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Resumen Contexto y objetivos Esta es la primera encuesta nacional que evalua los programas de la residencia de Urologia en Grecia. El objetivo principal de este estudio es evaluar el nivel de confianza y la percepcion de los residentes griegos de Urologia respecto a su programa educativo y detectar las areas susceptibles a ser mejoradas. Material y metodos Se elaboro una encuesta de 51 preguntas a traves de una plataforma electronica y fue respondida por 91 de 104 residentes griegos desde marzo de 2019 hasta mayo de 2019. Se utilizo el test exacto de Fisher, el test de chi-cuadrado y el test de Kruskal-Wallis, con una significacion estadistica establecida en p = 0,05. Resultados La satisfaccion global de la formacion quirurgica obtuvo una media de 6/10, independientemente de la jornada laboral, de trabajar en un departamento universitario, el ano de posgrado (postgraduate year) o el numero de residentes en el centro. La mayoria de los residentes no habia realizado ninguna ecografia escrotal ni estudios de flujo-presion, pero estaba familiarizado con la ecografia de vias urinarias (KUB). La insercion del cateter doble J y la cistoscopia eran procedimientos conocidos para los residentes. El 70,4% de los residentes senalaron la burocracia como un problema importante. El 80,2% no habia realizado ninguna litotricia extracorporea por ondas de choque, y el 58,2% de los residentes habia realizado menos de 10 ureteroscopias. Solo en el ultimo ano, los residentes realizaron mas de 10 procedimientos de reseccion transuretral de tumor vesical y de reseccion transuretral de la prostata. La mayoria de los residentes mencionaron que rara vez realizaban los pasos basicos de muchos procedimientos urologicos por via abierta o laparoscopica. Sorprendentemente, el 59,3% de los residentes no habia publicado ningun estudio sometido a revision por pares en revistas cientificas. El 44% afirmo rara vez sentirse satisfecho con su trabajo y el 59,3% reporto la sensacion de agotamiento (burnout) ocasional. La tasa de respuesta alcanzo el 87,5%. Conclusiones Teniendo en cuenta los resultados de esta encuesta, las autoridades reguladoras deberian aunar esfuerzos para establecer un plan de estudios estructurado de formacion clinica, quirurgica y de investigacion en Urologia en toda Europa.

Background and objectives This is the first national survey assessing Greek Urology residency programs. The main objective of this study is to assess the level of confidence and perception of Greek Urology residents regarding their educational program and detect areas of improvement. Material and methods A 51-question survey was developed via an electronic platform and answered by 91 out of 104 Greek residents from March 2019 until May 2019. Fisher's exact test, chi-squared test and Kruskal–Wallis test were used with statistical significance set at p = .05. Results The median overall satisfaction regarding surgical training was 6/10 regardless of working schedule, working in a University Department, PGY or number of residents in clinic. Most residents have not performed any scrotal ultrasound or pressure-flow-studies; however, they are more familiar with KUB ultrasound. Double-J stent insertion and cystoscopy were common procedures for residents. Bureaucracy was reported as a major issue by 70.4% of residents. ESWL has not been performed by 80.2% of residents, 58.2% residents performed less than 10 ureteroscopies, and only the last year trainees performed more than 10 TURBT and TURP. Most residents mentioned to rarely perform basic steps in many open or laparoscopic urological procedures. Surprisingly, 59.3% of residents have not published any study in peer-reviewed journals. Regarding satisfaction, 44% rarely feel satisfied at work and 59.3% sometimes suffer from burnout. Response rate reached 87.5%. Conclusions Considering the results from this survey, regulatory authorities should join forces to establish a structured curriculum of clinical, surgical and research training in Urology across Europe.

Athanasios Dellis,1 Roubini Zakopoulou,2 Andromahi Kougioumtzopoulou,3 Kimon Tzannis,2 Konstantinos Koutsoukos,2 Charalampos Fragkoulis,4 Efthymios Kostouros,5 Athanasios Papatsoris,6 Ioannis Varkarakis,6 Konstantinos Stravodimos,7 Eleni Boutati,8 Stamata Pagoni,5 Miltiadis Seferlis,9 Michael Chrisofos,10 Vasilios Kouloulias,3 Konstantinos Ntoumas,4 Charalambos Deliveliotis,6 Constantine Constantinides,7 Meletios A Dimopoulos,2 Aristotelis Bamias8 1 2nd Department of Surgery, National & Kapodistrian University of Athens, Aretaieion University Hospital, Athens, Greece; 2Oncology Unit, Department of Clinical Therapeutics, National & Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece; 3Radiotherapy Unit, 2nd Department of Radiology, National & Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece; 4Department of Urology, General Hospital of Athens “G. Gennimatas”, Athens, Greece; 5 3rd Department of Internal Medicine, General Hospital of Athens “G. Gennimatas”, Athens, Greece; 6 2nd Department of Urology, National & Kapodistrian University of Athens, Sismanoglio Hospital, Athens, Greece; 7First Department of Urology, National and Kapodistrian University of Athens, “Laiko” General Hospital, Athens, Greece; 8 2nd Propaedeutic Department of Internal Medicine, National & Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece; 9Department of Urology, Thriasion General Hospital, Athens, Greece; 10 3rd Department of Urology, National & Kapodistrian University of Athens, Attikon University Hospital, Athens, GreeceCorrespondence: Aristotelis Bamias 2nd Propaedeutic Department of Internal Medicine, National & Kapodistrian University of Athens, Attikon University Hospital, Athens, GreeceTel +30 2105831256 Fax +30 210 5326454Email abamias@med.uoa.grBackground: Utilization of neoadjuvant chemotherapy for the treatment of muscle invasive bladder cancer in everyday practice differs from that of clinical trials. We describe the patterns of referral for “neoadjuvant chemotherapy”, treatment and outcomes in a multidisciplinary tumor board.Methods: This was an observational study. Patients referred for neoadjuvant chemotherapy received 4 cycles of dose-dense gemcitabine/cisplatin and were then assessed for definitive local therapy. Patients had a minimum follow-up of 2 years. Primary objective was a 3-year disease-free survival rate.Results: Forty-six patients (clinical stages II: 28, IIIA: 9, IIIB: 4, IVA: 3, missing: 2) were included. Following chemotherapy, 30 underwent radical cystectomy, 8 radiotherapy and 8 no further therapy. Pathological downstaging was observed in 14 (46.6%) of the 30 patients who underwent radical cystectomy; clinical TNM staging was correlated with disease-free survival in the whole population, while clinical and pathological stages, as well as pathological downstaging, were correlated with disease-free survival in patients undergoing radical cystectomy. Three-year disease-free survival rates for the whole cohort and for patients undergoing radical cystectomy were 67.3% (95% confidence interval [CI]: 51– 79.2) and 65.2 (95% CI: 44.9– 79.6), respectively.Conclusion: Real-world muscle invasive bladder cancer patients who receive neoadjuvant chemotherapy are characterized by more advanced diseases and less frequent radical surgery than those included in clinical trials. Nevertheless, outcomes were comparable and, therefore, offering patients with stage II–IVA muscle invasive bladder cancer neoadjuvant chemotherapy after assessment by multidisciplinary tumor boards should be strongly encouraged.Keywords: bladder cancer, neoadjuvant, chemotherapy, cystectomy, radiotherapy

