The association between the size of residual stone fragments detected by abdominal x-ray after ureteroscopy and laser lithotripsy, and the risk of repeat surgical intervention depends on patient body mass index. Nonobese patients with residual stone fragments of any size are at increased risk for repeat intervention compared to those with a negative abdominal x-ray. The predictive value of abdominal x-ray after ureteroscopy and laser lithotripsy is limited in obese patients.

Clinical and demographic predictors of repeat stone surgery.

OBJECTIVE: To identify the clinical and demographic predictors of repeat stone surgery. MATERIALS AND METHODS: We retrospectively analysed 1496 consecutive patients, aged > 18 years, who underwent stone surgery at our institution in the period from January 2009 to May 2017 and who had at least 12 months of postoperative follow-up. We defined surgical recurrence as repeat surgery on the same renal unit or on the opposite renal unit if the original imaging did not demonstrate significant stones on that side. Characteristics associated with the risk of surgical recurrence in univariate Cox regression analysis were entered into a multivariate model. RESULTS: Most patients underwent ureteroscopy and laser lithotripsy (83.0%). Approximately 60% of the patients had a personal history of stone disease and 50% were obese. Over a mean (median; interquartile range) follow-up of 4.1  (3.9; 2.4-5.9) years, 24.5% of patients had surgical recurrence, with 82% of repeat surgeries performed for symptomatic nephrolithiasis. The factors associated with increased risk of surgical recurrence in the multivariate model were: age <60 years, female gender, malabsorptive gastrointestinal disease, diabetes, recurrent urinary tract infections, personal history of nephrolithiasis, renal stones and bilateral nephrolithiasis. The hazard ratios for these variables ranged within an interval of <0.5 (from 1.30 to 1.71). CONCLUSION: We identified eight demographic and clinical factors associated with increased risk of repeat renal stone surgery. These factors could be combined as a numerical count that allows stratification of patients into low-, intermediate- and high-risk subgroups.

Prediagnostic prostate-specific antigen kinetics and the risk of biopsy progression in active surveillance patients.

OBJECTIVE: To analyze the association between prediagnostic prostate-specific antigen kinetics and the risk of biopsy progression in prostate cancer patients on active surveillance, and to study the effect of prediagnostic prostate-specific antigen values on the predictive performance of prostate-specific antigen velocity and prostate-specific antigen doubling time. METHODS: The study included 137 active surveillance patients with two or more prediagnostic prostate-specific antigen levels measured over a period of at least 3 months. Two sets of analyses were carried out. First, the association between prostate-specific antigen kinetics calculated using only the prediagnostic prostate-specific antigen values and the risk of biopsy progression was studied. Second, using the same cohort of patients, the predictive value of prostate-specific antigen kinetics calculated using only post-diagnostic prostate-specific antigens and compared with that of prostate-specific antigen kinetics based on both pre- and post-diagnostic prostate-specific antigen levels was analyzed. RESULTS: Of 137 patients included in the analysis, 37 (27%) had biopsy progression over a median follow-up period of 3.2 years. Prediagnostic prostate-specific antigen velocity of more than 2 ng/mL/year and 3 ng/mL/year was statistically significantly associated with the risk of future biopsy progression. However, after adjustment for baseline prostate-specific antigen density, these associations were no longer significant. None of the tested prostate-specific antigen kinetics based on combined pre- and post-diagnostic prostate-specific antigen values were statistically significantly associated with the risk of biopsy progression. CONCLUSIONS: Historical prediagnostic prostate-specific antigens seems to be not clinically useful in patients diagnosed with low-risk prostate cancer on active surveillance.

Development and multi-institutional validation of an upgrading risk tool for Gleason 6 prostate cancer.

