EXIT from TRansrectal prostate biopsies (TREXIT): sepsis rates of transrectal biopsy with rectal swab culture guided antimicrobials versus freehand transperineal biopsy.

BACKGROUND: Transrectal prostate biopsy (TRUSBx) holds a risk of prostate biopsy related sepsis. We discuss our step-wise strategies aiming to reduce this risk, including targeted antimicrobials and switching to a freehand transperineal approach (FHTPBx). SUBJECTS AND METHODS: This longitudinal cohort study included three groups. Group A underwent TRUSBx with empirical augmented antimicrobial prophylaxis; Group B underwent TRUSBx with targeted antimicrobial prophylaxis, based on rectal-swab cultures/sensitivity; Group C underwent FHTPBx with empirical antimicrobial prophylaxis. Post biopsy sepsis, defined according to the surviving sepsis campaign and confirmed with blood or urinary cultures, were determined and rates between groups were analysed using fisher's exact test. RESULTS: Of all 1501 patients, 23 developed post biopsy sepsis; Group A (12/609, 2.0%), B (9/403, 2.2%), C (2/489, 0.4%). Targeted antimicrobials did not reduce the risk of post biopsy sepsis following TRUSBx (A vs B, 2.0% vs 2.2%; p = 0.82). Patients with antimicrobial-resistant rectal flora had an increased post biopsy sepsis rate following TRUSBx despite targeted antimicrobials (9.1% vs 1.1%, p = 0.003). Switching to FHTPBx reduced the risk of developing post biopsy sepsis (A vs C, 2% vs 0.4%, p = 0.03; B vs C, 2.2% vs 0.4%, p = 0.03). CONCLUSIONS: Targeted antimicrobials based on rectal swab culture failed to reduce the overall risk of post biopsy sepsis, while FHTPBx nearly eliminated this risk. We recommend the use of transperineal prostate biopsies for all patients as the most effective method to reduce the risk of sepsis.

The Fate of Ureteral Memokath Stent(s) in a High-Volume Referral Center: An Independent Long-Term Outcomes Review.

Purpose: To independently assess upper urinary tract Memokath (MMK-051) stent outcomes in a national tertiary referral center. Materials and Methods: Two researchers, completely independent to the treating team, reviewed electronic MMK-051 stent(s) patient management records. Outcomes included time to first complication, complication(s)-severity, MMK-051 stent lifespan and change incidence, salvage therapy, further surgical intervention, and mortality. Results and Limitations: One hundred patients received 162 MMK-051 stent(s) (59% with malignant and 63% with distal ureteral obstruction [UO]) with only three lost to follow-up (FU). At 5-year mean FU, only 25 patients had complication-free original MMK-051 stents (14 alive, 11 dead). Of the remaining 75 patients, 22 had other stents, 12 had major surgery (e.g., nephrectomy), 3 became dialysis dependent, and 14 stabilized without ureteral stenting after original MMK-051 removal. Malignant obstruction patients had greater original MMK-051 stent longevity (p < 0.02), but also 20 of the 21 deaths (95%). The 72% mean 5-year stent complication rate included migration (46%), blockage (34%), nonfunctioning kidney (8%), urosepsis needing intravenous antibiotics (8%), and others (6%), including one postoperative death, one ureteral injury, and two with intractable pain. Median time to first complication was 12.5 months. Conclusions: MMK-051 stents had optimal utility in managing malignant UO and in those unfit for corrective surgery. Longer independently assessed mean 5-year outcomes review revealed much higher complication rates (72%) than previously reported. Future international metallic ureteral stent guidelines should encourage clinicians to adopt patient-centered multidisciplinary assessment and selection, with counseling plus goal-setting, and harmonized long-term protocol-based reporting, for optimized future patient safety and outcomes.

Targeted and systematic cognitive freehand-guided transperineal biopsy: is there still a role for systematic biopsy?

