Endophytic to total tumour volume ratio: An added variable to patients with T1b/T2 renal tumours undergoing partial nephrectomy.

INTRODUCTION: Partial nephrectomy is the standard of care to patients with small renal masses. It is still encouraged to larger tumours whenever feasible. The aim of this study is to look for the endophytic to total tumour volume ratio as an added variable to study the complexity of partial nephrectomy to patients with T1b/ T2 renal tumours. METHODS: Retrospective data collection of patients that had partial nephrectomy for T1b/T2 renal tumours by a single surgeon was done. Radiological re-assessment for the CT images to measure the endophytic to total tumour volume ratio was done. RESULTS: The mean age of the patients was 63 years. The study included 25 males and 11 females. All cases were managed by open surgery using retroperitoneal transverse lateral lumbotomy and warm ischemia was used in all patients. The mean tumour volume was 74 cc, the mean endophytic tumour volume was 29 cc. The mean percentage of endophytic to total tumour volume was 42%. CONCLUSIONS: Partial nephrectomy is safe for most of the patients with good performance status, having large renal masses. More complex surgery can be predicted in patients with endophytic to total tumour volume greater than 42%.

History of infantile BCG immunization did not predict lamina propria invasion and/or high-grade in patients with non-muscle invasive bladder cancer.

OBJECTIVE: To evaluate the utility of infantile BCG vaccination history in predicting stage and grade of tumours in non-muscle invasive bladder cancer (NMIBC). MATERIALS AND METHODS: We retrospectively analyzed data from patients from a single center who were diagnosed with new NMIBC and underwent transurethral resection of bladder tumour (TURBT) between 2017 and 2022. We assessed BCG immunization status with various demographics and comorbidities, as well as tumour recurrence, progression, stage, and grade. RESULTS: A total of 188 patients met the inclusion criteria for our study. The mean age of patients at the time of diagnosis was significantly lower in those that had been immunized with BCG (71 ± 9) than those who had not (77 ± 10) (p < 0.0001). History of BCG immunization did not correlate with sex, history of diabetes mellitus (DM), prior history of intravesical BCG treatment, and tumour recurrence, progression, stage, and grade. CONCLUSIONS: History of infantile BCG vaccination did not correlate with the depth of invasion and/or the grade in patients with non-muscle invasive bladder cancer. Patients that received infantile BCG vaccination were significantly younger at the time of diagnosis of NMIBC.

A geographic-location-based medical school admissions process does not influence pre-clerkship and licensing examination academic performance.

Background: Students are selected for admission to the Northern Ontario School of Medicine University (NOSM U) MD degree program using criteria aiming to maximize access of persons thought most likely to practice in the region, including use of a geographic context score (GCS) which ranks those with lived experience in northern Ontario and/or rurality most highly. This study investigates the effect of this admissions process upon medical school academic performance. Methods: We used a retrospective cohort design combined with multiple linear regression analysis to investigate the relationship between admission scores and performance on pre-clerkship courses, and the Medical Council of Canada Qualifying Exam Part 1 (MCCQE1).The GCS did not significantly explain performance variance on any pre-clerkship course, nor on the MCCQE1, while the undergraduate Grade Point Average correlated with most assessment scores. The number of prior undergraduate biomedical courses predicted science and clinical skills performance, particularly in Year 1, but not with MCCQE1 scores. Performance on Year 2 courses, particularly foundational sciences and clinical skills, significantly predicted MCCQE1 scores. Results: Our data suggest that admission geographic context scoring is unrelated to future academic performance. Further, students with fewer prior undergraduate biomedical courses may benefit from increased support and/or a modified program during the early years.

