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Penile cancer (PeCa) is a rare urological malignancy characterized by significant geographical variations in both incidence and mortality rates. Due to its rarity and the consequent lack of randomized trials, current management is based on retrospective studies and small prospective trials. In addition, both the diagnostic pathways and treatment strategies exhibit substantial heterogeneity, differing significantly between less-developed and well-developed countries. The prognosis of PeCas is determined by the presence and extent of regional lymph node (LN) involvement. Therefore, the early detection and treatment of LN metastasis is paramount to ensure better outcomes. In recent decades, overall survival of PeCas has increased, mainly due to advancements in imaging techniques and risk stratification. We aim to provide an overview of the current role of PET CT imaging in the management of patients with PeCa.

Introduction: Most men diagnosed with very-low and low-risk prostate cancer are candidates for active surveillance; however, there is still a misclassification risk. We examined whether PI-RADS category 4 or 5 combined with ISUP 1 on prostate biopsy predicts upgrading and/or adverse pathology at radical prostatectomy., Materials and Methods: A total of 127 patients had ISUP 1 cancer on biopsy after multiparametric MRI (mpMRI) and then underwent radical prostatectomy. We then evaluated them for ISUP upgrading and/or adverse pathology on radical prostatectomy., Results: Eight-nine patients (70%) were diagnosed with PI-RADS 4 or 5 lesions. ISUP upgrading was significantly higher among patients with PI-RADS 4-5 lesions (84%) compared to patients with equivocal or non-suspicious mpMRI findings (26%, p < 0.001). Both PI-RADS 4-5 lesions (OR 24.3, 95% CI 7.3, 80.5, p < 0.001) and stage T2 on DRE (OR 5.9, 95% CI 1.2, 29.4, p = 0.03) were independent predictors of upgrading on multivariate logistic regression analysis. Men with PI-RADS 4-5 lesions also had significantly more extra-prostatic extension (51% vs. 3%, p < 0.001) and positive surgical margins (16% vs. 3%. p = 0.03). The only independent predictor of adverse pathology was PI-RADS 4-5 (OR 21.7, 95% CI 4.8, 99, p < 0.001)., Conclusion: PI-RADS 4 or 5 lesions on mpMRI were strong independent predictors of upgrading and adverse pathology. Incorporating mpMRI findings when selecting patients for active surveillance must be further evaluated in future studies.

Objective: Muscle-invasive bladder cancer is an aggressive disease. Yet, many patients, especially those with advanced age and multiple comorbidities, do not receive treatment with curative intent. We evaluated the disease course and health care burden of these patients., Materials and Methods: Bi-center, retrospective analysis of patients diagnosed with muscle-invasive bladder cancer who did not undergo curative-intent treatment (radical cystectomy or trimodal therapy) between 2016 and 2021. Patient characteristics and treatment burden were described. Metastasis-free, cancer-specific, and overall survivals were evaluated using the Kaplan-Meier method., Results: Sixty-six patients with a median age of 86 (IQR 78,90) were evaluated. The median follow-up for survivors was 29 months (IQR 9, 44). All patients were diagnosed with muscle-invasive bladder cancer, and 32 (48%) presented with clinical T3 and T4 disease. The median age adjusted Charlson comorbidity index at diagnosis was 7 (IQR 6,8). Treatment with curative intent was not provided due to comorbidities and low-performance status in 58 patients (88%) and patient refusal in 8 (12%). Two-year estimated metastasis-free survival, cancer-specific survival, and overall survival were 11%, 18%, and 12%, respectively. During follow-up, 7 patients (10%) were treated with chemotherapy, 4 (6%) received immunotherapy, 21 (32%) radiation, and 17 (26%) had emergent operations due to hematuria. Twenty-four patients (37%) required nephrostomy tubes, and 39 (59%) required an indwelling urinary catheter for various periods. Forty-three patients (65%) suffered from recurrent hematuria episodes. Overall, median emergency room visits were 4 (IQR 2, 6), and median hospital admission was 16 days (IQR 9, 29)., Conclusions: Untreated muscle-invasive bladder cancer is associated with a limited lifespan and a high disease burden for the patient and health system. These data should be taken into consideration and portrayed to the patient when curative intent treatment is chosen to be avoided., Competing Interests: Declaration of competing interest We have no financial disclosures to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Preoperative identification of the bowel on imaging is essential in planning renal access during percutaneous nephrolithotomy (PCNL) and avoiding colonic injury. We aimed this study to assess which noncontrast computed tomography (NCCT) window setting provides the optimal colonic identification for PCNL preoperative planning. Methods: Ten urologic surgeons (four seniors, six residents) reviewed 22 images of NCCT scans in both abdomen and lung window settings in a randomized blinded order. Colonic area delineation in each image was performed using a dedicated, commercially available area calculator software. A comparison of the marked colonic area between the abdomen and lung window settings was performed. Results: Overall, the mean marked colonic area was greater in the lung window compared with the abdomen window (8.82 cm 2 vs 7.4 cm 2 , respectively, p < 0.001). Switching the CT window from abdomen to lung increased the identified colonic area in 50 cases (50%). Intraclass correlation showed good agreement between the senior readers and among all readers (0.92 and 0.87, respectively). Similar measurements of the colonic area in both abdomen and lung windows were observed in 26/44 (60%) of the seniors cases and in 7/66 (10%) of the resident cases ( p = 0.002). Conclusion: Lung window solely or in combination with abdomen window appears to provide the most accurate colonic identification for preoperative planning of PCNL access and potentially reduce the risk of colonic injury. This pattern is more evident among young urologists, and we propose to introduce it as a standard sequence in PCNL preplanning.

Introduction: We aimed to assess rates of depression in patients with bladder cancer undergoing radical cystectomy and identify its predictors., Methods: Depressive symptoms in 42 consecutive patients were evaluated using the Beck's Depression Inventory (BDI) on the day prior to surgery, postoperative day (POD) 6, six weeks after surgery, and 12-18 months postoperatively., Results: Fifteen patients (36%) presented with BDI scores ≥10 before the operation; this rate increased to 64% on POD 6 and 69% at six weeks post-surgery. Depression score rose from a preoperative median of seven to 11 on POD 6 (p=0.003) and to 15 at six weeks after surgery (p=0.001). Patients who arrived with a BDI score of <10 had a higher increase in the BDI at six weeks compared to patients with depressive symptoms prior to surgery (average increase of 9.8 vs. 0.8, p<0.01). Age, gender, type of diversion, and complications were not associated with depression at presentation or progression of depression. Patients who did not receive neoadjuvant chemotherapy tended to be at increased risk for depression progression (57.1% vs. 14.3%, p=0.093). Twenty-four patients completed a fourth questionnaire 12-18 months postoperatively. The median BDI score was eight; three patients with disease recurrence had a higher increase in the BDI score (average 12.7 vs. -5.2, p<0.01)., Conclusions: Depression among patients facing cystectomy is high, and postoperative progression is substantial. Patients without depressive symptoms preoperatively are at increased risk of developing postoperative depression. After 12-18 months, the most influential risk factor for depression is recurrence. These findings highlight the need to consider interventions in selected patients.