The role of medical expulsive treatment (MET) is controversial. Fragility index is an additional metric to assess randomized controlled trials (RCTs) outcome validity and indicates how many patients would be required to convert a trial from being statistically significant, to not significant. The larger is the FI, the better the trial’s data. The aim of this study is to assess FI of RCTs regarding MET for ureteral stones. A systematic literature search was performed. RCTs, reporting stone expulsion as a dichotomous outcome, showing statistical significance were eligible. FI (the number of patients needed to change from a non-event to event group, to lose statistical significance) and Fragility quotient (FI divided by total sample size), were calculated while Pearson’s correlation and Mann–Whitney U test were used as appropriate. Thirty-six RCTs were eligible, with median FI = 3.5 and fragility quotient = 0.042, median sample size = 81, median journal impact factor = 1.73 and median reported p value = 0.008. In 33.3% of the studies, number of patients lost during follow-up was larger than FI, while in 13.89% of the studies, FI was 0, indicating use of inappropriate statistical method. Pearson’s correlation showed significant positive association between FI and sample size (r = 0.981), number of events (r = 0.982) and impact factor (r = 0.731), while no association was found with p value or publication year. In this analysis, a calculated FI of 3.5 indicates that findings from RCTs on MET for ureteral stones are fragile and should be interpreted in combination with clinical thinking and expertise.

Testicular plasmacytoma is a rare extramedullary manifestation of plasma cell dyscrasia. We report a case of a 53-year-old man who presented with a metachronous testicular lesion originating from a soft tissue plasmacytoma of the oral cavity. He underwent radical orchiectomy and a year later, presented with testicular plasmacytoma in the contralateral testis. He received induction chemotherapy, autologous stem cell transplantation with high dose melphalan and maintenance with lenalidomide, as he refused orchiectomy and achieved complete remission. However, six months post-transplant, he relapsed with localized disease in his testis, received second-line chemotherapy, after refusing orchiectomy and still remains in partial remission and alive.

INTRODUCTION AND OBJECTIVE:Prostate cancer (PCa) is one of the most common neoplasms in Europe, with annual incidence of 336.000. PCa patients frequently encounter health-related quality of life (Q...

Background/ Aims Anthropometric characteristics, namely overweight/obesity, height and waist circumference have been associated with various cancer types. The aim of this systematic review and meta-analysis is to evaluate the potential associations between anthropometric characteristics and bladder cancer risk, synthesizing longitudinal cohort studies. Methods Literature search across MEDLINE, EMBASE, Scopus, Google Scholar and Cochrane Central was performed up to December 31, 2019 and data abstraction was performed independently by two authors. Random-effects (DerSimonian-Laird) models were used to estimate pooled relative risks (RR) and 95% confidence intervals (95%CI); subgroup analyses were performed geographical region, mean age, publication year, length of follow-up, sample size, method of BMI estimation and adjustment for smoking. Results A total of 27 studies were included (88,593 bladder cancer cases in a total cohort of 49,647,098 subjects). Increased bladder cancer risk was noted in overweight men (pooled RR=1.12, 95%CI: 1.04-1.21) but not in overweight women. Both obese men (pooled RR=1.14, 95%CI: 1.06-1.22) and women (pooled RR=1.19, 95%CI: 1.02-1.38) showed increased risk. Interestingly, height increase per 5 cm did not seem to affect risk of bladder cancer in men (pooled RR=1.03, 95%CI: 0.99- 1.06) and women (pooled RR=1.02, 95%CI: 0.97-1.06). Larger waist circumference was associated with bladder cancer risk in men (pooled RR=1.18, 95%CI: 1.09-1.26) but not women. Conclusion In conclusion, bladder cancer risk seems to be related with obesity overall and central obesity in men. In contrast to other cancer types, height does not seem to affect risk, but more studies are needed to extract safe conclusions.

Background Venous thromboembolic events (VTEs) frequently occur in cancer patients. Risk assessment models (RAMs) for cancer-associated thrombosis have been proposed. However, advanced urinary tract cancer (aUTC) was not adequately represented in these models. We studied the incidence of VTEs, the risk factors, and the applicability of recently described RAMs. Patients and Methods Data from 335 patients with aUTC treated with chemotherapy between April 1995 and September 2015 in a single institution were analyzed. Results A total of 95.2% received platinum-based first-line chemotherapy. Twenty-nine patients (8.7%) experienced VTEs. The 6-, 12-, and 24-month VTE incidence was 7.4% (95% confidence interval [CI], 4.8-10.6), 8.1% (95% CI, 5.4-11.5) and 9.4% (95% CI, 6.4-13.1), respectively. No significant association of VTE incidence with the Khorana risk score was observed. History of vascular event (VTE and/or arterial thromboembolic event) was significantly associated with the development of VTE. Patients with such history had a 6-, 12-, and 24-month VTE incidence of 16.2% (95% CI, 6.6-29.7), 19.2% (95% CI, 8.4-33.3), and 25.2% (95% CI, 12.5-40.1) compared to 6.2% (95% CI, 3.7-9.4), 6.6% (95% CI, 4.1-10), and 7.1% (95% CI, 4.4-10.6) of those who did not. The discriminatory ability of this factor adjusted for leucocyte count, sex, Eastern Cooperative Oncology Group performance status, and type of chemotherapy reached 0.79 (95% CI, 0.71-0.87) compared to the 0.58 (95% CI, 0.49-0.66) for the Khorana risk score. Conclusion Development of tumor-specific algorithms for the risk of VTEs is advisable. Patients with aUTC and a history of vascular events are at high risk for VTE development, and prophylaxis should be prospectively studied in this group.

Context In recent years, focal therapy has emerged as a treatment option for a selected group of men with localized prostate cancer. Cryotherapy and high-intensity focused ultrasound (HIFU) are the most investigated types of focal treatment with other options currently under evaluation. Objective The objective of the study was to give a comprehensive overview of six available focal treatment options for prostate cancer with their rationale, delivery mechanism, and outcomes. Information acquisition The SIU ICUD chapter on available Energies to Treat Prostate Cancer was used as a guide to describe the different technologies. For outcomes, a literature search was conducted using PubMed key words including focal therapy, HIFU, cryotherapy, irreversible electroporation, vascular-targeted photodynamic therapy, laser interstitial therapy, radiofrequency ablation, microwave therapy, and their synonyms in MeSH terms. Conclusion Focal therapy appears to have encouraging outcomes on quality of life and urinary and erectile function. For oncological outcomes, it is challenging to fully interpret the outcomes due to heterogeneity in patient selection and short-term follow-up. Electronic supplementary material The online version of this article (10.1007/s00345-018-2364-x) contains supplementary material, which is available to authorized users.

