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PURPOSE To generate and present the survey results on critical issues relevant to screening, diagnosis, and staging tools for prostate cancer (PCa) focused on developing countries. METHODS A total of 36 of 300 questions concern the main areas of interest of this paper: (1) screening, (2) diagnosis, and (3) staging for various risk levels of PCa in developing countries. A panel of 99 international multidisciplinary cancer experts voted on these questions to create recommendations for screening, diagnosing, and staging tools for PCa in areas of limited resources discussed in this manuscript. RESULTS The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time. CONCLUSION The voting results and recommendations presented in this document can be used by physicians to support the screening, diagnosis, and staging of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for screening, diagnosis, and staging of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.

PURPOSE A group of international urology and medical oncology experts developed and completed a survey on prostate cancer (PCa) in developing countries. The results are reviewed and summarized, and recommendations on consensus statements for very low-, low-, and intermediate-risk PCa focused on developing countries were developed. METHODS A panel of experts developed more than 300 survey questions of which 66 questions concern the principal areas of interest of this paper: very low, low, and intermediate risk of PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up for very low-, low-, and intermediate-risk PCa in areas of limited resources discussed in this manuscript. RESULTS The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time. CONCLUSION The voting results and recommendations presented in this document can be used by physicians to support management for very low, low, and intermediate risk of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment for very low, low, and intermediate risk of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.

Objectives: To evaluate the differences of peri-operatory and oncological outcomes between Laparoscopic Radical Cystectomy and Open Radical Cystectomy in our center. Materials and Methods: Overall, 50 patients were included in this non randomized match-pair analysis: 25 patients who had undergone Laparoscopic Radical Cystectomy for invasive bladder cancer (Group-1) and 25 patients with similar characteristics who had undergone Open Radical Cystectomy (Group-2). The patients were operated from January 2005 to December 2012 in a single Institution. Results: Mean operative time for groups 1 and 2 were 350 and 280 minutes (p=0.03) respectively. Mean blood loss was 330 mL for group 1 and 580 mL for group 2 (p=0.04). Intraoperative transfusion rate was 0% and 36% for groups 1 and 2 respectively (p=0.005). Perioperative complication rate was similar between groups. Mean time to oral intake was 2 days for group 1 and 3 days for group 2 (p=0.08). Median hospital stay was 7 days for group 1 and 13 for group 2 (p=0.04). There were no differences in positive surgical margins and overall survival, between groups. Conclusions: In a reference center with pelvic laparoscopic expertise, Laparoscopic Radical Cystectomy may be considered a safe procedure with similar complication rate of Open Radical Cystectomy. Laparoscopic Radical Cystectomy is more time consuming, with reduced bleeding and transfusion rate. Hospital stay seems to be shorter. Oncologically no difference was observed in our mid-term follow-up.

Objectives: To evaluate the histopathology of small renal tumor biopsies following cryoablation. Methods: We retrospectively evaluated small renal tumor biopsy specimens after cryoablation treatment for renal cell carcinoma and determined the ability to differentiate tumor types, effect on nuclear grading, immunohistochemical staining, and if the number of freeze cycles affected interpretation. Results: Of the biopsy specimens, 66% were diagnostic of tumor and 34% showed normal renal parenchyma. Tumor subtype was determined in 91% of diagnostic cases. Nuclear grading was affected due to freeze effect, complicating the assessment of chromatin pattern and nucleolar details at low magnification. In particular, the distinction between Fuhrman nuclear grades I and II was compromised; these were designated as low nuclear grade. Immunohistochemical staining was retained similar to untreated tumors. Tumor subtyping was not affected after one or two freeze cycles. Conclusions: Biopsies performed immediately after cryoablation can be used to render an optimal histologic diagnosis.

