[Single use versus reusable flexible ureteroscopy for the treatment of urolithiasis: a comparative study of perioperative complications].

OBJECTIVE: To compare the perioperative complications of patients who underwent flexible ureteroscopy (fURS) for the treatment of urolithiasis according to the type of ureteroscope used, single-use (suURS) or reusable (rURS) flexible ureteroscope. PATIENTS AND METHODS: A retrospective and single-center study was conducted between January 2017 and May 2019, including all fURS performed for nephrolithiasis management. During the study period, 5rURS and 1suURS (UscopePU3022) were available. The primary endpoint was the occurrence of 30-days postoperative complications, especially infectious complications, classified according to Clavien-Dindo grading system. RESULTS: Overall, 322 consecutive fURS were included corresponding to 186 rURS (57.8%) and 136 suURS (42.2%). Respectively in rURS and suURS groups, the median (IQR) age was 57 (45-65) vs 57 (44-66) years (p=0.75), 83 (44.6%) vs 63 (46.3%) female were included (p=0.82), and median (IQR) Charlson score was 2 (1-3) vs 2 (0-3) (p=0.15). Fifty-one patients (15.8%) developed postoperative complications, 28 patients (15%) in rURS group and 23 patients (17.6%) in suURS group (p=0.64). Most of them (n=47, 92.1% of overall complications) were minor (Clavien I-II). Occurrence of urinary tract infection in suURS group (n=13; 9.5%) was equally comparable with rURS group (n=10; 5.4%), p=0.15. CONCLUSIONS: Our data suggests that suURS represents a safe alternative to rURS. Compared to reusable devices, UscopePU3022 use was associated with a similar complication rates, however, did not decrease the occurrence of infectious events.

Miami Pouch: A Simple Technique for Efficient Continent Cutaneous Urinary Diversion.

OBJECTIVE: To report a contemporary series of Miami pouch (MP) enriched with a full technical description and step-by-step video to contribute to wider use. PATIENTS AND METHODS: A retrospective charts review of all patients who had a MP at our center between January 2016 and December 2017 was performed. The MP technique uses the terminal 15cm of ileum and the right colon to build an intestinal heterotopic pouch located in the right iliac fossa and connected to the skin by an efferent catheterizable tube. Primary outcome was continence defined as the absence of leakage between clean intermittent self-catheterization (CISC) with a maximal interval of 4 hours between each CISC. RESULTS: Fifteen patients had MP during the study period. Thirty-day postoperative Clavien III complications were observed in 2 (13.3%) patients. At 39 months of median follow-up, continence was obtained for all patients except for 2 patients whom reported intermittent night-time leakages due to long intervals (5 to 7 hours) between 2 CISC. No significant alteration of renal function was reported and no stenosis of the efferent tube neither difficulty to perform CISC was observed. CONCLUSIONS: For patients who are candidates for radical cystectomy and not eligible for orthotopic neobladder, intestinal heterotopic pouch with a cutaneous continent urinary diversions as MP may be a reliable alternative. Patients should be informed of the existence of a valid alternative to ileal conduit since it may fit their expectations of a preserved body image without urine collecting appliances.

The prognostic value of serum procalcitonin in acute obstructive pyelonephritis.

PURPOSE: To evaluate the prognostic value of procalcitonin (PCT) in the occurrence of infectious complications in the management of acute obstructive pyelonephritis (AOP) compared with other biological parameters (leucocyte count, C-reactive protein [CRP]). METHODS: We conducted a retrospective study including patients who were treated for AOP and performed serum PCT tests in our center between January 1, 2017 and December 31, 2017. Upper urinary tract obstruction was confirmed by either ultrasound or CT urography. Clinical examinations and laboratory tests including leukocyte count, CRP, urine and blood cultures, and serum PCT measurements were performed in the emergency unit. Treatment included early renal decompression using indwelling ureteral stents or nephrostomy and empiric antibiotic therapy. The primary endpoint was occurrence of severe sepsis (SS), a composite criterion including urosepsis and/or septic shock and/or admission to the intensive care unit (ICU) and/or death. RESULTS: A total of 110 patients (median age: 61 years) were included, of whom 56.3% were female. SS occurred in 39 cases (35.4%). Multivariate regression analysis showed that serum PCT (OR 1.08; 95% CI 1.03-1.17; p = 0.01), CRP (OR 1.007; 95% CI 1.001-1.015; p = 0.03), and diabetes mellitus (OR 5.1; 95% CI 1.27-27.24; p = 0.04) were independent predictors for SS. Serum PCT was the biological marker associated with the highest accuracy to predict SS (ROC 0.912 (95% CI 0.861-0.962) and was superior to CRP (p < 0.001): the sensitivity and specificity of PCT to predict SS were 95% and 77%, respectively, with a serum PCT cutoff value of 1.12 µg/L. CONCLUSIONS: PCT levels > 1.12 µg/L could help physicians to identify high-risk patients who could benefit from early and aggressive management in collaboration with intensive care specialists.