Introduction: Symptomatic hydronephrosis associated with muscle invasive bladder cancer (MIBC) necessitates percutaneous nephrostomy (PCN) insertion before neoadjuvant chemotherapy (NAC). This study assesses the impact of PCN presence on standard intended NAC quality, its related complications and outcome after radical cystectomy (RC)., Materials and Methods: The study comprises a retrospective, multicenter cohort of 193 consecutive RCs performed between 2016 and 2019. Eighty (42%) of these patients received NAC and were divided in 2 comparison groups by presence (n = 26; 33%) or absence (n = 54; 67%) of PCN. Endpoints included completion of adequate NAC treatment (cisplatin-based chemotherapy for at least 4 courses), complications during NAC, post-RC complications and hospital stay., Results: Overall, patients with PCN (45/193; 23%) featured a higher referral rate to NAC (58% vs. 36%, P = .01), worse glomerular filtration rates (P < .001) and more adverse events (P = .04), in comparison to non-PCN patients. In the NAC cohort, PCN patients had less adequate treatment rates (54% vs. 85%, P = .005), and more infections (35% vs, 7%; P = .008) and hospitalizations (58% vs. 13%; P < .001) during chemotherapy. Post-RC outcome was similar for both comparison groups. PCN was an independent risk factor for inadequate NAC (OR = 3.9, P = .04), and infections (OR = 11.3, P = .01) and hospitalizations (OR = 7.5, P = .004) during NAC., Conclusions: PCN in MIBC patients is a significant risk factor for inadequate NAC and adverse events during treatment. This finding may quire the rationale of NAC, potentially leading to consideration of NAC avoidance and upfront RC in PCN patients. Further survival studies with long follow-up are needed for elucidating this issue., Competing Interests: Disclosure All authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To clinically and histologically characterize prostatic nodules resistant to morcellation ("beach balls," BBs)., Patients and Methods: We reviewed a consecutive cohort of 559 holmium laser enucleation of the prostate (HoLEP) procedures performed between January 2020 and November 2023. The BBs group comprised 55 men (10%) and the control group comprised 504 men (90%). The clinical, intraoperative, outcome, and histologic data were statistically processed for the prediction of the presence of BBs and their influence on the perioperative course and outcome., Results: The BBs group in comparison to the controls was older (75 vs 73 years, respectively, p = 0.009) and had higher rates of chronic retention (51 vs 29%, p = 0.001), larger prostates on preoperative abdominal ultrasound (AUS) (140 vs 80 cc, p = 0.006 E-16 ), longer operating time (120 vs 80 min, p = 0.001), higher weights of removed tissue (101 vs 60 gr, p = 0.008 E-10 ), higher complication rates (5 vs 1%, p = 0.03), and longer hospitalization (p = 0.014). A multivariate analysis revealed that larger prostates on preoperative AUS and older age independently predicted the presence of BBs which would prolong operating time. ROC analyses revealed that a threshold of 103 cc on AUS predicted BBs with 94% sensitivity and 84% specificity. BBs were mostly characterized histologically by stromal component (p = 0.005)., Conclusions: BBs are expected in older patients and cases of chronic retention. Prostatic volume is the most reliable predictor of their presence. They contribute to prolonged operating time and increased risk of complications. The predominantly stromal composition of the BBs apparently confers their resistance to morcellation., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Objective: We compared the oncologic outcomes of patients with non-muscle invasive bladder cancer (NMIBC) who underwent transurethral resection of bladder tumor (TUBRT) using sterile water vs glycine irrigation. The tumoricidal and immunogenic effects of these solutions on urothelial cancer cell lines were investigated., Methods: The medical records of 530 consecutive patients who underwent TURBT using sterile water or glycine irrigation for NMIBC were reviewed. Recurrence and progression rates were evaluated using time dependent analyses.Bladder cancer cell lines (RT4, T24 and 5637) were treated with glycine and sterile water. Cell viability was evaluated with the XTT assay. Cell membrane calreticulin levels were evaluated with flow cytometry. Extracellular high mobility group box 1 (HMGB1) and heat shock 70 (HSP70) protein levels were evaluated using western blots., Key Findings and Limitations: After propensity score matching each study arm comprised 161 patients. Median follow-up was 13.6 months (IQR 6.2, 24.5). The 2-year recurrence free survival was significantly lower in the sterile water vs glycine group (43% vs 71%, respectively, p<0.0001). Similarly, the 2-years progression free survival was significantly lower in the sterile water vs glycine group (85% vs 94%, respectively, p<0.014). Sterile water treatment resulted in the lowest number of viable cells. Early and late immunogenic cell death markers were markedly elevated in cells treated with glycine., Conclusions and Clinical Implications: Sterile water compared to glycine irrigation during TURBT for NMIBC was associated with higher recurrence and progression rates. Possible explanation for these findings is the diminished immune response associated with sterile water reflected in a comparatively lesser expression of immune response inducers., Patient Summary: We compared two irrigation fluids in non-muscle-invasive bladder cancer surgery: glycine and sterile water. Glycine outperformed sterile water in cancer recurrence, possibly boosting immunogenicity over sterile water., (Copyright © 2024 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: We aimed to assess rates of depression in patients with bladder cancer undergoing radical cystectomy and identify its predictors., Methods: Depressive symptoms in 42 consecutive patients were evaluated using the Beck's Depression Inventory (BDI) on the day prior to surgery, postoperative day (POD) 6, six weeks after surgery, and 12-18 months postoperatively., Results: Fifteen patients (36%) presented with BDI scores ≥10 before the operation; this rate increased to 64% on POD 6 and 69% at six weeks post-surgery. Depression score rose from a preoperative median of 7 to 11 on POD 6 (p=0.003) and to 15 at six weeks after surgery (p=0.001). Patients who arrived with BDI score of <10 had a higher increase in the BDI at six weeks compared to patients with depressive symptoms prior to surgery (average increase 9.8 vs. 0.8, p<0.01). Age, gender, type of diversion, and complications were not associated with depression at presentation or progression of depression. Patients who did not receive neoadjuvant chemotherapy tended to be at increased risk for depression progression (57.1% vs. 14.3%, p=0.093). Twenty-four patients completed a fourth questionnaire 12-18 months postoperatively. Median BDI score was 8; three patients with disease recurrence had a higher increase in the BDI score (average 12.7 vs. -5.2, p<0.01)., Conclusions: Depression among patients facing cystectomy is high and postoperative progression is substantial. Patients without depressive symptoms preoperatively are at increased risk of developing postoperative depression. After 12-18 months, the most influential risk factor for depression is recurrence. These findings highlight the need to consider interventions in selected patients.

Introduction:   Prostate cancer screening with PSA is associated with low specificity; furthermore, little is known about the optimal timing of biopsy.  We aimed to evaluate whether a risk classification system combining PSA density (PSAD) and mpMRI can predict clinically significant cancer and determine biopsy timing., Materials and Methods:  We reviewed the medical records of 256 men with a PI-RADS ≥ 3 lesion on mpMRI who underwent transperineal targeted and systematic biopsies of the prostate between 2017-2019.  Patients were stratified into three risk groups based on PSAD and mpMRI findings. The study endpoint was clinically significant prostate cancer (CSPC).  The association between the risk groups and CSPC was evaluated., Results:  Based on the proposed risk stratification system 42/256 men (16%) were high-risk (mpMRI finding of extra-prostatic extension and/or seminal vesicle invasion and/or a PI-RADS 5 lesion with a PSAD > 0.15 ng/mL²), 164/256 (64%) intermediate-risk (PI-RADS 4-5 lesions and/or PSAD > 0.15ng/mL² with no high-risk features) and 50/256 (20%) low-risk (PI-RADS 3 lesions and PSAD ≤ 0.15 ng/mL²).  High-risk patients had significantly higher rates of CSPC (76%) when compared to intermediate-risk (26%) and low-risk (4%).  On multivariable logistic regression analysis adjusted for age, previous biopsy, and clinical T-stage we found an association between intermediate-risk (OR = 4.84, p = 0.038) and high-risk (OR = 40.13, p < 0.001) features and CSPC.  High-risk patients had a shorter median biopsy delay time (110 days) compared to intermediate- and low-risk patients (141 and 147 days, respectively).  We did not find an association between biopsy delay and CSPC., Conclusions:   Our findings suggest that a three-tier risk classification system based on mpMRI and PSAD can identify patients at high-risk for CSPC who may benefit from earlier biopsy.

Introduction: To investigate the association between modified frailty index (mFI) scores and radical cystectomy outcomes., Materials and Methods: We conducted a multicenter retrospective analysis of 292 patients who underwent radical cystectomy between 2015 and 2019. The patients were stratified according to mFI scores (mFI 0-1 vs. mFI ≥2). Baseline characteristics were compared between groups. The primary endpoints were cancer-specific survival (CSS) and overall survival (OS), and the secondary endpoint was the 30-day postoperative complication rate., Results: One group included 164 patients with mFI 0-1 and the other included 128 patients with mFI ≥2. The cohort's median age was 69 years, and median follow-up for survivors was 33 months. Thirty-day major postoperative complication rate was 19%. Ninety patients (31%) died during the study period, 70 of them (24%) from bladder cancer. Older age, male sex, lower kidney function, and diversion to an ileal conduit were significantly more common in the mFI ≥2 group. The postoperative complication rates were comparable between groups, but the CSS and OS were significantly lower in the frailer group (p = 0.007 and p = 0.03, respectively). An mFI score ≥ 2 emerged as an independent risk factor for cancer-specific death (hazard ratio [HR] = 1.7, p = 0.03) and overall-mortality (HR = 1.8, p = 0.008)., Discussion: High mFI scores are associated with shorter CSS and OS after radical cystectomy. Healthcare providers should be encouraged to calculate frailty preoperatively for judicious patient selection in light of the predicted outcomes., Competing Interests: Declaration of Competing Interest Roy Mano is a paid consultant for N1X10., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background and Purpose: Minimal invasiveness improves outcome in many surgical fields including urology. We aimed to assess intraoperative performance and clinical outcome of miniaturized holmium laser enucleation of prostate (MiLEP) (22FR)., Methods: We ran a propensity score-matched analysis among all consecutive laser enucleations of prostate performed between 9/2022 and 2/2023. It resulted in two matched comparison groups: MiLEP 22 FR (n = 40) and holmium laser enucleation of prostate (HoLEP 26 Fr) (n = 40). Statistical analysis was performed., Results: MiLEP was associated with significantly less intraoperative irrigation (20.5 L vs 15 L, p = 0.002 E-3 ), less decrease in body core temperature (0.6°C vs 0.1°C, p = 0.003 E-5 ), and less need for meatal dilation (25% vs 78%, p = 0.01 E-3 ). These parameters were identified as being independent in the multivariate analysis. There was a trend toward less and a shorter period of postoperative stress incontinence (SI) for the MiLEP group compared to the HoLEP group: 15% and 42% (p = 0.01) at 1 month, 8% and 14% (p = 0.07) at 2 months, and 0 and 0.3% (p = 1) at 3 months, respectively. There were no differences in prostatic enucleation effectiveness, operative time, hospital stay, complications, and improvement in the international prostate symptom score and quality of life score., Conclusions: MiLEP is feasible and provides better maintenance of body core temperature, reduction in amount of fluid irrigation, and decrease in need for meatal dilation without affecting effectiveness in comparison with HoLEP. MiLEP may reduce early postoperative stress incontinence, thereby shortening the recovery period., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Extended longevity leads to greater numbers of elderly patients with benign prostatic hyperplasia (BPH) who seek surgical solutions. We assessed the clinical characteristics and outcomes of octogenarians and nonagenarians with BPH who underwent en bloc holmium laser enucleation of prostate (HoLEP). Retrospective cohort of all consecutive HoLEP patients treated in our medical center between January 2020 and January 2023. Cohort was divided into group aged < 80 years (n = 290) and group aged ≥ 80 years (n = 77). Their demographics, presentations, indications, and outcomes were compared. Octogenarians and nonagenarians had higher rates of indwelling catheters (p = 0.00001), chronic retention (p = 0.00006), larger prostates (p = 0.03), higher American Anesthesiology Association scores (p = 0.000001), and more antiplatelet medications (p = 0.0003) at presentation. They had longer operations (median 115 vs 90 min, respectively, p = 0.0008), longer hospital stay (median 2 vs 1 day, p = 0.01 E-7 ), a higher complication rate (17% vs 7%, p = 0.02), and a higher transitory urinary incontinence (TUI) rate (54% vs 9%, p = 0.00001). TUI was more prevalent in the older group with indwelling catheters (61% vs, 13%, p = 0.00001). The functional outcome was similar for both age groups, and all patients could void spontaneously after the procedure. En-bloc HoLEP improves urinary symptoms and quality of life in patients ≥ 80 years of age despite larger prostates, more comorbidities, and higher complications rate, compared to younger men. HoLEP bestows a significant improvement in urologic quality of life regardless of age., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background and Objectives: Antileucine-rich glioma-inactivated 1 (anti-LGI1) autoimmune encephalitis was first described in 2010 and is today the most common type of limbic encephalitis. During the course of the disease, 60%-88% of the patients develop hyponatremia. The etiology of the sodium disorder is unclear, often presumed to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Other electrolyte abnormalities have not been reported in association with anti-LGI1 antibody encephalitis. Due to the presence of hypomagnesemia and hypophosphatemia in our patients, we set out to try to find the expression of LGI1 protein in the kidney as an explanation for these abnormalities., Methods: We reviewed the medical files of all patients diagnosed with anti-LGI1 antibody encephalitis, at the Department of Neurology in the Tel Aviv Medical Center between January 2011 and December 2020, exploring for electrolyte abnormalities. Using tissue staining, Western blot, mass spectrometry, and RNA expression techniques, we tried to demonstrate the expression of LGI1 protein in the human kidney., Results: We identified 15 patients diagnosed with anti-LGI1 antibody encephalitis. Their average age was 65 years (44-80), and 9 were male individuals. Thirteen of the 15 patients (87%) developed varying degrees of hyponatremia. Laboratory studies demonstrated low serum osmolality, low serum blood urea nitrogen, and low uric acid, with a high urinary sodium and inappropriately high urine osmolality, supporting the presumable diagnosis of SIADH. One patient with hyponatremia that was tested, had high levels of copeptin, supporting the diagnosis of SIADH. In addition to hyponatremia, 7 patients (47%) exhibited other electrolyte abnormalities; 5 patients (33%) had overt hypophosphatemia, 4 patients (27%) had overt hypomagnesemia, and 2 other patients (13%) had borderline low magnesium levels. Western blot analysis of human kidney lysate, mass spectrometry, and qRT-PCR failed to demonstrate the expression of LGI1 protein in the kidney., Discussion: Hyponatremia in patients with anti-LGI1 antibody encephalitis is due to SIADH as previously assumed. Other electrolyte abnormalities such as hypomagnesemia and hypophosphatemia occur in at least 40% of patients and may be another clue for the diagnosis of anti-LGI1 antibody encephalitis. Because we failed to demonstrate LGI1 expression in the kidney, the results of our study suggest that renal losses lead to these disturbances, most probably due to SIADH., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