BACKGROUND: Many patients with low-risk prostate cancer (PC) who are diagnosed with Gleason score 6 at biopsy are ultimately found to harbor higher grade PC (Gleason ≥ 7) at radical prostatectomy. This finding increases risk of recurrence and cancer-specific mortality. Validated clinical tools that are available preoperatively are needed to improve the ability to recognize likelihood of upgrading in patients with low-risk PC. METHODS: More than 30 clinicopathologic parameters were assessed in consecutive patients with Gleason 6 PC upon biopsy who underwent radical prostatectomy. A nomogram for predicting upgrading (Gleason ≥ 7) on final pathology was generated using multivariable logistic regression in a development cohort of 431 patients. External validation was performed in 2 separate cohorts consisting of 1151 patients and 392 patients. Nomogram performance was assessed using receiver operating characteristic curves, calibration, and decision analysis. RESULTS: On multivariable analysis, variables predicting upgrading were prostate-specific antigen density using ultrasound (odds ratio [OR] = 229, P = .003), obesity (OR = 1.90, P = .05), number of positive cores (OR = 1.23, P = .01), and maximum core involvement (OR = 0.02, P = .01). On internal validation, the bootstrap-corrected predictive accuracy was 0.753. External validation revealed a predictive accuracy of 0.677 and 0.672. The nomogram demonstrated excellent calibration in all 3 cohorts and decision curves demonstrated high net benefit across a wide range of threshold probabilities. The nomogram demonstrated areas under the curve of 0.597 to 0.672 for predicting upgrading in subsets of men with very low-risk PC who meet active surveillance criteria (all P < .001), allowing further risk stratification of these individuals. CONCLUSIONS: A nomogram was developed and externally validated that uses preoperative clinical parameters and biopsy findings to predict the risk of pathological upgrading in Gleason 6 patients. This can be used to further inform patients with lower risk PC who are considering treatment or active surveillance.

Prognostic implications of partial sampling of radical prostatectomy specimens: comparison of 3 methods.

PURPOSE: We analyzed the prognostic implications of positive margins and extraprostatic extension missed by different methods of partially sampling prostatectomy specimens. MATERIALS AND METHODS: The study group consisted of 1,499 patients treated with radical prostatectomy. All specimens were processed uniformly and submitted entirely. For each patient with a positive margin or extraprostatic extension we determined whether these pathological characteristics would have been diagnosed had the specimen been examined by 3 partial sampling techniques. The Harrell concordance index was used to quantify the predictive performance of the Cox models based on the potential findings of the different sampling methods. RESULTS: Partial sampling methods 1 and 2, which included the examination of alternate slides, missed 13% to 21% of positive margins and 27% to 46% of extraprostatic extensions. The effect on biochemical recurrence-free survival of these undetected pathological features was similar to that of positive margins and extraprostatic extension that would have been diagnosed by corresponding techniques. Method 3, which sampled the entire posterior region, the mid anterior prostate and the rest of the ipsilateral anterior gland (if sizeable tumor was seen), detected 95% of positive margins and 94% of extraprostatic extensions. The extraprostatic extension missed by this method was not associated with a significant increase in the risk of biochemical recurrence. The Harrell concordance index of the multivariate models was 0.806, 0.797, 0.795 and 0.804 based on the results of complete sampling, and methods 1, 2 and 3, respectively. CONCLUSIONS: Examining alternate sections of prostatectomy specimen results in missing clinically important positive margins and extraprostatic extension. It decreases our ability to predict biochemical recurrence-free survival.

Improving risk stratification in patients with prostate cancer managed by active surveillance: a nomogram predicting the risk of biopsy progression.

OBJECTIVE: To develop a clinical tool that integrates different risk factors and provides individual predictions of the risk of biopsy progression in patients with prostate cancer managed by active surveillance. MATERIALS AND METHODS: Our analysis included 205 patients on active surveillance, each of whom had had at least two surveillance biopsies. We used the Cox proportional hazard regression model to analyse the association between different risk factors and progression-free survival over successive biopsies. This multivariate model was then used to develop a nomogram. Discrimination and calibration of the nomogram were internally validated using 200 bootstrap resamplings. RESULTS: The median follow-up of patients free of progression was 4.6 years. A total of 58 (28%) patients experienced progression. Factors significantly associated with progression were: overall number of positive cores in the diagnostic and first surveillance biopsies, race and prostate-specific antigen density. The bootstrapping concordance index of the nomogram including these variables was 81%. The nomogram tended to underestimate the probability of progression but it identified fairly accurately the distinct groups of patients at low, intermediate and high risk of progression. CONCLUSIONS: In the development cohort, the nomogram was able to separate patients with respect to their risk of biopsy progression. Since accurate risk stratification is essential to optimize patient care, this tool, if external validation confirms its performance, may prove useful for both the counselling and management of patients with low-volume, Gleason 6 prostate cancer.