Resumen Introduccion La retropulsion de los calculos durante la litotricia ureteroscopica puede conducir a procedimientos adicionales necesarios para los calculos residuales. Se han introducido varios dispositivos en un intento de reducir la retropulsion. Nos pusimos en marcha para informar de nuestra experiencia inicial al utilizar el nuevo gel polimerico BackStop®. Material y metodos Hemos recogido de forma prospectiva los datos sobre 7 procedimientos de ureteroscopia con calculos ureterales distales tratados con BackStop®. Se recogieron los datos perioperatorios, tales como tamano del calculo, ubicacion, tiempo quirurgico, tasa libre de calculo, presencia o ausencia de retropulsion. El exito se definio como la ausencia de fragmentos residuales, de retropulsion y de procedimientos adicionales que se requieren. Resultados Todos los pacientes quedaron libres de litiasis tras la URS y no se produjo ninguna retropulsion. No hubo complicaciones intraoperatorias ni migracion de gel o problemas con la disolucion del gel. Conclusiones BackStop® es un nuevo tratamiento prometedor para prevenir la retropulsion durante la litotricia intracorporea ureteral. Es seguro, facil de aplicar y muy eficaz en la prevencion de la migracion de fragmentos de calculos. Backstop® tiene el potencial para reducir el tiempo quirurgico.

Cryotherapy techniques date back as far as the mid-1800s, when James Arnott demonstrated the effectiveness of salt/ice mixtures in palliation of breast, uterine, and skin cancers. Subsequent advances saw the use of liquid air and solid carbon dioxide in the treatment of various conditions, particularly benign dermatologic lesions (1). Cooper and Lee introduced the first automated cryosurgical apparatus cooled by circulating liquid nitrogen in 1961 and initially used it for treating neuromuscular disorders (2). Liquid nitrogen probes were soon being used in the treatment of benign prostatic hypertrophy and prostate cancer, though complications were quite common, resulting in the procedures falling out of favor until the 1990s, when intraoperative ultrasound techniques were developed, allowing more accurate monitoring of the freezing process (1). The advent of "third-generation" argon and helium gas probes in 2000 and preoperative computer thermal mapping techniques have allowed even more precise placement, temperature control, and further reduction in post-procedural morbidity (3). Cryosurgical techniques are currently used to treat a wide variety of conditions, but significant urologic indications include treatment of low and intermediate risk prostate cancer and renal cell carcinoma < 4 cm in diameter.

Purpose of review Penile cancer is a devastating disease, usually diagnosed late, that requires wide excisions, which causes alterations in self-esteem and body image, affecting sexual and urinary functions, which compromise quality of life. Recently, an increasing interest in penile-sparing surgeries (PSSs) has emerged, aiming to spare patients from these complications. Recent findings Several options of PSS have been popularized for selected cases (Ta-1, Tis and some T2), such as wide local excision, circumcision, partial penectomy, total or partial glansectomies with or without glans-resurfacing procedures, as well as new glans reconstructions using spatulated urethral advances or free skin grafts. These options, in general, achieve good local control, with adequate functional results and satisfactory cosmetic appearance. The local recurrences, however, are slightly higher than amputations. Contemporary techniques such as laser or cryotherapy can be performed in selected cases. Summary PSS must be indicated only for superficial penile cancer cases, such as Tis and Ta-1, and for selected invasive lesions (small distal pT2 tumors). Candidates for PSS should be adherent to follow-up requirements, allowing early detection of local recurrences. Prompt and effective salvage procedures are mandatory in these situations.

To evaluate the histopathology of small renal tumor biopsies following cryoablation.We retrospectively evaluated small renal tumor biopsy specimens after cryoablation treatment for renal cell carcinoma and determined the ability to differentiate tumor types, effect on nuclear grading, immunohistochemical staining, and if the number of freeze cycles affected interpretation.Of the biopsy specimens, 66% were diagnostic of tumor and 34% showed normal renal parenchyma. Tumor subtype was determined in 91% of diagnostic cases. Nuclear grading was affected due to freeze effect, complicating the assessment of chromatin pattern and nucleolar details at low magnification. In particular, the distinction between Fuhrman nuclear grades I and II was compromised; these were designated as low nuclear grade. Immunohistochemical staining was retained similar to untreated tumors. Tumor subtyping was not affected after one or two freeze cycles.Biopsies performed immediately after cryoablation can be used to render an optimal histologic diagnosis.

