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A spermatocytic tumor is a rare tumour that has only been found in 1–12% of patients presenting with a testicular germ cell tumour. The tumor metastasizes only in few cases, having more chance when sarcomatoid or anaplastic transformation is seen. Orchiectomy without radio- and chemotherapy has been advised as standard therapy. In this case report, we describe a 68-year old patient with a testicular mass in his left hemiscrotum. An ultrasound showed two hypo-echogenic lobulated nodular laesions. Normal serum tumor marker level was observed. An inguinal orchiectomy was performed. Histopathological examination showed a spermatocytic tumour. Knowledge about a spermatocytic tumour and its hallmarks are essential. A short follow-up with CT and physical examination is advised. [ABSTRACT FROM AUTHOR]

Objectives: To compare the oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) undergoing kidney‐sparing surgery (KSS) with fibre‐optic (FO) vs digital (D) ureteroscopy (URS). To evaluate the oncological impact of image‐enhancement technologies such as narrow‐band imaging (NBI) and Image1‐S in patients with UTUC. Patients and Methods: The Clinical Research Office of the Endourology Society (CROES)‐UTUC registry is an international, multicentre, cohort study prospectively collecting data on patients with UTUC. Patients undergoing flexible FO‐ or D‐URS for diagnostic or diagnostic and treatment purposes were included. Differences between groups in terms of overall survival (OS) and disease‐free survival (DFS) were evaluated. Results: The CROES registry included 2380 patients from 101 centres and 37 countries, of whom 401 patients underwent URS (FO‐URS 186 and D‐URS 215). FO‐URS were performed more frequently for diagnostic purposes, while D‐URS was peformed when a combined diagnostic and treatment strategy was planned. Intra‐ and postoperative complications did not differ between the groups. The 5‐year OS and DFS rates were 91.5% and 66.4%, respectively. The mean OS was 42 months for patients receiving FO‐URS and 39 months for those undergoing D‐URS (P = 0.9); the mean DFS was 28 months in the FO‐URS group and 21 months in the D‐URS group (P < 0.001). In patients who received URS with treatment purposes, there were no differences in OS (P = 0.9) and DFS (P = 0.7). NBI and Image1‐S technologies did not improve OS or DFS over D‐URS. Conclusions: D‐URS did not provide any oncological advantage over FO‐URS. Similarly, no differences in terms of OS and DFS were found when image‐enhancement technologies were compared to D‐URS. These findings underline the importance of surgeon skills and experience, and reinforce the need for the centralisation of UTUC care. [ABSTRACT FROM AUTHOR]

Purpose: To review the current data on retrograde ejaculation (RE) and ejaculatory dysfunction (EjD) after endoscopic and minimally invasive surgical treatment of benign prostatic obstruction (BPO) and, their perceived impact in the quality of life (QoL) and sexual life of patients and their partners. Methods: Narrative review of systematic reviews (SR) assessing comparative rates of RE, EjD or erectile dysfunction (EF) was carried out. Relevant articles on the prevalence of RE, EjD or EF and on their impact in the QoL or sexual life of patients and partners were manually selected based on relevance. Results: Twelve SRs reporting on comparisons of different endoscopic/minimally invasive treatments of BPO were found. Data on outcomes varied widely. Overall, after conventional TURP or laser techniques 42–75% of patients present RE. Prostatic incision and ablative procedures present lowest rates of de novo RE or EjD whereas laser adenomectomy and ejaculation preservation procedures preserve antegrade ejaculation in 46–68% of patients. EjDs is associated to LUTS and present in 10% of sexualy active men before intervention. It modulates the QoL and sexual life of the couple. In spite of the scarce literature assessing patient's and partner's perception of postoperative EjD, it strongly suggests that both parties value the maintenance of the ejaculatory function. Conclusion: Ejaculation-preserving techniques and minimally invasive techniques successfully prevent BPO treatment-induced RE or EjD in 70–100% of the cases. While this is appealing to patients and spouses, technique selection and treatment durability are issues to be discussed with the couple. [ABSTRACT FROM AUTHOR]

