The relationship between the force applied and perceived by the surgeon during ureteral access sheath placement: ex-vivo experimental model.

PURPOSE: To define a peak force of insertion (PFOI) threshold for ureteral damage during ureteral access sheath (UAS) placement on an experimental ureteral orifice model. METHODS: A specially designed water tank using 2 laparoscopic 5 mm ports and 2 different size (10 Fr and 8 Fr) sealing cap adaptors (SCA) as ureteral orifices was used to perform the test. A 10-12 Fr UAS was fixed to a load cell and the force of insertion (FOI) was continuously recorded with a digital force gauge.13 experts in the field of endourology who participated performed 3 UAS insertions. The FOI was recorded initially with 10 Fr followed by 8 Fr SCA. On the final insertion, the orifice was obstructed, leaving a 5 cm length to insert the UAS. The experts were asked to "Stop at the point they anticipate ureteral damage, and they would not proceed in real life". RESULTS: Using 10 Fr SCA the PFOI was 2.12 ± 0.58 Newton (N) (range:1.48-3.48) while 8 Fr SCA showed a PFOI 5.76 ± 0.96 N (range:4.05-7.35). Six of the experts, said they would stop proceeding when they reached above 5.1 N. Three experts had PFOI < 5.1 N and the other 4 stated they would go with PFOIs of 5.88, 6.16, 6.69 and 7.35 N when using SCA of 8 Fr.The highest load they would stop proceeding had a PFOI of 6.09 ± 1.87 N (range: 2.53-10.74). CONCLUSION: The PFOI threshold for ureteral damage inserting UAS of the experts is variable. Although FOI is a subjective perception, experience suggests that ureteral injury may occur at an average of 6.05 N perceived by surgeons' tactile feedback. In-vivo measurement of UAS PFOI may confirm a threshold.

Multidrug refractory aggressive metastatic TFE3 (+) renal cell carcinoma: A case report.

BACKGROUND: Transcription factor E3 (TFE3) related renal cell carcinomas constitute a very small percent of all renal tumors in adults. Prognosis mainly depends on the stage of the disease at the time of diagnosis which is often poor. There is yet to be a standardized treatment protocol. Treatment options include agents identical to TFE3(-) cell renal carcinoma treatment. We present a case of a young woman with a rapidly progressing metastatic TFE3 (+) renal cell carcinoma. CASE REPORT: A 31 year old female presented with abdominal mass, distension, nausea. Initial tests and tumor markers found to be normal. Abdominal CT scan revealed a left retroperitoneal mass along with three other neighboring masses in liver manifesting as metastases. Trucut biopsy and immunohistochemical staining confirmed the retroperitoneal mass as TFE3 (+) renal cell carcinoma.Management and outcome: Sunitinib, pazopanib, nivolumab, axitinib treatments are consecutively given after surgery. It is noteworthy that rapid progression was observed under nivolumab treatment. DISCUSSION: During surveillance, rapid progression is noted under consecutive immunotherapy which was unexpected. Thus, there is a need for more standardized treatment protocols and invention of new agents for management of TFE3 (+) renal cell carcinoma.

Can serum matrix metalloproteinase-9 and SMAD-2 levels predict lamina propria invasion in bladder urothelial carcinoma?

INTRODUCTION: Matrix metalloproteinase-9 (MMP-9) has a role in the destruction of lamina propria (LP) of the bladder wall and SMAD-2 promotes cell-to-cell adhesion. This study aimed to investigate the association between LP invasion and serum protein and mRNA expression levels of MMP-9 and SMAD-2 in bladder cancer (BC) patients. METHODS: Serum samples were taken from 57 patients with suspicious BC before TUR-BT (Group 1) and 20 patients with benign diseases as control (Group 2). The mRNA expression and serum protein levels of MMP-9 and SMAD-2 were analyzed using Real-Time PCR and ELISA methods, respectively. The comparison of protein and mRNA expression levels of MMP-9 and SMAD-2 were done statistically between Group 1 and 2, as well as for different T stages of BC. RESULTS: The protein levels of MMP-9 (2448 vs 637.5 pg/mL, P = .0001) and SMAD-2 (6.85 vs 1.61 P = .0001) were significantly higher in Group 1 compared to Group 2. The mRNA expression levels of MMP-9 (P = .89) and SMAD-2 (P = .99) did not significantly differ between the groups. The protein levels of MMP-9 in T1 patients were significantly higher from both of pTa patients (P = .018) and pT2 (P = .02). The protein levels of SMAD-2 were not statistically different between T stages. Similarly, the mRNA expression levels of MMP-9 and SMAD-2 were not different between T stages. CONCLUSIONS: The protein levels of MMP-9 and SMAD-2 were increased in BC patients while mRNA expressions were not different. Furthermore, the increased protein level of MMP-9 in T1 patients was more pronounced which may be related to LP invasion of the tumor.