OBJECTIVES: To assess whether targeted cognitive freehand-assisted transperineal biopsies using a PrecisionpointTM device still require additional systematic biopsies to avoid missing clinically significant prostate cancer, and to investigate the benefit of a quadrant-only biopsy approach to analyse whether a quadrant or extended target of the quadrant containing the target only would have been equivalent to systematic biopsy. PATIENTS AND METHODS: Patients underwent combined systematic mapping and targeted transperineal prostate biopsies at a single institution. Biopsies were performed using the Precisionpoint device (Perineologic, Cumberland, MD, USA) under either local anaesthetic (58%, 163/282), i.v. sedation (12%, 34/282) or general anaesthetic (30%, 85/282). A mean (range) of 24 (5-42) systematic and 4.2 (1-11) target cores were obtained. Magnetic resonance imaging (MRI) scans were reported using the Likert scale. Clinically significant cancer was defined as Gleason 7 or above. Histopathological results were correlated with the presence of an MRI abnormality within a spatial quadrant and the other adjoining or non-adjoining (opposite) quadrants. Histological concordance with radical prostatectomy specimens was analysed. RESULTS: A total of 282 patients were included in this study. Their mean (range) age was 66.8 (36-80) years, median (range) prostate-specific antigen level 7.4 (0.91-116) ng/mL and mean prostate volume 45.8 (13-150) mL. In this cohort, 82% of cases (230/282) were primary biopsies and 18% (52/282) were patients on surveillance. In all, 69% of biopsies (195/282) were identified to have clinically significant disease (Gleason ≥3 + 4). Any cancer (Gleason ≥3 + 3) was found in 84% (237/282) of patients. Of patients with clinically significant disease, the target biopsies alone picked up 88% (171/195), with systematic biopsy picking up the additional 12% (24/195) that the target biopsies missed. This altered with Likert score; 73% of Likert score 3 disease was detected by target biopsy, 92% of Likert score 4 and 100% of Likert score 5. Target biopsies with additional same-quadrant-only systematic cores picked up 75% (18/24) of significant cancer that was missed on target only, found in the same quadrant as the target. CONCLUSION: Systematic biopsy is still an important tool when evaluating all patients referred for prostate biopsy, but the need is decreased with increasing suspicion on MRI. Patients with very high suspicion of prostate cancer (Likert score 5) may not require systematic cores, unless representative surrounding biopsies are required for other specific treatments (e.g. focal therapy, or operative planning). More prospective studies are needed to evaluate this in full.

Minimum 5-year follow-up of 1138 consecutive laparoscopic radical prostatectomies.

OBJECTIVES: To investigate the long-term outcomes of laparoscopic radical prostatectomy (LRP). PATIENTS AND METHODS: In all, 1138 patients underwent LRP during a 163-month period from 2000 to 2008, of which 51.5%, 30.3% and 18.2% were categorised into D'Amico risk groups of low-, intermediate- and high-risk, respectively. All intermediate- and high-risk patients were staged by preoperative magnetic resonance imaging or computed tomography and isotope bone scanning, and had a pelvic lymph node dissection (PLND), which was extended after April 2008. The median (range) patient age was 62 (40-78) years; body mass index was 26 (19-44) kg/m(2) ; prostate-specific antigen level was 7.0 (1-50) ng/mL and Gleason score was 6 (6-10). Neurovascular bundle was preservation carried out in 55.3% (bilateral 45.5%; unilateral 9.8%) of patients. RESULTS: The median (range) gland weight was 52 (14-214) g. The median (range) operating time was 177 (78-600) min and PLND was performed in 299 patients (26.3%), of which 54 (18.0%) were extended. The median (range) blood loss was 200 (10-1300) mL, postoperative hospital stay was 3 (2-14) nights and catheterisation time was 14 (1-35) days. The complication rate was 5.2%. The median (range) LN count was 12 (4-26), LN positivity was 0.8% and the median (range) LN involvement was 2 (1-2). There was margin positivity in 13.9% of patients and up-grading in 29.3% and down-grading in 5.3%. While 11.4% of patients had up-staging from T1/2 to T3 and 37.1% had down-staging from T3 to T2. One case (0.09%) was converted to open surgery and six patients were transfused (0.5%). At a mean (range) follow-up of 88.6 (60-120) months, 85.4% of patients were free of biochemical recurrence, 93.8% were continent and 76.6% of previously potent non-diabetic men aged <70 years were potent after bilateral nerve preservation. CONCLUSIONS: The long-term results obtainable from LRP match or exceed those previously published in large contemporary open and robot-assisted surgical series.

