Do men with bladder stones benefit from treatment of benign prostatic obstruction?

OBJECTIVE: To identify whether men aged ≥40 years with bladder stones (BS) benefit from treatment of benign prostatic obstruction (BPO). PATIENTS AND METHODS: A regional, retrospective study of patients undergoing BS surgery between January 2011 and December 2018 was performed using a prospectively collected database. The primary outcome was BS recurrence after successful removal. Kruskal-Wallis and chi-squared statistical tests were used. RESULTS: A total of 174 patients underwent BS removal and 71 (40.8%) were excluded due to BS formation secondary to causes other than BPO. Hence, 103 men aged ≥40 years had BS successfully removed, of which 40% had a history of upper tract urolithiasis. These men were divided into three groups: those undergoing contemporaneous medical, surgical, or no BPO treatment. Age, diabetes, previous urolithiasis and previous BPO surgery were well matched between the BPO treatment groups. In all, 18 of these men (17%) had BS recurrence after 46 months follow-up. Recurrences were significantly lower following BPO surgery; one of 34 (3%) men versus five of 28 (18%) with no BPO treatment (P = 0.048) and 12 of 41 (29%) with medical BPO treatment (P = 0.003). Recurrences after medical and no BPO treatment were similar (P = 0.280). In all, 34 men (33%) had BPO complications that were similar between groups (P = 0.378). CONCLUSION: This is the largest reported cohort of men, with the longest follow-up after BS removal. Most men aged ≥40 years with BS benefit from BPO surgery. However, the study findings also support a multifactorial aetiology for BS, which questions the dogma that BS are an 'absolute indication' for BPO surgery, as is stated in the Non-neurogenic Male Lower Urinary Tract Symptoms European Association of Urology Guideline. Assessment and management of all causative factors is likely to enable selection of which men will benefit from BPO surgery and to reduce BS recurrence rates.

Case report of ureteric transection of lower moiety in high-speed road traffic collision.

Ureteric injuries from blunt trauma are rare in adults requiring prompt diagnosis and management. To our knowledge this is the second case report of a complete transection of the ureter due to blunt injury at the pelvi-ureteric junction in an adult. Following a high-speed road traffic collision, a 26-year-old female with bilateral duplex kidneys was admitted with complete transection of the lower moiety of her right collecting system confirmed on computed tomography Urogram. This was repaired successfully with a minimally invasive laparoscopic technique in keeping with European Association of Urology guidelines. A 3-month follow-up MAG 3 renogram indicated adequate drainage from the right kidney with no evidence of obstruction. This successful outcome demonstrates a laparoscopic repair is achievable and favourable, improving post-operative recovery and reduction of inpatient length of stay. We recommend that a laparoscopic approach should be attempted unless laparotomy is indicated for other injuries.

Shockwave Lithotripsy Is an Efficacious Treatment Modality for Obese Patients with Upper Ureteral Calculi: Logistic Regression and Matched-Pair Analyses from a Dedicated Center Comparing Treatment Outcomes by Skin-to-Stone Distance.

Objectives: To assess the association of skin-to-stone distance (SSD) and stone-free rates following extracorporeal shockwave lithotripsy (SWL) using two statistical methods: logistic regression and a matched-pair analysis approach. Patients and Methods: Patients with a solitary radio-opaque upper ureteral calculus diagnosed on noncontrast computed tomography were included. Patients were treated with a Sonolith I-Sys Lithotripter (focal depth 17 cm). Stone treatment success was defined as stone free (fragments ≤3 mm) at 3 months. Failure was defined as persistent fragments beyond 3 months or requirement for intervention with ureteroscopy. The outcome was assessed by a plain kidney, ureter, and bladder radiograph (KUB) at 2 weeks. Logistic regression was used to determine association of patient and stone factors with treatment failure. The patient cohort was divided into tertiles by SSD, and matched-pair analysis was undertaken between individuals from the top and bottom tertiles (SSD ≤12 cm and SSD ≥14 cm). Matching criteria consisted of age, sex, maximum stone diameter (±2 mm), and stone density (±250 HU). Results: From a database of 2849 patients who underwent SWL, 397 patients were identified who had treatment of a single upper ureteral stone. Age (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.04, p = 0.007), SSD (OR: 1.16, 95% CI: 1.03-1.32, p = 0.02), stone side (OR: 1.65, 95% CI 1.01-2.73, p = 0.05), stone diameter (OR: 1.09, 95% CI: 1.00-1.19, p = 0.05), and multiple sessions (OR: 4.65, 95% CI: 2.61-8.29, p < 0.001) were significantly associated with treatment failure by logistic regression univariable analysis. Multiple sessions was the only factor significantly associated with treatment failure on multivariable analysis (OR: 4.03, 95% CI: 2.18-7.42, p < 0.001). From a cohort of 141 patients with SSD ≥14 cm and 174 patients with a SSD ≤12 cm, 66 matches were identified (132 patients). Forty-nine patients (74.2%) with SSD ≥14 cm were deemed stone free at follow-up vs 51 patients (77.3%) with SSD ≤12 cm (p = 0.85). Conclusion: This study demonstrates by two statistical methods that SWL can provide efficacious treatment of upper ureteral stones in obese patients and that the upper threshold of SSD for SWL with Sonolith I-SYS could be revised to allow these patients the benefits of SWL.

