A Retrospective Analysis of 83 Patients with Testicular Mass Who Underwent Testis-Sparing Surgery: The Eurasian Uro-oncology Association Multicenter Study.

INTRODUCTION: Herein, we analyzed the histopathological, oncological and functional outcomes of testis-sparing surgery (TSS) in patients with distinct risk for testicular cancer. METHODS: This is a multicenter retrospective study on consecutive patients who underwent TSS. Patients were categorized in high- or low-risk testicular germ cell tumor (TGCT) according to the presence/absence of features compatible with testicular dysgenesis syndrome. Histology was categorized per size and risk groups. RESULTS: TSS was performed in 83 patients (86 tumors) of them, 27 in the high-risk group. Fifty-nine patients had a non-tumoral contralateral testis present. Sixty masses and 26 masses were benign and TGCTs, respectively. No statistical differences were observed in mean age (30.9 ± 10.32 years), pathological tumor size (14.67 ± 6.7 mm) between risk groups or between benign and malignant tumors (p = 0.608). When categorized per risk groups, 22 (73.3%) and 4 (7.1%) of the TSS specimens were malignant in the high- and low-risk patient groups, respectively. Univariate analysis showed that the only independent variable significantly related to malignant outcome was previous history of TGCT. During a mean follow-up of 25.5 ± 22.7 months, no patient developed systemic disease. Local recurrence was detected in 5 patients and received radical orchiectomy. Postoperative testosterone levels remained normal in 88% of those patients with normal preoperative level. No erectile dysfunction was reported in patients with benign lesions. CONCLUSION: TSS is a safe and feasible approach with adequate cancer control, and preservation of sexual function is possible in 2/3 of patients harboring malignancy. Incidence of TGCT varies extremely between patients at high and low risk for TGCT requiring a careful consideration and counseling.

[De-escalation: Testicular cancer.] / La desescalada en urología: cáncer de testículo.

OBJECTIVES: To provide a priority algorithm for determinate diagnostic, therapeutic and follow-up procedures regarding at testicular cancer, adjusted by institutional requirements. Testicular cancer patient assessment during COVID-19 Pandemia. MATERIAL AND METHODS: Review of relevant manuscript published up to date, draft creation correctedt hough modified nominal group until final corrected manuscript. RESULTS: A lack of scientific evidence exists through a large amount of manuscripts. The authors support prioritizing diagnostic and therapeutic procedures. Once priorities have been established, that will facilitate providing each patients the limited resources. Initial diagnostic procedures for testicular cancer such as scrotal US, orchiectomy, staging CT and adjuvant treatment (if required) are priority. Reducing the usage of chemotherapy with respiratory toxicity and increasing the usage ofgrowth factors during chemotherapy treatment are the main stakeholders of treatment. Besides, providing active surveillance on non-risk factor clinical stage I is alsoa priority. In case of positive COVID-19, it is important to high light that the vast majority of patients are tentatively cured. CONCLUSIONS: During de-escalation phases, patients diagnosed with testicular cancer should receive priority care during initial assessment. The follow-ups of patients with low -risk and without recurrence for a long time, might be delayed.

OBJETIVOS: Establecer la prioridad de los distintos procedimientos diagnósticos, terapéuticos y de seguimiento sobre el cáncer de testículo para adaptarse adecuadamente a la situación asistencial de cada centro. Valorar precauciones y adaptaciones durante la situación actual de desescalada en el curso de la pandemia COVID-19. Valoración del paciente con cáncer de testículo en presencia de pandemia infectiva.MATERIAL Y MÉTODOS: Revisión de la literatura relevante publicada hasta la fecha, elaboración de un borrador corregido por técnica de grupo nominal modificada, hasta obtener un documento de consenso entre los autores. RESULTADOS: En ausencia de evidencia científica relevante la mayor parte de las publicaciones, y la conclusiónde los autores, abogan por priorizar los procedimientos diagnósticos y terapéuticos de los pacientes. Una vez priorizados será menos complejo adaptar los recursos limitados a las necesidades más perentorias de los pacientes. En el cáncer de testículo los procedimientos iniciales que incluyen ecografía escrotal, orquiectomía, estudio de extensión, y tratamiento complementario si necesario, son de máxima necesidad. Se propone disminuir el uso de fármacos con potencial toxicidad respiratoria, y aumentar la utilización de los estimulantes de colonias hematopoyéticas, asi como promover seguimiento activo en estadio clínico I sin factores de riesgo. En caso de infección activa subrayamos que la mayoría de los pacientes son potencialmente curables. CONCLUSIONES: En el proceso de desescalada los pacientes con cáncer de testículo deben ser atendidos de forma preferente, especialmente durante evaluación y tratamiento iniciales. Las revisiones de pacientes con remisiones estables pueden retrasarse razonablemente sin excesivo riesgo de progresion en estadios bajos.