The optimal therapy for patients with non-metastatic biochemically relapsed prostate cancer (BRPC-M0) after local therapy is elusive. Thus, the evaluation of new non-toxic compounds in BRPC-M0 patients is warranted. PectaSol ® -Modified citrus pectin (P-MCP) is a food supplement categorized as GRAS (Generally Recognized As Safe) by the FDA. It is a competitive inhibitor of the galectin-3 protein, which is involved in cancer pathogenesis. In an early report of the present phase 2 study, P-MCP treatment for 6 months led to prostate-specific antigen doubling time (PSADT) improvement in 75% of patients with BRPC-M0. Herein, we report the second long-term treatment phase of an additional 12 months of P-MCP therapy (4.8 g × 3/day orally) in patients without disease progression after the initial 6 months of therapy. Of the 46 patients that entered the second treatment phase, 7 patients withdrew consent and decided to continue therapy out of pocket, and 39 initiated the second treatment phase. After a total of 18 months of P-MCP treatment, 85% ( n = 33) had a durable long-term response, with 62% ( n = 24) showing decreased/stable PSA, 90% ( n = 35) PSADT improvement, and all with negative scans. No patient had grade 3/4 toxicity. In conclusion, P-MCP may have long-term durable efficacy and is safe in BRPC-M0.

Objective: Multiparametric magnetic resonance imaging (mpMRI) is central to diagnosing prostate cancer; however, not all imaged lesions represent clinically significant tumors. We aimed to evaluate the association between the relative tumor volume on mpMRI and clinically significant prostate cancer on biopsy., Materials and Methods: We retrospectively reviewed the medical records of 340 patients who underwent combined transperineal targeted and systematic prostate biopsies between 2017 and 2021. Tumor volume was estimated based on the mpMRI diameter of suspected lesions. Relative tumor volume (tumor density) was calculated by dividing the tumor and prostate volumes. The study outcome was clinically significant cancer on biopsy. Logistic regression analyses were used to evaluate the association between tumor density and the outcome. The cutoff for tumor density was determined with ROC curves., Results: Median estimated prostate and peripheral zone tumor volumes were 55cm 3 and 0.61cm 3 , respectively. Median PSA density was 0.13 and peripheral zone tumor density was 0.01. Overall, 231 patients (68%) had any cancer and 130 (38%) had clinically significant cancer. On multivariable logistic regression age, PSA, previous biopsy, maximal PI-RADS score, prostate volume, and peripheral zone tumor density were significant predictors of outcome. Using a threshold of 0.006, the sensitivity, specificity, positive and negative predictive values of peripheral zone tumor density were 0.9, 0.51, 0.57, and 0.88, respectively., Conclusion: Peripheral zone tumor density is associated with clinically significant prostate cancer in patients with PI-RADS 4 and 5 mpMRI lesions. Future studies are required to validate our findings and evaluate the role of tumor density in avoiding unnecessary biopsies., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Although prostate-specific membrane antigen (PSMA) PET/CT has been shown valuable for staging biopsy-proven [B(+)] high-risk prostate cancer, elderly patients are occasionally referred for PSMA PET/CT without a preimaging confirming biopsy [B(-)]. The current study evaluated the rate, clinical characteristics, and PET-based stage of elderly B(-) patients and explored whether biopsy status affects therapeutic approach. Methods: One hundred consecutive patients at least 80 y old who underwent staging 68 Ga-PSMA-11 PET/CT were included. For each patient, we documented whether preimaging biopsy was performed, the clinical parameters, the PET-based staging parameters, and the primary therapy received. Results: Thirty-four (34%) of the elderly patients included in the study had no preimaging biopsy. Compared with B(+) patients, B(-) patients were older (median age, 87 vs. 82 y; P < 0.01), with worse performance status ( P < 0.01) and higher prostate-specific antigen (PSA) levels (median, 57 vs. 15.4 ng/mL; P < 0.01). On 68 Ga-PSMA-11 PET/CT, all B(-) patients had avid disease, with trends toward higher rates of bone metastases (47.1% vs. 28.8%) and overall advanced disease (50% vs. 33.3%) than in B(+) patients. Among patients with localized ( n = 36) or locally advanced ( n = 25) disease, B(-) patients were less commonly referred than B(+) patients for definitive therapies ( P < 0.01). However, higher age, Eastern Cooperative Oncology Group performance status, and PSA were other probable factors determining their therapeutic approach. Among 39 patients with advanced disease, 38 received hormonal therapy irrespective of their biopsy status. Among B(-) patients with advanced disease who were referred for hormonal therapy, 12 of 13 with follow-up data showed a biochemical or imaging-based response. Conclusion: Real-life experience with 68 Ga-PSMA-11 PET/CT indicates that around one third of elderly patients are referred for imaging without a preimaging confirming biopsy. These patients are likely to be older, with a worse clinical status and higher PSA levels. Advanced disease might be more likely to be identified on their 68 Ga-PSMA-11 PET/CT images, and if it is, their biopsy status does not preclude them from receiving hormonal therapy., (© 2023 by the Society of Nuclear Medicine and Molecular Imaging.)

Purpose: Cancer is the second leading cause of death globally. However, by implementing evidence-based prevention strategies, 30%-50% of cancers can be detected early with improved outcomes. At the integrated cancer prevention center (ICPC), we aimed to increase early detection by screening for multiple cancers during one visit., Methods: Self-referred asymptomatic individuals, age 20-80 years, were included prospectively. Clinical, laboratory, and epidemiological data were obtained by multiple specialists, and further testing was obtained based on symptoms, family history, individual risk factors, and abnormalities identified during the visit. Follow-up recommendations and diagnoses were given as appropriate., Results: Between January 1, 2006, and December 31, 2019, 8,618 men and 8,486 women, average age 47.11 ± 11.71 years, were screened. Of 259 cancers detected through the ICPC, 49 (19.8%) were stage 0, 113 (45.6%) stage I, 30 (12.1%) stage II, 25 (10.1%) stage III, and 31(12.5%) stage IV. Seventeen cancers were missed, six of which were within the scope of the ICPC. Compared with the Israeli registry, at the ICPC, less cancers were diagnosed at a metastatic stage for breast (none v 3.7%), lung (6.7% v 11.4%), colon (20.0% v 46.2%), prostate (5.6% v 10.5%), and cervical/uterine (none v 8.5%) cancers. When compared with the average stage of detection in the United States, detection was earlier for breast, lung, prostate, and female reproductive cancers. Patient satisfaction rate was 8.35 ± 1.85 (scale 1-10)., Conclusion: We present a proof of concept study for a one-stop-shop approach to cancer screening in a multidisciplinary outpatient clinic. We successfully detected cancers at an early stage, which has the potential to reduce morbidity and mortality as well as offer substantial cost savings.[Media: see text].

Objective: To assess the outcome of tandem polymeric internal stents (TIS) for benign ureteral obstruction (BUO). Material and Methods: We conducted a retrospective study that included all consecutive patients treated for BUO by means of TIS in a single tertiary center. Stents were replaced routinely every 12 months or earlier, when indicated. The primary outcome was permanent stent failure, and the secondary outcomes included temporary failure, adverse events, and renal function status. Kaplan-Meier and regression analyses were used to estimate outcomes, and logistic regression was used to assess the association between clinical variables and outcomes. Results: Between July 2007 and July 2021, 26 patients (34 renal units) underwent a total of 141 stent replacements, with median follow-up of 2.6 years (interquartile range [IQR] 0.75-5). Retroperitoneal fibrosis was the leading cause of TIS placement (46%). Permanent failures occurred in 10 (29%) renal units, and the median time to permanent failure was 728 days (IQR 242-1532). There was no association between preoperative clinical variables and permanent failure. Temporary failure occurred in four renal units (12%), which were treated by nephrostomy and eventually returned to TIS. Urinary infection and kidney injury rates were one event for every four and eight replacements, respectively. There was no significant alteration in serum creatinine levels throughout the study ( p  = 0.18). Conclusion: TIS provides long-term relief for patients with BUO and offers a safe and effective solution for urinary diversion, while avoiding the need for external tubes.