Tumour suppressor gene (CDKNA2) status on chromosome 9p in resected renal tissue improves prognosis of localised kidney cancer.

BACKGROUND: Genetic alterations on chromosome 9p, including inactivation of the tumour suppressor gene, CDKN2A, result in cellular proliferation and growth of tumours. Our aim was to use microsatellite analysis and fluorescence in situ hybridization (FISH) to characterise the architecture of this region. RESULTS: Seventy-five out of 77 clear cell renal cell cancers (tumour/normal pairs) were interpretable for LOH analysis on chromosome 9p (two tumours were excluded, as all five primers were uninformative). Twenty out of 75 (26.6%) tumours showed LOH in at least one of the five primers employed. Most allelic deletions were detected, telomeric to the CDKN2A region at D9S916, with 11 out of 52 informative tumours (21%) displaying LOH. The LOH in the coding region of CDKN2A, at D9S974 and D9S942, was associated with a higher pT-stage (p = 0.004) and metastasis (p = 0.006, both markers). The rate of chromosome 9p deletion in ccRCC was 44% (35/80 cases) according to FISH. Somatic copy number loss of chromosome 9p was associated with a larger tumour size (p = 0.002), higher pathological tumour stage (p = 0.021), presence of tumour necrosis (p = 0.019) and microvascular invasion (p = 0.032). The cases with copy number loss, loss of heterozygosity and copy number neutral (n = 42) were at a higher risk of cancer-specific death when compared to tumours in category D (n = 32) (Log-rank: p = 0.001). Seventeen patients with localised ccRCC developed recurrence, and fourteen of those showed either LOH or somatic copy number loss at CDKN2A (Log-rank: p = 0.005). Multivariate analysis showed that LOH or copy number loss at CDKN2A retained its independent prognostic effect, improving the predictive accuracy of stage and SSIGN score by concordance Index C from 0.823 to 0.878 (p = 0.001). MATERIALS AND METHODS: Cytogenetics data, microsatellite analysis and FISH were acquired for a cohort of patients undergoing resection for clinically localised renal cancer between January 2001 and December 2005. Five microsatellite markers (D9S916, D9S1814, D9S974, D9S942 and D9S171) assessed loss of heterogeneity (LOH) using DNA samples and in the same cohort FISH analysis was accomplished on tissue microarray slides. The FISH data were scored by two observers blinded to the histological data of the patients. Cytogenetic aberrations were correlated with histological and clinical outcomes by univariate and multivariate analyses using different prognostic models. Disease specific and recurrence free survival based on cytogenetic changes were assessed by Kaplan Meier methods. CONCLUSIONS: A comprehensive cytogenetic analysis using microsatellite analysis and FISH of the CDKN2A region on chromosome 9p improves the predictive accuracy of known prognostic factors in clinically localised renal cell carcinoma undergoing surgical resection.

Microsatellite alteration and immunohistochemical expression profile of chromosome 9p21 in patients with sporadic renal cell carcinoma following surgical resection.