Objective To evaluate the association of preoperative noncontrast computed tomography stone characteristics, laser settings, and stone composition with cumulative holmium:yttrium-aluminum-garnet (Ho:YAG) laser time/energy. Materials and Methods We retrospectively reviewed patients who underwent semirigid/flexible ureteroscopy and Ho:YAG laser lithotripsy (200 or 365 μm laser fiber; 0.8-1.0 J energy; and 8-10 Hz rate) at 2 tertiary care centers (April 2010-May 2012). Studied parameters were as follows: patient's characteristics; stone characteristics (location, burden, hardness, and composition); total laser time and energy; and surgical outcomes. Results One hundred patients met our inclusion criteria. Mean stone size was 1.01 ± 0.42 cm and volume 0.33 ± 0.04 cm3. Mean stone radiodensity was 990 ± 296 HU, and Hounsfield units density 13.8 ± 6.0 HU/mm. All patients were considered stone free. Stone size and volume had a significant positive correlation with laser energy (R = 0.516, P

To characterize laparoscopic ultrasonic dissector surgical plume emission (laminar or turbulent) and investigate plume settlement time between curved and straight blades.A straight and a curved blade laparoscopic ultrasonic dissector were activated on tissue and in a liquid environment to evaluate plume emission. Plume emission was characterized as either laminar or turbulent and the plume settlement times were compared. Devices were then placed in liquid to observed consistency in the fluid disruption.Two types of plume emission were identified generating different directions of plume: laminar flow causes minimal visual obstruction by directing the aerosol downwards, while turbulent flow directs plume erratically across the cavity. Laminar plume dissipates immediately while turbulent plume reaches a second maximum obstruction approximately 0.3 s after activation and clears after 2 s. Turbulent plume was observed with the straight blade in 10 % of activations, and from the curved blade in 47 % of activations. The straight blade emitted less obstructive plume.Turbulent flow is disruptive to laparoscopic visibility with greater field obstruction and requires longer settling than laminar plume. Ultrasonic dissectors with straight blades have more consistent oscillations and generate more laminar flow compared with curved blades. Surgeons may avoid laparoscope smearing from maximum plume generation depending on blade geometry.

INTRODUCTION AND OBJECTIVES: Recent studies have shown a role for early urethral primary realignment after complex pelvic trauma. Technical difficulties may be overcome with appropriate technique and technology. We examined the success rate of early urethral primary realignment of total posterior urethral disruption after complex pelvic trauma and the correlation of the severity of pelvic fracture. METHODS: An analysis of a prospective database was performed of patients with pelvic fracture associated with total urethral disruption underwent urethral realignment from 2005 to 2012 at Level I Trauma Center. Fractures were classified according to the orthopedic Young-Burgess classification. Initial urological management consisted of suprapubic tube insertion when the patient was unable to void. We utilized anterograde flexible cystoscopy via suprapubic tube, retrograde rigid cystoscopy and real-time fluoroscopy. Failure of realignment was defined as the inability of urethral catheterization using a retrograde/ anterograde approach. Follow up consisted of urethrograms, urofluxometry and cystoscopy evaluation. We also analyzed continence and erectile function after trauma. The necessity of other procedures such as dilatation, DVIU or urethroplasty was also evaluated after catheter removal. RESULTS: A total of 480 consecutive patients were screened and we found 18 patients with total posterior urethral disruption after complex pelvic trauma with the inability to void. The mean patient age was 40 years. The success rate of the procedure was 100%. Mean operating time was 47 11 minutes. Estimated blood loss was minimal. A total of patients 50.0% had associated organ related injuries. The realignment was accomplished within 3 days after admission. There was no correlation between the orthopedic type of classification and the success of urethral realignment. A total of 10 (56%) patients developed urethral strictures during follow up. Urinary incontinence occurred in 3 (17%) patients and 10 (56%) patients self-reported erectile dysfunction after the trauma. The mean follow up of these patients were 30.2 months. CONCLUSIONS: Early primary endoscopic realignment of total posterior urethral disruption after complex pelvic trauma had 100% success rate due to technology and surgical technique. Moreover, there was no correlation of the severity of pelvic fracture. Pelvic orthopedic classification did not show correlation with post procedure urinary incontinence or erectile function after the trauma.