Introduction: The reported yield of non-contrast computed tomography (NCCT) in assessing flank pain and obstructive urolithiasis (OU) in emergency departments (EDs) is only ~ 50%. We investigated the potential capability of serum and urinary markers to predict OU and improve the yield of NCCT in EDs., Methods: All consecutive ED patients with acute flank pain suggestive of OU and assessed by NCCT between December 2019 and February 2020 were enrolled. Serum white blood cells (WBC), C-reactive protein (CRP) and creatinine (Cr) levels, and urine dipstick results were analyzed for association with OU, and unjustified NCCT scan rates were calculated., Results: NCCTs diagnosed OU in 108 of the 200 study patients (54%). The median WBC, CRP, and Cr values were 9,100/µL, 4.3 mg/L, and 1 mg/dL, respectively. Using ROC curves, WBC = 10,000/µL and Cr = 0.95 mg/dl were the most accurate thresholds to predict OU. Only WBC ≥ 10,000/µL (OR = 3.7, 95% CI 1.6-8.3, p = 0.002) and Cr ≥ 0.95 mg/dl (OR = 5, 95% CI 2.3-11, p < 0.001) were associated with OU. Positive predictive value and specificity for detecting OU among patients with combined WBC ≥ 10,000 and Cr ≥ 0.95 were 83% and 89%, respectively. Patients negative to the serum markers criteria underwent significantly more unjustified NCCTs (p = 0.03). The negative predictive value of the serum criteria for justified NCCT scanning was 81%., Conclusions: WBC and Cr may be valuable serum markers in predicting OU among patients presenting to EDs with acute flank pain. They may potentially reduce the number of unjustified NCCT scans in the ED setting., (© 2023. The Author(s), under exclusive licence to American Society of Emergency Radiology (ASER).)

Introduction: Prognostic models of survival can identify patients with extrinsic malignant ureteral obstruction who will benefit from long-term drainage as offered by tandem ureteral stents. The study aims to validate a simplified prognostic model published by Cordeiro et al. and to identify additional prognostic predictors in a cohort of patients drained solely with tandem ureteral stents., Methods: Medical records of consecutive patients who underwent drainage of malignant ureteral obstruction with tandem ureteral stents between 2007 and 2020 were reviewed retrospectively; patients with benign ureteral obstruction were excluded. Risk factors for survival included were: [1] the number of malignancy-related events (categorized as ≥4 and <4) and [2] the Eastern Cooperative Oncology Group Index (categorized as ≥2 and <2)]. Patients with ≥1 risk factor were grouped as intermediate-unfavorable risk and those without risk factors as favorable risk. The Kaplan-Meier and log-rank tests were used for survival analysis. Univariable and multivariable Cox regression analyses were used to identify predictors of outcome., Results: The study cohort consisted of 65 patients; the median age was 60 years (IQR 51-72). The median follow-up time from diagnosis of hydronephrosis was 51 months (IQR 38-64). Estimated probabilities of survival at 1 month, 6 months 1 year, and 2 years were 100%, 87%, 75% and 57%, respectively in the favorable risk group ( n  = 40), and in the intermediate-unfavorable risk group ( n  = 25), 96%, 72%, 52%, and 20%, respectively, ( p  = .003). On multivariable analysis, the presence of ≥4 malignancy-related events (HR = 2.04, 95% CI [1.07-3.86], p  = .03) and lung metastasis (HR = 2.37, 95% CI [1.0-5.6], p  = .05) were associated with shorter survival., Conclusions: Our findings validate the prognostic model published by Cordeiro et al. The model can be applied when counseling patients being considered for drainage with tandem ureteral stents.

Introduction: The association between blood markers and testicular viability after testicular torsion (TT) is not well known. We evaluated the role of complete blood count markers and C-reactive protein (CRP) in predicting testicular viability after TT., Methods: Fifty men, ≥18 years of age, operated for TT between the years 2015-2020 were enrolled. Blood markers including neutrophil-, lymphocyte-, and platelet count, and CRP were obtained. Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were calculated. The study outcome was testicular salvage., Results: Median age was 23 years (interquartile range [IQR]: 21, 31). Median duration of torsion was 10 h (IQR: 6, 42). Sonographic texture of the testis was homogenous in 27 (56%) patients and heterogenous in 21 (44%). During scrotal exploration, 36 patients (72%) underwent orchiopexy and 14 (28%) underwent orchiectomy. Patients who underwent orchiopexy were younger (22 years vs. 31 years, p = 0.009), had a shorter duration of torsion (median 8 h vs. 48 h, p &lt; 0.001), and a homogenous texture on scrotal ultrasound (76.5 vs. 7.1%, p &lt; 0.001). Median NLR, PLR, and CRP were higher among patients who underwent orchiectomy; however, these differences did not reach statistical significance. Patients with heterogenous echotexture were significantly more likely to undergo orchiectomy (odds ratio = 42, 95% confidence interval: 7, 831, adjusted p value = 0.009)., Conclusions: We found no association between blood-based biomarkers and testicular viability after TT; however, testicular echotexture significantly predicted outcome., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Objective: To assess a novel combined laser suction handpiece (LSH) for performing PCNL in a clinical setting., Methods: The study comprised 40 consecutive PCNLs performed between May 2019 and February 2020. The first 20 procedures (Group A) were performed with conventional ultrasonic or pneumatic devices and the other 20 (Group B) were performed with the use of the new LSH. All patients were treated by tubeless supine PCNL. The groups were compared for demographics, clinical data, operative time, lithotrite effectiveness, stone clearance rate (SCR), and outcome., Results: Groups A and B were similar in age, and in stone size, complexity, and density (Hounsfield units) ( p  < 0.05). The average operative time was 99 and 78 min, SCR 143 and 200 mm 3 /min, hospital stay 1.6 and 1.1 days, and stone-free rate 90% and 95%, respectively. Despite a trend toward better results with the new LSH, none of these comparisons reached statistical significance. Ineffective lithotripsy with the initial device (ultrasonic) requiring conversion to another modality (ballistic) occurred in six (30%) procedures in Group A, while all procedures were effectively accomplished with the LSH in Group B ( p  = 0.02). There were two complications in Group A and none in Group B ( p  > 0.05)., Conclusions: The LSH is as effective and safe as the traditional lithotrites for performing PCNLs. This new tool completes the capabilities of the holmium laser high-power machines, enabling them to serve as the sole platform for all endourological treatments.

We aimed to validate a formula for improving the estimation of prostatic volume by abdominal ultrasound (AUS) prior to transurethral laser enucleation. A total of 293 patients treated for benign prostate hyperplasia (BPH) by laser enucleation from 2019−2022 were included. The preoperative AUS volume was adjusted by the formula 1.082 × Age + 0.523 × AUS − 53.845, which was based on specimens retrieved by suprapubic prostatectomy. The results were compared to the weight of the tissue removed by laser enucleation as determined by the intraclass correlation coefficient test (ICC). The potential impact of preoperative planning on operating time was calculated. The ICC between the adjusted volumes and the enucleated tissue weights was 0.86 (p < 0.001). The adjusted volume was more accurate than the AUS volume (weight-to-volume ratio of 0.84 vs. 0.7, p < 0.001) and even more precise for prostates weighing >80 g. The median operating time was 90 min. The adjusted volume estimation resulted in an overall shorter expected preoperative operating time by a median of 21 min (24%) and by a median of 40 min in prostates weighing >80 g. The adjustment formula accurately predicts prostate volume before laser enucleation procedures and may significantly improve preoperative planning, the matching of a surgeon’s level of expertise, and the management of patients’ expectations.

Objectives: To evaluate the associations of peri-operative neutrophil-to-lymphocyte ratio (NLR) and change in NLR with survival after radical cystectomy., Patients and Methods: We retrospectively reviewed a multicentre cohort of patients with bladder cancer who underwent radical cystectomy between 2010 and 2020. Preoperative NLR, postoperative NLR, delta-NLR (postoperative minus preoperative NLR) and NLR change (postoperative divided by preoperative NLR) were calculated. Patients were stratified based on elevation of preoperative and/ or postoperative NLR above the median values. Multivariable Cox regression models were used to evaluate the associations of peri-operative NLR and NLR change with survival., Results: The study cohort included 346 patients with a median age of 69 years. The median (interquartile range) preoperative NLR, postoperative NLR, delta-NLR and NLR change were 2.55 (1.83, 3.90), 3.33 (2.21, 5.20), 0.43 (-0.50, 2.08) and 1.2 (0.82, 1.96), respectively. Both preoperative and postoperative NLR were elevated in 110 patients (32%), 126 patients (36%) had an elevated preoperative or postoperative NLR, and 110 patients (32%) did not have an elevated NLR. On multivariable analysis, increased preoperative and postoperative NLR were significantly associated with decreased survival. While delta-NLR and NLR change were not associated with outcome, patients with elevations in both preoperative and postoperative NLR had the worst overall (hazard ratio [HR] 2.97, 95% confidence interval [CI] 1.78, 4.95; P < 0.001) and cancer-specific survival rates (HR 2.41, 95% CI 1.3, 4.4; P = 0.004)., Conclusions: Preoperative and postoperative NLR are significant predictors of survival after radical cystectomy; patients in whom both NLR measures were elevated had the worst outcomes. Future studies should evaluate whether an increase in NLR during long-term follow-up may precede disease recurrence., (© 2022 The Authors. BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Introduction: We aimed to analyze patterns of referral, yield, and clinical implications of non-contrast computed tomography (NCCT) in the acute evaluation of flank pain suspected as obstructive urolithiasis (OU) in a high-volume emergency department (ED)., Methods: The study comprised 506 consecutive NCCTs performed in the ED over four months. Detection rates of OU, incidental, and alternative findings were calculated. Imaging signs suspicious for recent passage of stones were considered positive for OU, while renal stones without signs of obstruction were considered unrelated to the acute presentation. OU, other findings requiring hospitalization, and incidental findings warranting further workup were considered situations in which NCCTs were warranted., Results: NCCTs confirmed an OU diagnosis in 162 (32%) patients and non-clinically significant nephrolithiasis in 125 (25%). They revealed other findings in 108 (21%) patients, including 42 (8%) with clinically significant incidental findings and 26 (5%) with alternative diagnoses requiring hospitalization. NCCTs were entirely negative in 111 (22%) patients. Corroboration of these outcomes, together with overlapping of OU, incidental, and alternative significant findings in some patients resulted in an overall justified NCCT request rate of 44%., Conclusions: The yield of NCCT performed in acute presentations of flank pain suspected as OU is relatively low, and over one-half of the scans are unwarranted. The pattern of requesting NCCT in the ED needs refinement to avoid abuse that may lead to radiation overexposure, psychological burden, physical harm, and financial overload.