[Quality of life and overall survival in high risk patients after radical cystectomy with a simple urinary derivation]. / Calidad de vida y supervivencia global en pacientes de alto riesgo tras cistectomía radical con una derivación urinaria simple.

OBJECTIVE: To evaluate quality of life (QoL) and overall survival after radical cystectomy with cutaneous ureterostomies for locally advanced bladder cancer in elderly patients with high surgical risk. METHODS: Fifty eight patients older than 74 years (mean age 80,6±4,3) with locally advanced bladder cancer (group A), underwent radical cystectomy and ureterocutaneous diversion. Patients completed the EORTC QLQC30 before and six months after surgery to assess functional, clinical and QoL outcomes. The same evaluation was carried out in a control group (group B) of 29 patients (mean age 82,3±3,8 years), who had refused cystectomy. Questionnaires were also administered to patients of both groups who survived at least 20 months and 5 years. RESULTS: All patients presented with an ASA score ≥3. Mean hospital stay was 15.1 days (±4.8) in group A and 23.5 days (±4.1) in Group B. No intraoperative complications occurred in group A. Postoperative overall survival evaluated within 6 months in group A was 97% versus 79% in group B (p<0.001). CONCLUSION: Radical cystectomy with cutaneous ureterostomy represents a valid alternative in elderly patients with invasive bladder cancer and high operative risk. Comparison between two groups showed a statistically significant difference for almost all the Qol related parameters and for short and medium term overall survival.

Laparoscopic radical prostatectomy for high-risk prostate cancer.

OBJECTIVE: To investigate the results of performing laparoscopic radical prostatectomy (LRP) in patients with high-risk prostate cancer (HRPC): PSA level of ≥20 ng/mL ± biopsy Gleason ≥8 ± clinical T stage ≥2c. PATIENTS AND METHODS: Of a total of 1975 patients having LRP during a 159-month period from 2000 to 2013, 446 (22.6%) had HRPC; all patients were staged by preoperative magnetic resonance imaging or computed tomography and isotope bone scanning. The median (range) patient age was 64.0 (36-79) years; body mass index 27.0 (18-43) kg/m(2) ; PSA level 8.1 (0.1-93) ng/mL and biopsy Gleason 8 (6-10). All patients had a pelvic lymphadenectomy, which was done using an extended template after April 2008 (53.3%). Neurovascular bundle (NVB) preservation was done in 41.5% (bilateral 26.3%; unilateral 15.2%) of patients; an incremental or partial nerve-sparing technique was used in 99 of the 302 (32.8%) NVBs preserved. RESULTS: The median (range) gland weight was 58.5 (20-161) g; operating time 180 (92-330) min; blood loss 200 (10-1400) mL; postoperative hospitalisation 3.0 (2-7) nights; catheterisation time 14 (2-35) days; complication rate 7.6%; lymph node (LN) count 16 (2-51); LN positivity 16.2%; LN involvement 2 (1-8); positive surgical margin (PSM) rate 26.0%; up-grading 2.5%; down-grading 4.3%; up-staging from T1/2 to T3, 24.7%; down-staging from T3 to T1/2, 6.1%. No cases were converted to open surgery and three patients were transfused (0.7%) after surgery. At a mean (range) follow-up of 24.9 (3-120) months, 79.2% of patients were free of biochemical recurrence, 91.8% were continent and 64.4% of previously potent non-diabetic men aged <70 years were potent after bilateral nerve preservation. CONCLUSION: The low morbidity, 55.4% specimen-confinement rate, 26.0% PSM rate, 79.2% biochemical disease-free survival, 91.8% continence rate and 64.4% potency rate, at 35.2 months in the present study serve as evidence firstly that surgery is an effective treatment for patients with HRPC, curing many and representing the first step of multi-modal treatment for others, and that LRP for HRPC appears to be as effective as open RP in this context.