Diagnostic accuracy of core biopsies of renal masses: Experience in a real-life setting from a tertiary center.

OBJECTIVE: To document and analyze diagnostic accuracy of renal core biopsy (RCB), its diagnostic correlation with resection specimens, and to question the need for immunohistochemistry (IHC) in the preoperative diagnosis of renal masses. MATERIAL AND METHOD: RCBs performed at a reference center between 2007 and 2017 were included. Pathological, clinical, and radiological data were obtained from medical records. RESULTS: Among 302 biopsies included in this study, 274 (90.7%) were diagnostic. Two hundred sixty-six were neoplastic and 179 were of primary renal origin. The most common secondary neoplasms were hematolymphoid (n = 35) and metastatic (n = 17). Sixty-nine tumors were classified as small renal masses (SRMs) (≤4 cm in diameter) and 53 of them were malignant. Nephrectomy was performed in 58 patients. Overall diagnostic accuracy between resections and RCBs was 88.7%. IHC was performed in 160 (53%) cases. In 15 of those, a definite diagnosis could not be rendered. Renal cell origin and subtype were determined by histomorphology alone in 81 and 75 cases, respectively. Sixty primary neoplasms of renal cell origin required IHC for diagnosis. CONCLUSION: RCB is a safe and highly accurate method for the diagnosis of both primary and secondary renal neoplasms. IHC is mostly required for the diagnosis of secondary tumors. Histomorphology is still the primary diagnostic tool, highly dependent on the experience of the surgical pathologist.

The clinical impact of the COVID-19 pandemic on daily urological practice: first 3-month multicenter results from Istanbul

Background/aim: The aim of this paper was to determine the general tendencies of urology patients and effect of COVID-19 pandemic on daily urological practice at tertiary centers located in the most affected area in Turkey. Materials and methods: We retrospectively analyzed the data of 39,677 patients (group 1) that applied to 6 different large-volume tertiary centers in Istanbul for outpatient consultation, surgery, or other procedures in the 3-month period between March 16 and June 14, 2020. The distribution of the number of patients who applied to subspecialty sections of urology outpatient clinics and inpatient services were recorded by weeks. That data was compared to data obtained from 145,247 patients that applied to the same centers in the same period of the previous year (group 2). The reflection of worldwide and Turkish COVID-19 case distribution on the daily urological practice was analyzed. Results: There was a decrease in the number of patients in all subspecialty sections the in group 1 compared to group 2; however, there was a significant proportional increase in urooncology and general urology admissions. A decrease of approximately 75% was observed in the total number of surgeries (p < 0.001). We detected a negative correlation between the numbers of admission to all outpatient clinics and COVID-19 cases or deaths in Turkey (p < 0.05). The same negative correlation was present for all surgical procedures and consultations (p < 0.05). The multivariate linear regression analysis revealed that the number of cases in Turkey, and the number of deaths worldwide affect the number of outpatient clinic admissions (R2 = 0.38, p = 0.028) and urological surgery (R2 = 0.33, p = 0.020) in Turkey negatively. Conclusion: This novel pandemic has implications even for urology practice. Urological surgical procedures were more affected by COVID-19-related deaths in Turkey and worldwide. Outpatient admissions and urological surgeries decreased significantly by increasing COVID-19 case numbers in Turkey and worldwide deaths.

The clinical predictive factors and postoperative histopathological parameters associated with upgrading after radical prostatectomy: A contemporary analysis with grade groups.