Purpose: To assess epidemiologic characteristics, clinical and pathologic patterns of presentation, and treatment strategies in a contemporary population with renal masses (RMs). Methods: The Clinical Research Office of the Endourological Society collected prospective epidemiologic, clinical, and pathologic data on consecutive patients with RMs who were treated during a 1-year period in 98 centers worldwide. Preoperative assessment and treatment were performed according to local clinical practice guidelines. Results: From January 2010 to February 2012, 4288 patients (4355 cases, 4815 tumors) were treated for a RM. The mean age of the cohort was 61.5 years, and the ratio male:female 1.8:1. Caucasians represented 75% of the population, and the median body mass index was 27. The cohort exhibited a high rate of comorbidity (65.6%), including a 48.5% rate of hypertension; one-third of patients had a combination of two or more comorbidities. One-third of patients (36%) had risk factors for renal-cell carcinoma (RCC), of which smoking and obesity were the most common. Diagnosis was incidental in 67% of cases, and 22.2% of cases had chronic kidney disease stage ≥III at presentation. Median radiologic size was 44 mm (range 2-300 mm) and 68% were cT1. Radical nephrectomy and nephron-sparing surgery (NSS) including ablation were performed in 52% and 46% of cases, respectively, while 3.6% of cases were actively surveyed. Median pathologic size was 43 mm (range 2-300 mm) and 63% of the RCCs were pT1. Conclusions: Current patterns of presentation of RMs are consistent with the decreasing trends in age and clinical or pathologic size and increasing incidental diagnosis. Patients exhibit a considerable basal comorbidity and presence of risk factors for RCC. Half of the cases are treated by a nephron-sparing modality with an increase in the penetration of NSS techniques in the contemporary urologic practice. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Simple renal cysts are a common entity, which may need observation and follow-up or treatment. The study, for the first time, systematically reviews the indications for follow-up or radiological treatment of simple renal cysts. To review the conservative and radiological management of simple renal cysts a systematic literature review was performed. Simple renal cysts are commonly found in the adult population. Increasing age is highly associated with its incidence. When they remain asymptomatic they require neither treatment nor follow-up. When the shape of the cyst is slightly irregular follow-up is mandatory to exclude malignant progression. Symptomatic cysts require intervention. Ultrasound or computed tomography guidance have been effectively used for cyst puncture. However, simple fluid aspiration is ineffective leading to cyst recurrence. Aspiration should be accompanied with the injection of a sclerosing agent to destroy renal cyst epithelium. Several issues such as the ultimate technique and agent remain to be clarified. High rates of cyst disappearance and long-lasting cyst volume reduction have been reported with the use of various sclerosants. Ethanol in high concentrations and multiple injections is more commonly used with new agents showing similar efficacy and better complication profile. Studies comparing radiological intervention to surgical excision are lacking. Simple renal cysts may not require treatment when asymptomatic. Radiological intervention with the use of sclerosants needs further evaluation and comparison with other treatment methods. [ABSTRACT FROM AUTHOR]

Abstract: Background: Low morbidity has been advocated for cryoablation of small renal masses. Objectives: To assess negative perioperative outcomes of laparoscopic renal cryoablation (LRC) with ultrathin cryoprobes and patient, tumour, and operative risk factors for their development. Design, setting, and participants: Prospective collection of data on LRC in five centres. Intervention: LRC. Measurements: Preoperative morbidity was assessed clinically and the American Society of Anaesthesiologists (ASA) score was assigned prospectively. Charlson Comorbidity Index (CCI) and Charlson-Age Comorbidity Index (CACI) scores were retrospectively assigned. Negative outcomes were prospectively recorded and defined as any undesired event during the perioperative period, including complications, with the latter classed according to the Clavien system. Patient, tumour, and operative variables were tested in univariate analysis as risk factors for occurrence of negative outcomes. Significant variables (p <0.05) were entered in a step-forward multivariate logistic regression model to identify independent risk factors for one or more perioperative negative outcomes. The confidence interval was settled at 95%. Results and limitations: There were 148 procedures in 144 patients. Median age and tumour size were 70.5 yr (range: 32–87) and 2.6cm (range: 1.0–5.6), respectively. A laparoscopic approach was used in 145 cases (98%). Median ASA, CCI, and CACI scores were 2 (range: 1–3), 2 (range: 0–7), and 4 (range: 0–11), respectively. Comorbidities were present in 79% of patients. Thirty negative outcomes and 28 complications occurred in 25 (17%) and 23 (15.5%) cases, respectively. Only 20% of all complications were Clavien grade ≥3. Multivariate analysis showed that tumour size in centimetres, the presence of cardiac conditions, and female gender were independent predictors of negative perioperative outcomes occurrence. Receiver operator characteristic curve confirmed the tumour size cut-off of 3.4cm as an adequate predictor of negative outcomes. Conclusions: Perioperative negative outcomes and complications occur in 17 % and 15.5%, respectively, of cases treated by LRC with multiple ultrathin needles. Most of the complications are Clavien grade 1 or 2. The presence of cardiac conditions, female gender, and tumour size are independent prognostic factors for the occurrence of a perioperative negative outcome. [Copyright &y& Elsevier]