La desescalada en urología: cáncer de testículo / De-escalation: Testicular cancer

OBJETIVOS: Establecer la prioridad de los distintos procedimientos diagnósticos, terapéuticos y de seguimiento sobre el cáncer de testículo para adaptarse adecuadamente a la situación asistencial de cada centro. Valorar precauciones y adaptaciones durante la situación actual de desescalada en el curso de la pandemia COVID-19. Valoración del paciente con cáncer de testículo en presencia de pandemia infectiva. MATERIAL Y MÉTODOS: Revisión de la literatura relevante publicada hasta la fecha, elaboración de un borrador corregido por técnica de grupo nominal modificada, hasta obtener un documento de consenso entre los autores. RESULTADOS: En ausencia de evidencia científica relevante la mayor parte de las publicaciones, y la conclusiónde los autores, abogan por priorizar los procedimientos diagnósticos y terapéuticos de los pacientes. Una vez priorizados será menos complejo adaptar los recursos limitados a las necesidades más perentorias de los pacientes. En el cáncer de testículo los procedimientos iniciales que incluyen ecografía escrotal, orquiectomía, estudio de extensión, y tratamiento complementario si necesario, son de máxima necesidad. Se propone disminuir el uso de fármacos con potencial toxicidad respiratoria, y aumentar la utilización de los estimulantes de colonias hematopoyéticas, asi como promover seguimiento activo en estadio clínico I sin factores de riesgo. En caso de infección activa subrayamos que la mayoría de los pacientes son potencialmente curables. CONCLUSIONES: En el proceso de desescalada los pacientes con cáncer de testículo deben ser atendidos de forma preferente, especialmente durante evaluación y tratamiento iniciales. Las revisiones de pacientes con remisiones estables pueden retrasarse razonablemente sin excesivo riesgo de progresion en estadios bajos

OBJECTIVES: To provide a priority algorithm for determinate diagnostic, therapeutic and follow-up procedures regarding at testicular cancer, adjusted by institutional requirements. Testicular cancer patient assessment during COVID-19 Pandemia. MATERIAL AND METHODS: Review of relevant manuscript published up to date, draft creation corrected though modified nominal group until final corrected manuscript. RESULTS: A lack of scientific evidence exists through a large amount of manuscripts. The authors support prioritizing diagnostic and therapeutic procedures. Once priorities have been established, that will facilitate providing each patients the limited resources. Initial diagnostic procedures for testicular cancer such as scrotal US, orchiectomy, staging CT and adjuvant treatment (if required) are priority. Reducing the usage of chemotherapy with respiratory toxicity and increasing the usage of growth factors during chemotherapy treatment are the main stakeholders of treatment. Besides, providing active surveillance on non-risk factor clinical stage I is also a priority. In case of positive COVID-19, it is important to highlight that the vast majority of patients are tentatively cured. CONCLUSIONS: During de-escalation phases, patients diagnosed with testicular cancer should receive priority care during initial assessment. The follow-ups of patients with low -risk and without recurrence for a long time, might be delayed

Utilization and Operative Influence of Renal Mass Biopsy in the Small Renal Mass: Analysis from the Clinical Research Office of the Endourological Society Small Renal Mass registry.