BACKGROUND AND AIM: Upgrading after radical prostatectomy (RP) is an ongoing problem since first description of Gleason score. In this retrospective study, our aim is to investigate upgrading after RP in grade groups (GG) and clinical predictive, and postoperative histopathological factors associated with GG upgrading (GGU). PATIENTS AND METHODS: A total of 753 patients undergoing RP between January 2006 and June 2019 at our institution were investigated. Overall cohort were divided into two groups according to GGU status after RP as nonupgrading and upgrading. Retrospectively documented preoperative clinical and postoperative histopathological parameters were compared between two groups. Furthermore, we investigated a subgroup of institutional cohort (n = 398) whose prostate biopsy (Pbx) and RP were performed in our institution and we also divided this cohort into two groups according to GGU status. χ2 and Mann-Whitney U tests were used for comparative analyses. The independent preoperative predictive and postoperative histopathological factors associated with GGU were investigated using multivariate logistic regression analysis. RESULTS: The total GGU was 55.8% in overall cohort and 45.2% in institutional cohort. The GGU was found as the most common in bioptic GG1 group in both overall (64.0%), and institutional (54.5%) cohorts. In multivariate analyses, the noninstitutional Pbx (odds ratio [OR] = 2.56; 95% confidence interval [CI]: 1.86-3.51; P < .001), tumor positive core numbers in Pbx (OR = 1.11; 95%CI: 1.04-1.19; P = .003), increased prostate specific antigen (PSA) density (OR = 3.59; 95%CI: 1.03-12.52, P = .045) and age (OR = 1.03; 95%CI: 1.00-1.05, P = .046) were independent clinical predictors of GGU in overall cohort whereas only increased PSA density (OR = 5.94; 95%CI: 1.28-27.50; P = .023) was independent predictor in institutional cohort. Among postoperative histopathological factors, perineural invasion (OR = 1.57; 95%CI: 1.70-3.87; P < .001 and OR = 2.53; 95%CI: 1.46-4.40; P = .001, respectively), increased maximum tumor diameter (OR = 1.46; 95%CI: 1.23-1.73; P < .001 and OR = 1.33; 95%CI: 1.07-1.66; P = .010, respectively), and high-grade prostatic intraepithelial neoplasia (HGPIN) existence at tumor surrounding tissue (OR = 1.96; 95%CI: 1.32-2.90; P = .001 and OR = 1.87; 95%CI: 1.10-3.21; P = .022, respectively) were independently associated with GGU after RP, in both of overall and institutional cohorts. CONCLUSIONS: Noninstitutional prostate biopsy, increased PSA density, higher tumor positive cores in Pbx and older age are the clinical predictors of upgrading after RP in contemporary GG. Perineural invasion, increased maximum tumor diameter, and HGPIN existence at tumor surrounding tissue are postoperative histopathological factors associated with GGU.

The pathological upgrading after radical prostatectomy in low-risk prostate cancer patients who are eligible for active surveillance: How safe is it to depend on bioptic pathology?

BACKGROUND: Active surveillance (AS) is one of the treatment alternatives in low-risk prostate cancer (PCa). The pathological upgrading after radical prostatectomy (RP) were investigated in patients who were eligible for AS in the present study. METHODS: Between August 2006 and July 2017, 627 patients underwent RP in our institution. One hundred and thirty-six patients who were eligible for AS at the time of RP were included in this study. The previously defined AS criteria Gleason 3 + 3=6 adenocarcinoma at maximum two biopsy cores, prostate-specific antigen (PSA) < 10 ng/mL and clinical T stage ≤ 2a were used in the study. The demographics, clinical, and histopathological outcomes were retrospectively compared between two groups, which were divided in accordance with the upgrading status at final pathology as Group 1 (n = 67, upgrading) and Group 2 (n = 69, nonupgrading). RESULTS: Gleason upgrading (GU) was found in 67 (49.3%) patients, and 17 patients (12.5%) were upstaged to pT3a. The upgrading to Gleason 3 + 4 was reported in 38.7% of patients, however, 7.4%, and 3.7% of the patients were upgraded to Gleason 4 + 3, and Gleason 4 + 4, respectively. The 10.3% of the patients had extraprostatic involvement, and the rate (19.4% vs 1.4%, P = .002) was significantly higher in Group 1. PSA density (P = .001), tumor size (P < .001), tumor percentage (P < .001), apical involvement (P = .013), and perineural invasion (P < .001) in RP specimen were higher in Group 1. Multivariate analysis showed that perineural invasion (OR = 4.26; 95%CI: 1.76-10.33; P = .001) and pathologic T stage (OR = 5.45; 95%CI: 1.08-27.4; P = .04) were independently associated with GU. CONCLUSIONS: Since 12.5% of the patients upstaged to pT3a disease, and there is a possible risk of Gleason 4 pattern, upgrading of the tumor should carefully be kept in mind before offering AS to low-risk patients with PCa.

Prospective evaluation of complications in laparoscopic urology at a mid-volume institution using standardized criteria: Experience of 1023 cases including learning curve in 9 years.