Biopsy features associated with prostate cancer progression in active surveillance patients: comparison of three statistical models.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Active surveillance is an established management option for patients with favourable-risk prostate cancer. However, about 25-30% of active surveillance patients demonstrate biopsy progression within the first 3-5 years of follow-up. Although several factors, such as the results of the diagnostic and surveillance biopsies, are known to be associated with the risk of progression, our ability to accurately predict this risk remains limited. Our analysis demonstrated that the overall number of positive cores in the diagnostic and first surveillance biopsies is strongly associated with the risk of progression in active surveillance patients. Furthermore, combined results of diagnostic and first surveillance biopsies provide more information about the probability of progression than they do separately. The most important variable affecting the progression-free survival was the overall number of cores positive for cancer. By 3 years of active surveillance, most of the patients who had four positive cores in the diagnostic and surveillance biopsies progressed, while those who had only one positive core had an excellent prognosis. These findings could be used to improve the accuracy of assessments of the prognosis of patients with low-risk prostate cancer and to help them make informed decisions about their treatment. OBJECTIVE: To analyse the prognostic importance of information provided by the diagnostic biopsy, the first surveillance biopsy and a combination thereof to identify active surveillance patients with a particularly high risk of progression. MATERIALS AND METHODS: The present study included 161 active surveillance patients who had at least two surveillance biopsies. The first surveillance biopsy was performed within 1 year of the diagnosis. Further surveillance biopsies usually took place every 1-2 years. Progression on the surveillance biopsy was defined as the presence of Gleason 4/5 cancer, > two positive cores or >20% involvement of any core. Cox proportional hazards regression analysis was used to examine the relationship between biopsy characteristics and progression. Three distinct statistical models were built using characteristics of diagnostic biopsies, surveillance biopsies, and a combination thereof. Harrell's c-index was used to quantify the predictive accuracy of each multivariate Cox model. RESULTS: The median follow-up was 3.6 years; 46 (28.6%) patients progressed. In multivariate analysis the major factor associated with progression was the number of positive cores. The model based on the combined results of diagnostic and first surveillance biopsies was significantly more predictive than the models based on the individual results of each biopsy. Patients with four positive cores in the diagnostic and first surveillance biopsies had estimated 5-year progression rate of 100%. CONCLUSION: The total number of positive cores in the diagnostic and first surveillance biopsies provides important information about the risk of prostate cancer progression in active surveillance patients.

