Accuracy of combined multi-parametric MRI and PSMA PET-CT in diagnosing localized prostate cancer: newer horizons for a biopsy-free pathway.

INTRODUCTION: Prostate-specific antigen (PSA) is a reliable biomarker for identification of prostate cancer, although a biopsy is still the gold standard for detecting prostate cancer. Similar to higher PIRADS lesions on MRI, the maximal standard uptake value (SUV max) on PSMA PET is linked to a higher likelihood of prostate cancer. Can an mpMRI in conjunction with PSMA PET Scan accurately predict prostate cancer and further trigger omission of biopsy similar to other solid organ urological malignancies? METHODS: Ga-68 PSMA PET and mpMRI were performed for each patient who was a part of this retrospective study. The PET-positive lesion's maximum standardized uptake value (SUVmax) was recorded. Prostate biopsies were performed on patients who had PSMA PET avid lesions and a PIRADS score of 4 or 5. Robot-assisted radical prostatectomy (RARP) was afterward performed on patients who had cancer on their prostate biopsy. The prostatectomy specimen's histopathological information was recorded. Cutoff values and correlations between the variables were determined using the ROC curves and Pearson's correlation test. RESULT: On the basis of suspicious DRE findings or elevated PSA, 70 men underwent mpMRI and PET scans. PIRADS 4 patients had a median (IQR) SUVmax of 8.75 (11.95); whereas, PIRADS 5 patients had an SUVmax of 24.5 (22). The mean SUVmax for patients whose biopsies revealed no cancer was 6.25 ± 1.41. With an AUC of 0.876 on the ROC curve, it was found that there was a significant positive correlation between the results of the mpMRI and PET scans and those of the histopathological investigation. A SUVmax ≥ 8.25 on PSMA PET for a PIRADS 4/5 lesion on mpMRI will aid in correctly predicting malignancy, with a sensitivity of 82.8% and specificity of 100%. CONCLUSION: The findings of this study were positive and indicated that patients with a high suspicion of prostate cancer on mpMRI and PSMA PET (PIRADS ≥ 4 and SUVmax ≥ 8.25). This study substantiates the fact that a combination of mpMRI and PSMA PET can accurately predict localized prostate cancer.

Current practice patterns in the perioperative management of patients undergoing radical cystectomy: Results from a global survey.

OBJECTIVE: To determine current practice patterns and adherence to various components of enhanced recovery after surgery in cystectomy (ERAC) protocol for peri-operative management of radical cystectomy patients through a global survey. METHODS: A survey containing 25 questions and addressing 15 of the 22 items of the ERAC protocol was developed and disseminated through Email to the urologists with recent bladder cancer publications. The mailing list was generated by retrieving Email-ids of corresponding authors of articles using the keyword "cystectomy" in Scopus from January 2018 to October 2020. RESULTS: The survey was completed by 443 respondents across the globe. About 51.5% of respondents used some form of bowel preparation. A minority used carbohydrate loading (29.8%) and Alvimopan (13.3%). A short duration of nil by mouth was practised by 28.9%. For antibiotic prophylaxis, 51.7% used one, and 42% used two antibiotics. Duration of antibiotics was 24 hours, 48 hours, and >48 hours for 47.6%, 16.9%, and 35.4%, respectively. For peri-operative analgesia, 43.6% used non-steroidal anti-inflammatory drugs, 9.3% opioids and 40.6% combination of both. Pharmacological thrombo-prophylaxis was routinely used by 74.7% respondents. There was significant variability in ERAC and non-ERAC components according to region of practice; The open surgical approach was most commonly used in Africa (92%), whereas it was the robotic approach in North America (or America?) (41%). The use of bowel preparation was higher in Asia (58%) and Africa (65%). Alvimopan use was more common in North America (58%). Most used 1 or 2 prophylactic antibiotics but the duration was shorter (<24 hours) in the Americas and European (58%-83%) compared to Asia and Africa (15%-35%). CONCLUSION: There is high variability in the use of different ERAC components. Other than the timely removal of the abdominal drain and the use of thromboprophylaxis, the overall adherence of ERAC components is low.

Comparison of stent related symptoms in patients taking mirabegron, solifenacin, or tamsulosin: A double blinded randomized clinical trial.