BACKGROUND: Long-term prognostic significance of loss of heterozygosity on chromosome 9p21 for localized renal cell carcinoma following surgery remains unreported. The study assessed the frequency of deletions of different loci of chromosome 9p along with immunohistochemical profile of proteins in surgically resected renal cancer tissue and correlated this with long-term outcomes. METHODS: DNA was extracted from renal tumours and corresponding normal kidney tissues in prospectively collected samples of 108 patients who underwent surgical resection for clinically localized disease between January 2001 and December 2005, providing a minimum of 9 years follow-up for each participant. After checking quality of DNA, amplified by PCR, loss of heterozygosity (LOH) on chromosome 9p was assessed using 6 microsatellite markers in 77 clear cell carcinoma. Only 5 of the markers showed LOH (D9S1814, D9S916, D9S974, D9S942, and D9S171). Protein expression of p15(INK4b), p16(INK4a), p14(ARF), CAIX, and adipose related protein (ADFP) were demonstrated by immunostaining in normal and cancer tissues. Loss of heterozygosity for microsatellite analysis was correlated with tumour characteristics, recurrence free, cancer specific, and overall survival, including significance of immunohistochemical profile of protein expressions. RESULTS: The main deletion was found at loci telomeric to CDKN2A region at D9S916. There was a significant correlation between frequency of LOH stage (p = 0.005) and metastases (p = 0.006) suggesting a higher LOH for advanced and aggressive renal cell carcinoma. Most commonly observed LOH in the 3 markers: D9S916, D9S974, and D9S942 were associated with poor survival, and were statistically significant on multivariate analysis. Immunohistochemical expression of p14, p15, and p16 proteins were either low or absent in cancer tissue compared to normal. CONCLUSIONS: Loss of heterozygosity of p921 chromosome is associated with aggressive tumours, and predicts cancer specific or recurrence free survival on long-term follow-up.

Real-life Experience: Early Recurrence With Hexvix Photodynamic Diagnosis-assisted Transurethral Resection of Bladder Tumour vs Good-quality White Light TURBT in New Non-muscle-invasive Bladder Cancer.

OBJECTIVE: To compare early recurrence between good-quality white-light transurethral resection of bladder tumor (GQ-WLTURBT) and photodynamic diagnosis-assisted (PDD) transurethral resection of bladder tumor (TURBT) in a real-life controlled setting. METHODS: A prospective controlled study was conducted commencing with a planned prospective cohort of patients with new tumors undergoing white-light TURBT in 2007-2008. Previously defined principles of GQ-WLTURBT for standardization and comparison of TURBT techniques, which are (1) cystoscopic mapping using a bladder diagram, (2) documented complete resection of the tumor, (3) resection performed or supervised by an experienced surgeon, (4) presence of detrusor muscle in the specimen, and (5) patient receiving mitomycin C within 24 hours of the resection, were applied. This was followed by a prospective cohort of new patients undergoing PDD-TURBT in 2009-2011. Only patients with new non-muscle-invasive bladder cancer (NMIBC) deemed to have had complete first TURBT were included for analysis. Tumor features and findings at first check cystoscopy and early re-TURBT (in high-risk NMIBC) were evaluated. Early recurrence (for calculating recurrence rate at first follow-up cystoscopy) was defined as pathologically confirmed tumor on early re-TURBT or recurrence at the first check cystoscopy. Comparison was analyzed between GQ-WLTURBT and good-quality PDD-TURBT (GQ-PDDTURBT). RESULTS: A total of 808 patients were evaluated. The overall RRFFCs for GQ-WLTURBT and GQ-PDDTURBT were 30.9% and 13.6%, respectively (odds ratio = 2.9; 95% CI = 1.6-5.0; P <.001), with statistically significant lower recurrence rates in low- and intermediate-risk NMIBC after GQ-PDDTURBT. CONCLUSION: Hexvix PDD-assisted TURBT is associated with a significantly lower risk of early recurrence compared with GQ-WLTURBT in a real-life clinical setting.

Carcinoma in situ is significantly underdetected by prenephroureterectomy ureteroscopy in the management of upper tract urothelial cancers.

Objective. Diagnostic reliability of prenephroureterectomy ureteroscopy (PNU) for the detection of upper tract carcinoma in situ (CIS) remains unproven in particular and underreported in general. Methods. Patients who underwent radical nephroureterectomy (RNU) in a large multicentre retrospective study for upper tract transitional cell carcinoma (UT-TCC) between January 2002 and December 2013 were identified from our hospitals databases. PNU appearances, stage, and grade of ureteroscopic biopsy were compared with final histology results of RNU to assess the diagnostic reliability of PNU for carcinoma in situ (CIS). Results. Three hundred patients underwent RNU for UT-TCC. 106 (106/300; 35.3%) of the cohort had PNU using white light with biopsies taken in most (92/106; 86.7%). Postnephroureterectomy histology of the cohort showed CIS in 65 (65/300; 21.6%) patients. Thirty nine of patients with CIS (39/65; 60%) had prenephroureterectomy ureteroscopy biopsies. Out of ten patients with CIS on ureteroscopic biopsies, six did not show CIS on final histopathology (6/10; 60%). Moreover, grading and staging on PNU biopsies of obvious tumours showed a significant nonconcordance with final histopathology of RNU specimen (P = 0.02). Overall survival was also shorter in patients with CIS compared with those without; this showed strong statistical significance (P = 0.004). Conclusions. There is a high incidence of CIS in upper tract with significant underdetection and discordance rate between the histopathology of biopsy samples obtained by white light PNU and resected specimen of radical nephroureterectomy. The presence of concomitant CIS and high stage disease in the upper tract TCC carried a poor prognosis following radical nephroureterectomy.