The wide availability of cross-sectional imaging is responsible for the increased detection of small, usually asymptomatic renal masses. More than 50 % of renal cell carcinomas (RCCs) represent incidental findings on noninvasive imaging. Multimodality imaging, including conventional US, contrast-enhanced US (CEUS), CT and multiparametric MRI (mpMRI) is pivotal in diagnosing and characterizing a renal mass, but also provides information regarding its prognosis, therapeutic management, and follow-up. In this review, imaging data for renal masses that urologists need for accurate treatment planning will be discussed. The role of US, CEUS, CT and mpMRI in the detection and characterization of renal masses, RCC staging and follow-up of surgically treated or untreated localized RCC will be presented. The role of percutaneous image-guided ablation in the management of RCC will be also reviewed.

Background: At present, it is not possible to predict the ablation zone volume following irreversible electroporation (IRE) for prostate cancer (PCa). This study aimed to determine the necessary electrical field threshold to ablate human prostate tissue in vivo with IRE. Methods: In this prospective multicenter trial, patients with localized PCa were treated with IRE 4 weeks before their scheduled radical prostatectomy. In 13 patients, numerical models of the electrical field were generated and compared with the ablation zone volume on whole-mount pathology and T2-weighted magnetic resonance imaging (MRI) sequences. Volume-generating software was used to calculate the ablation zone volumes on histology and MRI. The electric field threshold to ablate prostate tissue was determined for each patient. Results: A total of 13 patients were included for histological and simulation analysis. The median electrical field threshold was 550 V/cm (interquartile range 383–750 V/cm) for the software-generated histology volumes. The median electrical field threshold was 500 V/cm (interquartile range 386–580 V/cm) when the ablation zone volumes were used from the follow-up MRI. Conclusions: The electrical field threshold to ablate human prostate tissue in vivo was determined using whole-mount pathology and MRI. These thresholds may be used to develop treatment planning or monitoring software for IRE prostate ablation; however, further optimization of simulation methods are required to decrease the variance that was observed between patients.

Background:Metastatic RCC (mRCC) treatment has been revolutionized with 11 approved targeted agents. We report patterns of practice, outcomes and pharmacoeconomic analyses after the introduction of...

To identify prognostic molecular profiles in patients with mRCC treated with sunitinib, we performed immunohistochemical analysis for VEGF and PI3K/Akt/mTOR pathway components.The immunohistochemical expression of VEGF, p85α, p110γ, PTEN, p-Akt, p-mTOR, p-4E-BP1 and p-p70S6K was studied in 79 patients with mRCC who received first-line treatment with sunitinib. Expression was correlated with clinicopathological features and survival.VEGF was highly expressed (median H-Score 150), while positivity for the markers of the PI3K/Akt/mTOR pathway was: p85α 43/66 (65 %), p110γ41/60 (68 %), PTEN 32/64 (50 %), p-Akt57/63 (90 %), p-mTOR48/64 (75 %), p-4E-BP1 58/64 (90 %) and p-p70S6K 60/65 (92 %). No single immunohistochemical marker was found to have prognostic significance. Instead, the combination of increased p-mTOR and low VEGF expression was adversely correlated with overall survival (OS) (3.2 vs. 16.9 months, P = 0.001).Immunohistochemistry for VEGF and p-mTOR proteins may discriminate patients refractory to first-line sunitinib with poor prognosis. Prospective validation of our findings is needed.

Irreversible electroporation is a tissue ablation modality that uses high voltage electric energy to induce an increase in cell membrane permeability. This causes destabilization of the existing cellular transmembrane potential leading to cell death, due to the inability to maintain cellular homeostasis. This phase I-II study was designed to evaluate the histopathological outcomes of irreversible electroporation to prostate and surrounding tissue in radical prostatectomy specimens. Sixteen patients with prostate cancer underwent an irreversible electroporation ablation without curative intent, followed by radical prostatectomy scheduled 4 weeks later. For histopathological examination of the prostate, whole mounted tissue slices were examined by dedicated genitourinary pathologists. The borders of the ablation zone and residual tumor were outlined on the slides. The irreversible electroporation ablation zones were characterized as areas of fibrosis, necrosis and loss of epithelial tissue in terms of denudation in the glandular structures. The ablation zone was well demarcated, showing trenchant delineations between viable and nonviable tissue. The ablated tissue showed mild to moderate inflammation, with atrophic cells in 1 case. The area was surrounded by hemorrhage at the location of the electrodes. No skip lesions or viable tissue was seen in the ablation zone. Fibrinoid necrosis of the neurovascular bundle was observed in 13 patients and denudation of the urothelium of the prostatic urethra was seen in 9. Histopathological assessment of the prostate 4 weeks after irreversible electroporation ablation showed sharply demarcated fibrotic and necrotic tissue in the ablation zone. No viable tissue was observed in the irreversible electroporation ablation zone

Relapsed urothelial cancer represents an unmet medical need. Vinflunine is a third-generation antimicrotubuline inhibitor and is currently the only approved drug for second-line treatment across the European Union. We conducted a retrospective analysis assessing the efficacy and safety of vinflunine in 71 Greek patients with relapsed urothelial cancer who were treated between 2005 and 2014. An overall 84% of our patients received vinflunine as second-line treatment, 77% had a performance status of Eastern Cooperative Oncology Group scale 0 or 1, and 30% had liver metastasis at the time of vinflunine administration. A median of four cycles of vinflunine were administered (range 1-16). The most common reported adverse events were constipation, fatigue, and anemia. Median progression-free survival was 6.2 months (95% confidence interval: 4.4-8.8) and overall survival was 11.9 months (95% confidence interval: 7.4-21). Two patients (3%) achieved a complete remission, seven a partial remission (10%), and 22 (31%) had stable disease according to an intention-to-treat analysis. Hemoglobin level less than 10 g/dl and Eastern Cooperative Oncology Group performance status greater than 1 were independent adverse prognostic factors. Stratification according to the Bellmunt risk model was also associated with progression-free survival and overall survival in our population. Vinflunine appears to be a safe and effective treatment modality for relapsed urothelial cancer. More effective therapies and more accurate prognostic algorithms should be sought.

We reviewed the literature for articles in English in the Medline database from 1970 until today. The keywords used were “prostate cancer,” “fertility,” “radical prostatectomy,” “external beam radiotherapy,” “androgen deprivation therapy,” and “chemotherapy.” Only the studies with full paper were included in our review. The knowledge for this important issue is minimal and more minimal tends to be the consent of the patients. Prostate cancer does not seem to directly influence fertility, but all its therapies directly or indirectly seem to do so. In many of them, the impact may be reversible, but the mechanisms of this impact are still under consideration. Prostate cancer treatments, predominantly radiation, can cause long-term azoospermia; however, the data in the literature are sparse, mainly derived from small series, and based on these, no safe conclusions can be drawn.