BACKGROUND: The present study aims to assess the efficacy of mirabegron, a novel beta-3 agonist for ameliorating stent related symptoms (SRSs) as compared to tamsulosin and solifenacin. METHODS: Total of 150 patients undergoing ureteral stent placement following ureteroscopic lithotripsy, percutaneous nephrolithotomy, or laparoscopic/robotic pyeloplasty were randomized in 1:1:1 fashion to receive mirabegron 50 mg (group A), solifenacin 5 mg (group B), and tamsulosin 0.4 mg (group C) OD respectively. Patients were followed at POD10 (I visit), 4 weeks (II visit) after surgery, and 2 weeks post-stent removal. Validated vernacular version of ureteric stent symptoms questionnaire (USSQ) was administered to the patients at each visit. RESULTS: Out of 150 patients randomized, 123 patients (A; n = 41, B; n = 40, and C; n = 42) completed the study. The groups were comparable in terms of urinary index score of USSQ at I and II visits (p = 0.119 and 0.076, respectively). A lower proportion of patients in group B experiencing bodily pain at II visit (p = 0.039), however, pain scores were comparable. Significantly lower general health index scores were observed in group A at I visit and over 4 weeks (p = 0.007). No significant differences were observed in other domains of USSQ. Age, sex, and surgical procedure undertaken did not significantly impact the scores in various USSQ domains. CONCLUSION: Mirabegron demonstrates comparable benefit in alleviating SRSs with better general health indices and may be an effective alternative for SRSs, especially when tamsulosin or solifenacin are contra-indicated or poorly tolerated.

Isolated Renal Mucormycosis in Immunocompetent Hosts: Clinical Spectrum and Management Approach.

Isolated renal mucormycosis in immunocompetent hosts is a rare entity. We present the largest case series of isolated renal mucormycosis in immunocompetent hosts. Retrospective data of isolated renal mucormycosis from March 2012 to June 2017 was reviewed. Fifteen patients of isolated renal mucormycosis were identified. Contrast-enhanced computed tomography scan showed enlarged globular kidneys with decreased or patchy enhancement, perinephric stranding and thickened Gerota's fascia in all patients. Ten patients with unilateral involvement underwent nephrectomy and two of four patients with bilateral renal mucormycosis underwent bilateral nephrectomy. Two patients were managed with intravenous antifungal therapy alone. Overall, the mortality rate in our series was 40% (6/15). Isolated renal mucormycosis in healthy immunocompetent hosts is an emerging new entity. Prompt diagnosis based on the characteristic clinical and radiological picture and starting high-dose antifungal therapy at least 24 hours before surgical debridement offer the best chance of survival in these patients.

Human Papillomavirus in Urothelial Carcinoma of Bladder: An Indian study.

OBJECTIVES: To study the role of high-risk human papillomavirus (HPV-16 and HPV-18) types in the causation of urothelial carcinoma of the urinary bladder in Indian population. METHODS: 50 patients with Urothelial carcinoma of the urinary bladder were included in the study. Another 10 age-matched subjects who were hospitalized for transurethral resection of prostate for benign prostatic hyperplasia and/or ureterorenoscopy for ureteric stone disease were enrolled as controls. The tissue samples were analyzed for the presence of HPV-16 and HPV-18 DNA by polymerase chain reaction (PCR). The histopathology of the tumor tissue was carried out to assess the grade of the tumor. RESULTS: The mean age of the patients was 54.1 years. A total of 28 (56%) patients had high-grade tumors and 22 (44%) had low-grade disease. T2 or higher stage disease was observed in 18 (36%) patients. All cancerous specimens and control specimens were found to be negative by PCR for the presence of HPV DNA. CONCLUSION: HPV prevalence in the urothelium is very low irrespective of the stage and grade of the disease, and hence, it is unlikely to be the causative agent for urothelial carcinoma of the urinary bladder in Indian population. However, the role of other HPV types in the etiology of this tumor needs to be clarified.

Utility of early dynamic and delayed post-diuretic 18F-FDG PET/CT SUVmax in predicting tumour grade and T-stage of urinary bladder carcinoma: results from a prospective single centre study.