OBJECTIVE To determine whether evaluating perfusion patterns with contrast-enhanced ultrasonography using contrast-pulse sequence imaging (CPS; a new imaging method that enables selective visualization of perfusion) is possible at different times after cryoablation of renal tumours, and to describe the characteristics of CPS in a small group of patients. PATIENTS AND METHODS The efficacy of renal cryoablation is mainly judged using imaging. Seven randomly selected patients, each at a different time after laparoscopically assisted cryoablation of a renal tumour, were investigated with CPS and a microbubble-contrast agent. The perfusion characteristics in the lesions were scored by two investigators and described, and the lesions were measured. RESULTS In the seven patients treated with cryoablation for small renal tumours, eight CPS studies were performed. Five lesions showed no enhancement and one lesion, investigated 18 months after treatment was not recognized. In one patient, no enhancement was seen after 1 month but 7 months later, there were minimal contrast signals inside the treated area. The lesions could be measured with a mean standard deviation of 1.1 mm and a mean difference between the two investigators of 0.7 mm. CONCLUSION Our first experiences with CPS imaging for the follow-up of renal cryoablation show that this technique can be used to characterize perfusion defects at different times after cryoablation. [ABSTRACT FROM AUTHOR]

Purpose: To compare prostate shrinkage after transurethral microwave thermotherapy (TUMT) with calculated cell-kill.Materials and Methods: The calculated cell-kill from 33 males with benign prostatic hyperplasia (BPH) treated with TUMT according to the ProstaLund Feedback Treatment™ (PLFT) method was compared to the post-treatment prostate volume change. The prostate volume was estimated with three-dimensional transrectal ultrasound (3D-TRUS) planimetry at baseline, 3, 6, and 12 months follow-up. A paired t-test was used to test the statistical significance of differences between the cell-kill volume and the prostate volume change. Linear regression was used to infer a relationship between the cell-kill and the 3D-TRUS data. The reproducibility of the 3D-TRUS method was assessed in repeated measurements.Results: The mean prostate volume at baseline (N=33) was 56.1 cm3. After 3 (N=25), 6 (N=29) and 12 months (N=23), it was 45.5 cm3, 39.7 cm3, and 45.1 cm3, respectively. The corresponding average cell-kill volume was 16.4 cm3, 17.1 cm3, and 17.2 cm3, respectively. Predicted cell-kill volume was significantly larger than prostate shrinkage at 3 (p<0.0001), 6 (p=0.0002), and 12 months (p<0.0001), and showed a strong correlation at 3 and 6 months (r=0.74, p<0.0001). Correlation at 12 months was moderate (r=0.57, p=0.0041). Examination and investigation variability both averaged 2.5%.Conclusions: Cell-kill calculations of the PLFT method are proportional to the 3D-TRUS prostate shrinkage by a factor of 0.5 and have a precision of approximately ±10 cm3 for 90% of the patients during the first year after treatment. [Copyright &y& Elsevier]

We describe our technique for large renal vein control in the limited dissected space during laparoscopic nephrectomy. This technique is a simple, inexpensive and reliable method, especially for large and short renal vein ligation. [ABSTRACT FROM AUTHOR]

The authors reflect on the use of off-label drugs or pharmaceutical agents for treating urolithiasis. Topics covered include the use of α blockers for treating urinary stones, the highlights and findings of a research study conducted to performed medical expulsive therapy in adults with ureteric colic, and the need to improve standardization of patient outcome reporting.