Introduction and Objective: Definitive inclusion of renal mass biopsy (RMB) in small renal mass (SRM) diagnostic algorithm remains controversial. We assessed incidence and accuracy of RMB in SRMs in the CROES Renal Mass registry and the influence of preoperative RMB on perioperative complications after SRM nephron-sparing surgery (NSS). Materials and Methods: "ad hoc" description of incidence of preoperative RMB and characteristics of SRM cases with and without RMB. Accuracy of RMB was calculated in the SRM subcohort that received extirpative treatment and complication rate after NSS compared to between the two groups. Continuous variables were compared using t-test; categorical variables were compared using the chi-square test. K-statistics was used to analyze agreement between the biopsy histology and surgical pathology. Logistic regression was used to assess the association between RMB and NSS complications. All tests were two sided, and p-values <0.05 were considered statistically significant. Results: The rate of preoperative RMB in SRMs was 11.6% (175/1597) in Europe and the United States. RMB patients were more likely to have hypertension (p < 0.04), be on dialysis (p < 0.024), or smokers (p = 0.005), with multiple/bilateral tumors (0.008 and 0.010) and previous other malignancy (p = 0.021). They underwent radical nephrectomy more frequently than non-RMB group (p = 0.034). RMB was nondiagnostic in 16 cases (9%). Accuracy of RMB in distinguishing malignant from benign was 89.5%. Agreement between biopsy and final surgical pathology was 93% for malignant vs benign tumors (kappa = 0.655). Upstaging to pT3a occurred more frequently in the RMB group (12.6% vs 6.25% [p = 0.022]). Complication rate in renal mass-NSS subcohort was 15.8%, not statistically different between RMB and non-RMB groups. On logistic regression analysis, RMB was not associated with increased risk of postoperative complication after NSS (OR: 0.9, 95% CI: 0.43-1.89). Conclusion: The practice of RMB in SRM is still scarce despite high accuracy and concordance with final pathology. RMB does not seem to increase complication rate after NSS.

Can ablation win against partial nephrectomy and become first line therapy in cT1a renal tumours?

PURPOSE OF REVIEW: Currently, small renal masses account for the largest proportion of renal tumour and small renal cell carcinomas (RCC). Although partial nephrectomy, whenever possible, is recognized as the gold standard for treatment, thermal ablation has gained increasing attention as optional treatment in a population sector harbouring small renal masses/small RCCs. The purpose of this review is to update comparative outcomes between these two options of treatment. RECENT FINDINGS: Recent observational case-control and population-based cohorts applying propensity score or inverse probability treatment weighted methodology adjusting for baseline patient and tumour characteristics, compare outcomes between partial nephrectomy and thermal ablation (both cryotherapy and radiofrequency), radical nephrectomy and thermal ablation and between thermal ablation and nonsurgical management. Most of them focus on T1aRCC. SUMMARY: Comparative outcomes' evidence is limited to population-based or institutional series adjusted for baseline differences and systematic reviews. With exception of special clinical situations, thermal ablation provides similar estimated 5-year cancer and overall survival with a clear benefit in postoperative outcomes when compared to partial nephrectomy in cT1a older patients. The trade-off is more evident when thermal ablation is compared to radical nephrectomy. The advantages in terms of adverse events persist up to 1 year after treatment. Benefits are less apparent in solitary kidneys and when synchronous bilateral approaches are performed.

Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of localized high-risk disease.

PURPOSE: To provide a comprehensive overview and update of the joint consultation of the International Consultation on Urological Diseases (ICUD) and Société Internationale d'Urologie for the treatment of localized high-risk upper tract urothelial carcinoma (UTUC). METHODS: A detailed analysis of the literature was conducted reporting on treatment modalities and outcomes in localized high-risk UTUC. An international, multidisciplinary expert committee evaluated and graded the data according to the Oxford System of Evidence-based Medicine modified by the ICUD. RESULTS: Radical nephroureterectomy (RNU) is the standard of treatment for high-grade or clinically infiltrating UTUC and includes the removal of the entire kidney, ureter and ipsilateral bladder cuff. The distal ureter can be managed either by extravesical or transvesical approach, whereas endoscopically assisted procedures are associated with decreased intravesical recurrence-free survival. Post-operative intravesical chemotherapy decreases the risk of subsequent bladder tumour recurrence. Regional lymph node dissection is of prognostic importance in infiltrative UTUC, but its extent has not been standardized. Renal-sparing surgery is an option for manageable, high-grade tumours of any part of the upper tract, especially of the distal ureter, as an alternative to RNU. Endoscopy-based renal-sparing procedures are associated with a higher risk of recurrence and progression. CONCLUSIONS: A multimodal approach should be considered in localized high-risk UTUC to improve outcomes. RNU is the standard of treatment in high-risk disease. Renal-sparing approaches may be oncologically equivalent alternatives to RNU in well-selected patients, especially in those with distal ureteric tumours.