OBJECTIVE: Accurate pre-treatment grading and staging of bladder cancer are vital for better therapeutic decision and prognosis. The aim of the present study was to evaluate the correlation between maximum standardized uptake value (SUVmax) calculated during early dynamic and post-diuretic fluorine-18 fludeoxyglucose (18F-FDG) positron emission tomography (PET)/CT studies with grade and pT-stage of bladder cancer. METHODS: 39 patients with suspected/proven bladder carcinoma underwent 10-min early dynamic pelvic imaging and delayed post-diuretic whole-body FDG PET/CT imaging. SUVmax of the lesions derived from both studies was compared with grade and pT-stage. Relationship of SUVmax with grade and pT-stage was analyzed using independent sample t-test and analysis of variance. RESULTS: SUVmax of the early dynamic imaging showing tumour perfusion was independent from the SUVmax of delayed imaging. High-grade tumours showed higher SUVmax than low-grade tumours in the early dynamic imaging (5.4 ± 1.4 vs 4.7 ± 1.6; p-value 0.144) with statistically significant higher value in Stage pT1 tumours (6.8 ± 0.8 vs 5.5 ± 1.2; p-value 0.04). Non-invasive pTa tumours had significantly less SUVmax than higher stage tumours during early dynamic imaging [F(4,29) = 6.860, p 0.001]. CONCLUSION: Early dynamic imaging may have a role in predicting the grade and aggressiveness of the bladder tumours and thus can help in treatment planning and prognostication. Advances in knowledge: Dynamic PET/CT is a limitedly explored imaging technique. This prospective pilot study demonstrates the utility of this modality as a potential adjunct to standard FDG PET/CT imaging in predicting the grade and aggressiveness of the bladder tumours and thus can impact the patient management.

Robot-assisted vesicovaginal fistula repair: a safe and feasible technique.

INTRODUCTION AND HYPOTHESIS: Open transabdominal repair of vesicovaginal fistula (VVF) requires a long cystotomy incision, suprapubic drainage and delayed recovery. Laparoscopic repair is limited by difficult suturing in pelvic procedures. Therefore, the utility of robotic assistance is being increasingly explored. We share our initial experience of robot-assisted laparoscopic VVF repair. METHODS: The data from patients who underwent robot-assisted VVF repair from December 2014 to August 2016 were recorded and analyzed. Patients underwent standard preoperative evaluation. After cystovaginoscopy and placement of an access catheter across the fistula, a four-port transperitoneal approach was used. Following adhesiolysis, limited posterior cystotomy was performed. The vaginal and bladder flaps were separated and repaired in the transverse and vertical directions, respectively. V-Loc sutures were used for bladder closure. Omental/sigmoid colon epiploicae or a peritoneal flap was interposed. A pelvic drain was placed. RESULTS: During the study period, 30 patients underwent surgery, of whom 11 (36.7 %) had complex VVF (9 with failure of a previous repair, 1 following radiotherapy, and 1 with a large defect following obstructed labor), and 27 had supratrigonal VVF. The mean age of the patients was 43.5 ± 8.6 years. The mean operative time was 133 ± 48 min. Median blood loss was 50 ml (IQR 50 ml). No suprapubic catheter was placed. The median durations of drain placement and hospital stay were 3 days (IQR 2 days) and 7.5 days (IQR 4.5 days), respectively. The median duration of follow up was 38 weeks (IQR 46 weeks). No recurrence was seen in 28 patients (93.3 %). CONCLUSIONS: Current data suggest that robot-assisted VVF repair is safe and feasible and probides the advantages of minimally invasive surgery.

Sustained systemic response paralleled with ovarian metastasis progression by sunitinib in metastatic renal cell carcinoma: Is this an anti-angiogenic potentiation of cancer?

Metastatic renal cell cancer is associated with poor prognosis and survival and is resistant to conventional chemotherapy. Therapeutic targeting of molecular pathways for tumor angiogenesis and other specific activation mechanisms offers improved tumor response and prolonged survival. A 48-year-old, female patient presented with large right renal mass with features suggesting of renal cell cancer without metastasis on contrast enhanced computed tomography (CT). Right radical nephrectomy was done. After 9 months of surgery, she got metastasis in lung, liver and ovary. The patient received sunitinib via an expanded access program. After eight 6-week cycles of sunitinib, a reassessment CT scan confirmed an excellent partial response with the almost complete disappearance (90%) of liver and lung metastasis but the adnexal mass had increased in size (>10 times) and the possibility was thought of second malignancy. Excision of the mass performed. Histopathology of the mass depicted metastatic renal cell cancer. There is possibility of a 'site-specific anti-angiogenic potentiation mechanism' of malignancy in relation to sunitinib based upon the preclinical studies, in reference to the index case. Regression of one site with concurrent progression is possible. The exact mechanism of site-specific response, especially organ specific progression by vascular endothelial growth factor inhibitors in metastatic renal cell cancer warrants further study.