Objective To determine whether the use of 3-dimensional (3D) imaging translates into a better surgical performance of naïve urologic laparoscopic surgeons during pyeloplasty (PY) and partial nephrectomy (PN) procedures. Materials and Methods Eighteen surgeons without any previous laparoscopic experience were randomly assigned to perform PY and PN in a porcine model using initially 2-dimensional (2D) and 3D laparoscopy. A surgical performance score was rated by an “expert” tutor through a modified 5-item global rating scale contemplating operative field view, bimanual dexterity, efficiency, tissue handling, and autonomy. Overall surgical time, complications, subjective perception of participating surgeons, and inconveniences related to the 3D vision were recorded. Results No difference in terms if operative time was found between 2D or 3D laparoscopy for both the PY ( P = .51) and the PN ( P = .28) procedures. A better rate in terms of surgical performance score was noted by the tutors when the study participants were using 3D vs 2D, for both PY (3.6 [0.8] vs 3.0 [0.4]; P = .034) and PN (3.6 [0.51] vs 3.15 [0.63]; P = .001). No complications occurred in any of the procedures. Most (77.2%) of the participating naïve laparoscopic surgeons had the perception that 3D laparoscopy was overall easier than 2D. Headache (18.1%), nausea (18.1%), and visual disturbance (18.1%) were the most common issues reported by the surgeons during 3D procedures. Conclusion Despite the absence of translation in a shorter operative time, the use of 3D technology seems to facilitate the surgical performance of naïve surgeons during laparoscopic kidney procedures on a porcine model. [ABSTRACT FROM AUTHOR]

Background and Purpose: The vast increase in recent publications on renal mass biopsy (RMB) suggests an increased interest in the subject. The objective of the survey was to assess the use of RMB in current urologic practice, including related factors such as indications and patterns in practice. Methods: The link to a web-based questionnaire () was sent to all registered e-mail addresses (1854) of members of the Endourological Society in December 2010. The questionnaire contained six epidemiologic questions, 10 regarding patterns of practice, one regarding the influence of the literature, and one on future techniques. Chi-square test (for trends) was used to assess statistical significant differences among categorical answers. Results: In total, 190 responders completed the survey of whom 73% indicated performing RMB 'never' or 'rarely' compared with 9% performing RMB in 25% to 100% of cases. Thirteen percent of responders reported never to take a RMB. Of the latter, significantly fewer practice in university hospitals (6% vs 20%-30%, P=0.003). Main indications to perform RMB are still tumors in solitary/transplant kidneys and in metastatic disease. Lack of influence on clinical management and risk of false negatives were the main reasons not to perform biopsies. Sixty-one percent prefer histological biopsies compared with 8% who prefer cytological aspiration; 31% indicated that they combine both techniques. Other tissue differentiation techniques (Optical Coherence Tomography, Raman-spectroscopy) are unknown to 65% of urologists. Conclusion: RMB is not yet applied widely in urologic practice, with academic urologists performing RMB less infrequently. Core biopsies are still preferred, although combined with cytologic punctures by a considerable number of responders. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Ureteroscopy outcome depends on the availability of the technological equipment and the surgeon experience. This study tries to define the learning curve of ureteroscopy, to underline the current quality of training and to propose the minimum requirements for a curriculum in ureteroscopy. The aim of the present review was to study factors influencing training and the maintenance of skills in performing ureteroscopy (URS). We searched on the following keywords in the Medline, Embase and Cochrane databases: renal or ureteric stone; ureteroscopy; endourology; educational; training; learning curve; expertise; skill; residency; practice; simulator; and robotics. We have defined, when possible, levels and grades of evidence, based on 2009 recommendations of the Oxford Centre for Evidence-Based Medicine. We found that technological advancement and surgeon experience is a predictive factor for success or complications of URS. Experience may be related to special endourology training, time passed after basic training and the number of procedures performed. Studies suggest that a resident must perform a certain amount of cases to gain proficiency with URS, but there is still a need for well designed studies for the learning curve of URS to be accurately defined. Training models may be useful for training in URS and stone disintegration. Stone centres that provide all the endoscopic treatment options seem to provide the best conditions to ensure a sufficient volume of patients required. Defining minimum requirements for training in URS and for maintaining certification is a major challenge, as is defining the learning curve in URS. Careful curriculum design in high-volume stone centres may be the key to optimizing URS training. [ABSTRACT FROM AUTHOR]