Comprehensive analysis of post-diagnostic prostate-specific antigen kinetics as predictor of a prostate cancer progression in active surveillance patients.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: A significant proportion of patients diagnosed with prostate cancer do not require immediate treatment and could be managed by active surveillance, which usually includes serial measurements of prostate-specific antigen (PSA) levels and regular biopsies. The rate of rise in PSA levels, which could be calculated as PSA velocity or PSA doubling time, was previously suggested to be associated with the biological aggressiveness of prostate cancer. Although these parameters are obvious candidates for predicting tumour progression in active surveillance patients, earlier studies that examined this topic provided conflicting results. Our analysis showed that PSA velocity and PSA doubling time calculated at different time-points, by different methods, over different intervals, and in different sub-groups of active surveillance patients provide little if any prognostic information. Although we found some significant associations between PSA velocity and the risk of progression as determined by biopsy, the actual clinical significance of this association was small. Furthermore, PSA velocity did not add to the predictive accuracy of total PSA. OBJECTIVE: To study whether prostate-specific antigen (PSA) velocity (PSAV) and PSA doubling time (PSADT) are associated with biopsy progression in patients managed by active surveillance. PATIENTS AND METHODS: Our inclusion criteria for active surveillance are biopsy Gleason sum <7, two or fewer positive biopsy cores, ≤20% tumour present in any core, and clinical stage T1-T2a. Changes in any of these parameters during the follow-up that went beyond these limits are considered to be progression. This study included 250 patients who had at least one surveillance biopsy, an available PSA measured no earlier than 3 months before diagnosis, and at least one PSA measurement before each surveillance biopsy. We evaluated the association between PSA kinetics and progression at successive surveillance biopsies in different sub-groups of patients by calculating the area under the curve (AUC) as well as sensitivity and specificity of different thresholds. RESULTS: Over a median follow-up of 3.0 years, the disease of 64 (26%) patients progressed. PSADT was not associated with biopsy progression, whereas PSAV was only weakly associated with progression in certain sub-groups. However, incorporation of PSAV in models including total PSA resulted in a moderate increase in AUC only when the entire cohort was analysed. In other sub-groups the predictive accuracy of total PSA was not significantly improved by adding PSAV. CONCLUSIONS: Our findings confirm that PSA kinetics should not be used in decision-making in patients with low-risk prostate cancer managed by active surveillance. Regular surveillance biopsies should remain as the principal method of monitoring cancer progression in these men.

Pathological findings at radical prostatectomy in patients initially managed by active surveillance: a comparative analysis.

BACKGROUND: The purpose of our analysis was to determine if delays in treatment caused by active surveillance result in significant pathological changes when patients no longer meet the criteria on repeat biopsy and to study whether or not these changes may affect treatment outcomes. METHODS: Out of 207 men who were on active surveillance, 47 (23%) no longer met the criteria after one of the repeat biopsies. Twenty-two underwent radical prostatectomy at our institution and formed the main group (Group 1) of this study. One hundred sixty-four patients met the criteria for active surveillance but underwent immediate surgery. Of these patients, we selected 38 (23%) with the lowest predicted biochemical recurrence-free survival. These patients formed the comparison group (Group 2). Pathological features as well as postoperative biochemical outcomes were compared between the groups. RESULTS: Seven patients (32%) in Group 1 and four (11%) in Group 2 have predominantly high-grade cancer (i.e., ≥4/5 + 3) at pathology. The visually estimated percent of carcinoma was also higher in patients initially managed by active surveillance (median 12.5 vs. 5.0 in Groups 1 and 2, respectively, P = 0.009). Other pathological characteristics were similar in both groups. With limited duration of follow-up, postoperative biochemical recurrence-free survival did not differ significantly between the groups. CONCLUSIONS: Our study has demonstrated that both tumor grade and volume may increase during active surveillance. However, the clinical significance of these changes with respect to the outcomes of delayed treatment remains to be established.

Tumor focality is not associated with biochemical outcome after radical prostatectomy.

BACKGROUND: The clinical and prognostic significance of unifocal prostatic carcinoma is not clearly understood. In the current study, we sought to characterize the clinical and pathologic characteristics of unifocal and multifocal prostate cancers and to investigate the effects of tumor focality on biochemical outcome after radical prostatectomy. METHODS: Our analysis included 1,444 radical prostatectomy patients with available information concerning the number and location of tumor foci in the specimen. Each patient was assigned to one of three groups depending on whether they had unifocal, multifocal, or extensive cancer. Clinical and pathological features as well as biochemical outcomes were compared between the groups. RESULTS: Two hundred and seventy-two mens in the study cohort (18.8%) had unifocal cancer. The rates of unifocal cancer did not differ significantly between the three studied time intervals (17.3% in 1992-1998, 20.5% in 1999-2004, and 17.8% in 2005-2011). The number of positive biopsy cores was slightly lower in the unifocal group, while the overall amount of biopsy tissue containing cancer was similar in both groups. The patients in the multifocal group had higher pathologic Gleason scores, increased incidence of positive surgical margin, and larger tumors. The rate of clinically significant Gleason score upgrade was significantly higher in the multifocal group compared to the unifocal group (35.7% vs. 21.7%, respectively, P < 0.001). The biochemical outcome after radical prostatectomy did not differ between patients with unifocal and multifocal cancers both on univariate and multivariate analyses. CONCLUSIONS: Tumor focality is not an independent prognostic factor of biochemical outcome in radical prostatectomy patients.