Significance of chromosome 9p status in renal cell carcinoma: a systematic review and quality of the reported studies.

Defining the prognosis of renal cell carcinoma (RCC) using genetic tests is an evolving area. The prognostic significance of 9p status in RCC, although described in the literature, remains underutilised in clinical practice. The study explored the causes of this translational gap. A systematic review on the significance of 9p status in RCC was performed to assess its clinical applicability and impact on clinical decision-making. Medline, Embase, and other electronic searches were made for studies reporting on 9p status in RCC. We collected data on: genetic techniques, pathological parameters, clinical outcomes, and completeness of follow-up assessment. Eleven studies reporting on 1,431 patients using different genetic techniques were included. The most commonly used genetic technique for the assessment of 9p status in RCC was fluorescence in situ hybridization. Combined genomic hybridisation (CGH), microsatellite analysis, karyotyping, and sequencing were other reported techniques. Various thresholds and cut-off values were used for the diagnosis of 9p deletion in different studies. Standardization, interobserver agreement, and consensus on the interpretation of test remained poor. The studies lacked validation and had high risk of bias and poor clinical applicability as assessed by two independent reviewers using a modified quality assessment tool. Further protocol driven studies with standardised methodology including use of appropriate positive and negative controls, assessment of interobserver variations, and evidenced based follow-up protocols are needed to clarify the role of 9p status in predicting oncological outcomes in renal cell cancer.

Progression, interobserver agreement, and malignancy rate in complex renal cysts ( ≥ Bosniak category IIF).

OBJECTIVE: The objective of this study was to assess interobserver agreement, clinicopathologic correlation, and radiologic follow-up progression of complex cystic renal masses. PATIENTS AND METHODS: The medical records of 143 patients with 154 complex cystic renal masses were retrieved. Primary outcomes were interobserver agreement between the radiologists, and malignancy rates following surgical extirpation with or without follow-up in Bosniak IIF, III, and IV categories. Secondary outcomes were correlation between histology and degree of enhancement on contrast-enhanced computed tomography scans and survival analysis of patients with or without surgical intervention using the Kaplan-Meier analysis. RESULTS: The overall malignancy rate in patients who had surgery was 74.5% (29/39). Of 27 confirmed renal cell carcinoma on final histology, 9 were papillary renal cell carcinoma (incidence 33.3%). Assessment of interobserver agreement yielded a weighted kappa statistic value of 0.69 (95% confidence interval 0.56-0.82, P<0.0001). Radiologic progression rate of Bosniak IIF cysts over median follow-up of 18.5 months was 13% (10/78). There was no statistically significant difference between progression rate and regression rate of IIF cysts (13.8% vs. 11.5%) over the period of 24 months of follow-up. Most of the progression in complex cystic renal masses was seen in the first 2 years of follow-up. The malignancy rate on radiologic progression was 87.5% (8/9) and 75% (6/8) in Bosniak IIF and III cystic masses, respectively. The malignancy rate in Bosniak III cyst was 50% (4/8) without a period of initial observation or follow-up. CONCLUSIONS: A good degree of agreement exists between radiologists in classifying complex renal masses. Malignancy rate is considerably high in Bosniak IIF when they exhibit radiologic progression on systematic follow-up.

A minimally invasive temporary cavernoso-saphenous shunt in the management of priapism after failed conservative treatment.

Priapism is an urological emergency with detrimental consequences, if not managed expeditiously. Though a rare condition with an incidence between 0.3 and 1.5 per 100,000 population, its management options are limited and decision making could be challenging. We present a case of late presenting priapism for which the initial routine clinical care (aspiration, intracavernosal injection, and distal shunt) failed to relieve erection. Subsequently, the patient was successfully treated by a temporary cavernoso-saphenous shunt using carotid shunt and repeated heparin flushes. This novel surgical treatment offers an alternate method of relieving priapism, avoiding the long-term undesired effects associated with permanent proximal shunts such as cavernoso-venous grafts. Moreover, interval flushes (and/or repeated aspirations) with heparin ensures patency of this new shunt during the perioperative period. The patient recovered without any complications and the shunt was removed after one week. He has regained partial erection, however refused to have further treatment. Temporary cavernoso-saphenous shunt using carotid shunt offers an alternate option of management of priapism in patients with failed initial conservative treatment and distal shunts.