Efficacy and safety of prostate vaporesection using a 120-W 2-µm continuous-wave Tm:YAG laser (RevoLix 2) in patients on continuous oral anticoagulant or antiplatelet therapy.

The aim of our current study was to demonstrate the efficacy and safety of vaporesection using a 120-W Tm:YAG laser (Revolix Duo) in patients with BPH receiving systemic anticoagulation or antiplatelet therapy. Between April 2010 and November 2011, a total of 76 patients using oral antiplatelet or anticoagulant (OA) agents affected by LUTS for BPH were underwent thulium vaporesection of the prostate (ThuVARP) using a 120-W 2-µm CW Tm:YAG laser and evaluated at 3- and 6-month follow-up. Of these, in 41 patients (group A) was performed vaporesection while receiving OA therapy. In 35 patients (group B), OA agents were discontinued 10 days before surgery. There were no significant differences in average vaporesection times, catheterization time, or hospital stay. There was no significant change in serum sodium level before and immediately after vaporesection in either group. Significant improvements compared to baseline were observed at each postoperative assessment in both groups for Qmax, PVR, IPSS, and QoL. More specifically, the IPSS score improved from 21.7 at baseline to 5.2 at 6 months in group A and from 20.7 to 4.5 in group B. At 6 months, Qmax increased 226 and 190 % for the 2 groups, respectively. The PVR decreased from 119 at baseline to 11 mL at 6 months in group A and from 125 to 11 mL in group B. ThuVARP is a safe and efficient procedure for patients with BPH, refractory to pharmacotherapy, who require active antiplatelet or anticoagulant therapy.

Lumbar Ureteral Stenosis due to Endometriosis: Our Experience and Review of the Literature.

Endometriosis is a chronic gynaecological disorder characterized by the presence of endometrial tissue outside the uterus. The disease most often affects the ovaries, uterine ligaments, fallopian tubes, and cervical-vaginal region. Urinary tract involvement is rare, accounting for around 1%-2% of all cases, of which 84% are in the bladder. We report a case of isolated lumbar ureteral stenosis due to endometriosis in a 37-year-old patient. The patient came to our observation complaining from lumbar back pain and presented with severe fever. The urological examination found monolateral left positive sign of Giordano. Blood tests evidenced marked lymphocytosis and increased valued of C-reactive protein. Urologic ultrasound showed hydronephrosis of first degree in the left kidney and absence of images related to stones bilaterally. Uro-CT scan evidenced ureteral stenosis at the transition between the iliac and pelvic tracts. We addressed the patient to surgery, and performed laparoscopic excision of the paraureteral bulk, endoscopic mechanical ureteral dilation, and stenting. The histological examination evidenced glandular structures lined by simple epithelium and surrounded by stroma. Immunohistochemical test of the glandular epithelium showed positivity for estrogen and progesterone receptors and moreover stromal cells were positive for CD10. The finding suggested a very rare diagnosis of isolated lumbar ureteral endometriosis.

Longitudinal observational cohort study about detrusor underactivity as a risk factor for bladder neck contracture after retropubic radical prostatectomy: preliminary results.