Clinically significant Gleason sum upgrade: external validation and head-to-head comparison of the existing nomograms.

BACKGROUND: Several nomograms have been developed for the purpose of predicting the likelihood of an increase in Gleason sum (GS) from biopsy information compared with the GS determined after examination of the "entire prostate" in patients with prostate cancer. In this study, the authors evaluated and compared the ability of 4 nomograms (published by Capitanio et al, Chun et al, Kulkarni et al, and Moussa et al) to predict GS upgrades for patients with biopsy GS ≤6 prostate cancer who underwent radical prostatectomy (RP) at their center. METHODS: The entire study cohort included 942 patients with a biopsy GS ≤6. Predictive performances of the nomograms were compared using area under the receiver operating characteristic curve (AUC-ROC) analysis, calibration plots, and decision curve analysis (DCA) in the entire cohort, in patients with low-risk prostate cancer (LRPC), and a subgroup of those patients who underwent extended biopsy with ≥10 cores. RESULTS: Patients with a GS ≥7 at prostatectomy included 319 of 942 patients (33.9%) in the entire study cohort, 263 of 814 patients (32.2%) with LRPC, and 84 of 301 patients (27.9%) with LRPC who underwent extended biopsy. With an AUC-ROC of 0.637 to 0.647 in the different subgroups of patients with low-risk cancer, the Kulkarni et al nomogram demonstrated significantly higher discriminative ability compared with the other nomograms. The same nomogram provided a small clinical benefit at DCA. All nomograms were poorly calibrated. CONCLUSIONS: The available prognostic tools had limited ability to predict clinically significant upgrading in patients with biopsy GS ≤6 and, thus, the authors concluded that these tools are not ready for clinical application.

Clinical and demographic characteristics associated with prostate cancer progression in patients on active surveillance.

PURPOSE: Active surveillance is an established management option for patients with low risk prostate cancer. However, little is known about the characteristics associated with the increased probability of progression in patients on active surveillance. We analyzed our active surveillance cohort in search of such features. MATERIALS AND METHODS: A total of 272 men with prostate cancer have enrolled in our active surveillance program since 1994, of whom 249 underwent at least 1 surveillance biopsy and were included in analysis. Our active surveillance inclusion criteria are biopsy Gleason grade less than 7, 2 or fewer positive biopsy cores, 20% or less tumor in any core and clinical stage T1-T2a. Changes in any of these parameters during followup that went beyond these limits were considered progression. Univariate and multivariate Cox regression analysis was done to determine patient characteristics associated with an increased risk of progression. RESULTS: A total of 64 patients (26%) showed progression at a median 2.9-year followup on a mean of 2.3 surveillance biopsies. The progression risk was significantly increased in black patients (adjusted HR 3.87-4.12), and in men with a smaller prostate and higher prostate specific antigen density. The latter 2 variables had no specific cutoff for an association with progression. CONCLUSIONS: Black men with low risk prostate cancer should be advised that the risk of progression on active surveillance may be higher than that in the available literature. Integral prognostic tools incorporating race and prostate specific antigen density may be useful to accurately assess the individual risk of progression in patients on active surveillance.

Surgical margin status does not affect overall survival following radical prostatectomy: a single institution experience with expectant management.