Surgical management for upper urinary tract transitional cell carcinoma.

BACKGROUND: Upper tract transitional cell carcinomas (TCC) are uncommon and aggressive tumours. There are a number of surgical approaches to manage this condition including open radical nephroureterectomy and laparoscopic procedures. OBJECTIVES: To determine the best surgical management option for upper tract transitional cell carcinoma. SEARCH STRATEGY: A sensitive search strategy was developed to identify relevant studies for inclusion in this review. The following databases were searched for randomised trials evaluating surgical approaches to the management of upper tract TCC: Medline EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, British Nursing Index, AMED, LILACS, Web of Science®, Scopus, Biosis, TRIP, Biomed Central, Dissertation Abstracts, and ISI Proceedings. SELECTION CRITERIA: The following criteria that were considered for this review.Types of studies - All randomised or quasi-randomised controlled trials comparing the various surgical methods and approaches for the management of localised upper tract transitional cell carcinoma. Types of participants - All adult patients with localised transitional cell carcinoma. Localised disease was defined as limited to the kidney or ureter with no gross regional lymph nodal enlargement on imaging. Types of interventions - Any surgical method or approach for managing localised upper tract transitional cell carcinoma. Types of outcome measures - Overall and cancer-specific survival were primary outcomes. Surgery-related morbidity. Quality of life and health economics outcomes were secondary outcomes. DATA COLLECTION AND ANALYSIS: Two review authors examined the search results independently to identify trials for inclusion. MAIN RESULTS: We identified one randomised controlled trial that met our inclusion criteria. The trial showed that the laparoscopic approach had superior peri-operative outcomes compared to open approach. Laparoscopic was superior and statistically significant for blood loss (104 mL (millilitres) versus 430 mL, P < 0.001) and mean time to discharge (2.3 days versus 3.7, P < 0.001). Oncological outcomes (bladder tumour-free survival, metastasis-free survival, cancer-specific survival curves), at a median follow up of 44 months and in organ-confined disease, were comparable for both groups. AUTHORS' CONCLUSIONS: There is no high quality evidence available from adequately controlled trials to determine the best surgical management of upper tract transitional cell carcinoma. However, one small randomised trial and observational data suggests that laparoscopic approach is associated with less blood loss and early recovery from surgery with similar cancer outcomes when compared to open approach.

Functional and oncological outcomes of men under 60 years of age having endoscopic surgery for prostate cancer are optimal following intrafascial endoscopic extraperitoneal radical prostatectomy.

BACKGROUND: Endoscopic extraperitoneal radical prostatectomy (EERPE) is a well-established procedure for treatment of prostate cancer (PCa). Intrafascial nerve-sparing EERPE (nsEERPE) aims to preserve the neurovascular bundle and subsequently erectile function. This study assessed the functional and oncological outcomes of nsEERPE with particular regard to younger patients. METHODS: Data on 353 men undergoing EERPE between February 2006 and December 2009 was collected prospectively. Non-nerve-sparing EERPE was performed in men diagnosed with PCa with a Gleason score >6 and/or PSA >10 µg/l. nsEERPE was undertaken in men diagnosed PCa with PSA ≤10 µg/l and Gleason score ≤6. Biochemical failure (BF) was defined as PSA ≥0.2 µg/l after nadir or never reached nadir. Men were deemed continent if dry or using 1 confidence pad. Erections satisfactory for intercourse (ESI) or unsatisfactory for intercourse (EUI) were recorded. RESULTS: 102 Men (29%) had nsEERPE and 126 (36%) EERPE. pT2 positive surgical margin (PSM) rates were 20.5% for nsEERPE and 21.3% for EERPE (P = 1). Continence rates following nsEERPE were 59%, 86%, 97% and 52%, 76%, 86% following EERPE at 3, 6 and 12 months of follow-up respectively (P > 0.05). Erectile function rates for nsEERPE were 24%, 52%, 71% compared to 6%, 14%, 29% for EERPE at 3, 6 and 12 months respectively (P < 0.001). Erectile function in men <60 y having nsEERPE was 75% at 12 months. CONCLUSIONS: Continence returned more rapidly and erectile function was improved following nsEERPE vs. EERPE. These results suggest that nsEERPE can be performed with particularly good oncological and functional outcome in <60 y men.