Combination MRI-targeted and systematic prostate biopsy may overestimate gleason grade on final surgical pathology and impact risk stratification.

PURPOSE: Gleason grade (GG) on prostate biopsy is important for risk stratification and clinical decision making. Multiparametric MRI (mpMRI) improved detection of clinically significant disease and some studies suggest that MRI-fusion biopsy combined with systematic biopsy results in fewer upgrades on final surgical pathology. However, the downgrade rate is unclear and there is controversy in the literature. The objectives of this study are to assess the concordance of combination biopsy with final surgical pathology, and furthermore, to specifically determine downgrade rates. MATERIALS AND METHODS: In our institutional mpMRI-ultrasound fusion biopsy database, 173 underwent targeted and systematic biopsy followed by radical prostatectomy (RP). GG on targeted, systematic and combination (targeted and systematic) biopsy were compared with GG on RP. Concordance rates between biopsy types were compared with the McNemar test. Proportion of GG upgrade or downgrade at the time of RP was also evaluated. RESULTS: Surgical pathology was concordant with 44.5% of systematic biopsies, 46.8% of targeted biopsies, and 56.7% of combination biopsies. Combination biopsy significantly overestimated the final GG on RP compared to systematic biopsy (16.8% vs. 8.7% RR 1.93, 95% CI 1.36-2.75, P < 0.001). Downgrade rate from unfavorable to favorable intermediate-risk disease was 46.2%, and from high-risk to intermediate-risk disease was 45.1%. CONCLUSIONS: Combination (targeted and systematic) biopsy is associated with the highest concordance rate between biopsy and RP pathology when compared with systematic or targeted biopsy alone. However, targeting MRI lesions and therefore the higher risk components, may at times overestimate the final surgical pathology which can result in overtreatment of what may truly be less aggressive disease.

Stent duration and increased pain in the hours after ureteral stent removal.

INTRODUCTION To assess the relationship between pain after ureteral stent removal and patient and procedural factors. MATERIALS AND METHODS: A validated survey designed to assess the relationship between quality of life and treatment decisions in kidney stone disease was randomly distributed to patients with a history of a ureteral stent in seven medical centers across North America participating in an endourology research collaborative between July 2016 and June 2018. The primary outcome was increased pain after ureteral stent removal. Statistical analyses were performed using Chi-square and multiple logistic regression. RESULTS: A total of 327 surveys were analyzed. Twenty seven percent of patients reported increased pain in the hours after ureteral stent removal. Patients with a stent ≤ 7 days were significantly more likely to experience pain after stent removal compared to those with a stent > 7 days (33.3% versus 22.8%, p = 0.04). Female gender (OR: 2.41, 95% CI: 1.42-4.10) was associated with increased pain after stent removal, while increasing age was inversely associated (OR: 0.52, 95% CI: 0.36-0.74). After adjustment, patients with a stent > 7 days were significantly less likely to report pain in the hours after removal (OR: 0.59, 95% CI: 0.35-0.99). CONCLUSIONS: Approximately one in four patients will experience increased pain after ureteral stent removal. Female patients, younger patients, and patients with a stent ≤ 7 days were more likely to experience an increase in pain immediately following stent removal. Understanding factors associated with post-stent removal pain may be helpful in counseling patients at high risk stent removal morbidity.

Female underactive bladder - Current status and management.

Underactive bladder (UAB) is defined by the International Continence Society as a symptom complex characterized by a slow urinary stream, hesitancy, and straining to void, with or without a feeling of incomplete bladder emptying sometimes with storage symptoms. Until recently, the topic has received little attention in the literature probably due to a lack of consistent definitions and diagnostic criteria. We performed a literature review to identify articles related to the diagnosis and management of UAB, specifically in female patients. UAB is a common clinical entity, occurring in up to 45% of females depending on definitions used. Prevalence increases significantly in elderly women and women who live in long-term care facilities. The exact etiology and pathophysiology for developing UAB is unknown, though it is likely a multifactorial process with contributory neurogenic, cardiovascular, and idiopathic causes. There are currently no validated questionnaires for diagnosing or monitoring treatment for patients with UAB. Management options for females with UAB remain limited, with clean intermittent catheterization, the most commonly used. No pharmacotherapies have consistently been proven to be beneficial. Neuromodulation has had the most promising results in terms of symptom improvement, with newer technologies such as stem-cell therapy and gene therapy requiring more evidence before widespread use. Although UAB has received increased recognition and has been a focus of research in recent years, there remains a lack of diagnostic and therapeutic tools. Future research goals should include the development of targeted therapeutic interventions based on pathophysiologic mechanisms and validated diagnostic questionnaires.

Ureterorenoscopy for upper tract urothelial carcinoma: how often are we missing lesions?