Laparoscopic Partial Nephrectomy With Potassium-titanyl-phosphate Laser Versus Conventional Laparoscopic Partial Nephrectomy: An Animal Randomized Controlled Trial.

OBJECTIVE: To explore the feasibility, safety, and short-term results of potassium-titanyl-phosphate (KTP) laser laparoscopic partial nephrectomy (KTP-LPN) vs conventional laparoscopic partial nephrectomy (C-LPN). MATERIALS AND METHODS: Thirty large white female pigs were randomized to KTP-LPN or C-LPN. Laparoscopic radical right nephrectomy was performed, and an artificial renal tumor was placed in the left kidney in 3 locations. A week later, 15 pigs underwent C-LPN and 15 underwent KTP-LPN. All C-LPNs were performed with renal ischemia. A 120-W setting was used, without arterial clamping in the KTP-LPN group. Follow-up was done at day 1, week 3, and week 6. Retrograde pyelography was performed at 6 weeks, followed by animal sacrifice and necropsy. RESULTS: All KTP-LPNs were performed without hilar clamping. C-LPNs were performed with hilar clamping, closing of the collecting system, and renorraphy. In the KTP laser group, 2 pigs died due to urinary fistula in the first week after surgery. In the C-LPN group, 1 pig died due to myocardial infarction and another due to malignant hyperthermia. Hemoglobin and hematocrit recovery were lower at 6 weeks in the KTP-LPN group. Renal function 24 hours after surgery was worse in the KTP-LPN group but recovered at 3 weeks and 6 weeks. No differences were observed in surgical margins. The necropsy showed no differences. Limitations of the study are the impossibility to analyze the collecting tissue sealing by the KTP, and the potential renal toxicity of the KTP laser. CONCLUSION: Although KTP-LPN is feasible and safe in the animal model, further studies are needed.

Manejo de la obstrucción ureteral maligna / Management of malignant ureteral obstruction

OBJETIVO: El objetivo de esta revisión es describir las distintas alternativas terapéuticas en la obstrucción ureteral maligna -OUM- y analizar sus resultados a corto y largo plazo. MÉTODOS: Se realizó una búsqueda en castellano e inglés a través de las bases de datos PubMed y Google Scholar. Se examinaron las revisiones más relevantes, los artículos originales y las respectivas citas de los mismos. La última búsqueda se realizó en abril de 2016. RESULTADOS: El catéter doble J polimérico es la derivación interna más costo-efectiva y accesible, pero es también la de más corta duración. Su tasa de fracaso temprano va de 0% a 35% y su tasa de fracaso tardío, de 14% a 49%. El tiempo medio al fracaso tardío es de 3 a 12 meses. La nefrostomía es la derivación más segura por su baja tasa de fracaso, aunque presenta complicaciones frecuentes como la migración del catéter, y puede disminuir la calidad de vida. De los catéteres doble J metálicos, el único con adecuado sustento bibliográfico en OUM es el Resonance®. Su tasa de fracaso temprano oscila entre 0% y 15%, y el fracaso tardío, entre 7% y 41%, con un tiempo promedio al fracaso tardío de 2,6 a 13 meses. Con respecto a los stents metálicos, los mejores resultados pertenecen al Memokath 051®, con un fracaso temprano de 0% a 5%, fracaso tardío de 19% a 49% y un tiempo promedio al fracaso tardío de 7 a 11 meses. En los casos de fracaso de catéteres doble J poliméricos, los pacientes se vieron beneficiados con la colocación de un doble J en tándem, un doble J metálico o un stent, evitando la necesidad de una nefrostomía. En todos los casos el nivel de evidencia fue bajo. CONCLUSIONES: Los resultados sobre el manejo de la OUM son heterogéneos y con bajo nivel de evidencia. Los factores que influencian los resultados incluyen: características del catéter o stent utilizado, curso y pronóstico de la condición obstructiva y posiblemente preferencias por parte del paciente y del urólogo. Los catéteres doble J poliméricos parecen tener mayores tasas de fracaso tardío y temprano. Sin embargo, la diferencia con los catéteres doble J metálicos y los stents no es claramente evidente. Son necesarios trabajos prospectivos, multicéntricos y multidisciplinarios, para dilucidar la conveniencia y adecuada selección de uno u otro medio de derivación no quirúrgica)