INTRODUCTION: The objective of this report is to describe the oncologic outcomes of men with margin-positive prostate cancer who were managed expectantly following radical prostatectomy. MATERIALS AND METHODS: Between January 1992 and January 2011, 2166 men underwent an open radical prostatectomy by a single surgeon. Of these patients, 1592 (74%) had complete data and met the inclusion criteria of negative lymph nodes and no history of neoadjuvant or adjuvant therapy. This cohort was dichotomized by the presence or absence of at least one positive surgical margin. Groups were compared for differences in recurrence-free and overall survival. RESULTS: In total, 507 (32%) of 1592 patients had at least one positive surgical margin. Clinical and pathological characteristics of these patients indicated more aggressive disease. The median follow up for biochemical recurrence and overall survival was 3.4 years and 7.7 years, respectively. Of those patients with a positive margin, 147 (29%) recurred, with estimated 5 and 10 year biochemical recurrence rates of 31% and 47%, respectively. Multivariate analysis demonstrated that the presence of a positive margin was associated with a 2.45-fold increased hazard of recurrence (p < 0.001). Despite initial observation, surgical margin status was not associated with a decrease in overall survival on both uni- (p = 0.684) and multivariate analyses (p = 0.177). CONCLUSION: Although a positive surgical margin is associated with an increased risk of biochemical recurrence, patients in our series were not at an increased risk of all-cause mortality.

Gender-related differences in the risk factors for repeat stone surgery.

Our objective was to analyze and compare the associations between potential risk factors for nephrolithiasis and repeat stone surgery in male and female patients. We retrospectively analyzed 1970 patients who had stone surgery at our institution in the period from January 2009 to May 2017, were older than 18 years and had at least 12 months of postoperative follow-up. Our definition of surgical recurrence included repeat surgery on the same renal unit or on the opposite renal unit if the original imaging did not demonstrate significant stones on that side. Uni- and multivariate Cox regression models were built for each gender. We also explored the interactions between gender and other patient's characteristics in their effect on the risk of recurrence. Ureteroscopy was the most common treatment modality for both first (83%) and repeat (87%) procedures. Over a mean follow-up of 4.3 years (median 3.8, interquartile range 2.2-6.0), 413 (21.0%) patients had a surgical recurrence. In multivariate analyses, hypertension, diabetes, Caucasian race and younger age (less than 60 years) were significantly associated with the risk of surgical recurrence only in females. Interaction between these characteristics and gender was significant indicating a larger effect on the risk of surgical recurrence in females compared to males. Our study demonstrated a number of differences in the predictors of repeat surgery for nephrolithiasis between males and females. If confirmed by future studies these differences may be helpful for optimizing nephrolithiasis prevention efforts.

Semen quality remains stable during the chronic phase of spinal cord injury: a longitudinal study.

PURPOSE: In a longitudinal study we examined changes in semen quality with time during the chronic phase of spinal cord injury. MATERIALS AND METHODS: Included in this study were 87 men with spinal cord injury who underwent 2 or more semen retrieval procedures with a minimum of 3 years between the first and last procedures. Patients were selected from our database of 500 with spinal cord injury who were volunteers enrolled in the Male Fertility Research Program of the Miami Project to Cure Paralysis from January 1, 1991 through April 31, 2009. Semen was collected by masturbation, penile vibratory stimulation or electroejaculation. Semen analysis was done according to WHO criteria. We used a statistical generalized linear mixed model to analyze changes in sperm concentration, total sperm count, total motile sperm count and sperm motility with time. RESULTS: Mean patient age was 30.1 years (range 16 to 48) and mean time after injury at the initial sperm retrieval procedure was 7.1 years (range 1 to 26). Sperm concentration decreased slightly with time but all other parameters were unchanged, including total sperm count, indicating a stable, null pattern in measures with time. CONCLUSIONS: Semen quality does not show clinically significant progressive changes during years after injury in men with spinal cord injury. This information is relevant for urologists who counsel these patients on family planning. Also, routine sperm freezing for fertility preservation is not indicated in this patient population.

Treatment for ejaculatory dysfunction in men with spinal cord injury: an 18-year single center experience.