Fulminant Buddchiari syndrome caused by renal primitive neuroectodermal tumor with inferior vena cava thrombus extending to atrium.

Primitive neuroectodermal tumors (PNET) of the kidney are rare, the diagnosis usually being made at histopathology. A young female presented with a massive right renal mass with features of hepatic dysfunction. Computed tomography scan of the abdomen revealed a large tumor of right kidney with tumor thrombus extending from inferior vena cava (IVC) to right atrium with features suggesting Buddchiari syndrome (BCS). Needle biopsy of mass showed a round cell neoplasm and positive staining for neuron specific enolase and minimum inhibitory concentration-2 on immunohistochemistry. She was managed with neo-adjuvant chemotherapy, surgery and adjuvant chemotherapy. To the best of our knowledge this is the first case of renal PNET with inferior IVC tumor thrombus extending to right atrium with BCS. We suggest that renal PNET should be kept in mind as a differential diagnosis in young adults presenting with a large kidney mass extending to IVC that shows evidence of necrosis on imaging, which may be associated with BCS as in index case.

Efficacy of holmium laser urethrotomy in combination with intralesional triamcinolone in the treatment of anterior urethral stricture.

PURPOSE: To evaluate the outcome of visual internal urethrotomy with a holmium:yttrium-aluminum-garnet laser along with intralesional triamcinolone injection. MATERIALS AND METHODS: Patients with an anterior urethral stricture less than 3 cm in length were evaluated by clinical history, physical examination, uroflowmetry, and retrograde urethrogram preoperatively. All patients were treated with holmium laser urethrotomy and intralesional triamcinolone (80 mg) injection under general or regional anesthesia. An 18 F urethral catheter was placed for 5 days. All patients were followed up for 12 months postoperatively by history, uroflowmetry, and if required, retrograde urethrogram or urethroscopy every 3 months. RESULTS: The mean age of the patients was 42.9 years (range, 14 to 70 years). The overall recurrence rate was 24%. The success rate in patients with strictures less than 1 cm in length was 95.8%, whereas that in patients with strictures of 1 to 3 cm in length was 57.7% (p=0.002). The outcome did not depend on age, duration of symptoms, etiology, or location of stricture. CONCLUSIONS: Holmium laser urethrotomy with intralesional triamcinolone is a safe and effective minimally invasive therapeutic modality for urethral strictures. This procedure has an encouraging success rate, especially in those with stricture segments of less than 1 cm in length.

Status of oxidative stress in patients with renal cell carcinoma.

PURPOSE: Although oxidative stress is implicated in renal cell carcinoma pathogenesis, to our knowledge changes in oxidative stress parameters in patients who undergo surgery for renal cell carcinoma have not been studied previously. We investigated the status of oxidative stress in patients with renal cell carcinoma. MATERIALS AND METHODS: Reactive oxygen species, nitric oxide and glutathione were measured in the blood of 68 patients with renal tumor and in 30 age matched normal controls. Levels were measured again 1 week, and 1 and 2 months postoperatively in patients who underwent surgery for renal cell carcinoma. Levels of superoxide dismutase, catalase and lipid peroxidation were measured in tumor tissue and in normal renal parenchyma in 51 patients with renal tumor. RESULTS: Significantly increased reactive oxygen species and nitric oxide, and decreased glutathione were observed in patients with renal cell carcinoma compared to normal subjects and in patients with benign tumors. Superoxide dismutase and lipid peroxidation were increased and catalase was decreased in tumor tissue compared to normal renal tissue. Oxidative stress correlated with renal cell carcinoma grade and stage but decreased after curative resection. Patients with metastatic disease had persistently increased oxidative stress parameters. Antioxidant enzyme levels in benign tumor tissue were significantly higher than in renal cell carcinoma. CONCLUSIONS: Patients with renal cell carcinoma have increased oxidative stress, which is effectively alleviated by curative resection. In patients with benign tumors antioxidant defense mechanisms maintain normal redox status.

Plasma chromogranin A: clinical implications in patients with castrate resistant prostate cancer receiving docetaxel chemotherapy.