To present the positive impact of technique standardization on successful outcome, fluoroscopy, and total operating time (TOT) shortening in a prospective study.Six experienced endourologists participated. To assess whether the adaptation of standardized surgical steps improved their methodology with time, 253 patients were prospectively divided in three consecutive 1-month groups. Patients underwent stent placement and exchange and total operating and fluoroscopy times (FTs) were recorded. All surgeons were unaware of their mean recorded results until the end of the study. At the end of the third month, we evaluated if the suggested technique standardization established a decrease for both FT and TOT. Statistical significance was set to p 0.05.Total operating and FTs were significantly reduced with time between all groups of patients. For stent placement, TOT showed significant reduction between Groups A and C (p 0.001), while between other group comparisons did not reach significance. FT showed a significant reduction (p 0.001) in all group comparisons. For stent exchange, TOT reached significant improvement (p = 0.003) between Groups A and C, whereas between other groups was insignificant. FT improvement was significant between Groups A and C (p 0.001) and Groups B and C (p 0.001), but insignificant between Groups A and B.Even in experienced hands, the adaptation of technique standardization results in significant decrease of total operating and FTs and it is independent from feedback regarding their time performance.

Objective: This study evaluated the efficacy of hexaminolevulinate fluorescence cystoscopy as a diagnostic tool for bladder cancer. The study was a case series in the Department of Urology in Hippokratio General Hospital of Athens between October 2008 and May 2012. Methods: Fifty patients (43 males and 7 females) who were investigated for hematuria were included in the study. White light cystoscopy (WLC) was first performed in all patients and after was performed a fluorescence cystoscopy (BLC-blue light cystoscopy). Biopsies were collected from any suspicious area and resection of the tumors identified (TUR).Whenever no suspicious areas could be seen, a standard random mapping including 8 biopsies overall was completed. Results: Patients demographic data and clinical history are presented in Table 1. Two-hundred twenty specimens were extracted and bladder cancer was diagnosed in 137. There were 17 CIS lesions all diagnosed with BLC whereas only 11 with WLC. WLC correctly diagnosed 109/140 specimens and the positive and negative predictive values were 77.9% and 65% respectively. The sensitivity and specificity were 79.6% and 62.6% respectively. BLC diagnosed 125/169 specimens and the positive and negative predictive values were 73.9% and 76.5% respectively. The sensitivity of BLC was 91.2% and the specificity 46.9%. Conclusion: Hexaminolevulinate-guided cystoscopy is a valuable diagnostic method, with considerably improved accuracy and improvement in diagnosis of non-muscle-invasive bladder cancer and especially CIS.

Objective: To report continence and urodynamic findings after radical cystectomy and urinary diversion with modified S-ileal neobladder between January 1993 and January 2013. Patients and Methods: 181 patients were enrolled. Continence status, reservoir sensation, compliance, capacity and activity were assessed. Results: Daytime continence was reported by 88.0, 98.4 and 99.2%, while nighttime continence was reported by 70.2, 94.0 and 95.8% of our patients at 6 months, 5 years and 20 years, respectively. Enterocystometric capacity and maximum reservoir pressure were 366 vs. 405 ml and 502 ml, and 29 vs. 18 and 11 cm H2O, at 6 months, 5 years and 20 years, respectively. Median post-void residual urine volume was 32 ml at 6 months, 50 ml at 5 years and 120 ml at 20 years. Conclusions: The modified S-ileal neobladder technique has a very good long-lasting functional outcome, with high day- and nighttime continence levels as well as high acceptability rates from our patients.

Objective To evaluate the difference between the PSA density (PSAD) calculated with 3 imaging modalities and the PSAD of the radical prostatectomy specimen. Materials and methods The PSAD of 60 men with clinically localized prostate cancer was calculated with transabdominal ultrasound (TAUS), transrectal ultrasound (TRUS), and computed tomography (CT) before radical retropubic prostatectomy, and was compared with the PSAD of the surgical specimen using the paired t -test. The relationship of the real prostate volume and the difference between the PSAD calculated with the 3 imaging modalities and that of the PSAD of the specimen was analyzed using Pearson's correlation coefficient. Finally, the sensitivity of PSAD calculated with the examined imaging modalities and the specimen was also studied. Results The mean difference between the PSAD calculated by each one of the 3 imaging modalities and the PSAD of the specimen was −0.01 ng/ml/cm 3 ( P = 0.28) for TAUS, 0.01 ng/ml/cm 3 ( P = 0.37) for TRUS, and −0.03 ng/ml/cm 3 ( P = 0.001) for CT. This difference has not been shown to depend on the real prostate volume according to Pearson's correlation coefficient, which was 0.056 ( P = 0.673) for TAUS, −0.014 ( P = 0.917) for TRUS, and 0.184 ( P = 0.159) for CT. The sensitivity of PSAD calculated with TAUS, TRUS, and CT was 58.3%, 65%, and 45%, respectively, while that of the specimen was 70%. Conclusions Although PSAD showed a moderate sensitivity, TRUS and TAUS are the imaging modalities that calculate it closer to the real PSAD of the specimen.

Purpose To reach standardized terminology in focal therapy (FT) for prostate cancer (PCa). Methods A four-stage modified Delphi consensus project was undertaken among a panel of international experts in the field of FT for PCa. Data on terminology in FT was collected from the panel by three rounds of online questionnaires. During a face-to-face meeting on June 21, 2015, attended by 38 experts, all data from the online rounds were reviewed and recommendations for definitions were formulated. Results Consensus was attained on 23 of 27 topics; TargetedFT was defined as a lesion-based treatment strategy, treating all identified significant cancer foci; FT was generically defined as an anatomy-based (zonal) treatment strategy. Treatment failure due to the ablative energy inadequately destroying treated tissue is defined as ablation failure. In targeting failure the energy is not adequately applied to the tumor spatially and selection failure occurs when a patient was wrongfully selected for FT. No definition of biochemical recurrence can be recommended based on the current data. Important definitions for outcome measures are potency (minimum IIEF-5 score of 21), incontinence (new need for pads or leakage) and deterioration in urinary function (increase in IPSS >5 points). No agreement on the best quality of life tool was established, but UCLA-EPIC and EORTC-QLQ-30 were most commonly supported by the experts. A complete overview of statements is presented in the text. Conclusion Focal therapy is an emerging field of PCa therapeutics. Standardization of definitions helps to create comparable research results and facilitate clear communication in clinical practice. Electronic supplementary material The online version of this article (doi:10.1007/s00345-016-1782-x) contains supplementary material, which is available to authorized users.