OBJECTIVE: To determine the ability of ureterorenoscopy (URS) to identify the precise number and location of all lesions as compared with pathologic review of nephroureterectomy specimens, which have not been previously determined. Upper tract urothelial carcinoma (UTUC) comprises 5% of all urothelial malignancies in the United States. With advances in endoscopic equipment, there has been a move toward using flexible ureteroscopes to perform URS as part of the diagnostic evaluation and management. METHODS: We identified patients who had undergone URS with biopsy before radical nephroureterectomy for UTUC. Operative reports for each procedure were reviewed and compared with the surgical pathology reports. RESULTS: URS correctly identified the number and location of lesions in 57 of 76 patients (75%). The most common locations for missed lesions were in the ureter (9 patients) and renal pelvis (8 patients). Carcinoma in situ was missed on the initial biopsy for 9 patients. Three of 11 patients (27%) with a solitary lesion in the distal ureter visualized by URS had a missed lesion in the renal pelvis. URS with biopsy accurately predicted the grade of UTUC lesions in 79% of cases, whereas 65% of patients were upstaged on final pathology. CONCLUSION: URS with biopsy can accurately map UTUC in the majority of patients. However, up to 25% of patients will have missed lesions, and nearly 50% of these patients will have a missed carcinoma in situ lesion. Undergrading and understaging of UTUC lesions remain shortcomings with potentially severe consequences.

Effect of postcall fatigue on surgical skills measured by a robotic simulator.

PURPOSE: To examine the effect of a 24-hour call on residents' performance of a suturing task using the objective results calculated by the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA). SUBJECTS AND METHODS: Residents from urology and general surgery completed a single suturing skill immediately before and after a 24-hour call. Residents completed the task at least twice and were scored on three measures: time to complete the exercise, time to load the needle, and time to tie the knot. These scores were correlated with previous simulator experience, trainee level, and level of postcall fatigue. RESULTS: Thirteen residents (four senior and nine junior) participated; six had no simulator experience. All time measures were significantly longer when residents were postcall (p<0.05). In the precall measures, previous robotic simulator experience was associated with improved time for completion of the exercise, needle loading, and knot tying (p<0.05). In the postcall measures, however, the difference in performance between residents with and without previous simulator experience was no longer statistically significant (p>0.05). When examining factors that predicted an increased task time on multivariate analysis, being postcall consistently increased the time to complete the exercises, while previous simulator experience and trainee level decreased the time to complete tasks. CONCLUSIONS: Previous studies have shown that postcall-related fatigue is associated with decreased surgical skills in the operative room. We demonstrate this effect by having residents test their skills, precall and postcall, using a novel easily reproducible technique. Time to complete the three measures analyzed was significantly increased following a 24-hour call for all participants. Fatigue acts as an equalizer of abilities in that the effects of fatigue nullify the benefits of having previous robotic simulator experience.

Bladder cancers arise from distinct urothelial sub-populations.

Bladder cancer is the sixth most common cancer in humans. This heterogeneous set of lesions including urothelial carcinoma (Uca) and squamous cell carcinoma (SCC) arise from the urothelium, a stratified epithelium composed of K5-expressing basal cells, intermediate cells and umbrella cells. Superficial Uca lesions are morphologically distinct and exhibit different clinical behaviours: carcinoma in situ (CIS) is a flat aggressive lesion, whereas papillary carcinomas are generally low-grade and non-invasive. Whether these distinct characteristics reflect different cell types of origin is unknown. Here we show using lineage tracing in a murine model of carcinogenesis that intermediate cells give rise primarily to papillary lesions, whereas K5-basal cells are likely progenitors of CIS, muscle-invasive lesions and SCC depending on the genetic background. Our results provide a cellular and genetic basis for the diversity in bladder cancer lesions and provide a possible explanation for their clinical and morphological differences.

Formation and regeneration of the urothelium.

PURPOSE OF REVIEW: This review addresses significant changes in our understanding of urothelial development and regeneration. Understanding urothelial differentiation will be important in the push to find new methods of bladder reconstruction and augmentation, as well as identification of bladder cancer stem cells. RECENT FINDINGS: This review will cover recent findings including the identification of novel progenitor cells in the embryo and adult urothelium, function of the urothelium, and regeneration of the urothelium. Using Cre-lox recombination with cell-type-specific Cre lines, lineage studies from our laboratory have revealed novel urothelial cell types and progenitors that are critical for formation and regeneration of the urothelium. Interestingly, our studies indicate that Keratin-5-expressing basal cells, which have previously been proposed to be urothelial stem cells, are a self-renewing unipotent population, whereas P-cells, a novel urothelial cell type, are progenitors in the embryo, and intermediate cells serve as a progenitor pool in the adult. SUMMARY: These findings could have important implications for our understanding of cancer tumorigenesis and could move the fields of regeneration and reconstruction forward.