Contexte: La sélection étudiants à l'École de médecine du Nord de l'Ontario est fondée sur des critères visant à faciliter l'admission de candidats qu'on estime susceptibles de pratiquer dans la région. Un de ces critères est le score de contexte géographique (SCG) qui classe au premier rang les personnes ayant déjà vécu dans le Nord de l'Ontario ou en milieu rural. Cette étude examine l'effet de ce processus d'admission sur les résultats académiques des étudiants en médecine. Méthodes: Nous avons utilisé un modèle de cohorte rétrospective et une analyse par régression linéaire multiple pour étudier la relation entre les scores d'admission et les résultats obtenus aux cours avant l'externat et à l'examen d'aptitude du Conseil médical du Canada (EACMC), partie 1.Le SCG n'explique pas de manière significative la variance des résultats dans les cours pré-cliniques, ni à l'EACMC1, tandis que la moyenne pondérée cumulative au premier cycle est en corrélation avec la plupart des scores d'évaluation. Le nombre de cours en sciences biomédicales suivis dans un programme de premier cycle ont permis de prédire les résultats en sciences et en compétences cliniques, en particulier en première année, mais pas les résultats à l'EACMC1. Les résultats aux cours de deuxième année, en particulier de sciences fondamentales et de compétences cliniques, ont permis de prédire de manière significative les résultats à l'EACMC1. Résultats: Nos données portent à croire que le score de contexte géographique au moment de l'admission est sans lien avec les résultats académiques subséquents. En outre, les étudiants ayant suivi moins de cours en sciences biomédicales au premier cycle pourraient bénéficier d'un soutien plus important ou d'un programme adapté au cours des premières années.

Partial Nephrectomy for T1b/T2 Renal Mass: An Added Shift from Radical Nephrectomy.

The aim of our study was to show our short-term experience in managing large renal masses (cT1b/T2) through partial nephrectomy (PN) over the last 3 years. Retrospective data collection for all patients managed by PN for renal masses larger than 4 cm over the last 3 years. Epidemiological data were collected. Surgical data including surgical and ischemic times as well as intra and postoperative complications were collected. Pre- and postoperative estimated glomerular filtration rate (eGFR) data were collected and correlated as well as postoperative complications and recurrence. We could identify 47 patients managed by PN for radiologically confirmed >4 cm renal masses. The mean age of the patients was 55.7 ± 13.4, including 29 males and 18 females. Masses were T1b and T2 in 40 and 7 patients, respectively. The mean tumor size was 6.2 ± 1.5 cm. Using renal nephrometry score; 8, 28, and 11 had low, moderate, and high complexity, respectively. Renal cell carcinoma (RCC) was identified in 42 patients. Five patients out of 42 cancerous cases (12%) had pathological T3 RCC. The mean preoperative and postoperative eGFR were 89.09 ± 12.41 and 88.50 ± 10.50, respectively (P 0.2). The median follow-up was 14 months and within that short time, no patient had evidence for cancer recurrence. PN for large renal masses is safe in experienced hands and should be attempted in a higher percentage of patients, regardless of the tumor complexity. No cancer recurrence or deterioration of renal function was observed within our short-term follow-up.

Radical cystectomy for bladder urothelial carcinoma with aggressive variant histology.

PURPOSE: The aim of this study is to report our experience in managing bladder cancer in patients with variant pathology. METHODS: Retrospective data collection for all patients managed by radical cystectomy over the last 3 years for a variant pathol-ogy was completed. We specifically included micropapillary and nested variants. RESULTS: Ten patients were identified, with eight having micropapillary carcinoma (MPC) and two having nested vari-ants. Nine patients were male. The median age was 75. The two patients with nested variant were 56 and 62 years old, respec-tively, whereas all patients with MPC were over the age of 70. Upon cystectomy of all micropapillary cases, three patients (37.5%) had positive lymph node invasion and the final patholo-gy was T2 (two patients), T3 (two patients), and T4 (four patients). Barring a grade III complication Clavien-Dindo classi-fication due to wound dehiscence that necessitated secondary surgical closure, there were no specific perioperative complica-tions. Given the urethral invasion, cystourethrectomy was per-formed on the female patient. Within a median 13-month fol-low-up, three patients developed local recurrence, including two urethral and one new lateral pelvic mass. CONCLUSIONS: Considering the muscle invasive nature of micropapillary and nested bladder cancer, aggressive surgical management should not be postponed. Moreover, due to notable prevalence of concurrent and/or recurrent urethral involvement, initial urethrectomy or early and frequent postoperative ure-throscopy should be provided. Patients with variant histology bladder cancer may benefit from early radical cystectomy when compared to bladder sparing protocols and prostate sparing cystectomy treatment options.

Successful Surgical Management of Locally Advanced Renal Cell Carcinoma Invading Spleen and Pancreas.