The aim of this study was to evaluate the diagnostic and potential prognostic value of cell-free plasma DNA (CF-pDNA) in patients with suspected or histologically proven prostate cancer (PCa). We included 133 men with a diagnosis of PCa and 33 controls. PCa patients had blood samples prospectively drawn every 3 months for 2 years. CF-pDNA was measured by spectrophotometry. Considering a cut-off value of 140 ng/mL of CF-pDNA the area under the curve was of 0.824(0.757–0.879 with a sensitivity = 66.2 % and a specificity = 87.9 %) and the positive and negative likelihood ratio were of 5.46 and 0.39, respectively. CF-pDNA tends to decrease slightly and return to baseline values in about a week after biopsy. There was no statistical significant correlation between CF-pDNA levels at study entry with PSA, Gleason score, stage and biochemical recurrence free survival (BRFS). However, with a mean follow-up of 13.5 months, we could observe a significant shorter BRFS for patients with at least one value above 140 ng/mL of CF-pDNA during follow-up (p = 0.048). CF-pDNA is a potentially valuable biomarker for PCa diagnosis and a potential tool for the follow-up of patients with PCa.

INTRODUCTION AND OBJECTIVES: Success of treatment for renal and ureteral stones depends on qualitative data such as stone size and location. Surgical decision making and data set comparisons would be significantly enhanced by a consistent, reproducible system that quantitates the pertinent characteristics of renal and ureteral stones. We have developed and propose a standardized lithometric scoring system (S.T.O.N.E Score) to quantify the anatomical characteristics of stones on computerized tomography. METHODS: The STONE score consists of 5 features known to effect the stone free rates of nephrolithiasis with ureteroscopy. The features examined include (S)ize, (T)opography (location), (O)bstruction, (N)umber of stones, and (E)valuation of Hounsfield Units. Each component is scored on a 1-3 point scale as shown in Table 1. We applied the STONE score to 186 consecutive ureteroscopy at Denver Health Medical Center. A logistic model was formed to our data for stone free rates. Stone free was considered the absence of stones or residual stone fragments less than 2 mm on visual inspection or by KUB. RESULTS: Stone free rates were found to be related to STONE Sum. As STONE Sum increased, the stone free rates decreased with a logical regression trend. The logistic model found was Stone Free 1 1/[1 Exp(5.5246 0.3669 * Score)] with an ROC 0.7. The comparison between our data and the model is shown in Table 2. In the STONE model, a score less than 9 has a stone free rate of more than 90% while a stone score greater than 14 has a rate less than 60%. Sum scores of 5, 6 and 14 did not fit with the model, likely because of too few cases. None of the patients in our series had a sum of 15. CONCLUSIONS: Our model correlated with our stone free rate data; however, Our model was limited by our small sample size. A model with individual weights to each feature from a multi-institutional study would more accurately predict stone free rates. This is a pragmatic model to implement in a clinical setting and is the first model to predict stone free rates from ureteroscopy.

Blunt isolated pancreatic trauma is uncommon, accounting for 1%-4% of high impact abdominal injuries. In addition, its diagnosis can be difficult; physical signs may be poor and laboratory findings nonspecific, resulting in delayed treatment. Preserving the spleen during distal pancreatectomy (DP) is controversial. One of the spleen’s functions regards immunity; complications following splenectomy include leukocytosis, thrombocytosis, overwhelming post splenectomy sepsis and some degree of immunodeficiency. This is why many authors favor its preservation. We describe a case of a young man with an isolated pancreatic trauma due to a blunt abdominal trauma with a delayed presentation who was treated with spleen-preserving DP and we discuss the value of this procedure with reference to the literature.