Introduction: Current guidelines do not support the use of pretreatment imaging in patients with favorable intermediate-risk prostate cancer. 68 Ga-prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) is more accurate than conventional imaging for preoperative staging. We aimed to evaluate whether pretreatment 68 Ga-PSMA PET/CT is beneficial for identifying pathological lymph node involvement (LNI) and adverse pathology among patients with favorable intermediate-risk prostate cancer., Methods: We reviewed 88 patients with favorable intermediate-risk prostate cancer who underwent 68 Ga-PSMA PET/CT prior to radical prostatectomy and lymph node dissection from 2016-2020. The primary endpoint was the presence of pathological LNI. Association between pretreatment characteristics and outcomes were evaluated., Results: Preoperative 68 Ga-PSMA PET/CT showed suspicious uptake in lymph nodes in 4/88 patients (5%), hence, 20 patients would need to be scanned to identify a patient with a positive lymph node on imaging. Two patients had pathological LNI, only one of whom showed 68 Ga-PSMA PET/CT uptake prior to surgery. The sensitivity, specificity, positive predictive value, and negative predictive values of 68 Ga-PSMA PET/CT for identifying LNI were 50%, 97%, 25%, and 99%, respectively. After surgery, four patients had evidence of prostate-specific antigen (PSA) persistence. The rate of PSA persistence was higher among patients with LNI on preoperative 68 Ga-PSMA PET/CT (2/4, 50% vs. 2/84, 2%, p=0.009)., Conclusions: Preoperative imaging of favorable intermediate-risk prostate cancer patients using 68 Ga-PSMA PET/CT showed a low yield for identifying patients at higher risk. Consistent with current guidelines, our findings do not support the routine use of PET/CT in this group of patients. Future prospective studies are needed to validate our findings.

Background: Computerized tomography (CT) is considered indispensable in percutaneous nephrolithotomy (PCNL) planning. We aimed to define the reliability of pre-PCNL CT for planning renal access by assessing renal positional changes between supine and prone CTs., Subjects and Methods: CT urographies (CTU) of 30 consecutive patients were reviewed for distances upper pole (UP)-diaphragm, UP-diaphragm attachment, renal pelvis (RP)-lateral body wall, RP- posterior body wall, and lower pole (LP)- anterior-superior iliac spine (ASIS). The posterior and lateral renal axes angles were also calculated., Results: The most consistent overall movement in transition from prone to supine was backward rotation, as demonstrated by a decrease in distance UP-posterior body wall (p = 0.010) and increase in the posterior renal angle (p < 0.0001). This finding correlated with the patient's body mass index (BMI) (p = 0.029). The left kidney was more mobile than the right one, moving significantly for five of the measured parameters compared to the right kidney which moved significantly for only two parameters. The UP-diaphragm distance of the left kidney correlated with age (p = 0.014), the RP-lateral wall distance correlated with previous abdominal surgery (p = 0.006), and the RP-posterior wall distance with BMI (p = 0.017). On the right, the UP-diaphragm distance correlated with gender (p = 0.002) and the lateral renal rotation was smaller (p = 0.046)., Conclusions: Kidneys present significant mobility between supine and prone positions. CT assessment should be performed in the position expected during surgery and should be interpreted with caution, while a real-time imaging modality should be used in the operating room., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The aim of the study was to elaborate the incidence and type of skeletal involvement in a large cohort of patients with newly diagnosed prostate cancer (PCa) referred for Ga-68 PSMA-11 PET/CT staging in a single center., Methods: Study cohort included 963 consecutive patients with newly diagnosed PCa referred for Ga-68 PSMA-11 PET/CT study for staging. The incidence of bone involvement, type of bone metastases, and extent of disease were determined and correlated with the ISUP Grade Group (GG) criteria and PSA levels., Results: Bone metastases were found in 188 (19.5%) of 963 patients. Bone metastases were found in 10.7% of patients with PSA < 10 ng/dL and in 27.4% of patients with PSA > 10 ng/dL and in 6.1% of patients with GG ≤ 2/3 and in 8.9% of patients with GG 4/5. In 7.6% of the patients, skeletal involvement was extensive, while 11.9% of patients had oligometastatic disease. Osteoblastic type metastases were the most common type of bone metastases presented in 133 of the patients with malignant bone involvement (70.7%). More than half of them had only osteoblastic lesions (72 patients (38.3%)), while the other (61 patients (32.5%)) had also intramedullary and/or osteolytic type lesions. Intramedullary metastases were found in 97 patients (51.6%), while 41 (21.8%) of them were only intramedullary lesions. Osteolytic metastases were detected in 36 patients (19.2%), of which 8 were only osteolytic lesions., Conclusion: Although traditionally bone metastases of PCa are considered osteoblastic, osteolytic and intramedullary metastases are common, as identified on PET with labeled PSMA. Skeletal spread may be present also in patients with GG ≤ 2/3 and PSA < 10 ng/dL., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To assess the influence of COVID-19-imposed life changes on presentation and outcomes of patients with obstructing urinary stones complicated by infection., Patients and Methods: All patients presenting with obstructing urinary stones and infection 1 year before the pandemic (March 2019 to February 2020; n  = 66) and 1 year since its onset (March 2020 to February 2021; n  = 45) were enrolled. Demographics, clinical presentation, laboratory panel, stone characteristics and outcomes were compared between groups. Univariate and multivariate logistic regression models were performed for analysis., Results: The COVID-19 period was characterised by younger patients, female predominance, higher temperature at presentation and more bilateral obstructing stones ( p  < 0.05). The admission rate to intensive care units was double that of the pre-pandemic period, whereas time between diagnosis and treatment was similar. The univariate analysis revealed higher rates of severe sepsis (odds ratio [OR] = 3, p  = 0.01), systemic inflammatory response syndrome (SIRS) ≥ 2 (OR = 2.9, p  = 0.01) and risk, injury, failure, loss of kidney function and end-stage kidney (RIFLE) criteria ≥ 1 (OR = 2.2, p  = 0.04) in the pandemic period group. The multivariate analyses revealed the COVID-19 period as being the sole variable associated with severe sepsis (OR = 3.1, p  = 0.02), SIRS ≥ 2 (OR = 3.8, p  = 0.005) and RIFLE ≥ 1 (OR = 2.6, p  = 0.05)., Conclusions: The pandemic period was characterised by a worse clinical state at presentation of patients with obstructing urinary stones complicated by infection, probably reflecting delay in arrival to emergency services., Competing Interests: No competing financial interests exist., (© 2022 The Authors. BJUI Compass published by John Wiley & Sons Ltd on behalf of BJU International Company.)