PURPOSE: Irreversible electroporation (IRE) is a novel minimally invasive therapy for prostate cancer using short electric pulses to ablate prostate tissue. The purpose of this study is to determine the IRE effects in prostate tissue and correlate electrode configuration with the histology of radical prostatectomy (RP) specimens. We hypothesize that the area within the electrode configuration is completely ablated and that the area within the electrode configuration is predictive for the ablated area after treatment.METHODS: A prospective phase I/II study was conducted in 16 consecutive patients with histopathologically confirmed prostate cancer scheduled for RP. Focal or extended IRE treatment of the prostate was performed 4 weeks prior to RP. The locations of the electrodes were used to calculate the planned ablation zone. Following RP, the specimens were processed into whole-mount sections, histopathology (PA) was assessed and ablation zones were delineated. The area of the tissue alteration was determined by measuring the surface. The planned and the histological ablation zones were compared, analysed per individual patient and per protocol (focal vs. extended).RESULTS: All cells within the electrode configuration were completely ablated and consisted only of necrotic and fibrotic tissue without leaving any viable cells. The histological ablation zone was always larger than the electrodes configuration (2.9 times larger for the 3 electrodes configuration and 2.5 times larger for the ≥4 electrode configuration). These ablation effects extended beyond the prostatic capsule in the neurovascular bundle in 13 out of 15 cases.CONCLUSIONS: IRE in prostate cancer results in completely ablated, sharply demarcated lesions with a histological ablation zone beyond the electrode configuration. No skip lesions were observed within the electrode configuration.CLINICAL TRIALS: ClinicalTrials.gov Identifier: NCT01790451 https://clinicaltrials.gov/ct2/show/NCT01790451.

Over the last 13 years, renal cryoablation has emerged as a promising technique for the treatment of solid renal tumors. The improvement in imaging modalities such as ultrasound, computed tomography and MRI, as well as the introduction of thinner probes, has led to the spread of the minimally invasive percutaneous approach. We review the historical background of percutaneous renal cryoablation (PRC), present its basic principles, mention the contemporary clinical data and outcomes of this technique and suggest future directions for its wider application in renal tumors. Early results have demonstrated that it may offer an alternative for the treatment of small renal masses with the advantages of minimal complications, spared renal function, decreased overall costs and equivalent oncologic efficacy. Long-term results are required in order to apply this minimally invasive technique to a broader spectrum of patients.

Objective To present our 10-year experience with patients surgically treated for upper urinary tract transitional cell carcinoma. Patients and methods We reviewed the medical records of 264 patients (218 males and 46 females), aged 37–93 years (mean, 69.5), treated surgically for upper tract transitional cell carcinoma during the period January 1996 to December 2005. Results During the mean follow-up of 58 months (range, 12–120), local relapse was diagnosed in 14% of the patients. The mean time to recurrence was 13 months (range, 1–102). The overall mortality was 14%, and the mean survival was 109 months. Survival was significantly influenced by the following parameters: male gender (P = 0.0151), age over 80 years (P = 0.0012), location in both the pelviocaliceal system and the ureter (P = 0.051), a two incision operation (P = 0.0075), grade III (P = 0.0314), stage T3 and T4 (P Conclusions Tumor stage was identified as the most important determinant in predicting recurrence and survival. Other predictors of survival included male gender, age over 80 years, location in the pelviocaliceal system and the ureter, a two incision operation, and high grade.

Authors from Greece evaluated their experience of findings during re-exploration for small bowel obstruction after radical cystectomy. They found several abnormalities, more particularly unexpected, to account for this, and drew some conclusions as to the operative technique that might help to prevent them. OBJECTIVE To retrospectively evaluate the findings during re-exploration for obstructive ileus after radical cystectomy (RC) and ileal conduit diversion. PATIENTS AND METHODS During a 12-year period, 434 patients who had RC and ileal conduit diversion were retrospectively evaluated for the diagnosis of early (≤30 days after RC) or late abdominal re-exploration. The operative reports of patients requiring a second abdominal procedure were reviewed, evaluating in particular the reason for small bowel obstruction (SBO). In addition, the type of entero-enteric anastomosis and the retroperitonealization of the uretero-enteric anastomosis were compared between patients who required abdominal re-exploration for SBO and those who did not. RESULTS Abdominal re-exploration for SBO was necessary for 14 (3.2%) and 32 (7.3%) patients in the early and late postoperative period, respectively. The most common reasons for SBO were anastomotic malfunction (1.4%) and malignant recurrence (2.8%). Adhesions were the second most common cause leading to ileus in both periods (1.1% and 2.3%, respectively). When there was no retroperitonealization of the uretero-enteric anastomosis, SBO occurred more often both early and late (P = 0.06). Early anastomotic malfunction leading to SBO was more common (but not statistically significant, P = 0.06) when the entero-enteric anastomosis was hand-sutured end-to-end. CONCLUSIONS Anastomotic malfunction, bowel adhesions and internal hernias are responsible for SBO early after surgery. The above reasons, in addition to malignant recurrence, are the most common reasons for SBO in the late postoperative period.

To evaluate cancer involvement of internal female genitalia of patients undergoing anterior exenteration for clinically organ confined transitional cell carcinoma of the bladder, and identify potential preoperative risk factors. Charts and anterior exenteration specimens from 54 women with clinically organ confined transitional cell bladder cancer were retrospectively reviewed. Emphasis was given to the presence of internal genitalia involvement and or primary gynecologic pathology. Unsuspected internal genitalia involvement was reported in only three patients (5.7%). The vagina was involved in two cases (3.8%) while the uterus in one (1.9%). In all cases involvement was due to direst extension from bladder tumors of the base and dome respectively. No preoperative variable could predict internal genitalia involvement in a statistical significant manner. Benign pathology of the female reproductive organs was observed in six patients and involved in all cases the uterus (11.5%). Internal genitalia involvement after radical cystectomy for TCC tumors of the bladder is rare (5.8%). Preoperative risk factors could not be identified although all involved genitalia were seen in tumors of the bladder dome and base. Therefore large multi-institutional studies are needed in order to identify preoperative risk factors for internal genitalia involvement in females with bladder cancer.

Objectives Initial publications on postchemotherapy laparoscopic retroperitoneal lymph node dissection (LRPLND) have described significant intraoperative and postoperative morbidities. This report reviewed the complication rate with additional experience. Methods A retrospective review of the medical records of 16 consecutive patients who underwent postchemotherapy LRPLND by a single surgeon from September 1996 to September 2005 was performed. The evaluation included tumor type, clinical stage, pathologic stage, and intraoperative and postoperative complications. Results Postchemotherapy LRPLND was successfully performed in 14 (87.5%) of 16 patients. Seven patients (43.8%) developed complications and 2 (12.5%) required open conversion. The most complications occurred during the postoperative period and were classified as minor. Of the total patient population, 25% had minor postoperative complications. The median hospital stay was 2 days. No patient who underwent the procedure died. All intraoperative complications were vascular injuries and occurred during the first half of the series (1996 to 2000). In the second half of the series (2000 to 2005), no complications during the operative period and no vascular or major complications occurred. No retroperitoneal recurrence was noted during a mean follow-up of 32.7 months (range 5 to 108). One patient developed distant recurrence and underwent successful salvage chemotherapy. Conclusions Postchemotherapy LRPLND remains a challenging, but feasible, operation. With greater experience, the incidence of complications and morbidity can be reduced.