Automatic diagnosis systems capable of handling multiple pathologies are essential in clinical practice. This study focuses on enhancing precise lesion localization, classification and delineation in transurethral resection of bladder tumor (TURBT) to reduce cancer recurrence. Despite deep learning models success, medical applications face challenges like small and limited datasets and poor image characterization, including the absence lack of color/texture modeling. To address these issues, three solutions are proposed: (1) an improved texture-constrained version of the pix2pixHD cGAN for data augmentation, addressing the tradeoff of generating high-quality images with enough stochasticity using the Fréchet Inception Distance (FID) measure. (2) Introducing the Multiple Mask and Boundary Scoring R-CNN (MM&BS R-CNN), a new mask sub-net scheme where multiple masks are generated from the different levels of the mask sub-net pipeline, improving segmentation accuracy by including a new scoring module to refine object boundaries. (3) A novel accelerated training strategy based on the SGD optimizer with the second momentum. Experimental results show significant mAP improvements: the data generation scheme improves by more than 12 %; MM&BS R-CNN proposed architecture is responsible for an improvement of about 1.25 %, and the training algorithm based on the second-order momentum increases mAP by 2–3 %. The simultaneous use of all three proposals improved the state-of-the-art mAP by 17.44 %. • Improved instance segmentation network for bladder cancer addressing multi-pathology classification and the critical aspect of bad cancer resection that leads to cancer recurrence. • Data augmentation using an texture-constrained version of the pix2pixHD cGAN, generating high-quality images with enough stochasticity to promote generalization capability in limited datasets. • Increase of about 2-3% in mAP by training with the proposed second-order momentum optimizer. • Increase of 17.44% in mAP compared with BMask R-CNN. [ABSTRACT FROM AUTHOR]

Purpose: To compare the efficacy and safety of different treatment options for the management of proximal impacted ureteral stones (PIUS). Methods: A systematic literature search using Pubmed, Medline, Embase and Cochrane Library was conducted to obtain studies concerning different managements for PIUS up to Jan 2018. Summary odds ratios (ORs), standard mean differences (SMDs) or weighted mean differences with their 95% confidence intervals (CIs) were calculated to compare the efficacy and safety of all included treatment methods, registered in PROSPERO under number CRD42018092745. Results: A total of 15 comparative studies with 1780 patients were included. Meta-analyses of final stone-free rate (SFR) favored percutaneous nephrolithotomy (PCNL) over ureteroscopic lithotripsy (URL) (OR 10.35; 95% CI 5.26–20.35; P < 0.00001), laparoscopic ureterolithotomy over URL (OR 0.11; 95% CI 0.05–0.25; P < 0.00001) and URL over extracorporeal shockwave lithotripsy (OR 0.47; 95% CI 0.28–0.77; P = 0.003). As to complications, PCNL had a significantly higher blood transfusion rate (OR 7.47; 95% CI 1.3–42.85; P = 0.02) and a lower ureteral injury rate (OR 0.15; 95% CI 0.04–0.52; P = 0.003) compared with URL. It also shared a significantly lower stone-retropulsion rate (OR 0.03; 95% CI 0.01–0.15; P < 0.0001) and higher treatment costs (SMD = 2.71; 95% CI 0.71–4.70; P = 0.008) than URL. Conclusions: Our meta-analysis suggested that PCNL might be the best option for PIUS owing to its higher successful rate. Complications such as hemorrhage could be decreased by the application on mini-PCNL. [ABSTRACT FROM AUTHOR]

Purpose: This study is a systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes and the cost of open retropubic radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALP).Methods: Summary data was abstracted from 104 original research articles representing 227,400 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE and the Cochrane Library were reviewed in December 2016. A total of 104 publications were selected for inclusion. The primary outcomes were positive surgical margin (PSM) and major complication rate according to Clavien classifications. Secondary outcomes were operative time, length of hospital stay, estimated blood loss, transfusions, conversions, rate of post-operative erectile dysfunction and incontinence and total cost of procedure.Results: ORP had a significantly higher rate than RALP for PSM (OR: 1.18; 95% CI 1.05-1.32; p = 0.004), but the rate of PSM was not significantly different between ORP versus LRP (OR: 1.37; 95% CI 0.88-2.14; p = 0.17) and RALP versus LRP (OR: 0.83; 95% CI 0.40-1.72; p = 0.62). The major Clavien complication rate was significantly different between ORP and RALP (OR: 2.14; 95% CI 1.24-3.68; p = 0.006). Estimated blood loss, transfusions and length of hospital stay were low for RALP, moderate for LRP and high for ORP. The rate of erectile dysfunction (OR: 2.58; 95% CI 1.77-3.75; p < 0.001) and incontinence (OR: 3.57; 95% CI 2.28-5.58; p < 0.001) were significantly lower after RALP than LRP and equivalent for other comparisons. Total cost was highest for RALP, followed by LRP and ORP.Conclusions: For PSM and peri- and post-operative complications, RALP showed better results than ORP and LRP. In the context of the biases between the studies, one should interpret the results with caution. [ABSTRACT FROM AUTHOR]