Objective: To evaluate whether meatal stenosis treated concomitantly with urethral fistula repair alters the results of fistula closure., Methods: A retrospective cohort study, included were all children who underwent local fistula closure following hypospadias repair between 2006 and 2017. Patients who underwent reoperative urethroplasty were excluded. Data were extracted from electronic records, and missing data were supplied by telephone interviews. Characteristics of patients and fistulas were compared between children who underwent fistula closure only and those who underwent meatoplasty for meatal stenosis during the same surgery. The primary endpoint was fistula recurrence., Results: In total, 106 local repairs of urethrocutaneous fistulas were performed during the study period, and 25 of them included concomitant meatoplasty for meatal stenosis. There was no difference in terms of location, size, and number of fistulas or the number of recurrent fistulas between the 81 patients who underwent fistula closure only and the 25 who underwent concomitant meatoplasty. The fistula recurrence rate was 17 per 81 (21%) for the fistula only group and 5 per 25 (20%) for the fistula and meatoplasty group after a median follow-up of 7 and 8 years, respectively. Meatoplasty was required in a subsequent procedure in 5 of 81 in the former group vs 3 of 25 patients in the latter group., Conclusion: The presence and repair of meatal stenosis does not alter the recurrence rate of urethrocutaneous fistulas repaired concomitantly following hypospadias repair., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Concurrent systematic biopsies during image-guided targeted biopsies of the prostate were found to improve the detection rate of clinically significant prostate cancer (CSPC). However, these biopsies do not routinely include anterior or apical sampling. We aimed to evaluate the significance of anterior and apical samplings during combined biopsies., Methods: After obtaining institutional review board approval we identified 303 consecutive patients who underwent transperineal combined biopsies of the prostate between 2017-2020. Systematic biopsies were obtained from the peripheral zone, anterior zone, and apex. Study outcomes included CSPC and any cancer on anterior or apical biopsies. Logistic regression analyses were used to evaluate the association between pre-biopsy characteristics and study outcomes., Results: Median prostatic-specific-antigen value was 6.8 ng/dL. Most patients had stage T1c disease (77%). Overall, combined biopsies detected CSPC in 87 patients (29%). Any cancer and CSPC in the anterior zone were found in 54 (18%) and 19 (6%) patients, respectively. Any cancer and CSPC in the apex were found in 54 (18%) and 16 (5%) patients, respectively. Anterior/apical samplings upgraded the pathological result in 19 patients (6%). Logistic regression analyses demonstrated that PI-RADS 5 lesions predicted the presence of CSPC in both the anterior zone (OR = 8, 95%CI = 3-22, P <0.001) and apex (OR = 4, 95%CI = 1-10, P = 0.01)., Conclusions: Avoiding anterior and apical samplings during prostate biopsy does not result in substantial under-diagnosis of significant cancer. However, these areas are easily accessible using the transperineal approach and should be sampled in selected patients, particularly those with PI-RADS 5 lesions., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To investigate the prevalence of testicular microlithiasis and its association with sperm retrieval rates and histopathology in men with non-obstructive azoospermia., Methods: A total of 120 men underwent scrotal ultrasonography prior to microsurgical testicular sperm extraction. Sperm retrieval rate, testicular histopathology, testicular size, reproductive hormones, karyotyping, Y chromosome microdeletion analyses, and presence of varicoceles and hydroceles were compared between men with and without testicular microlithiasis., Results: The total sperm retrieval rate was 40%. Ten men with normal spermatogenesis were excluded. The remaining 110 men with non-obstructive azoospermia were analyzed and testicular microlithiasis was detected in 16 of them (14.5%). The sperm retrieval rate in that subgroup was only 6.2% (1/16) as opposed to 39.4% (37/94) in men with non-obstructive azoospermia and no evidence of microlithiasis (P = 0.009). The mean right and left testicular diameters were significantly lower in the microlithiasis group (P = 0.04). On multivariate logistic regression analysis, the presence of mictolithiasis (odds ratio 7.4, 95% confidence interval 2.3, 12.2; P = 0.01) was the only independent predictor of unsuccessful sperm retrieval. The 15 patients with microlithiasis and without successful sperm extraction were diagnosed by histopathology as having Sertoli cells only. The 16th patient with successful sperm retrieval had a histopathology of mixed atrophy and was diagnosed with Klinefelter syndrome., Conclusion: The presence of testicular microlithiasis is associated with low sperm retrieval rates among our cohort of men with non-obstructive azoospermia undergoing scrotal ultrasonography prior to microsurgical testicular sperm extraction. Larger, prospective studies should be conducted to confirm these findings., (© 2021 The Japanese Urological Association.)

Background: Patients hospitalized due to gross hematuria frequently complete evaluation in the outpatient setting. The use of office flexible cystoscopy during hospitalization may lead to prompt diagnosis and treatment but can be limited due to low visualization and artifacts that can hamper diagnostic ability., Objective: The objective of this study was to assess flexible cystoscopy findings and yield performed in patients hospitalized due to gross hematuria., Methods: Medical records of patients who underwent flexible cystoscopy while hospitalized during September 2018-December 2019 were reviewed. Cystoscopic findings were categorized into (1) suspicious mass in the bladder or prostate, (2) nonsuspicious changes in the bladder, and (3) nondiagnostic exam. Descriptive statistics were used to report the clinical characteristics of the study cohort and the findings of cystoscopy. Univariate logistic regression analyses were used to identify predictors of malignant findings., Results: The study cohort consisted of 69 patients (median age of 76 years). Initial cystoscopy findings were suspicious for malignancy in 26/69 patients (38%), nonsuspicious for malignancy in 34/69 patients (49%), and nondiagnostic in 9/69 patients (13%). The median follow-up time was 9 months (range 4-14 months). Twenty patients (29%) were diagnosed with malignancy (sensitivity of 75% and specificity of 78%). The procedure led to either diagnosis or treatment of 39 patients (57%). However, in 30 patients (43%), the initial cystoscopy did not aid in the diagnosis, led to misdiagnoses, or required a follow-up cystoscopy. On univariate analyses, none of the precystoscopy variables were predictive of bladder malignancy., Conclusion: Flexible cystoscopy in the setting of acute hematuria requiring hospitalization did not lead to diagnosis or treatment in over 40% of cases. In this setting, consideration should be given to performing an upfront cystoscopy under anesthesia., (© 2021 The Author(s). Published by S. Karger AG, Basel.)

Optimal therapy of biochemically relapsed prostate cancer (BRPC) after local treatment is elusive. An established modified citrus pectin (PectaSol ® , P-MCP), a dietary polysaccharide, is an established antagonist of galectin-3, a carbohydrate-binding protein involved in cancer pathogenesis. Based on PSA dynamics, we report on the safety and the primary outcome analysis of a prospective phase II study of P-MCP in non-metastatic BRPC based. Sixty patients were enrolled, and one patient withdrew after a month. Patients ( n = 59) were given P-MCP, 4.8 grams X 3/day, for six months. The primary endpoint was the rate without PSA progression and improved PSA doubling time (PSADT). Secondary endpoints were the rate without radiologic progression and toxicity. Patients that did not progress by PSA and radiologically at six months continued for an additional twelve months. After six months, 78% ( n = 46) responded to therapy, with a decreased/stable PSA in 58% ( n = 34), or improvement of PSADT in 75% ( n = 44), and with negative scans, and entered the second twelve months treatment phase. Median PSADT improved significantly ( p = 0.003). Disease progression during the first 6 months was noted in only 22% ( n = 13), with PSA progression in 17% ( n = 10), and PSA and radiologic progression in 5% (n = 3). No patients developed grade 3 or 4 toxicity.

Introduction: We aimed to compare the treatment patterns and oncological outcomes, including postoperative morbidity and chemotherapy use, between octogenarians and patients <80 years of age who underwent radical cystectomy for bladder cancer., Methods: We conducted a retrospective analysis of 119 patients who underwent radical cystectomy for bladder cancer at our center between January 2013 and April 2019. Comorbidities, clinical and pathological data, 30-day postoperative morbidity, and perioperative chemotherapy use were compared between octogenarians (n=31) and younger patients (n=88). Cancer-specific and overall survival rates were estimated with the Kaplan-Meier method and compared between the groups., Results: No significant differences were found between the age groups in the clinical and pathological findings, including Charlson comorbidity index, modified frailty index, albumin level, renal function, and TNM stage. The median followup for survivors was 19 months (interquartile range [IQR] 11-30). Major complications (Clavien-Dindo grade ≥3) and 30-day postoperative mortality rates did not differ between the age groups (p=0.3 and p=0.18, respectively). Despite no difference in baseline glomerular filtration rates, perioperative chemotherapy utilization rate was lower among octogenarians compared to younger patients (13% vs. 34%, p=0.03). Estimated two-year cancer-specific survival rates for octo-generians and younger patients were 40% and 75%, respectively. Similarly, estimated two-year overall survival rates were 30% and 69%, respectively. Both cancer-specific and overall survival rates were significantly lower in octogenarians (p=0.007 and p=0.001, respectively)., Conclusions: Radical cystectomy in octogenarians results in comparable short-term outcomes as in younger patients. However, in the elderly population, perioperative chemotherapy utilization rates are lower and survival is inferior.

Background: High-risk prostate cancer is associated with adverse pathology and unfavorable outcomes after radical prostatectomy. 68 Ga-PSMA PET/CT is more accurate than conventional imaging for preoperative staging. We aimed to evaluate whether lymph node involvement on 68 Ga-PSMA PET/CT prior to radical prostatectomy in patients with high-risk prostate cancer is associated with worse short-term oncologic outcomes., Methods: We retrospectively reviewed 149 patients with high-risk localized or locoregional prostate cancer who underwent 68 Ga-PSMA PET/CT prior to radical prostatectomy between 2015 and 2020. None of the patients received neoadjuvant or adjuvant treatment. The study endpoints were PSA persistence and biochemical recurrence. Logistic regression models were used to identify preoperative predictors of PSA persistence. Kaplan-Meier analyses were used to estimate biochemical recurrence-free survival., Results: Of 149 identified patients, 19 (13%) were found to have lymph node involvement on preoperative 68 Ga-PSMA PET/CT. The sensitivity, specificity, and accuracy of 68 Ga-PSMA PET/CT for identifying pathologic lymph node involvement were 68%, 95%, and 92%, respectively. PSA persistence rate was lower among patients with PET-negative lymph nodes than those with PET-positive nodes (15 vs. 84%, p < 0.001). Positive nodes on imaging (OR = 41.03, p < 0.001) and clinical T2c-T3 stage (OR = 6.96, p = 0.002) were associated with PSA persistence on multivariable analysis. Among patients with PET-negative nodes the 1- and 2-year biochemical recurrence-free survival rates were 87% and 76%, respectively., Conclusions: Preoperative staging with 68 Ga-PSMA PET/CT may identify a subgroup of high-risk prostate cancer patients with favorable short-term outcomes after radical prostatectomy without adjuvant treatment. Future studies will evaluate whether these results are sustained during long-term follow-up., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Data on who among the infertile male population may benefit from round spermatid injections (ROSI) are lacking., Objective: To determine the probability of finding round spermatids suitable for ROSI in men with non-obstructive azoospermia (NOA) in whom no spermatozoa were retrieved at testicular sperm extraction., Materials and Methods: Four-hundred fifty-seven consecutive men with azoospermia underwent testicular sperm extraction. Clinical examination included age, secondary sexual characteristics, testicular size, reproductive hormone estimation, karyotyping, and Y chromosome microdeletion analyses. Histologic examination was performed, and histologic classification was determined by the most advanced spermatogenetic cell identified in the combined histologic and cytologic examination., Results: Of the 457 azoospermic men, 342 were diagnosed with NOA, and 148 (148/342, 43%) had mixed atrophy on histopathology and retrievable spermatozoa. No spermatozoa were found in 194/342 men with NOA (57%). Histopathology diagnosed 145/194 (75%) of them with Sertoli cell only, 45/194 (23%) with spermatocyte maturation arrest, and 4/194 (2%) with spermatid maturation arrest., Conclusions: Histopathologically identified round spermatids without spermatozoa were rare in men with NOA. Only very few of them are likely to reap the benefits of ROSI, thus presenting the need to reconsider its actual clinical value., (© 2021 American Society of Andrology and European Academy of Andrology.)