OBJECTIVES: Irreversible electroporation (IRE) is an ablative therapy with a low side-effect profile in prostate cancer. The objective was: 1) To compare the volumetric IRE ablation zone on grey-scale transrectal ultrasound (TRUS), contrast-enhanced ultrasound (CEUS) and multiparametric MRI (mpMRI) with histopathology findings; 2) To determine a reliable imaging modality to visualize the IRE ablation effects accurately.METHODS: A prospective phase I-II study was performed in 16 patients scheduled for radical prostatectomy (RP). IRE of the prostate was performed 4 weeks before RP. Prior to, and 4 weeks after the IRE treatment, imaging was performed by TRUS, CEUS, and mpMRI. 3D-analysis of the ablation volumes on imaging and on H&E-stained whole-mount sections was performed. The volumes were compared and the correlation was calculated.RESULTS: Evaluation of the imaging demonstrated that with T2-weighted MRI, dynamic contrast enhanced (DCE) MRI, and CEUS, effects of IRE are visible. T2MRI and CEUS closely match the volumes on histopathology (Pearson correlation r = 0.88 resp. 0.80). However, IRE is not visible with TRUS.CONCLUSIONS: mpMRI and CEUS are appropriate for assessing IRE effects and are the most feasible imaging modalities to visualize IRE ablation zone. The imaging is concordant with results of histopathological examination.KEY POINTS: • mpMRI and contrast-enhanced ultrasound are appropriate imaging modalities for assessing IRE effects • mpMRI and CEUS are the most feasible imaging modalities to visualize IRE ablation zone • The imaging is concordant with results of histopathological examination after IRE • Grey-scale US is insufficient for assessing IRE ablations.

Background: Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique. Objective: To report a large multi-institutional series of minimally invasive SP (MISP). Design, setting, and participants: Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis. Intervention: Laparoscopic or robotic SP. Outcome measurements and statistical analysis: Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score 15 ml/s, and no perioperative complications. Results and limitations: Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100 ml (range: 89-128). Median estimated blood loss was 200 ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p = 0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p = 0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss ( p = 0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. Conclusions: This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications. Patient summary: Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.

The impact of transrectal ultrasound (TRUS)-guided prostate biopsies on erectile function was prospectively studied. Forty-six men (median age: 67.51 years) who underwent TRUS-guided prostate biopsies completed the International Index of Erectile Function (IIEF)-5 questionnaire at the day of the biopsy, 1 and 3 months later. Erectile dysfunction (ED) severity was classified into five categories. Concomitant ED-related systemic diseases and/or medications that could affect erectile function were also recorded. The paired t-test was used for statistical analysis. The median IIEF-5 score was 15.91 prior to biopsies, while 1 and 3 months after, the median IIEF-5 score was 14.33 and 14.81 respectively (P > 0.05). Prior to prostate biopsies, ED was reported by 38 patients (82.60%): mild ED in 39.13%, mild to moderate in 19.56%, moderate in 15.21% and severe ED in 8.69%. Concomitant ED-related systemic diseases and/or medications were recorded in 28 patients (60.86%). One month after, ED was revealed in 42 patients (91.30%): mild ED in 26.08%, mild to moderate in 30.43%, moderate in 19.56%, and severe ED in 15.21%. Three months post-biopsy, ED was reported by 41 patients (89.13): mild ED in 21.73%, mild to moderate in 28.26%, moderate in 21.73%, and severe ED in 17.39%. Overall, three and two patients (6.52% and 4.34%) had prostate biopsy attributed ED (i.e. without concomitant ED-related disease or medication) 1 and 3 months after prostate biopsies. TRUS-guided prostate biopsies did not induce ED in a statistically significant manner. Evaluating potency at referral for TRUS-guided prostate biopsies is advisable.

Objectives Percutaneous renal tumor cryoablation is being evaluated as a treatment option for small renal tumors. However, when tumors are located centrally, involvement of the collecting system by the radiographic iceball can occur. We reviewed our series of computed tomography (CT)-guided percutaneous renal tumor cryoablation to identify those cases in which there appeared to be involvement of the collecting system by the radiographic iceball and to determine any clinical sequelae of such involvement. Methods Retrospective review of the medical records identified 6 patients who had undergone CT-guided percutaneous renal tumor cryoablation with evidence of collecting system involvement. Measurements of the tumor size, size of the radiographic iceball, and the size of the immediate postprocedure “cryozone” (region of apparent treatment on contrast-enhanced CT) were obtained from the preprocedure, intraprocedure, and immediate postprocedure CT scans. Follow-up imaging was obtained beginning at 3 to 6 months. Results Six patients were identified who met the inclusion criteria and had at least 3 months of documented follow-up. Despite the apparent involvement of the collecting system during the cryoablation procedure, no patient developed clinical signs or symptoms or radiographic evidence of a urine leak or fistula formation. Furthermore, no evidence of ureteral narrowing or stricture formation has been found to date, with a mean follow-up of 167.7 days (range 90 to 288). Conclusions We observed no clinically appreciable urine leaks despite what appeared to be obvious involvement of the collecting system by the radiographic iceball. However, care should be exercised to avoid this insult when possible until additional research has confirmed its safety.

Bladder calculi account for 5% of urinary calculi and usually occur because of bladder outlet obstruction, neurogenic voiding dysfunction, infection, or foreign bodies. Children remain at high risk for developing bladder lithiasis in endemic areas. Males with prostate disease or relevant surgery and women who undergo anti-incontinence surgery are at a higher risk for developing vesical lithiasis. Open surgery remains the main treatment of bladder calculus in children. In adults, the classical treatment for bladder calculi is endoscopic transurethral disintegration with mechanical cystolithotripsy, ultrasound, electrohydraulic lithotripsy, Swiss Lithoclast, and holmium:YAG laser. Novel modifications of these treatment modalities have been used for large calculi. Open and endoscopic surgery requires anesthesia and hospitalization. Alternatively, extracorporeal shock wave lithotripsy has been demonstrated to be simple, effective, and well tolerated in high-risk patients. Recently, simultaneous percutaneous suprapubic and transurethral cystolithotripsy has been tested as well as percutaneous cystolithotomy by using a laparoscopic entrapment sac.

fi c apid technological developments and global communication in the past two decades have evolutionized the surgical sciences. Advances in ptics and instrumentation encouraged a leap from raditional open operating techniques to the minially invasive surgeries of today. Urology has been t the forefront of these innovations, introducing ndourologic techniques into everyday practice to reat a myriad of genitourinary ailments. Patients ave embraced these novel approaches as they ave addressed concerns of postoperative pain, osmesis, and convalescence. However, inherent limitations with some advanced inimally invasive techniques have restricted uniersal mastery by urologists. For example, laparocopic urologic surgery has been relatively slow to be ncorporated into general practice. Two-dimensional isualization, restricted maneuverability, and dampned tactile feedback, present challenges to surgeons rained in traditional open approaches. Although eneral surgery has the cholecystectomy and gyneology has the tubal ligation, urology lacks a simple aparoscopic platform for acquiring the requisite kill. The learning curve for urologic laparoscopy is ong, necessitating significant training and continued xposure. The advent of computer-assisted robotic systems as provided a potential solution to address these imitations. They also open the door for developing ovel, until now impossible, procedures. Morever, the rapid expansion of Internet resources and odern audiovisual media has allowed for realime guidance and remote surgical assistance. This eview addresses the background, advances, and ontinuing challenges associated with robotic surical systems and telesurgery.