Background: Current surgical and ablative treatment options for prostate cancer (PCa) may result in a high incidence of (temporary) incontinence, erectile dysfunction and/or bowel damage. These side effects are due to procedure related effects on adjacent structures including blood vessels, bowel, urethra and/or neurovascular bundle. Ablation with irreversible electroporation (IRE) has shown to be effective and safe in destroying PCa cells and also has the potential advantage of sparing surrounding tissue and vital structures, resulting in less impaired functional outcomes and maintaining men's quality of life.Methods/design: In this randomized controlled trial (RCT) on IRE in localized PCa, 200 patients with organ-confined, unilateral (T1c-T2b) low- to intermediate-risk PCa (Gleason sum score 6 and 7) on transperineal template-mapping biopsies (TTMB) will be included. Patients will be randomized into focal or extended ablation of cancer foci with IRE. Oncological efficacy will be determined by multiparametric Magnetic Resonance Imaging, Contrast-Enhanced Ultrasound imaging if available, TTMP and Prostate Specific Antigen (PSA) follow-up. Patients will be evaluated up to 5 years on functional outcomes and quality of life with the use of standardized questionnaires.Discussion: There is critical need of larger, standardized RCTs evaluating long-term oncological and functional outcomes before introducing IRE and other focal therapy modalities as an accepted and safe therapeutic option for PCa. This RCT will provide important short- and long-term data and elucidates the differences between focal or extended ablation of localized, unilateral low- to intermediate-risk PCa with IRE.Trial Registration: Clinicaltrials.gov database registration number NCT01835977. The Dutch Central Committee on Research Involving Human Subjects registration number NL50791.018.14. [ABSTRACT FROM AUTHOR]

Objective: To determine if the application of using standard tools on tumor complexity and comorbidity indexes may replace the traditional choice of nephron-sparing procedure (NSP) based on clinical maximal tumor diameter (cMTD), age, and comorbidity. Patients and Methods: Anatomic complexity scores (PADUA and RENAL) and Charlson comorbidity index (CCI) and CCI age-adjusted (CACI) were applied to 261 cases of either nephron-sparing surgery (NSS) or cryoablation (CA). Patient- and tumor-related preoperative variables, PADUA, RENAL, CCI, and CACI, were evaluated for their association and as treatment predictors in uni- and multivariate regression analysis. Discriminative ability of each of the models generated was compared for their receiver operating curve area under the curve (AUC). Survival analysis was performed using log rank tests. Results: In total, 124 cases underwent partial nephrectomy and 137 cases CA. cMTD, RENAL, PADUA, age, and CACI were independently associated with the choice of NSS. Five models integrating a combination of age, cMTD, CACI, PADUA, and RENAL (scores and complexity groups) showed an AUC >0.72 to predict the odds of receiving NSS. The discriminative ability of these five models was not statistically significantly different. Conclusions: cMTD, RENAL, PADUA, age, and CACI are preoperative variables independently associated with the choice of NSP. Models incorporating tools on tumor anatomic complexity and CACI may replace the decision-making in the type of NSP based on cMTD and age. The use of these models can be of value for future standardization and comparison. [ABSTRACT FROM AUTHOR]

The aim of the present review was to compare state-of-the-art care and future perspectives for the detection and treatment of non-muscle-invasive transitional cell carcinoma ( TCC) of the bladder. We provide a summary of the third expert meeting on 'Optimising the management of non-muscle-invasive bladder cancer, organized by the European Association of Urology Section for Uro- Technology ( ESUT) in collaboration with the Section for Uro- Oncology ( ESOU), including a systematic literature review. The article includes a detailed discussion on the current and future perspectives for TCC, including photodynamic diagnosis, optical coherence tomography, narrow band imaging, the Storz Professional Image Enhancement system, magnification and high definition techniques. We also provide a detailed discussion of future surgical treatment options, including en bloc resection and tumour enucleation. Intensive research has been conducted to improve tumour detection and there are promising future perspectives, that require proven clinical efficacy. En bloc resection of bladder tumours may be advantageous, but is currently considered to be experimental. [ABSTRACT FROM AUTHOR]