AIM: To evaluate the laparoscopic operations performed in our department according to the modified Clavien classification system of complications. MATERIALS AND METHODS: Between September, 2005 and February, 2014, a total of 1023 laparoscopic cases were performed. This period was divided into three terms (Terms 1, 2 and 3 consisting of 38, 32 and 32 months, respectively). According to the European Scoring System (ESS), easy (E), slightly difficult (SD), fairly difficult (FD), difficult (D), very difficult (VD) and extremely difficult (ED) cases were 35, 88, 170, 390, 203 and 137, respectively. The perioperative complications were evaluated based on the 3 time periods, with a specific emphasis on determining the learning curve according to the modified Clavien classification system of complications. RESULTS: A total of 236 (23.1%) complications were observed according to the modified Clavien classification. The minor (Clavien I-II) and major (Clavien III, IV and V) complication rates were 20.5% (n = 210) and 2.4% (n = 26), respectively. Clavien I was the most frequently encountered type of complication (n = 120, %11.7). No significant difference was observed among all 3 time periods regarding total complication rates. The D cases had the highest complication rate compared to E, SD, FD, VD and ED cases among all three terms. The total number of complications increased significantly with increasing grade of technical difficulty according to the ESS. CONCLUSION: Complications encountered in our laparoscopic surgery experience were predominantly minor, and the rate of complications was not significantly increased during the learning curve. The present data can provide guidance and manage expectations for surgeons introducing laparoscopy into their practice.

Robotic Flexible Ureteroscopy: A Step-by-Step Video by Using Roboflex Avicenna Platform.

BACKGROUND: The management of kidney stones, particularly those in the renal pelvis, is a critical aspect of urology. The European Association of Urology guidelines recommend Extracorporeal Shock Wave Lithotripsy or Endourology methods, encompassing Percutaneous Nephrolithotomy and Ureterorenoscopy (URS), for stones ranging from 10-20 mm. Robotic-assisted urological procedures have gained prominence in recent years, promising enhanced precision and safety. OBJECTIVE: To provide a detailed account of the technical aspects and outcomes of a robotic URS (robo-URS) procedure in a 63-year-old male patient with a 15-mm renal pelvis stone, serving as a reference for urologists considering this approach. MATERIALS: The patient presented with right flank pain, and an unenhanced computed tomography scan confirmed the presence of a 15 × 12 × 13 mm stone in the right renal pelvis. After assessment and preparation, robo-URS was performed using the Roboflex Avicenna robotic platform (ELMED, Ankara, Turkey) in conjunction with conventional urological instruments and laser technology. RESULTS: The procedure was completed successfully in 50 minutes without any detectable blood loss or intraoperative complications. CONCLUSION: Robo-URS is a promising approach for managing renal pelvis stones. The procedure, demonstrated in this video article, underscores its technical feasibility, safety, and efficacy, making it a valuable resource for urologists seeking to expand their knowledge in stone management techniques.

Peak Force of Insertion During Ureteral Access Sheath Placement In An Ex-Vivo Experimental Model With Different Commercially Available Access Sheaths.

OBJECTIVES: To measure the force necessary to win the resistance during insertion of ureteral access sheaths (UAS) in an experimental homemade model and to compare the peak force of insertion (PFOI) of different commercially available UASs. METHODS: Three investigators (2 novice and 1 expert) inserted the UASs into 2 different adapters with diameters of 10 Fr and 8 Fr. The force of insertion was continuously measured with a digital force gauge connected to the UAS during each insertion. Four different brands of UAS with different diameters, totally 11 different UASs were used for the experiment. The PFOI of each UAS was compared among each other and adapter diameters. RESULTS: The mean PFOI in adapters 1 and 2 were 1.85 N and 5.32 N, respectively. All of the mean PFOIs were significantly lower in adapter 1 compared to adapter 2, regardless of the novice vs expert surgeons and the UASs. (p<0.001) In adapter 1, the mean PFOI was lowest with the UAS-1 and highest with the UAS-8. In adapter 2, the mean PFOI was lowest with the UAS-3 and highest with the UAS-9. For adapters 1 and 2, no statistical difference was found when comparing an expert and the two novice surgeons. CONCLUSION: The PFOI during UAS placement is not solely correlated with UAS thickness and adapter diameters. Other factors such as hydrophilic coating, UAS flexibility, inner dilator properties, UAS smoothness and the actual measured external diameter of UASs should be taken into consideration. The clinical relevance and ureteral injury risk of the UAS PFOI needs to be studied.

The prognostic role of histomorphological subtyping in nonmetastatic papillary renal cell carcinoma after curative surgery: is subtype really irrelevant? A propensity score matching analysis of a multi-institutional real life data.