OBJECTIVES: To evaluate the association between preoperative detrusor underactivity (DU) and symptomatic bladder neck contracture (BNC) in patients undergoing radical retropubic prostatectomy (RRP), in order to identify a possible new risk factor in the etiopathogenic mechanisms of BNC after RRP. METHODS: A total of 100 prostate cancer patients underwent RRP after preoperative complete urodynamic examination. Detrusor contractility was evaluated by bladder contractility index (BCI), power at maximum flow (WF-Qmax), and maximum velocity of detrusorial contraction (MVDC). Follow-up included uroflowmetry with bladder post-voiding volume evaluation at 3 and 6 months after surgery and repeated urodynamic examination at 12 months. Statistical evaluation was performed using the Student's t test (P < 0.01). RESULTS: The mean patient age was 65.6 ± 5.4 years, and pathological stage ranged from T2a to T2c. A total of 40 patients (40 %) presented normal detrusor contractility, 47 (47 %) mild DU, and 13 (13 %) severe DU. Detrusor overactivity (DO) was observed in 12 patients (12 %), small cystometric capacity in 10 (10 %), low compliance in 16 (16 %), DO plus DU (mild or severe) in 6 (6 %), and DO plus small cystometric capacity together with low compliance in 5 (5 %). Normal urodynamics were observed in 38 patients (38 %). Overall BNC incidence was 12. All patients with BNC presented preoperative DU; none presented DO or low bladder compliance. DU severity and BNC occurrence were significantly correlated (P < 0.01) for all 3 urodynamic parameters (BCI, WF-Qmax, and MVDC). CONCLUSIONS: We identify DU as a possible novel risk factor for BNC formation after radical prostatectomy that may contribute to its development.

Pacemakers in the upper urinary tract.

BACKGROUND: Pacemakers in upper urinary tract (UUT) are still under study. AIM: We reviewed the role of some cells that seem to be involved in the propulsion of urinary bolus from UUT to the bladder. MATERIALS & METHODS: We focuses on evaluating studies on the mechanisms by which the UUT propels urine to the bladder via pacemaker cells. RESULTS: Electric active pacemaker cells generate pyeloureteric autorhythmicity driving adjacent smooth muscle cells (SMCs); it emphasizes the role of the interstitial cells of Cajal-like cells (ICC-LCs) localized in the UUT. Interstitial cells of Cajal (ICCs) are now thought to cooperate in conducting and amplifying pacemaker activity in the UUT. These cells produce electrical slow-wave potentials and determine the propagation of peristaltic activity. Identification of ICC-LCs is facilitated by use of c-kit antibodies. Contraction waves arising from the UUT and the propagation of these waves may require the direct involvement of ICC-LCs, as c-kit immunoreactivity appears developmentally at the same time as coordinated unidirectional peristaltic contraction. ICC-LCs observed in the UUT have morphological features similar to those of c-kitpositive ICCs in the gastrointestinal tract. In addition to gastrointestinal motility, ICCs may also play a significant role in the propagation, coordination, and modulation of ureteropelvic peristalsis. DISCUSSION: Alterations in ICC-LCs are closely associated with a variety of motility disorders and many congenital urological diseases of the UUT such as primary obstructive megaureter, congenital ureteropelvic junction obstruction, and vesicoureteral reflux. CONCLUSION: These observations open the way for further investigations of this cell type.

Isolated large hydatid cyst in the kidney of an elderly man.

Cystic disease (CD) is a parasitic infestation by Echinococcus granulosus and occurs endemically in many countries, associated with sheep farming. Renal involvement is rare (2-4%) and is often indicative of disseminated disease. Echinococcal larvae can reach the kidneys through the bloodstream or lymph glands or through a direct route. The larvae grow slowly, and patients bearing larvae are typically asymptomatic. We report the case of a 79-year-old male with an isolated hydatid cyst in the kidney and describe its management by transperitoneal nephrectomy. Diagnosis was based on epidemiology and imaging findings, and was confirmed by histopathological and serum examinations.