Selective Trans-arterial Embolization of Iatrogenic Vascular Lesions Did Not Influence the Global Renal Function After Partial Nephrectomy.

OBJECTIVE: To evaluate the renal function outcomes after selective trans-arterial embolization (SAE) of iatrogenic vascular lesions (IVL), including pseudoaneurysm and arteriovenous fistula, following partial nephrectomy (PN). MATERIALS AND METHODS: A multi-institutional study was conducted including consecutive patients who underwent PN between January 2009 and March 2019. Two surgical approaches were used: open and robot-assisted PN. Patients with SAE were identified and matched (1:2) with patients without IVL. The matching criteria were age, gender, Charlson score, creatinine clearance, RENAL score, and tumor size. The primary outcome was the evolution of global renal function at 6-months postoperatively. RESULTS: A total of 493 consecutive PN (360 open PN and 133 robot-assisted PN) were included. IVL occurred in 17 cases (3.4%) without statistical difference according to the surgical approach (P = .78). Patients from embolization group were matched to 34 cases without postoperative IVL. Groups were comparable concerning clinical, tumor and surgical characteristics. The clinical success of SAE, defined as the absence of recourse to a second embolization or a total nephrectomy, was obtained in 16 (94.1%) cases. No minor or major complications were reported after SAE. The preoperative estimated glomerular filtration rate (eGFR) was similar between control group (93 [85-102] ml/min) and embolization group (95 [83-102] ml/min) (P = .99). Median (IQR) eGFR between control group (87 [72-95] ml/min) and embolization group (83 [76-93] ml/min) at a follow-up of 6 months showed no significant difference (P = .73). CONCLUSION: IVL are rare complications of PN. SAE is an effective and minimally invasive management tool, with no deleterious effect on global renal function.

Predictive risk factors of urinary tract infection following flexible ureteroscopy despite preoperative precautions to avoid infectious complications.

PURPOSE: Urinary tract infection (UTI) is a common complication after flexible ureteroscopy (fURS) despite technical precautions to avoid infectious complications. The aim was to investigate incidence and predictive risk factors of UTI following fURS procedure. PATIENTS AND METHODS: We conducted a retrospective study including consecutive fURS performed in our center from January 2015 to March 2019. The indications were: nephrolithiasis management and diagnosis and conservative treatment of upper urinary tract urothelial carcinomas (UTUC). Since 2015, we had technical precautions to avoid postoperative infectious complications: centralized collection of preoperative urine cultures which are examined daily by an urologist and a service provider, systematic use of ureteral access sheath and application of standardized antibiotic prophylaxis measures. The primary endpoint was occurrence of UTI within 15 days following fURS. RESULTS: Six hundred and four fURS were included for nephrolithiasis (n = 462) and UTUC management (n = 142). The median (IQR) age in the study cohort was 61(48-68) years, 268 female patients were included (44.4%), the median (IQR) Charlson score was 2(1-4) and single-use fURS were used in 186 cases (30.8%). Postoperative UTI occurred in 41 cases (6.7%). In multivariate analysis, female gender (OR 2.20 [1.02-5.02], p = 0.04), UTI within the last 6 months (OR 2.34 [1.12-5.11], p = 0.02), preoperative polymicrobial urine culture (OR 4.53 [1.99-10.56], p < 0.001) and increased operative time (OR 1.02 [1.002-1.031], p = 0.02) remain associated with postoperative UTI. CONCLUSIONS: In a large cohort study, female gender, prior UTI, increased operative time and preoperative polymicrobial urine culture were associated with the occurrence of postoperative UTI. Limiting operative time and improving our knowledge of polymicrobial urine cultures could reduce the infectious risk.