We investigated the learning curve, pathological results and perioperative morbidity of laparoscopic partial nephrectomy (LPN).The records of all LPN cases at our institution between January 1999 and March 2004 were reviewed. Of 223 cases 217 (97.3%) were performed for an enhancing renal mass.Mean tumor size was 2.6 cm (range 1 to 10) and 95.4% of patients had a normal contralateral kidney. Transient vascular control was performed in 75.1% of cases. Mean operative time (186 minutes) decreased with surgeon experience (p = 0.003) but was independent of tumor size (p = 0.964). Mean warm ischemia time (27.6 minutes) depended on tumor size (p = 0.005) but not on experience (0.964). Mean blood loss was 385 cc and the perioperative transfusion rate was 6.9%. Postoperative complications occurred in 23 cases (10.6%) with the most common being ileus (1.8%), bleeding (1.8%) and urinary leakage (1.4%). Although the mean serum creatinine change after LPN was a function of tumor size (p0.001), it was clinically insignificant (0.13 mg/dl). No significant relationship was observed between warm ischemia time and creatinine change (p = 0.262). The final pathological evaluation revealed renal cell carcinoma in 144 patients (66.4%) and the overall positive margin rate was 3.5%. Only 2 renal cell carcinoma recurrences in the operated kidney (1.4%) were identified (mean followup +/- SD 24 +/- 12 months).LPN is an effective approach for treating small renal masses with low perioperative morbidity. Contrary to previous reports, more than 30% of the enhancing renal lesions excised in this series were found to be benign on final pathological evaluation.

OBJECTIVES To review our experience with intact extraction and morcellation of nephrectomy specimens, and the advantages and disadvantages of morcellation indicated by current reports. PATIENTS AND METHODS In a previous study, 56 consecutive patients undergoing radical and simple transperitoneal laparoscopic nephrectomy were prospectively evaluated. Morcellation specimens (33) were extracted at the umbilical or lateral port sites and intact specimens (23) through an infra-umbilical incision. Data were obtained on pathology, narcotic requirements, hospital stay, complications, estimated blood loss, size of renal mass based on preoperative imaging, specimen weight and extraction incision length RESULTS The mean incision length was 1.2 cm in the morcellation group and 7.1 cm in the intact group (P

To evaluate, in an animal model, differences in wound healing and scar formation in healthy urethra and bladder neck incised with the erbium (Er):yttrium-aluminum-garnet (YAG) and holmium (Ho):YAG lasers.In each of 18 domestic pigs, three 1-cm-long incisions were made, two at the bladder neck and one in the mid-urethra, using either the Er:YAG laser (9 pigs) or the Ho:YAG laser (9 pigs). In each laser group, 3 animals were killed on postoperative days 0, 6, and 14. The width of collateral damage, as evidenced by coagulation necrosis and granulation tissue at the wound base, and the incision depth were evaluated during tissue analysis.The collateral damage with the Er:YAG laser at postoperative day 0, 6, and 14 was 20 +/- 5, 900 +/- 100, and 430 +/- 100 microm, respectively. The collateral damage with the Ho:YAG laser was 660 +/- 110, 2280 +/- 700, and 1580 +/- 250 microm, respectively. The amount of granulation tissue was significantly less (P0.05) at all time points with the Er:YAG laser. Similarly, the incision depths for the Er:YAG and Ho:YAG laser at postoperative day 6 (1100 +/- 200 microm versus 1500 +/- 300 microm, respectively) and 14 (670 +/- 140 microm versus 1240 +/- 140 microm, respectively) were also significantly less (P0.05) for the Er:YAG laser group, indicating faster healing of the wound created.In this in vivo animal study, incisions in the urethra and bladder neck made with the Er:YAG laser healed faster and with less scar formation than incisions made with the Ho:YAG laser.

Introduction: Open-ended straight ureteral stents are typically used for the support of the ureteroileal anastomosis during the creation of an orthotopic ‘S-pouch’ ileal neobladder. The use of double J stents as an alternative in this setting is evaluated. Materials and Methods: Medical charts from 43 patients undergoing radical cystectomy with formation of an ileal ‘S-pouch’ neobladder were retrospectively evaluated. In 30 patients (group A), a 6-Fr open-ended straight ureteral catheter was used to stent the ureteroileal anastomosis, while a double J stent was used for the same reason in 13 patients (group B). The ureteral catheter was removed 15 days after the procedure while the double J stent 3 weeks postoperatively. Hospital stay, early and late complications were evaluated for both groups during a mean follow-up period of 22.5 and 19.6 months respectively. Results: Stricture of the ureteroileal anastomosis was observed in 2 (6.6%) and 1 (7.6%) patient of groups A and B respectively. All complications presented with similar rates, except for an increased but not statistically significant incidence of urethrovesical anastomotic leakage and early urinary tract infections in group B. Hospital stay was significantly (p < 0.005) shorter for patients of group B (9.9 vs. 15.2 days). Conclusions: The use of double J stents to support the ureteroileal anastomosis can be used as an alternative to open-ended ureteral stents. With double J stents a shorter hospital stay was achieved with similar complication rates but a higher incidence of upper urinary tract infections.

To preserve sexual function following radical prostatectomy, one must avoid injury to the neurovascular bundles (NVBs). In the conventional open surgical technique, the use of energy sources for hemostasis is avoided to prevent damage to the cavernous nerves. In contrast, during laparoscopic radical prostatectomy, electrosurgical and ultrasonic energy sources are frequently used for hemostasis during dissection of the prostate. In this study, we evaluated the acute and chronic physiological effects of various hemostatic energy sources on cavernous nerve function in the canine model.A total of 12 dogs were divided into 4 groups based on the type of energy source used for hemostasis during unilateral dissection of the NVB. The groups included conventional dissection with suture ligatures (group 1), monopolar (group 2) or bipolar (group 3) electrosurgery and ultrasonic shears (group 4). The contralateral NVB was left undissected as a control. Erectile function was assessed acutely and after 2 weeks of survival by measuring peak intracavernous pressures in response to cavernous nerve stimulation.Following conventional techniques of nerve sparing, the erectile response to nerve stimulation was unaffected. In contrast, the use of energy sources in proximity to the NVB during nerve preservation was associated with a substantial decrease in erectile response both acutely (74% to 91% decrease compared to controls) and after 2 weeks (93% to 96% decrease).In the chronic canine model, use of hemostatic energy sources in proximity to the prostate during dissection of the neurovascular bundle is associated with a significantly decreased erectile response to cavernous nerve stimulation.