Over the last two decades, the treatment of metastatic RCC has changed significantly, and the role of surgery is being debated. A 50-year-old man presented with pain in his left loin. An ultrasound, followed by a CT scan, revealed a 17.5 cm left renal mass invading the left suprarenal gland, spleen, and pancreatic tail. Radical nephrectomy through chevron incision under epidural block with general anesthesia was performed. The entire mass was removed en bloc. The estimated blood loss was 300 mL, and no blood transfusions were performed. The operation took approximately 2 h. Histological examination revealed clear cell renal carcinoma with extension into the spleen, pancreatic tail, and diaphragmatic fibers with negative resection margin. The patient discharged after a 3-day uneventful hospital stay. Aggressive surgical removal of a locally invasive renal cell carcinoma is feasible and should be considered in patients with good performance status and no or minimal distant metastases.

Adverse pathological outcomes of patients with de novo muscle invasive bladder cancer in Northern Ontario.

OBJECTIVE: This study aimed to investigate the clinical and pathological characteristics of patients with de novo muscle-invasive bladder cancer (MIBC) who underwent radical cystectomy in Northern Ontario. METHODS: This is a retrospective cross-sectional study of patients with de novo T2 MIBC who underwent radical cystectomy over a 2-year-period in Thunder Bay Regional Health Sciences Centre. Clinical and pathological characteristics of Trans Urethral Resection of Bladder Tumors and cystectomy specimens were analyzed. RESULTS: Of the 59 patients aged 67 ± 8.8 years, predominated by males (80%), 27.1% were younger than age 60. After surgery, upstaging was noted in 59.3% (T3 in 27.1% and T4 in 32.2%) while node positive was noted in 36% of patients. Prostate adenocarcinoma was incidentally discovered in 20 (34%) of patients with 50% considered significant (Gleason score ≥ 7). Downstaging was found in those who had neoadjuvant chemotherapy (p = 0.001). CONCLUSIONS: The high prevalence of younger ages (less than 60), a high rate of upstaging, the presence of high-grade incidental prostate cancer, and lymph node positives in T2 de novo MIBC in Northern Ontario, warrants further investigation of potential causes and risk factors at individual, public, and population health levels in the region.

Aristolochic acid: What urologists should know.

To the Editor, Aristolochic acid is one of major causes for upper tract urothelial carcinoma, especially in younger population. While it is mentioned as a cause in guidelines, little is actually known about the toxin by urologists. We are aiming in our letter to provide some direct and clear information to ourselves that would help us to know more about that toxin and how it can adversely affect our patients [...].

A Rare Case of Simultaneous Pheochromocytoma Accompanied with an Ileocecal Neuroendocrine Tumor.

The detection rates of neuroendocrine tumors (NETs) are rising, which has led to a better understanding of their histopathologic characteristics. We present a case of adrenal pheochromocytoma with an incidental finding of a concurrent ileocecal NET detected on early post-adrenalectomy imaging. A 59-year-old male was noted to have microscopic hematuria on a routine workup. Further imaging identified a right adrenal lesion suggestive of pheochromocytoma. He was reporting intermittent headaches, and his urinary normetanephrine and norepinephrine levels were elevated. He underwent a right retroperitoneal adrenalectomy, and pathology confirmed a pheochromocytoma with no malignancy. Postoperatively, he developed a hematoma at the surgical bed that was identified on CT scan. An incidental lesion at the level of the ileocecal valve was noted on the CT scan as well. This was further investigated by colonoscopy and biopsy that confirmed a carcinoid tumor. He had no gastrointestinal symptoms, chromogranin A was normal, and 24-h urinary 5-hydroxyindolacetic acid levels were slightly elevated. He subsequently underwent a laparoscopic right hemicolectomy 3 months from his initial adrenalectomy. Final pathology confirmed a grade 2 NET with metastatic involvement of 4 regional lymph nodes. We report an extremely rare case of simultaneous pheochromocytoma accompanied with an ileocecal NET. Genetic testing for multiple endocrine neoplasia was undertaken and was found negative for 9 tested genes.

Radical cystectomy for clinical T4b urothelial carcinoma: An Ontario, single-center experience.