OBJECTIVE: Development of castrate resistant prostate cancer (CRPC) indicates progressive disease with poor survival. Docetaxel has variable response with a good proportion of nonresponders. Neuroendocrine differentiation, hypothesised as one of the mechanisms behind development of CRPC, can be assessed by plasma Chromogranin A (CgA). We evaluated the clinical importance of circulating CgA in CRPC patients receiving Docetaxel. METHODS: Plasma CgA was assessed by ELISA in 14 patients with CRPC receiving 3-weekly docetaxel. Baseline PSA, baseline CgA, PSA response, CgA response and clinical response to chemotherapy were evaluated and analysed. RESULTS: Increased plasma CgA was observed in 64.3% of patients. There was no correlation between baseline CgA and PSA. Two patients with PSA < 10 ng/ml had elevated CgA. Baseline CgA was not influenced by variables such as site of metastasis and time to develop CRPC status. Seven patients (50%) had PSA-response and 5 (36%) CgA-response. In 4 patients PSA response and CgA response were discordant. Compared to men with normal baseline CgA, a higher proportion of those with elevated baseline CgA had PSA response (55% vs 40%), symptomatic response (66% vs 40%) and radiological response (55% vs 20%). Two patients with symptomatic response had only CgA response. Three patients having disease progression despite PSA response had increasing CgA. CONCLUSIONS: CgA and PSA are complementary tumour markers in CRPC. CgA may help in predicting the response of docetaxel therapy. Rising CgA during therapy may be associated with bad prognosis whereas CgA response is likely to be associated with clinical response.

Is there an adjunctive role of tamsulosin to extracorporeal shockwave lithotripsy for upper ureteric stones: results of an open label randomized nonplacebo controlled study.

OBJECTIVES: To investigate the role of tamsulosin as an adjunct to management of upper ureteric stones (UUS) with extracorporeal shock wave lithotripsy (SWL). METHODS: In this prospective, randomized, open label study, patients with single UUS (for SWL) were randomly assigned into 2 groups based on whether they received 0.4 mg tamsulosin (group A and B, respectively) during treatment. Repeat SWL was performed at week 1, 3, and 5 after first session. Primary outcome variables were success rate and pain intensity. RESULTS: A total of 40 patients (20 each group) completed the requisite follow-up. Success rate was higher in group A after 1 SWL-session (55% vs 25%, respectively; P = .05). There was an insignificant trend of decreased number of days (30.7 +/- 19.7 vs 39.0 +/- 19.9; P = .19), number of SWL sessions (1.6 vs 2.0; P = .10), and pain experienced (score on visual analog scale, 25.3 +/- 17.9 vs 38.3 +/- 28.0, respectively; P = .41) in group A. Three in group A and 6 in B developed steinstrasse (P = .69). Overall, 1 in group A required auxiliary procedures as compared with 3 in control group (P = .60). CONCLUSIONS: Tamsulosin improves clearance rate of UUS after single SWL. However, it does not provide significant advantage in terms of decreasing pain associated with this treatment.

Non-interventional management of obstructive acute renal-failure in hormone-naïve prostate cancer.

Advanced carcinoma prostate (CaP) commonly presents as bilateral ureteric obstruction. The management often requires androgen ablation along with temporary urinary diversion (percutaneous nephrostomy or ureteric catheterization) which is not infrequently associated with complications. Two patients of hormone-naïve CaP presented to our emergency department with oliguric renal failure due to bilateral ureteric obstruction and were treated with dialysis, ketoconazole (for androgen ablation) and corticosteroids; urinary diversion was not feasible in either at the time of presentation. Brisk diuresis occurred within 48 hours obviating the need of urinary diversion. Follow-up of these cases is presented and justification of this approach is discussed.

Reninoma treated with nephron-sparing surgery.

A 14-year-old hypertensive boy was evaluated in our clinic. The physical examination was essentially normal except for his high blood pressure. Laboratory findings showed increased plasma renin activity. Abdominal ultrasonography detected a hypoechoic, 2-cm mass in right kidney. Contrast-enhanced computed tomography of the abdomen revealed a well-circumscribed, solid, hypoenhancing cortical lesion in the middle of the right kidney. Magnetic resonance angiography documented bilateral normal renal arteries. With a preoperative diagnosis of reninoma, the patient underwent nephron-sparing surgery. Intraoperative frozen section analysis revealed a benign lesion. Subsequently, histopathologic examination and electron microscopy confirmed the diagnosis of juxtaglomerular cell tumor. The patient remained normotensive in the postoperative period. Follow-up intravenous urography showed bilateral normally functioning kidneys.