Aim: To assess the precision of preoperative ultrasonography (US)-determined prostate volume and to propose formulas for improving it., Methods: This retrospective study comprised 155 consecutive men who underwent open prostatectomy for benign prostatic hyperplasia (BPH) between 2013 and 2019. Preoperative prostate volume was estimated by either abdominal US (AUS) ( n  = 92) or transrectal US (TRUS) ( n  = 63), and was compared with the weight of surgically enucleated tissue at a conversion rate of 1 ml (US) = 1 g tissue. Statistical analysis was conducted and a novel formula for prostate volume was constructed., Results: The median prostate volumes by AUS and TRUS were 140 ml [interquartile ratio (IQR) 111-182] and 108 ml (IQR 93-120), respectively. Enucleated tissue weight was lower than the AUS assessment by a median difference of 50 g (IQR 28.7-75.7; p  < 0.001), and lower than the TRUS assessment by a median difference of 27 g, IQR 10-43, p  < 0.001). Using a cutoff of 80 ml, 30 (33%) AUS patients and 23 (36%) TRUS patients underwent unneeded open procedures. Mathematical calculations revealed two formulas that significantly adjusted for the actual weight: 1.082*Age + 0.523*AUS - 53.845 for AUS and 0.138*age + 2.22*prostate-specific antigen + 0.453*TRUS + 11.682 for TRUS ( p  < 0.001). These formulas increased the overall US prostate volume accuracy from 65% to 85%., Conclusion: Assessment of prostate volume by US is imprecise for decision-making of whether to perform open simple prostatectomy for BPH. Our novel formulas may enhance stratification of patients with prostatic enlargement to a more optimal surgical approach. Future studies in larger cohorts are needed to substantiate our results., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest., (© The Author(s), 2021.)

Bone metastases from prostate cancer (PCa) often show an increase in density on computed tomography (CT) after successful androgen deprivation therapy (ADT). Density may be reduced, however, as the disease progresses or, contrarily, when disease is no longer active. The current study investigated the role of 68Ga-PSMA-11 positron emission tomography/computed tomography (PET/CT) in differentiating between these two conditions., Methods: The study cohort included 15 PCa patients with sclerotic/blastic bone metastasis in whom reduction in bone density of metastasis was noted on follow-up 68Ga-PSMA-11 PET/CT after ADT. Each patient had two PET/CT scans. Prior to the first scan, six patients were castration naïve and nine patients were already treated. All patients had ADT between the two PET/CT scans. PET parameters (SUVmax and tumor-to-background ratio), and CT parameters (HUmax) were determined and compared for each lesion on both scans. Patient's response was based on prostate-specific antigen (PSA) levels and appearance of new lesions. The Kolmogorov-Smirnov test was used to evaluate normal distribution of the continuous variables., Results: Post-ADT reduction in bone density was identified in 37 lesions. The mean HUmax was 883.9 ± 175.1 on the first scan and 395.6 ± 157.1 on the second scan ( p < 0.001). Twenty-one of the 37 lesions showed no increased tracer uptake on the second PET/CT scan raising the likelihood of a response. The other 16 lesions were associated with increased uptake suggestive of an active resistant disease. Bone density was not different in lesions that no longer showed an increased uptake as compared with those that did. Seven of the study patients responded to therapy, and none of the 16 lesions found in these patients showed increased 68Ga-PSMA-11 uptake. In eight patients with progressive disease, all 12 lesions in five of them showed increased 68Ga-PSMA-11 uptake, there was mixed response in two patients (having two lesions with increased uptake and one without) and although all three lesions no longer showed an increased uptake, new lesions were detected in the eighth patient., Conclusion: A decrease in density of bone lesions may reflect clinical progression, or contrarily, a response to therapy in patients with PCa and skeletal involvement treated with ADT. Uptake of 68Ga-PSMA-11 may separate between these two vastly opposing conditions.

Background: Assessing the extent of disease in newly diagnosed prostate cancer (PC) patients is crucial for tailoring an appropriate treatment approach. Prostate-specific membrane antigen (PSMA)-targeted positron emission tomography/computed tomography (PET/CT) reportedly has greater accuracy than conventional imaging for staging PC. As with any imaging modality, pitfalls and nonspecific findings do occur. The PSMA reporting and data system (PSMA-RADS) version 1.0 offers structured interpretation of PSMA-targeted studies and classifies lesions by likelihood of clinical significance. The aim of this retrospective study was to evaluate the clinical significance of equivocal bone findings on staging PSMA-targeted imaging, as defined by PSMA-RADS version 1.0, in the preoperative setting. Fifteen of 406 consecutive patients staged by PET/CT prior to radical prostatectomy had equivocal bone lesions. The scans were retrospectively scored with the PSMA-RADS version 1.0 system, blinded to disease course and follow-up data. Postoperative persistence of prostate-specific antigen levels supported by imaging and histological findings was used as the reference standard for the true significance of equivocal imaging findings., Results: Thirteen of the 15 patients had an overall PSMA-RADS score of 3B, of whom only two had true metastatic disease. The remaining patients had scores of 4 (n = 1) or 5 (n = 1), all confirmed as true positive prostate-related malignant lesions. A per-lesion analysis identified 29 bone lesions, of which 27 were scored PSMA-RADS 3B, and only three of them were true metastases. Thus, debatable lesions proved to have no clinical significance in 84.6% of cases, and only 11% of equivocal PSMA-RADS 3B bone lesions were true positive., Conclusions: In intermediate and high-risk patients staged prior to radical prostatectomy, the majority of PSMA-RADS 3B lesions are of no clinical relevance. Bone lesions judged as being highly suspicious for metastases (PSMA-RADS 4/5) were all validated as true positives.

Introduction: To assess long-term outcomes of double internal stents (DIS) for the relief of external malignant ureteral obstruction (MUO). Materials and Methods: DIS (7F each; 12-month indwelling time) were inserted under general anesthesia in 62 consecutive patients (75 renal units) with MUO during 2007-2018. Surveillance was performed every 3 months, and stents were exchanged routinely every year. The need for permanent stent retrieval was considered stent failure. Maintenance of stent patency and disease-specific survival (DSS) were estimated (Kaplan-Meier). Risk factors were also assessed (univariate and multivariable Cox regression analyses). Results: The median follow-up was 27 months (interquartile range [IQR] 20-27). The most frequent tumors causing obstruction were colorectal and ovarian cancers. Six patients (10%) had stent failure caused by sepsis, creatinine elevation, or hematuria. The average time to failure was 15 months (range 1-27). A history of radiation and an estimated glomerular filtration rate (eGFR) ≤45 mL/(min/1.73 m 2 ) were associated with stent failure ( p  = 0.038 and p  = 0.001, respectively). Thirty-nine patients died with a median DSS of 21 months (IQR 8.6-not reached). Multivariate analysis identified eGFR ≤60 mL/(min/1.73 m 2 ) (hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.1-4.2, p  = 0.02) and need for balloon dilation (HR 2.1, 95% CI 1.1-4.1, p  = 0.02) as independent predictors for disease-related mortality. Twenty-six patients (42%) had stent-related complications, for example, irritative symptoms, hematuria, and infections, of whom only two failed. Conclusions: One-year indwelling DIS provide effective long-term relief of MUO and represent a simple and effective alternative to other methods of urinary diversion. They avoid the need for external tubes and contribute to improved patient satisfaction.

Objective: Image guided biopsies are an integral part of prostate cancer evaluation. The effect of delaying biopsies of suspicious prostate mpMRI lesions is uncertain and clinically relevant during the COVID-19 crisis. We evaluated the association between biopsy delay time and pathologic findings on subsequent prostate biopsy., Materials and Methods: After obtaining IRB approval we reviewed the medical records of 214 patients who underwent image-guided transperineal fusion biopsy of the prostate biopsy between 2017 and 2019. Study outcomes included clinically significant (ISUP grade group ≥2) and any prostate cancer on biopsy. Logistic regression was used to evaluate the association between biopsy delay time and outcomes while adjusting for known predictors of cancer on biopsy., Results: The study cohort included 195 men with a median age of 68. Median delay between mpMRI and biopsy was 5 months, and 90% of patients had a ≤8 months delay. A significant association was found between PI-RADS 5 lesions and no previous biopsies and shorter delay time. Delay time was not associated with clinically significant or any cancer on biopsy. A higher risk of significant cancer was associated with older age (P = 0.008), higher PSA (0.003), smaller prostate volume (<0.001), no previous biopsy (0.012) and PI-RADS 5 lesions (0.015)., Conclusions: Our findings suggest that under current practice, where men with PI-RADS 5 lesions and no previous biopsies undergo earlier evaluation, a delay of up to 8 months between imaging and biopsy does not affect biopsy findings. In the current COVID-19 crisis, selectively delaying image-guided prostate biopsies is unlikely to result in a higher rate of significant cancer., Competing Interests: Conflict of Interest All authors declare that they have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Abdominal tumors invading the inferior vena cava (IVC) present significant challenges to surgeons and oncologists., Objectives: To describe a surgical approach and patient outcomes., Methods: The authors conducted a retrospective analysis of surgically resected tumors with IVC involvement by direct tumor encasement or intravascular tumor growth. Patients were classified according to level of IVC involvement, presence of intravascular tumor thrombus, and presence of hepatic parenchymal involvement., Results: Study patients presented with leiomyosarcomas (n=5), renal cell carcinoma (n=7), hepatocellular carcinoma (n=1), cholangiocarcinoma (n=2), Wilms tumor (n=1), neuroblastoma (n=1), endometrial leiomyomatosis (n=1), adrenocortical carcinoma (n=1), and paraganglioma (n=1). The surgeries were conducted between 2010 and 2019. Extension of tumor thrombus above the hepatic veins required a venovenous bypass (n=3) or a full cardiac bypass (n=1). Hepatic parenchymal involvement required total hepatic vascular isolation with in situ hepatic perfusion and cooling (n=3). Circular resection of IVC was performed in five cases. Six patients had early postoperative complications, and the 90-day mortality rate was 10%. Twelve patients were alive, and six were disease-free after a mean follow-up of 1.6 years., Conclusions: Surgical resection of abdominal tumors with IVC involvement can be performed in selected patients with acceptable morbidity and mortality. Careful patient selection, and multidisciplinary involvement in preoperative planning are key for optimal outcome.