MRI-targeted biopsy for detecting prostate cancer: have the guidelines changed our practices and our prostate cancer detection rate?

PURPOSE: In our center, until 2018, MRI-targeted biopsy was underused. Since January 2018, we systematically performed MRI-targeted biopsy for suspicious PI-RADS ≥ 3 lesions in accordance to the recent guidelines. We hypothesized that the implementation of systematic prebiopsy MRI would increase the detection rate (DR) of prostate cancer (PCa) without increasing DR of clinically insignificant PCa (insignPCa). PATIENTS AND METHODS: A retrospective study including consecutive men who underwent prostate biopsy for suspicion of PCa in our center between January 2017 and December 2018 was conducted. Combined biopsies were performed for suspicious MRI and systematic biopsies for nonsuspicious MRI. The primary outcome was to compare the DR of PCa per year. Secondary outcomes included DRs of clinically significant PCa (csPCa) and insignPCa between both years and outcomes of targeted vs systematic biopsies. RESULTS: A total of 306 men (152 in 2017 and 154 in 2018) were included. Respectively, median (IQR) age was 69 (63-75) vs 70 (65-76) years (p = 0.29) and median (IQR) PSA density was 0.17 (0.13-0.28) vs 0.17 (0.11-0.26) (p = 0.24). There was a significant increase in prebiopsy MRI performed (120 [78.9%] vs 143 [92.8%]; p < 0.001) in 2018. DRs of PCa (94 [61.8%] vs 112 [72.7%]; p = 0.04) and csPCa (76 [50%] vs 95 [61.6%]; p = 0.04) increased in 2018, while the insignPCa DR was stable (p = 0.13). The DR of PCa was 58.3%, 65% and 71.2%, respectively, in targeted, systematic and combined biopsies (p = 0.02). In case of nonsuspicious MRI, the prevalence of csPCA was 12.5%. CONCLUSIONS: Introducing systematical MRI-targeted biopsy in our clinical setting increased the PCa DR without overdiagnosing insignPCa. Implementation of prebiopsy MRI does not seem to avoid the need for systematic biopsy, and nonsuspicious MRI should not obviate the need for prostate biopsy when otherwise clinically indicated.

Withholding gonadotropins until human chorionic gonadotropin administration.

Withholding gonadotropins in women who exhibit high estradiol responses before follicles reach full maturation is called "coasting." Coasting, or suspending gonadotropin administration, can be an effective strategy for decreasing the risk of ovarian hyperstimulation syndrome (OHSS) while reducing cancelation rates. In in vitro fertilization cycles, mechanistically it is believed that withholding gonadotropins starves smaller follicles, induces apoptosis, and decreases the potential for these follicles to elaborate vascular endothelial growth factor, a known mediator of OHSS. It is generally accepted that coasting should be initiated when the estradiol (E2) level is >3000 pg/mL in the setting of immature follicles. The human chorionic gonadotropin (hCG) trigger should be administered when the E2 level subsequently drops to a "safe" level. Cycle cancellation should be considered if, after 3 to 4 days of coasting, the E2 level remains excessively elevated. Oocyte retrieval may also be cancelled if the E2 level on the day after hCG trigger drops precipitously. In gonadotropin-releasing hormone agonist (GnRHa)-based protocols, one can consider withholding GnRHa administration if the E2 level continues to increase after a few days of coasting. Current data seem to show that the coasting period is short and/or is less likely to be required in GnRH-antagonist protocols as compared with GnRHa-based protocols. Large randomized control trials are still needed to establish the relative efficacy of coasting versus embryo cryopreservation in the context of OHSS prevention.

The role of laparoscopy in the treatment of early ovarian carcinoma.