INTRODUCTION: Guidelines surrounding the management of T4b muscle-invasive bladder cancer (MIBC) with radical cystectomy (RC) are limited and lack clarity. Our objective was to analyze our single-center experience to provide additional insight into the role of RC. METHODS: We performed a retrospective data analysis using clinical, radiological, and pathological information for all patients managed by RC for cT4b MIBC at the Thunder Bay Regional Health Sciences Centre (July 2015 to July 2020). Patients that had MIBC as their first diagnosis were termed the de novo group and patients that were initially diagnosed as having non-MIBC were termed the progressive group. RESULTS: Nineteen consecutive patients (16 males and three females), with a median age of 68 years, managed by two urologists over the last five years, met study criteria. Eleven (58%) of the patients had de novo MIBC while eight (42%) presented with progressive disease. All patients had dysuria as a presenting symptom. Only one (5%) patient received neoadjuvant chemotherapy. There were low rates of perioperative transfusion (11%), bowel resections (5%), postoperative transfusions (0%), ileus (32%), urine leak (16%), and wound dehiscence (5%). Fourteen patients (74%) had positive lymph nodes. All patients had adjuvant chemotherapy. The one-year recurrence rate in these patients was 53%, with 32% of recurrence being distant metastasis. The one-year survival rate was 95%. CONCLUSIONS: Patients in the de novo and progressive arms of our cohort had similar rates of surgical complications and disease recurrence. We found operative morbidity and disease control to be reasonable, suggesting RC can be considered more often in the management of T4b MIBC patients.

Micropapillary bladder cancer: an added indication to prophylactic urethrectomy.

There is little research on the role of urethrectomy during cystectomy in patients with micropapillary bladder cancer (MPBC). We present two cases of MPBC cystectomy and suggest that urethrectomy be performed concurrently as a preventive measure. The first case involved a woman who had a mixed solid and papillary bladder tumour. An anterior pelvic exenteration was performed as well as a total urethrectomy. The T4a micropapillary variant tumour was confirmed by pathology. The second case involved a man with T1 MPBC who was treated with a BCG induction course. A recurrent muscle-invasive MPBC was discovered during follow-up. During the radical cystoprostatectomy, the urethra was spared. T2 MPBC was discovered through pathology. He had a urethrectomy 6 months later due to urethral bleeding, and the pathology revealed micropapillary cancer of the urethra.

Bacillus Calmette-Guerin vaccine and bladder cancer incidence: Scoping literature review and preliminary analysis.

BACKGROUND: The Bacillus Calmette-Guerin (BCG) vaccine has long been used for the prevention of tuberculosis (TB) around the world. BCG is also used as an immunotherapy agent for the treatment of non-muscle invasive urinary bladder cancer. This scoping literature review and preliminary data analysis aims to summarize the literature correlating infantile BCG vaccination with the incidence of future bladder cancer. METHODS: Studies were identified by a formal literature search of MEDLINE and Cochrane Central Registrar of Controlled Trials following PRISMA guidelines. Preliminary data analysis was conducted on publicly accessible data summarizing the impact of gender, BCG vaccination, and socio-economic effects on crude and age-standardized rates of bladder cancer. RESULTS: As part of our analysis, preliminary regression models demonstrated BCG vaccination status, gender, and socio-economic status to have statistically significant effects on crude and age-standardized rates of bladder cancer incidence. BCG vaccination was associated with a 35-37% lower age-standardized rate of bladder cancer incidence. CONCLUSIONS: There is very little literature examining the relationship between prior BCG vaccination and rates of bladder cancer incidence. Our limited data analysis indicates that a relationship does exist between infantile BCG vaccination and later bladder cancer development, although extensive future investigation is needed in this area.

Bilateral Single-Stage Nephrectomy for Synchronous Bilateral Renal Cell Carcinoma.

Bilateral synchronous renal cell carcinoma (RCC) is uncommonly encountered. Debate exists among urologists in managing these cases in a single surgery versus staged surgeries. We aim to report our experience in managing encountered cases using single-stage surgeries. Retrospective collection of cases with pathologically confirmed RCC that had single-stage bilateral renal surgery over the past 2 years. Three cases were identified. Patients were managed using bilateral transverse lateral lumbotomy. All patients did not have intraoperative or postoperative complications. Kidney function stayed stable after surgery. Single-stage bilateral renal surgery is a safe procedure. Bilateral transverse lateral lumbotomy allows for a fast and safe surgery with minimal complications. There is a possible histological dis-concordance in bilateral synchronous RCC.

Systematic Review: Safety of Intravesical Therapy for Bladder Cancer in the Era of COVID-19.