BACKGROUND AND AIM: The role of histomorphological subtyping is an issue of debate in papillary renal cell carcinoma (papRCC). This multi-institutional study investigated the prognostic role of histomorphological subtyping in patients undergoing curative surgery for nonmetastatic papRCC. PATIENTS AND METHODS: A total of 1,086 patients undergoing curative surgery were included from a retrospectively collected multi-institutional nonmetastatic papRCC database. The patients were divided into 2 groups based on histomorphological subtyping (type 1, n = 669 and type 2, n = 417). Furthermore, a propensity score-matching (PSM) cohort in 1:1 ratio (n = 317 for each subtype) was created to reduce the effect of potential confounding variables. The primary outcome of the study, the predictive role of histomorphological subtyping on the prognosis (recurrence free survival [RFS], cancer specific survival [CSS] and overall survival [OS]) in nonmetastatic papRCC after curative surgery, was investigated in both overall and PSM cohorts. RESULTS: In overall cohort, type 2 group were older (66 vs. 63 years, P = 0.015) and more frequently underwent radical nephrectomy (37.4% vs. 25.6%, P < 0.001) and lymphadenectomy (22.3% vs. 15.1%, P = 0.003). Tumor size (4.5 vs. 3.8 cm, P < 0.001) was greater, and nuclear grade (P < 0.001), pT stage (P < 0.001), pN stage (P < 0.001), VENUSS score (P < 0.001) and VENUSS high risk (P < 0.001) were significantly higher in type 2 group. 5-year RFS (89.6% vs. 74.2%, P < 0.001), CSS (93.9% vs. 84.2%, P < 0.001) and OS (88.5% vs. 78.5%, P < 0.001) were significantly lower in type 2 group. On multivariable analyses, type 2 was a significant predictor for RFS (HR:1.86 [95%CI:1.33-2.61], P < 0.001) and CSS (HR:1.91 [95%CI:1.20-3.04], P = 0.006), but not for OS (HR:1.27 [95%CI:0.92-1.76], P = 0.150). In PSM cohort balanced with age, gender, symptoms at diagnosis, pT and pN stages, tumor grade, surgical margin status, sarcomatoid features, rhabdoid features, and presence of necrosis, type 2 increased recurrence risk (HR:1.75 [95%CI: 1.16-2.65]; P = 0.008), but not cancer specific mortality (HR: 1.57 [95%CI: 0.91-2.68]; P = 0.102) and overall mortality (HR: 1.01 [95%CI: 0.68-1.48]; P = 0.981) CONCLUSIONS: This multiinstitutional study suggested that type 2 was associated with adverse histopathologic outcomes, and predictor of RFS and CSS after surgical treatment of nonmetastatic papRCC, in overall cohort. In propensity score-matching cohort, type 2 remained the predictor of RFS. Eventhough 5th WHO classification for renal tumors eliminated histomorphological subtyping, these findings suggest that subtyping is relevant from the point of prognostic view.

Use of a combined retroperitoneoscopic and transperitoneal laparoscopic technique for the management of renal cell carcinoma with level I tumor thrombi.

BACKGROUND: To report our initial experiences using a combined retroperitoneoscopic and transperitoneal laparoscopic technique for the management of renal cell carcinoma with level I tumor thrombi. MATERIALS AND METHODS: Two patients underwent this technique for tumors 11- and 13-cm in diameter. After transection of the renal artery with limited mobilization of the kidney using a retroperitoneoscopic approach, additional ports were placed, and the management of the tumor thrombus was performed in the large working space provided by the transperitoneoscopic approach. RESULTS: The technique was feasible in the present 2 cases. The total operative times were 170 and 200 min, respectively. The estimated blood loss was 450 cc in the first case and 200 cc in the second case. No complications were observed in either of the patients. CONCLUSIONS: Based on the initial clinical experience, we have presented a feasible surgical option for the laparoscopic management of renal cell carcinoma with level I thrombi.

Increased risk of advanced prostate cancer associated with MnSOD Ala-9-Val gene polymorphism.

We aimed to investigate the association between manganese superoxide dismutase (MnSOD) Ala-9-Val gene polymorphism and the initiation and/or progression of prostate cancer (PCa) as well as to evaluate its potential interactions with advanced age and smoking status. MnSOD Ala-9-Val gene polymorphism was carried out in 134 (mean age 64.1±7.48) PCa patients and 159 (mean age 62.5±7.53) healthy controls with serum prostate specific antigen (PSA) levels (<4 ng/ml) and normal digital rectal examination (DRE) findings in this prospectively designed study. PCa patients were classified as low stage disease (T1 or T2 and N0M0 stages) and high stage disease (T3 or T4 and N0M0 or N1 or M1 stages). Genotypes for MnSOD Ala-9-Val gene polymorphism were identified by using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFPL). Despite lack of association between different genotypes of MnSOD Ala-9-Val gene polymorphism and the presence of PCa, patients with Ala/Ala genotype were at an increased risk of high stage disease compared with those with the Val/Val genotype [odds ratio (OR), 3.77; 95% CI, 1.30-10.94; P=0.012]. However, no significant difference was observed in the distribution of each genotype among PCa patients, with respect to tumor grade. On the other hand, smoking status and aging did not seem to change the association between genotypes and PCa risk. Ala/Ala genotype of MnSOD polymorphism may have an effect on adverse features of PCa such as high stage disease.