PURPOSE: In what is to our knowledge the largest study of its kind to date we retrospectively reviewed the records of 3,152 semen retrieval procedures in a total of 500 men with spinal cord injury to make recommendations to the medical field on ejaculatory dysfunction treatment in this specialized patient population. MATERIALS AND METHODS: We retrospectively studied data from 1991 to 2009 in the Miami Project to Cure Paralysis male fertility research program at our institution. We assessed the semen retrieval success rate and semen quality. RESULTS: Of the 500 men 9% could ejaculate by masturbation. Penile vibratory stimulation was successful in 86% of patients with a T10 or rostral injury level. Electroejaculation was successful in most cases of failed penile vibratory stimulation. Sperm were obtained without surgical sperm retrieval, in 97% of patients completing the treatment algorithm. Total motile sperm counts exceeded 5 million in 63% of cases. CONCLUSIONS: Sperm can be easily obtained nonsurgically from most men with spinal cord injury. Sufficient sperm are available for simple insemination procedures. A treatment algorithm based on our experience is presented.

Influence of Lower Pole Infundibulopelvic Angle on Success of Retrograde Flexible Ureteroscopy and Laser Lithotripsy for the Treatment of Renal Stones.

Objectives: Influence of renal anatomy on success rates for shockwave lithotripsy has been reported in the literature with emphasis on lower pole anatomy. Influence of renal anatomy has not been evaluated in the setting of ureteroscopy and laser lithotripsy for stone treatment. This study analyzed the influence of infundibulopelvic angle (IPA) of the lower pole on the outcomes of ureteroscopy and laser lithotripsy with respect to stone-free rate and surgical recurrence. Materials and Methods: We retrospectively analyzed 735 renal units undergoing retrograde flexible ureteroscopy (fURS) with laser lithotripsy between January 2009 and December 2016. All cases were performed at a single institution. No exclusion criterion was applied with regard to preoperative stone location. Success was defined as no evidence of residual stone fragments on kidney, ureter, and bladder radiograph within 2 months of surgery. Failure was defined as any stone present on imaging. Lower pole IPA was measured on intraoperative retrograde pyelogram as described by Elbahanasy et al. Univariate and multivariate analyses of factors contributing to stone-free rate were performed. Secondary outcomes included surgical recurrence-free survival. Results: Of the 735 cases evaluated, 243 cases had a retrograde pyelogram stored in our Picture Archiving and Communication System (PACS) sufficient for IPA interpretation. Of these patients, 122 (50%) were women. In total, 127 patients (52.3%) were stone free on follow-up imaging, whereas 116 (47.7%) had residual stone burden. In total, 144 (59%) patients had ≤3 mm stone burden on follow-up imaging. In multivariate analysis, residual stone fragments were significantly associated with acute IPA <90° (<0.001), lower pole stones preoperatively (<0.001), and larger stone size (0.001). IPA <90° and larger stone size were both found to be statistically significantly associated with need for repeat surgery. Conclusions: Our data show that more acute IPA and larger preoperative stone size negatively affect stone-free rate and need for repeat surgery after retrograde fURS with laser lithotripsy for treatment of renal stones.

A Comprehensive Analysis of the Association Between Gleason Score at a Positive Surgical Margin and the Risk of Biochemical Recurrence After Radical Prostatectomy.

Our objective was to identify the best of the existing definitions of Gleason score (GS) at a positive surgical margin (PSM) by validating them in our radical prostatectomy cohort. We analyzed 251 patients who had mixed (3+4, 3+5, 4+3 or 5+3) pathologic GS and PSM. We used 5 definitions to record GS at a PSM. Univariate and multivariate analyses were used to study the association between each definition and the risk of biochemical recurrence (BCR). We also tested the prognostic value of multivariate models including established predictors and each of the studied definitions of GS at a PSM. GS 3+3 was seen at a PSM in 57.4% of the cases and was more common in patients with lower overall GS. Over a median follow-up of 4.0 years 89 patients (35.5%) developed BCR. All of the definitions of GS at a PSM were independent predictors of the BCR-free survival. Most of them also improved the prognostic value of the multivariate models when added to the established parameters. The degree of improvement was similar for the most complex definition (full GS at a PSM) and the easiest to record binary definition (presence of Gleason 4/5 pattern at a PSM). We conclude that compared with the other possible options of reporting GS at a PSM, the presence of Gleason 4/5 pattern may be the most practical definition. It is at least as predictive as other definitions, may be the easiest to record and is the best studied of the existing alternatives.