A novel coronavirus has emerged in late 2019 capable of causing a severe respiratory disease known as COVID-19. Its pathogenesis appears to be the initiation of an immune response and resulting cytokine storm that damages the healthy lung tissue of the host. Some epidemiological studies found bacillus Calmette-Guérin (BCG) vaccine can help to decrease morbidity and mortality of the viral infection. We aim to review and summarize what is known about COVID-19 and the current implications of intravesical BCG with regard to the disease.

Spontaneous Retroperitoneal Hemorrhage in a Patient with Acquired Cystic Kidney Disease.

Spontaneous retroperitoneal hemorrhage (SRH) is a rare emergency. It is usually encountered in patients on hemodialysis and is associated with high rate of morbidity and mortality. This is a case from the emergency department. The patient had unstable vitals with SRH following dialysis. Immediate exploration and nephrectomy using transverse lateral lumbotomy incision were done. Patients on hemodialysis are at a risk of SRH and frequent surveillance is recommended. Acquired cystic kidney disease (ACKD) can develop in hemodialysis patients and put them at risk for bleeding. Transverse lateral lumbotomy may be a safe option for direct access to the kidney in emergency kidney surgery.

Solitary prostatic cancer metastasis to the testis: A case report and lessons to learn.

Prostate cancer (Pca) is a complex disease. Several case series and reports have described the spread of Pca to unusual organs, like esophagus, eye and periureteric fat causing ureteropelvic junction obstruction. Spread of Pca to the testis has been reported in few case reports, however Pca was always firstly diagnosed in all published cases and testicular spread of cancer has been diagnosed during follow up of the patients. This case is unique in that, the patient initially presented with a testicular mass and histologic examination after orchiectomy allowed to diagnose prostatic cancer. This patient was 81 years old and he never had PSA screening by his family doctor. PSA was not even done initially by us considering his age and the presentation with testicular mass. This case may impact clinical practice in several ways: 1) considering Pca always in the differential diagnosis of any disease of an adult man, regardless of its presentation because we did not do that at initial patient evaluation and PSA was only measured after orchiectomy when pathology demonstrated metastatic Pca; 2) suggesting standard orchiectomy with epididemectomy for surgical castration instead of the current surgical technique of subcapsular/subepididymal orchiectomy, because our patient had cancer involving his epididymis as well; 3) suggesting to include PSMA as a part of preoperative staging for high risk Pca patients, in consideration that PSMA is proving to be a promising new imaging technique that can help diagnosing metastatic Pca in unusual locations.

'Top-Down' holmium laser enucleation of the prostate. Report of initial cases performed by a single surgeon.

OBJECTIVES: To present the 12-month outcomes of 'Top-Down' holmium laser enucleation of the prostate (HoLEP). PATIENTS AND METHODS: We retrospectively reviewed the charts of prospectively collected patients who underwent Top-Down HoLEP between 2017 and 2018. All cases were operated upon by a single urologist (H.E), using a 100-W holmium:YAG laser with a 550-µm laser fibre. We recorded the enucleation time, morcellation time, intraoperative, and postoperative complications. All patients had postoperative follow-up visits at 1, 3, 6 and 12 months. The evaluation included the International Prostate Symptom Score (IPSS), quality-of-life (QoL) assessment, measurement of maximum urinary flow rate (Qmax) and the post-void residual urine volume (PVR). RESULTS: A total of 60 consecutive patients were recruited. The median (range) prostatic volume, resected prostatic weight, and percentage of resected prostatic tissue were 124 (70-266) mL, 90 (44-242) g and 76 (46-97)%, respectively. The median (range) enucleation and morcellation times were 80 (25-200) and 14.5 (4-58) min, respectively. One patient had a simple bladder mucosal injury and another developed clot retention. At 3 months, three patients (5%) had stress urinary incontinence (SUI) and eight patients (13.3%) presented with urge UI (UUI). At the last follow-up visit, one patient (1.7%) presented with persistent SUI, while three patients (5%) presented with UUI. The IPSS and QoL significantly improved during the follow-up period (P = 0.045 and P = 0.04, respectively). CONCLUSION: The results of the Top-Down technique are comparable to those of traditional HoLEP. However, the Top-Down technique may reduce the complexity, operating time, and SUI rates. ABBREVIATIONS: BN: bladder neck; HoLEP: holmium laser enucleation of the prostate; PVR: post-void residual urine volume; Qmax: maximum urinary flow rate; QoL: quality of life; TOV: trial of voiding; (S)(U)UI: (stress) (urge) urinary incontinence.