Laparoscopic excision of local recurrence of renal cell carcinoma.

BACKGROUND AND OBJECTIVE: To report a single center's experience with laparoscopic excision of local recurrence of renal cell carcinoma. METHODS: Between January and August 2011, 5 patients who underwent laparoscopic excision of local recurrence were identified from the institutional laparoscopic surgery database. RESULTS: Four radical nephrectomies and 1 partial nephrectomy were performed for primary tumors. The mean ages of the patients were 57.4 y (range, 48 to 68) and 62.8 y (range, 53 to 71) at the time of primary surgery and laparoscopic recurrence excision, respectively. The average size of the primary tumor was 7.2cm (range, 4.5 to 11). The mean size of local recurrence was 3.46cm (range, 2.8 to 4.5). The original tumor T stages were T1b, T2b, and T4 in 3, 1, and 1 cases, respectively. The mean time to diagnosis of recurrence was 51.2 mo (range, 15 to 136). The pathology of one patient who had previously received targeted therapy with sunitinib, was necrosis, unlike the other 4 pathologies which revealed renal cell carcinoma. The mean operative time, estimated blood loss, and length of hospital stay were 86 min (range, 70 to 100), 100 mL (range, 20 to 300), and 4 d (range, 2 to 8), respectively. One pleural injury did not need open conversion and was repaired laparoscopically. At a mean follow-up of 8.4 mo, the cancer-specific and disease-free survival rates were 100% and 60%, respectively. CONCLUSION: Laparoscopic excision of local recurrence of RCC is a feasible technique in well-selected patients with low-volume mass not involving the adjacent organs.

How accurate is 68Gallium-prostate specific membrane antigen positron emission tomography / computed tomography (68Ga-PSMA PET/CT) on primary lymph node staging before radical prostatectomy in intermediate and high risk prostate cancer? A study of patient- and lymph node- based analyses.

BACKGROUND AND AIM: Gallium-68 (68Ga)-Prostate Membrane Specific Antigen Positron Emission Tomography/Computed Tomography (68Ga-PSMA PET/CT) is an emerging diagnostic modality which is gaining importance in individualized prostate cancer (PCa) management era. This study aimed to investigate the diagnostic accuracy of 68Ga-PSMA PET/CT on primary LN staging before radical prostatectomy (RP) in intermediate and high risk PCa. MATERIALS AND METHODS: The retrospectively documented 49 patients with intermediate and high risk non-metastatic PCa who had 68Ga-PSMA PET/CT before RP were enrolled into this study. The histopathology of dissected LNs was used as reference standard to evaluate the accuracy of 68Ga-PSMA PET/CT on primary LN staging, both in per-patient (n = 49) and in per-node (n = 454) analyses. The diagnostic accuracy was investigated using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and by area under the curve (AUC) provided using receiver operating curve (ROC) analysis. RESULTS: Median age was 64 (48-79) years and, median and mean PSA values were 10 (1.31-138) ng/ml and 16.2 (±19.8) ng/ml, respectively. 22 (44.9%) and 27 (55.1%) of patients had intermediate and high risk PCa, respectively. A total of 5 (10.2%) patients had histopathologically proven LN metastasis and 3 (60%) of them was detected in 68Ga-PSMA PET/CT. In per patient analysis, the sensitivity, specifity, PPV and NPV of 68Ga-PSMA PET/CT on primary LN staging were 0.60, 0.96, 0.60 and 0.96, respectively. Among overall 454 LNs, 16 (3.5 %) of them were reported as metastatic in histopathology and, 13 (2.9%) of these metastatic LNs were detected in 68Ga-PSMA PET/CT. In per-node analysis, the sensitivity, specificity, PPV and NPV of 68Ga-PSMA PET/CT on primary LN staging were 0.82, 0.99, 0.87 and 0.99, respectively. The ROC analyses found AUCs for primary LN staging as 0.777 (95%CI:0.508-1.0) in per patient analysis and, as 0.904 (95%CI:0.790 - 1.0) in per node analysis, respectively. CONCLUSION: The use of 68Ga-PSMA PET/CT has promising diagnostic accuracy on primary LN staging before RP in intermediate and high risk PCa. However, the efforts should be taken to increase sensitivity of 68Ga-PSMA PET/CT in individualized treatment era.

External validation of the VENUSS prognostic model to predict recurrence after surgery in non-metastatic papillary renal cell carcinoma: A multi-institutional analysis.