18 F-PSMA-1007 is a novel prostate-specific membrane antigen (PSMA)-based radiopharmaceutical for imaging prostate cancer (PCa). The aim of this study was to compare the diagnostic accuracy of 18 F-PSMA-1007 with 68 Ga-PSMA-11 PET/CT in the same patients presenting with newly diagnosed intermediate- or high-risk PCa. Methods: Sixteen patients with intermediate- or high-risk PCa underwent 18 F-PSMA-1007 and 68 Ga-PSMA-11 PET/CT within 15 d. PET findings were compared between the 2 radiotracers and with reference-standard pathologic specimens obtained from radical prostatectomy. The Cohen κ-coefficient was used to assess the concordance between 18 F-PSMA-1007 and 68 Ga-PSMA-11 for detection of intraprostatic lesions. The McNemar test was used to assess agreement between intraprostatic PET/CT findings and histopathologic findings. Sensitivity, specificity, positive predictive value, and negative predictive value were reported for each radiotracer. SUV max was measured for all lesions, and tumor-to-background activity was calculated. Areas under receiver-operating-characteristic curves were calculated for discriminating diseased from nondiseased prostate segments, and optimal SUV cutoffs were calculated using the Youden index for each radiotracer. Results: PSMA-avid lesions in the prostate were identified in all 16 patients with an almost perfect concordance between the 2 tracers (κ ranged from 0.871 to 1). Aside from the dominant intraprostatic lesion, similarly detected by both radiotracers, a second less intense positive focus was detected in 4 patients only with 18 F-PSMA-1007. Three of these secondary foci were confirmed as Gleason grade 3 lesions, whereas the fourth was shown on pathologic examination to represent chronic prostatitis. Conclusion: This pilot study showed that both 18 F-PSMA-1007 and 68 Ga-PSMA-11 identify all dominant prostatic lesions in patients with intermediate- or high-risk PCa at staging. 18 F-PSMA-1007, however, may detect additional low-grade lesions of limited clinical relevance., (© 2020 by the Society of Nuclear Medicine and Molecular Imaging.)

Introduction: Data on the accuracy of 68Ga-PSMA positron emission tomography/computed tomography (PET/CT) in patients with intermediate/high-risk prostate cancer are being accumulated. Its role in assessing the extent of local disease has not been fully elaborated., Aim: To determine the performance characteristics of 68Ga-PSMA PET/CT in identifying local disease extension in patients with intermediate/high risk prostate cancer., Methods: 68Ga-PSMA PET/CT studies of 61 consecutive patients with intermediate/high-risk prostate cancer who underwent radical prostatectomy were reviewed by nuclear medicine specialists. Tumor location, extraprostatic extension (EPE), seminal vesicle invasion (SVI), and lymph nodes involvement (LNI) were compared to pathological findings. The incremental value of 68Ga-PSMA PET/CT to established nomograms was determined., Results: Two patients without pathologic uptake of 68Ga-PSMA were excluded. Seventeen patients were diagnosed with EPE (29%), 12(20%) had SVI and 3(5%) LNI. The concordance between tumor location and 68Ga-PSMA PET/CT findings was 48%, and EPE was not indicated by PET in any of the patients. The sensitivity, specificity, positive, and negative predictive value for SVI were 58%, 96%, 78%, 90%, respectively (area under the receiver operating characteristic curve = 0.77) and for LNI 67%, 98%, 67%, 98%, respectively (area under the receiver operating characteristic curve = 0.82). Incorporating imaging findings into the MSKCC-SVI nomogram enhanced the diagnostic accuracy from 0.84 to 0.95 (Integrated Discrimination Increment 0.24, P = 0.004)., Conclusion: In patients with intermediate/high-risk prostate cancer, 68Ga-PSMA PET/CT provides information regarding intraprostatic tumor location, SVI and LNI but has no role in assessment for EPE. This information might be useful for pretreatment counseling, decision-making and possibly preoperative planning., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The aim of the current study was to assess whether and to what extent monitoring response to treatment using prostate-specific membrane antigen (PSMA)-based positron-emitting tomography/computerized tomography (PET/CT) studies contribute clinically relevant data to routine clinical follow-up during treatment of patients with metastatic prostate cancer (PCa)., Results: Fifty-two patients with metastatic PCa who underwent [ 68 Ga]Ga-PSMA-11 PET/CT imaging and serum prostate-specific antigen (PSA) level measurements before and during treatment were investigated. Response was categorized by serum PSA dynamics according to improvement, stable disease, and disease progression and compared to change in imaging findings on pre- and post-treatment PET/CTs. McNemar's test was used to assess agreement between PET/CT- and PSA-based responses to treatment. Thirty-four patients (65.4%) had compatible biochemical- and imaging-based response to treatment. However, the imaging and biochemical responses were discrepant in 18/52 patients (34.6%). PET/CT showed progressive disease in 5/52 patients (9.6%) and improvement/stable disease in 13/52 (25%) compared to biochemical assessment results. Discrepancy between imaging and biochemical response was most prominent in biochemically stable patients (90.9%), followed by patients with biochemical progression (33.3%), and in only few (8.7%) patients with biochemical improvement. The imaging-based response was suitable for choosing subsequent treatment in 22 of 30 patients (73.3%) with longer follow-up (median time of 10.3 months (IQR 6.3-18.2)). The relevance of the imaging methodology was reflected by its ability to assess individual lesions in cases of heterogeneous lesion responses, reveal the appearance of new lesions, and identify lesions that required specific consideration, such as targeted radiotherapy., Conclusions: Results of this retrospective analysis showed that biochemical responses to treatment and [ 68 Ga]Ga-PSMA-11 PET/CT-based responses to treatment differ in one third of metastatic PCa patients. The latter additionally enabled lesion-based and not solely patient-based analysis. Monitoring response during treatment by [ 68 Ga]Ga-PSMA-11 PET/CT is suitable for decision-making in patient management and choice of treatment in the majority of patients.

Purpose: To compare surgical site infections (SSI) rate after radical cystectomy (RC) over time and ascertain whether antibiotic prophylaxis should be enhanced., Methods: All medical records of RC patients in a single tertiary uro-oncology center between 2007 and 2017 were analyzed. SSI was defined using the criteria of the US Centers for Disease Control and Prevention. All bacterial culture results and antimicrobial resistance rates were recorded. Lastly, multivariable logistic regression analysis was performed to ascertain SSI predictors., Results: RC was performed in 405 patients, of which 96 (23.7%) developed SSI. No differences were demonstrated in the mean age, gender, NIDDM prevalence, neoadjuvant chemotherapy, positive preoperative urine culture, bowel preparation, and surgery time between both groups. However, statistically significant higher median BMI, age-adjusted Charlson Comorbidity score, usage of ceftriaxone preoperatively, and intensive care unit (ICU) hospitalization were noted in SSI patients. Overall, 62/96 (63.5%) SSI patients had a positive wound culture, with only 16.7% of the pathogens being sensitive to their perioperative antibiotics. Lastly, on multivariable analysis rising BMI, preoperative ceftriaxone and ICU hospitalization were associated with a higher SSI rate., Conclusions: Preoperative BMI reduction, and maximal preoperative medical optimization in an attempt to lower ICU admittance rates, should be part of the ideal strategy for lowering SSI rates. Additionally, preoperative antibiotics should be enhanced to harbor-wide spectrum coverage, based on local resistance rates.

Introduction: Laparoscopic preparation of the ureter is a challenging part of upper urinary tract reconstruction, due to limited depth perception provided by the camera and lack of wristed motion of most laparoscopic instruments needed for adequate spatulation and scar tissue removal. One solution has been to perform the more difficult portions of the surgery in an extracorporeal manner. A hybrid intracorporeal-extracorporeal approach to upper tract ureteral reconstruction facilitates ureteral preparation at the stage of mastering the technique., Material and Methods: This retrospective study included 100 patients with primary ureteropelvic junction obstruction, who underwent laparoscopic pyeloplasty from 2014 to 2017. The patients were stratified into 2 groups: those who underwent conventional laparoscopic surgery and those who were managed with the hybrid approach. For the hybrid approach, externalizing the ureter to skin level required additional mobilization of the upper urinary tract., Results: A total of 47 patients underwent conventional laparoscopic pyeloplasty and 53 - hybrid surgery. The maximum body mass index was 32. The hybrid approach was 8.5 minutes shorter compared to the conventional approach (p <0.001). No complications higher than Clavien-Dindo IIIb (n = 2) were observed (in both groups). Complete success (the resolution of pain and/or hydronephrosis) was observed in 92.5% in the hybrid group and in 95.7% in the conventional treatment group., Conclusions: Hybrid pyeloplasty may be considered safe and effective. It has the advantage of making the surgery less challenging and time-consuming while offering improved precision. The advantages of the technique are particularly apparent during training. This technique can be recommended in the learning process of the surgeon., Competing Interests: All authors state that they have no conflict of interest that might potentially bias their work., (Copyright by Polish Urological Association.)