OBJECTIVE: To describe the different therapeutic alternatives in malignant ureteral obstruction (MUO), and to analyze short and long-term results. METHODS: We conducted a bibliographic search about MUO in Spanish and English languages in PubMed and Google Scholar. We examined the most relevant reviews, original manuscripts and their respective citations. Last search was on April 2016. RESULTS: Polymeric double J stent is the cheapest and most accessible internal urinary diversion, but has also the shortest duration. Early and late failure rates were 0-35% and 14-49% respectively. Mean time to late failure was 3-12 months. Percutaneous nephrostomy is the safest alternative in terms of failure rates, though it has frequent complications such as tube dislodgement, and may have a negative effect on quality of life. The only metallic double J stent with enough bibliographic background is the Resonance® stent. Early failure was 0-15% and late failure 4-41%, with a mean time to late failure of 2.6-13 months. Regarding metallic stents, Memokath 051® has obtained the best results, with 0-5% early failure rates, 19-49% late failures and mean time to late failure of 7-11 months. In patients with polymeric double J stent failure, patients benefited from tandem double J stents, metallic double J catheters or metallic stents, avoiding the need of a percutaneous nephrostomy. The evidence level was low in all cases. CONCLUSIONS: Results in MUO are very heterogeneous and have a low evidence level. Factors that influence results include stent characteristics, status and prognosis of the obstructive condition and probably patient and physician’s preferences. Polymeric double J stents seem to have higher early and late failure rates than metallic double J catheters and metallic stents. Even though, the difference is not clearly evident. Prospective, multicenter, multidisciplinary trials are necessary to elucidate convenience and adequate selection of each type of stent

Guidelines on Testicular Cancer: 2015 Update.

CONTEXT: This is an update of the previous European Association of Urology testis cancer guidelines published in 2011, which included major changes in the diagnosis and treatment of germ cell tumours. OBJECTIVE: To summarise latest developments in the treatment of this rare disease. Recommendations have been agreed within a multidisciplinary working group consisting of urologists, medical oncologists, and radiation oncologists. EVIDENCE ACQUISITION: A semi-structured literature search up to February 2015 was performed to update the recommendations. In addition, this document was subjected to double-blind peer review before publication. EVIDENCE SYNTHESIS: This publication focuses on the most important changes in treatment recommendations for clinical stage I disease and the updated recommendations for follow-up. CONCLUSIONS: Most changes in the recommendations will lead to an overall reduction in treatment burden for patients with germ cell tumours. In advanced stages, treatment intensification is clearly defined to further improve overall survival rates. PATIENT SUMMARY: This is an update of a previously published version of the European Association of Urology guidelines for testis cancer, and includes new recommendations for clinical stage I disease and revision of the follow-up recommendations. Patients should be fully informed of all the treatment options available to them.

Classification and detection of errors in minimally invasive surgery.

PURPOSE: To provide a comprehensive review of the classification of surgical errors as well as general measures to detect and prevent their occurrence. MATERIALS AND METHODS: Search in PubMed, Medline, and Cochrane library with combination of the key words: Endoscopy or surgical procedures, minimally invasive, and medical error. Relevant articles were selected by three senior authors involved in minimally invasive surgery (MIS). RESULTS: Error is an unintended healthcare outcome caused by a defect in the delivery of care to a patient. Surgical errors are common and account for half of all hospital adverse events (AEs). Urology is the fifth specialty in decreasing order of AE. Errors may be classified according to the place where they occur (co-face or systemic), to the outcomes (near miss, recovery, and remediation). A specific classification for errors in MIS has also been described (Cushieri), depending on the step of the surgical procedure in which they occur. Each classification serves definite purposes, and no one can be definitive over the others. No classification has been applied so far to urology. Detection through appropriate reporting is the basis for prevention. CONCLUSION: Surgical errors represent a significant proportion of all medical error. Multiple classifications exist, depending on the purposes they are intended to serve. A classification based on the place of occurrence of the errors has been adopted in the medical system; however, when referring to MIS, a finer classification is proposed.