OBJECTIVE: Recently, VENUSS (VEnous extension, NUclear Grade, Size, Stage), as a prognostic model, was defined to predict disease recurrence (DR) after curative surgery of non-metastatic papillary renal cell carcinoma (papRCC). This study aimed to validate the VENUSS prognostic model in a large multi-institutional European cohort of patients with histopathologically proven papRCC after curative surgery for non-metastatic disease. PATIENTS AND METHODS: Overall, 980 patients undergoing partial or radical nephrectomy for sporadic, unilateral and non-metastatic papRCC between 1987 and 2020 were included from 7 European tertiary institutions. The primary outcome was the prediction of DR by VENUSS score and VENUSS risk groups. Chi-square, Kruskal-Wallis, Cox-regression and Kaplan-Meier survival analyses were used in statistical methods. The Concordance (C) Index was calculated to assess model's discriminatory power. RESULTS: The median age was 64 (IQR:55-70) years and 82.6 % (n = 809) of patients were male. Median VENUSS score was 2 (IQR: 0-4), and 62.9 % (n = 617), 23.9 % (n = 234) and 13.2 % (n = 129) of patients was classified into low, intermediate and high risk according to the VENUSS model, respectively. At a median follow-up of 48 (IQR:23-88) months, the disease recurred in 6.6%, 18.8% and 63.8%, and the 5-year recurrence-free survival was 93.8%, 80.7% and 26.7% in low, intermediate and high-risk groups, respectively. (P < 0.001) Each increase in VENUSS score had 1.52-fold (95%CI:1.45-1.60, P < 0.001) DR risk. Compared with the VENUSS low risk, the intermediate risk had a 2.91-fold increased DR risk (95%CI:1.90-4.46, P < 0.001) and 17.9-fold (95%CI:12.25-26.25, P < 0.001) in high risk, while it was 6.07-fold greater in high risk vs. intermediate risk (95%CI:4.17-8.83, P < 0.001). The discrimination was 81.2% (95%CI:77.5%-84.8%) for the VENUSS score, and 78.6% (95%CI:74.8%-82.4%) for VENUSS risk groups, respectively. Both the VENUSS score and groups were well calibrated. CONCLUSIONS: This contemporary multi-institutional European large dataset validated the use of VENUSS score and VENUSS risk groups on the prediction of DR after curative surgery in patients with non-metastatic papRCC. The VENUSS prognostic model can provide valuable information for patient counselling, follow-up and patient selection for adjuvant trials.

Response rates and adverse effects of continuous once-daily sunitinib in patients with advanced renal cell carcinoma: a single-center study in Turkey.

OBJECTIVE: Therapy targeted against the vascular endothelial growth factor pathway is a standard of care for patients with metastatic renal cell carcinoma. This study assessed the response rates and toxicity profiles of sunitinib on a continuous once-daily dosing regimen in Turkish patients with metastatic renal cell carcinoma. METHODS: Between April 2006 and August 2010, 74 patients with metastatic renal cell carcinoma who received sunitinib on a continuous, once-daily dosing regimen were included. Sunitinib was administered daily at a dose of either 37.5 mg (94% of the patients) or 25 mg (6% of the patients), without interruption, either as a second-line treatment after interferon-α or as a first-line treatment. Response, toxicity, progression-free survival and overall survival were evaluated. RESULTS: Of the 74 patients, 65 (88%) were diagnosed with clear cell renal cell carcinoma. The median treatment duration was 10 months (range, 2-42 months). The most common treatment-related adverse events were fatigue (75%), stomatitis (51%) and hypertension (50%). The most common Grade 3 or 4 adverse events were anemia (10%) and hand-foot syndrome (7%). Dose reductions were required in 50% of the patients, and early treatment discontinuation was necessary in 16% of the patients. Cardiovascular events were the most common adverse events that resulted in drug discontinuation. The objective response rate and the disease control rate were 30 and 78%, respectively. The median progression-free survival and overall survival were 13 and 25 months, respectively. CONCLUSIONS: Continuous, once-daily administration of sunitinib was generally well tolerated in Turkish patients with advanced renal cell carcinoma in a daily practice setting. This study's response rates were comparable to those in previous randomized trials.

Tissue Resonance Interaction Method (TRIMprob) has the potential to be used alongside the recognized tests in the screening protocols for prostate cancer.

