Kidney computed tomography perfusion in patients with ureteral obstruction.

INTRODUCTION: Kidney perfusion on CT is an encouraging surrogate for renal scintigraphy in assessing renal function. However, data on dynamic volumetric CT in patients with kidney obstruction is lacking. Thus, the aim of this study is to determine the feasibility of CT-based renal perfusion using a dynamic volume to assess renal hemodynamics at different degrees and durations of obstruction. MATERIALS AND METHODS: We included patients with unilateral kidney obstruction in our single-center, prospective study. The patients were divided into three groups. Patients without dilatation of the pelvicalyceal system (PCS) and normal parenchyma thickness were included into Group 1; patients with PCS dilatation and parenchyma thickness 1.8-2.4 cm-into Group 2; and patients with ureteropyelocalicoectasia and parenchyma thickness less than 1.8 cm-into Group 3. RESULTS: Total of 56 patients were enrolled. In Group 1 mean values of cortical and medullar arterial blood flow, blood volume, and extraction fraction were within the normal range. Changes in contralateral kidney were not determined. Patients from Group 2 showed significant differences in blood flow parameters in the cortical and medulla of the obstructed kidney. No changes in perfusion values in the contralateral kidney was observed. In patients from Group 3 there was a marked decrease in perfusion on the side of obstruction compared to Group 2, indicating that the degree of expansion of the PCS directly correlates with the change in blood flow. However, in the contralateral kidney, these indicators exceeded the normal values of perfusion. CONCLUSION: CT perfusion allows to objectively assess changes in blood flow in the setting of renal obstruction. The degree of obstruction directly affects the measured rate of blood flow.

Adjuvant chemotherapy after radical cystectomy: Do all patients who need chemotherapy after surgery actually receive it?

Background: Compliance with the guideline recommendations for neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer is incomplete. The adjuvant chemotherapy approach has the advantage of pathology-based decision-making, allowing for patient selection. In addition, radical surgery is not delayed and treatment-related toxicity does not impair surgical fitness. The proportion of patients who completed chemotherapy after cystectomy among those who were fit and in need of treatment were evaluated. The reasons for not completing adjuvant chemotherapy were determined. Materials and methods: We retrospectively evaluated all patients who had undergone radical cystectomy at our center over the last 7 years. Indications for adjuvant chemotherapy included pathological T > 2, any node+, or surgical margin involvement. Only patients who were fit for chemotherapy before surgery were included in the study. Results: Of the 52 patients with muscle-invasive bladder cancer, 14 received neoadjuvant chemotherapy or unfit for chemotherapy were excluded. Of the remaining 38 patients, 14 (37%) had bladder-confined cancers and did not require additional chemotherapy. Of the 24 patients who needed chemotherapy and were fit to receive it, 8 patients completed treatment (33%), and 3 discontinued treatment due to toxicity. Twelve patients (50%) declined chemotherapy, whereas 1 patient became unfit for chemotherapy after surgery. Conclusions: While the adjuvant chemotherapy approach could save unnecessary treatment in 37% of patients, two-thirds of those who needed chemotherapy did not complete it. Patient refusal was the primary reason for not receiving treatment.

The Impact of Radiographic, Metabolic and Demographic Characteristics on Kidney Stone Recurrence.

Urolithiasis is a frequent disease with cited rates of recurrence after initial diagnosis that vary widely and range between 35% and 50%. We assessed the radiographic recurrence rate in patients with urinary stones and its risk factors. We retrospectively identified patients who were diagnosed with urinary stones on non-contrast computed tomography from 2010 to 2011, and underwent another imaging examination at least six months afterwards. We collected patient demographic, clinical, laboratory and radiologic data and compared patients with and without urinary stone recurrence. Ultimately, 237 patients were included in the study; the mean follow-up was 6.7 years; 88 patients (37.1%) had recurrence based on our recurrence criteria. On univariate analysis, the significant parameters for recurrence were baseline serum calcium and uric acid, stone location in the kidney, surgical intervention and stone burden volume. On multivariate analysis, surgical intervention (OR 3.07, p = 0.001), baseline calcium (OR 2.56, p = 0.011), baseline uric acid (OR 1.30, p = 0.021) and stone location in the kidney (OR 2.16, p = 0.012) were associated with higher risk of recurrence. These findings may guide personalized follow-up protocols for patients with urolithiasis based on their risk factors.

Potential Markers to Reduce Non-Contrast Computed Tomography Use for Symptomatic Patients with Suspected Ureterolithiasis.