EAU guidelines on testicular cancer: 2011 update.

CONTEXT: On behalf of the European Association of Urology (EAU), guidelines for the diagnosis, therapy, and follow-up of testicular cancer were established. OBJECTIVE: This article is a short version of the EAU testicular cancer guidelines and summarises the main conclusions from the guidelines on the management of testicular cancer. EVIDENCE ACQUISITION: Guidelines were compiled by a multidisciplinary guidelines working group. A systematic review was carried out using Medline and Embase, also taking Cochrane evidence and data from the European Germ Cell Cancer Consensus Group into consideration. A panel of experts weighted the references, and a level of evidence and grade of recommendation were assigned. RESULTS: There is a paucity of literature especially regarding longer term follow-up, and results from a number of ongoing trials are awaited. The choice of treatment centre is of the utmost importance, and treatment in reference centres within clinical trials, especially for poor-prognosis nonseminomatous germ cell tumours, provides better outcomes. For patients with clinical stage I seminoma, based on recently published data on long-term toxicity, adjuvant radiotherapy is no longer recommended as first-line adjuvant treatment. The TNM classification 2009 is recommended. CONCLUSIONS: These guidelines contain information for the standardised management of patients with testicular cancer based on the latest scientific insights. Cure rates are generally excellent, but because testicular cancer mainly affects men in their third or fourth decade of life, treatment effects on fertility require careful counselling of patients, and treatment must be tailored taking individual circumstances and patient preferences into account.

Efficacy and safety of intraprostatic temperature-controlled microwave thermotherapy in patients with benign prostatic hyperplasia: results of a prospective, open-label, single-center study with 1-year follow-up.

BACKGROUND AND PURPOSE: Different devices for transurethral microwave thermotherapy (TUMT) are currently available for the treatment of benign prostatic hyperplasia (BPH). We evaluated the efficacy and safety of the Prostalund Feedback Treatment (PLFT), which continuously records the intraprostatic temperature, and its impact on sexual function of the patients. PATIENTS AND METHODS: A total of 41 patients with lower urinary tract symptoms attributed to BPH were entered in this prospective open-label, single-center study of PLFT. The initial evaluation was performed according to a standard protocol. At 3, 6, and 12 months, the International Prostate Symptom Score (IPSS), bother score, sexual function, and peak flow rate (Qmax) were recorded. In addition, determination of prostate volume by transrectal ultrasonography (TRUS) and measurement of residual urine volume were repeated at the 6- and 12-month visits. All adverse events were also recorded. Patients with IPSS of < or =7, > or =50% improvement in IPSS from baseline, a Qmax of > or =15 mL/sec, or > or =50% improvement in Qmax from baseline were judged responders to the treatment. RESULTS: Thirty-three of the patients completed the 12-month visit. The response rate was 88% (29 of 33 patients). There was a statistically significant decrease in IPSS at the 12-month visit, the mean IPSS being 7.1 v 21.9 at baseline (P<0.001). The mean IPSS was 10.3 and 7.6 at the 3- and 6-months' follow-up, respectively. The bother score presented a similar improvement, with a decrease from a mean of 4.2 at baseline to a mean of 1.4 after 12 months (P<0.001). The mean Qmax improved from 8.4 mL/sec at baseline to 15.9 mL/sec, 19.2 mL/sec, and 17.8 mL/sec at 3, 6, and 12 months, respectively (P<0.001). The mean change in prostate volume, as determined by TRUS, was 16 mL at 6 months and 19 mL at 12 months (P<0.001). The procedure was well tolerated. The mean post-treatment catheterization time was 17.90 days. Bladder spasms and urinary tract infection were the most common adverse events. Coitus ability remained practically unchanged after treatment (from 71% to 74.3%), but the number of patients with ejaculation decreased (from 78% to 51.4%). CONCLUSION: Our results indicate that PLFT is an effective and safe treatment for most patients with BPH.