The objective of this study was to evaluate the accuracy of the magnetic induction technique with a nonlinear tunable oscillator (the Tissue Resonance Interaction Method [TRIMprob]) in the diagnosis of prostate cancer (CaP). Overall, 148 men were split into two groups (patients at risk of CaP [Group 1] and controls [Group 2]) and evaluated with the TRIMprob. Group 1 consisted of 100 patients (mean age: 63.8 +/- 7.2 years) with elevated prostate-specific antigen (>4 ng/mL) levels and/or abnormal digital rectal examination. Eleven patients (Group 2a, mean age: 59.5 +/- 7.3) with previously biopsy-proven CaP served as positive controls. In addition, 37 voluntary men (Group 2b, mean age: 39.8 +/- 10.4) with normal prostate-specific antigen and digital rectal examination without lower urinary tract symptoms served as negative controls. Non-linear resonance was analyzed at 465 MHz and a cut-off value of 40 units was detected as the resonance value for the best threshold to distinguish benign conditions from CaP after transrectal ultrasonography-guided biopsy with a standard 10-12 core technique in Group 1. Mean resonance values (+/-standard deviation) with the TRIMprob examination for patients in Groups 1 and 2b were 36.72 +/- 22.35 and 73.64 +/- 10.06, respectively, whereas for patients in Group 2a, it was 13.73 +/- 12.12 (P < 0.01). Sensitivity, specificity, positive and negative predictive values of the TRIMprob using the study cohort of Group 1 were found as 76%, 61.3%, 39.6% and 88.5%, respectively. Despite some technical limitations, the non-invasive TRIMprob examination may have a role in screening protocols for CaP.

Diabetes mellitus is the only independent predictor of both postoperative and long term renal functions in elective laparoscopic partial nephrectomy with limited or overextended warm ischemia.

OBJECTIVE: To investigate the predictive factors of renal functional change at postoperative period and at last follow-up in patients undergoing elective and clamped laparoscopic partial nephrectomy (LPN) with limited (≤20 minutes) and overextended (≥40 minutes) warm ischemia time (WIT). MATERIAL AND METHODS: From our prospectively collected LPN database, elective and warm ischemia-applied LPNs were retrospectively analyzed in two groups: limited (n=55, Group 1, WIT≤20 minutes) and overextended (n=28, Group 2, WIT≥40 minutes) WITs. Preoperatively, estimated glomerular filtration rate (eGFR) was ≥60 mL/min/1.73 m2 in all patients. Demographic, clinical, perioperative and renal functional parameters were compared between two groups. Age, diabetes mellitus (DM), pathological tumor size, preoperative eGFR and WIT were used in multivariable analyses to investigate the independent predictors of de novo Stage 3 or greater chronic kidney disease (CKD) (eGFR<60 mL/min/1.73m2) at postoperative period and at the last follow-up. RESULTS: Preoperative (p=0.009) and pathological (p=0.011) tumor size, PADUA (p=0.001) and R.E.N.A.L. Nephrometry (p=0.006) scores and operative time (p<0.001) were significantly higher in Group 2. Preoperative eGFR (86 vs. 88 mL/min/1.73 m2, p=0.328) was similar between two groups. In postoperative period, compared to Group 1, decreased eGFR (86 vs. 62.5 mL/min/1.73 m2, p<0.001) and percent preserved eGFR (97.2 vs. 77.2%, p<0.001) were found in Group 2. After median follow-up of 33 and 30 months (p=0.732) for Groups 1 and 2, respectively, eGFR at the last follow-up (84 vs. 80.0 mL/min/1.73 m2, p=0.347) and percentage preserved eGFR at last follow-up (97.7 vs. 92.5%, p=0.806) were similar between two groups. Overextended WIT (≥40 minutes), preoperative decreased eGFR (<77.5 mL/min/1.73m2) and DM were the independent predictors of de novo Stage 3 or greater CKD at postoperative period, while DM and age were the predictors of de novo Stage 3 or greater CKD at the last follow-up. CONCLUSION: Overextended WIT (≥40 minutes) caused significant postoperative renal functional loss in elective LPN but this functional loss recovers at long term follow-up. However, diabetes mellitus is the only predictor of renal functional loss both in the postoperative period and at the last follow-up.

Primary urethral plasmacytoma: a case report and literature review.

Plasmacytomas of the urethra are extremely rare neoplasias; they may occur as isolated tumors or concomitantly with generalized multiple myeloma. Herein, we describe the clinical presentation and characteristics of a patient with primary plasmacytoma of the urethra. A 51-year-old man presented with terminal hematuria and a palpable penile mass. Magnetic resonance urethrography revealed a 3-cm long stenotic segment along which the urethral mucosa was found to be irregular. On urethroscopy, papillary mucosal projections extending to the presphincteric area were noted. Lesions were found to be composed primarily of neoplastic plasma cells capable of producing mainly lambda light chain. Upon diagnosis, the patient received external beam radiation therapy targeting the pelvic region. The lesion diminished in size progressively during the treatment course. He was disease-free after 6 months. Although it is a relatively rare disease, primary urethral plasmacystoma should be considered in the differential diagnosis of urethral tumors and radiation therapy should be an integral part of the treatment strategy.