Most patients with ureterolithiasis are managed successfully with conservative treatment. In this context, delineation of clinical risk factors that identify patients with low risk for surgical intervention may reduce use of Non-Contrast Computed Tomography (NCCT). Here, emergency department patient files from a 14-month period were reviewed retrospectively, to identify patients who underwent NCCT and showed a ureteral stone. Demographic, clinical and laboratory information was collected. Patients were grouped to either requiring surgical intervention (Group 1) or having successful conservative management (Group 2). The cohort included 368 patients; 36.1% ultimately required surgical intervention (Group 1) and 63.9% were successfully treated conservatively (Group 2). On univariate analysis, patients who required surgical intervention were older, had longer duration of symptoms, had history of urolithiasis and surgical intervention for urolithiasis and had higher serum creatinine levels. Multivariate analysis identified the following risk factors associated with surgical intervention: creatinine >1.5 mg/dL, duration of symptoms ≥ 1.5 days and age > 45 years. Patients with 0, 1, 2 or 3 of the identified risk factors had 19%, 32%, 53% and 73% likelihood, respectively, of surgical intervention. Incorporating these data may reduce the use of NCCT scans in patients who are likely to pass a stone via conservative management.

When should we give up on expectant management for patients with proximal ureteral stones?

Background: Proximal ureteral stones (PUS) have relatively low rates of spontaneous expulsion. However, some patients do well on expectant management. Our aim was to compare risk factors for surgical intervention in patients with PUS who underwent primary intervention to those subjected to expectant management. Materials and methods: We retrospectively reviewed the medical charts of patients presented to the emergency room with symptoms of renal colic and underwent computerized tomography between August 2016 and August 2017. A total of 97 consecutive patients were identified with up to 10mm PUS. We collected patient demographics, clinical, and imaging data, and performed binary regression analysis for risk of intervention. Results: The average age was 49years (range 17-97) and average stone size was 7.1mm (range 3-10). Forty-one patients underwent immediate intervention while the remaining 56 patients were treated conservatively. Of the 56 patients treated conservatively, 26 underwent delayed intervention while 30 reported spontaneous stone expulsion. On univariate analysis of all 97 patients, statistically significant risk factors for intervention were found based on stone size, age, serum lymphocyte, platelet counts, and stone density. Of these risk factors, stone size ≥ 7mm (p = 0.012, odds ratio = 5.4) and platelet count ≤ 230K/µL (p = 0.027, odds ratio = 4.9) remained statistically significant on multivariate analysis. Conclusion: Stone size and platelet count were found to be risk factors for surgical intervention in patients with up to 10mm PUS. These findings may assist in identifying patients who are more suitable for conservative approach.

Surgical Outcomes in High-risk Prostate Cancer and Salvage Radical Prostatectomy.

BACKGROUND: Patients with high-risk prostate cancer are at higher risk of treatment failure, development of metastatic disease, and mortality. There is no consensus on the treatment of choice for these patients, and either radical prostatectomy (RP) or external beam radiation therapy (EBRT) is recommended. Surgery is less common as the initial treatment for high-risk patients, possibly reflecting the concerns regarding morbidity as well as oncological and functional outcomes. Another high-risk group includes patients with failure of previous EBRT or focal treatment. For these patients, salvage radical prostatectomy (SRP) can be offered. OBJECTIVES: To describe our experience with surgery of high-risk patients and SRP. METHODS: This cohort included all high-risk patients undergoing RP or SRP at our institution between January 2012 and December 2019. We reviewed the electronic medical charts and collected pathological, functional, and oncological outcomes. RESULTS: Our cohort included 39 patients; average age was 67.8 years, and average follow-up duration was 40.9 months. The most common postoperative morbidity was transfusion of packed cells. There were no life-threatening events or postoperative mortality. Continence was preserved (zero to one pad) in 76% of the patients. Twenty-three patients (59%) had undetectable prostate specific antigen levels following the surgery, 11 (30%) were treated with either adjuvant or salvage EBRT, and 12 patients (31%) were found with no evidence of disease and no additional treatment was needed. CONCLUSIONS: Radical prostatectomy and SRP are safe options for patients presenting with high-risk prostate cancer, with good functional and oncological outcomes.

Radical Cystectomy after Previous Radiation or Pelvic Surgery: Is It Associated with Increased Morbidity?

BACKGROUND: Radical cystectomy is a complicated surgery with significant risks. Complications of Clavien-Dindo grade 3-4 range from 25% to 40% while risk of mortality is 2%. Pelvic surgery or radiotherapy prior to radical cystectomy increases the challenges of this surgery. OBJECTIVES: To assess whether radical cystectomy performed in patients with prior history of pelvic surgery or radiation was associated with increased frequency of Clavien-Dindo grade 3 or higher complications compared to patients without prior pelvic intervention. METHODS: We retrospectively evaluated all patients who underwent radical cystectomy at our center over a 7-year period. All patients with pelvic radiation or surgery prior to radical cystectomy comprised group 1, while group 2 included the remaining patients. RESULTS: In our study, 65 patients required radical cystectomy at our institution during the study period. Group 1 was comprised of 17 patients and group 2 included 48 patients. Four patients from group 2 received orthotopic neobladder, while an ileal conduit procedure was performed in the remaining patients. Estimated blood loss and the amount of blood transfusions given was the only variable found to be statistically different between the two groups. One patient from group 1 had four pelvic interventions prior to surgery, and her cystectomy was aborted. CONCLUSIONS: Radical cystectomy may be safely performed in patients with a history of pelvic radiotherapy or surgery, with complication rates similar to those of non-irradiated or operated pelvises.