Objectives: Neoadjuvant chemotherapy has been used to improve outcome after cystectomy or for selection for bladder preservation in patients with bladder cancer. We have shown encouraging results using docetaxel and cisplatin in patients with advanced urothelial cancer. We are reporting the results of a phase II study using this combination as neoadjuvant treatment in patients with muscle invasive bladder cancer. Methods: Fifty patients were treated with docetaxel and cisplatin at 75mg/m 2 every 3 weeks for 3 cycles prior to cystectomy. Median follow-up was 70.2 months. Results: Chemotherapy was well tolerated. 5-year survival and progression-free survival (PFS) were 51.92% (95% confidence intervals [CI]: 37.76–66.08) and 52.47% (95%CI: 37.99–66.95). Multivariate analysis showed that clinical stage (cT) ≤ 3a was associated with improved 5-year survival (86.42% vs. 40.81%, p =0.027). Forty one patients underwent cystectomy. No tumor was found in 15 cases (36.6%). 5-year survival was 60.34% (95%CI: 52.2–68.48) and PFS was 57.11% (95%CI: 41.29–72.93). Absence of residual tumor was associated with improved 5-year survival (93.33% vs. 40.72%, p =0.031). Conclusions: Neoadjuvant chemotherapy with docetaxel and cisplatin is feasible and produced high pathological complete remission rate and excellent outcome in patients with no residual tumor.

Studies have demonstrated that biological tissues possess unique electrical properties. We evaluate the electrical properties of renal tumors using a specialized probe with the capability of measuring intra-tissue capacitance in an ex vivo model of fresh surgically excised tissue.An electrical monitoring device was used to measure tissue capacitance at a frequency of 1 MHz on 34 ex vivo kidney specimens freshly obtained after surgical excision. Tissue capacitance was promptly measured in the excised tumor as well as surrounding normal parenchyma and fat. Dielectric permittivity in each tissue was calculated using the measured capacitance data. These data were compared and correlated to pathological findings.The final pathology on the 34 specimens revealed 28 renal cell carcinomas (RCC), 3 oncocytomas and 3 angiomyolipomas. In patients with RCC dielectric permittivity of tumor tissue was 1.43 +/- 0.39 times greater than that of surrounding normal parenchyma (p0.001). The average tumor-to-normal tissue dielectric permittivity ratio for RCC was significantly greater than that for angiomyolipoma (1.43 +/- 0.39 vs 0.73 +/- 0.77, p0.05) but similar to that for oncocytoma (1.43 +/- 0.39 vs 1.63 +/- 0.77, p = 0.39).Tissue capacitance measurements may be used to differentiate renal tumor from surrounding normal tissue. In vivo studies will ultimately determine the clinical use of this technology in localizing renal neoplasms and differentiating between malignant and benign tissues.

Objectives To provide information about the long-term efficacy of transvesical prostatectomy from a contemporary series of patients. When comparing minimally invasive procedures with open prostatectomy, the data for the latter are usually provided from old studies or from recent ones performed in developing countries. However, this procedure is still used frequently for large-size prostates. Methods During a 5-year period, 232 patients with large (greater than 75 g) prostates underwent open transvesical prostatectomy for symptomatic benign prostatic hyperplasia. Patient charts were retrospectively reviewed for preoperative and postoperative International Prostate Symptom Scores, postvoid residual urine volumes, maximal flow rates, early and late postoperative complications, and the need for reoperation. The preoperative International Prostate Symptom Score, postvoid residual urine volume, and maximal flow rate were compared with the corresponding postoperative data at 8 to 12 months and at the last follow-up visit. Results Complete data evaluation was possible for 151 patients, with a mean follow-up of 41.8 ± 15.6 months. Improvement in International Prostate Symptom Score, postvoid residual urine volume, and maximal flow rate was statistically significant (P

Objectives To analyze complications of abdominal laparoscopic surgery of the urinary tract at a single institution during a 5-year period. Methods From 1996 to 2000, we identified 894 abdominal laparoscopic procedures performed at a single institution: 600 nephrectomies (live donor, simple, radical, nephroureterectomy, and partial), 112 pyeloplasties, 61 renal biopsies, 35 retroperitoneal lymph node dissections, 31 renal cyst ablations, 18 adrenalectomies, and 37 other abdominal procedures. The charts were retrospectively reviewed for complications, which were classified as operative, postoperative, or medical. Complications were correlated with patient age and American Society of Anesthesiologists score. Statistical analysis was performed with Fisher's exact test and chi-square tests. Results A total of 118 complications (13.2%) occurred. Two patients (0.2%) died. As a result of operative complications, the procedure of 13 patients (1.5%) was converted to an open one. As a result of postoperative complications, 13 (1.5%) underwent operative and 6 (0.7%) nonoperative intervention. The most common intraoperative complications were vascular (n = 23), adjacent organ (n = 10), and bowel (n = 9) injuries. The most common postoperative complications were neuromuscular pain (n = 12), hematoma (n = 11), urine leak (n = 7), and wound infection (n = 7). The differences in the annual complication rates for all procedures did not attain statistical significance (P = 0.5). Among all procedures, excluding live donor nephrectomy, complications of any kind correlated with a greater patient American Society of Anesthesiologists score (P = 0.01). Conclusions Rather than decreasing, the overall incidence of laparoscopic complications did not change significantly during a 5-year period at our institution. The factors contributing to this observation likely included the progression of inexperienced individual surgeons through the learning curve, the introduction of new, more sophisticated laparoscopic procedures, and stable rates of patient comorbidity. This experience may represent the average complication rate for urologic laparoscopy at a large-volume, academic training center.

IntroductionCurrent surgical and ablative treatment options for prostate cancer have a relatively high incidence of side effects, which may diminish the quality of life. The side effects are a consequence of procedure-related damage of the blood vessels, bowel, urethra or neurovascular bundle. Ablation with irreversible electroporation (IRE) has shown to be effective in destroying tumour cells and harbours the advantage of sparing surrounding tissue and vital structures. The aim of the study is to evaluate the safety and efficacy and to acquire data on patient experience of minimally invasive, transperineally image-guided IRE for the focal ablation of prostate cancer.Methods and analysisIn this multicentre pilot study, 16 patients with prostate cancer who are scheduled for a radical prostatectomy will undergo an IRE procedure, approximately 30 days prior to the radical prostatectomy. Data as adverse events, side effects, functional outcomes, pain and quality of life will be collected and patients will be controlled at 1 and 2 weeks post-IRE, 1 day preprostatectomy and postprostatectomy. Prior to the IRE procedure and the radical prostatectomy, all patients will undergo a multiparametric MRI and contrast-enhanced ultrasound of the prostate. The efficacy of ablation will be determined by whole mount histopathological examination, which will be correlated with the imaging of the ablation zone.Ethics and disseminationThe protocol is approved by the ethics committee at the coordinating centre (Academic Medical Center (AMC) Amsterdam) and by the local Institutional Review Board at the participating centres. Data will be presented at international conferences and published in peer-reviewed journals.ConclusionsThis pilot study will determine the safety and efficacy of IRE in the prostate. It will show the radiological and histopathological effects of IRE ablations and it will provide data to construct an accurate treatment planning tool for IRE in prostate tissue.Trial registration numberClinicaltrials.gov database: NCT01790451.