Laparoscopic management of early ovarian cancer (EOC) has constituted a controversial issue since it was first described. Recent data reinforced the arguments supporting the use of laparoscopy in the management of EOC. Advances in laparoscopy have enabled surgeons to meet the International Federation of Gynecology and Obstetrics' criteria for staging of EOC. Although most study results are encouraging, the sample size is still too small to be able to draw definite conclusions. Frequently cited concerns such as accuracy of staging, intraabdominal tumor rupture and port site metastasis should not be used as arguments against laparoscopic management of EOC. Clinical evidence is clearly in favor of a larger role for laparoscopy in the management of EOC. This should encourage studies with larger sample sizes to confirm the validity of laparoscopic management of EOC.

Optimal stimulation protocols for in vitro fertilization.

OBJECTIVE: To update clinicians on different gonadotropin regimens for ovarian stimulation for IVF including the use of urinary and recombinant gonadotropins, the value of added LH to FSH in the stimulation regimen, the use of GnRH agonists and antagonists, and the role of minimal stimulation protocols. DESIGN: Literature review and critical analysis of major articles during the last five years on ovarian stimulation for IVF. CONCLUSION(S): Urinary and recombinant gonadotropins, for ovarian stimulation for IVF, are probably equally safe and effective. The higher cost for recombinant products limits their worldwide use in IVF. Conflicting data exist regarding the benefit of adding LH to FSH in the stimulation regimens. The use of different GnRH-agonists, of varying potency, may account for different levels of LH suppression. Adding LH should be considered in severe situations of LH suppression such as with the use of potent GnRH-agonists or when GnRH-antagonists are introduced during the course of stimulation. GnRH-antagonists provide advantages to patients in terms of fewer injections, shorter stimulation days, and avoidance of adverse effects of agonists. The incidence of ovarian hyperstimulation syndrome is probably less with antagonists compared to agonists, with the option to use an agonist as a surrogate LH surge. Fixed and early start of the antagonist is probably more effective than an individualized and late start. The earlier reported lower pregnancy rates with antagonists compared to agonists is not fully understood and needs to be continually monitored. Minimal stimulation protocols using a combination of clomiphene citrate and gonadotropins are attractive and should be considered in some patients owing to lower costs and acceptable success rates. The optimal stimulation protocol for IVF should be an individualized regimen based on the patient's ovarian physiology and prior IVF experience, if any.

Regulation of signaling phosphoproteins by epidermal growth factor and Iressa (ZD1839) in human endometrial cancer cells that model type I and II tumors.

To understand how type I and II endometrial tumors uniquely respond to tyrosine kinase inhibitor treatments, we evaluated the signaling pathways of epidermal growth factor (EGF) receptor (EGFR) under the effects of EGF and Iressa (ZD1839, gefitinib) using Ishikawa H and Hec50co cells that model type I and II endometrial carcinomas, respectively. The cells were assayed for the expression of EGFR and both cell lines express an average of 100,000 EGFR per cell; however, Ishikawa H cells express higher levels of HER-2/neu compared with Hec50co cells (1.38 x 10(5) compared with 2.04 x 10(4), respectively). Using the Kinetworks multi-immunoblotting approach, which profiles 31 signaling phosphoproteins, the most striking result was that Hec50co cells show a higher number of basal phosphorylated sites compared with Ishikawa H cells. Furthermore, we identified targets of Iressa treatment in both cell lines. Iressa, at a dose of 1 micromol/L, blocked the autophosphorylation of EGFR in Ishikawa H and Hec50co cells with some distinctive effects on downstream effectors. Nevertheless, in both cell lines, EGF stimulated and Iressa blocked the major EGFR target mitogen-activated protein kinases extracellular signal-regulated kinase 1 and 2 equally. The high basal phosphorylation of numerous signaling molecules in Hec50co cells that were not inhibited by Iressa indicates that other growth factor pathways are active in addition to EGFR. We conclude that endometrial cancer cells that model type I and II carcinomas have the capacity to respond to EGFR inhibition as a therapeutic strategy; however, the response of the more aggressive type II tumors may be limited by the constitutive activation of other signaling pathways.