Do patients with ureterolithiasis treated conservatively return to follow up?

INTRODUCTION Distal ureteral stones (DUS) are common in patients presenting to the emergency department (ED) with renal colic. The majority of DUS will pass spontaneously and therefore conservative care is common. Follow up is imperative as some of these stones might not pass and potentially lead to complications. The aim of our study was to evaluate the rate of compliance with follow up and to find predictive variables for it. MATERIALS AND METHODS: We retrospectively surveyed the medical records of all patients who had a non-contrast computed tomography (NCCT) at our ED between 01/03/16 and 31/5/17. We included patients with a DUS smaller than 10 mm that were treated conservatively. We obtained demographic, clinical, laboratory and imaging data. Compliance to follow up was evaluated by surveying the medical records and by calling the patients. We then compared the characteristics of patients who returned for follow up to those who did not. RESULTS: A total of 230 consecutive patients were included in our cohort: 194 (84%) patients were male and the average age was 46 y (21-82); 138 patients (60%) returned for a follow up visit while 92 patients (40%) did not. Univariate analysis revealed stone size and admission to hospital to be predictive of compliance to follow up while multivariate analysis revealed only hospital admission to be predictive of compliance. CONCLUSIONS: Only 60% of the patients with DUS treated conservatively return for a follow up visit. Hospital admission, which likely reflects appropriate patients counseling by a urologist and adequate follow up scheduling, was found to be associated with increased compliance with follow up.

Prediction of Surgical Intervention for Distal Ureteral Stones.

Introduction and Objective: Eighty percent of patients with distal ureteral stones <10 mm will ultimately pass the stone under conservative care. Nonetheless, some may experience related morbidity before surgical intervention is performed. Our study aims to find predictive variables for surgical intervention. Methods: We retrospectively surveyed medical records of patients found to have distal ureteral stone up to 10 mm by noncontrast computed tomography (NCCT) done between March 1, 2016 and May 31, 2017. Demographic, clinical, laboratory, and radiologic data were obtained. We compared characteristics of patients who underwent surgical intervention (ureteroscopy/renal drainage) with those treated conservatively. Results: A total of 268 consecutive patients were included: 226 (84%) were male and the average age was 46 years (18-82). Of these patients, 60 patients (22%) underwent surgical intervention (group 1) and 208 patients (78%) were treated expectantly (group 2). No significant differences were observed with respect to demographic data or proportion of patients treated with medical expulsive therapy between the groups. Univariate analysis found stone diameter, stone-to-ureterovesical junction (UVJ) distance, stone density, presence of a "rim sign" on NCCT, and pain duration at presentation to be significantly different between the groups. Multivariate analysis showed stone diameter, stone-to-UVJ distance, and pain duration at presentation to be independently predictive for intervention. Receiver operating characteristics curve analysis identified stone size >4 mm, stone-to-UVJ distance >4 mm, and pain duration >4 days to be the most significant cutoff points for patient risk stratification-"Rule of 4's." Further analysis showed that the prevalence of intervention among patients with 0, 1, 2, and 3 risk factors was 4.3%, 22.1%, 45%, and 66.7%, respectively. Conclusions: Stone size, stone distance from the UVJ, and pain duration play a significant role in predicting surgical intervention. "Rule of 4's" may aid in early recognition of patients who will ultimately undergo intervention and omit the burden of nonfavorable expectant management.

Spermatogenesis in Testicles with Germ Cell Tumors.

BACKGROUND: Almost 50% of patients with germ-cell tumors (GCT) are subfertile, and every step of the treatment may further impair fertility. As a result, sperm banking is often advised prior to radical orchiectomy. However, whether affected testes contribute to fertility is unclear. OBJECTIVES: To determine whether maximal tumor diameter (MTD) is correlated with ipsilateral fertility (IF) in patients treated for GCT. METHODS: We reviewed medical charts for demographic and clinical data of patients with GCT who had undergone orchiectomy at our institution between 1999 and 2015. The extent of spermatogenesis was categorized into three groups: full spermatogenesis, hypospermatogenesis, and absence of spermatogenesis. The presence of mature spermatozoa in the epididymis tail was also assessed. We defined IF as the combination of full spermatogenesis in more than 100 tubules and the presence of mature spermatozoa in the epididymis tail. Mann-Whitney was applied to determine the correlation between MTD and IF. RESULTS: Of 57 patients, IF was present in 28 (49%). Mean patient age was 32.8 years in patients with positive IF and 33.4 years those with negative IF. Seminoma was diagnosed in 46.4% of patients with positive IF and in 65.5% of patients with negative IF. Full spermatogenesis was observed in 33 patients (57.8%). In 48 (82.7%), mature epididymal spermatozoa were found. No correlation was found between MTD and IF. CONCLUSIONS: IF is present in almost half of the patients undergoing radical orchiectomy. Because IF cannot be predicted by MTD, routine pre-orchiectomy sperm banking is suggested.