This paper confronts two approaches to classify bladder lesions shown in white light cystoscopy images when using small datasets: the classical one, where handcrafted-based features feed pattern recognition systems and the modern deep learning-based (DL) approach. In between, there are alternative DL models that had not received wide attention from the scientific community, even though they can be more appropriate for small datasets such as the human brain motivated capsule neural networks (CapsNets). However, CapsNets have not yet matured hence presenting lower performances than the most classic DL models. These models require higher computational resources, more computational skills from the physician and are more prone to overfitting, making them sometimes prohibitive in the routine of clinical practice. This paper shows that carefully handcrafted features used with more robust models can reach similar performances to the conventional DL-based models and deep CapsNets, making them more useful for clinical applications. Concerning feature extraction, it is proposed a new feature fusion approach for Ta and T1 bladder tumor detection by using decision fusion from multiple classifiers in a scheme known as stacking of classifiers. Three Neural Networks perform classification on three different feature sets, namely: Covariance of Color Histogram of Oriented Gradients, proposed in the ambit of this paper; Local Binary Patterns and Wavelet Coefficients taken from lower scales. Data diversity is ensured by a fourth Neural Network, which is used for decision fusion by combining the outputs of the ensemble elements to produce the classifier output. Both Feed Forward Neural Networks and Radial Basis Functions are used in the experiments. Contrarily, DL-based models extract automatically the best features at the cost of requiring huge amounts of training data, which in turn can be alleviated by using the Transfer Learning (TL) strategy. In this paper VGG16 and ResNet-34 pretrained in ImageNet were used for TL, slightly outperforming the proposed ensemble. CapsNets may overcome CNNs given their ability to deal with objects rotational invariance and spatial relationships. Therefore, they can be trained from scratch in applications using small amounts of data, which was beneficial for the current case, improving accuracy from 94.6% to 96.9%. [ABSTRACT FROM AUTHOR]

Objectives To determine short-term differences in renal function evolution between patients with renal cell carcinoma ( RCC) submitted to radical nephrectomy ( RN) and living kidney donors matched for age and gender., To assess the role of co-morbidity as a risk factor for developing an estimated glomerular filtration rate ( eGFR) of <60 mL/min/1.73 m2., Patients and Methods In this retrospective study patients undergoing Radical Nefrectomy ( RN) between January 2000 and February 2011 for suspicion of localised RCC were matched by age and gender to living kidney donors., Renal function was compared between the groups using the Modification in Diet and Renal Disease ( MDRD) equation at 1 year after RN., Charlson co-morbidity score, incidence of hypertension, diabetes and cardiovascular disease were compared and assessed as predictors for developing an eGFR of <60 mL/min/1.73 m2., Results In all, 196 patients were included, 98 in each group., The mean age was respectively 60.6 ( RCC group) and 59.1 years (donors)., The 1-year postoperative mean eGFR (available in 89 patients with RCC and 87 donors) was similar, at a mean ( sd) of 56.7 (16.4) mL/min/1.73 m2 in patients with RCC and 56.2 (9.8) mL/min/1.73 m2 in donors ( P = 0.83)., In patients with RCC the incidence and severity of co-morbidities was significantly higher., A preoperative eGFR of 60-89 mL/min/1.73 m2 was the only independent risk factor for developing a postoperative eGFR of <60 mL/min/1.73 m2 (odds ratio 4.4, confidence interval 2.1-9.5, P < 0.001, 95% confidence interval)., Conclusions In our cohorts with advanced age the 1-year follow-up eGFR was similar in both groups., Despite increased co-morbidity in the RCC group there was no increased decline in renal function., Only reduced preoperative eGFR could be identified as risk factor for developing a postoperative eGFR of <60 mL/min/1.73 m2. [ABSTRACT FROM AUTHOR]

Purpose: To assess the use of prognostic factors and models in renal-cell carcinoma (RCC) and to gain insight in the motivations precluding prognosis estimation and the use of prognosticators. Materials and Methods: A questionnaire was sent to 110 urologists involved in the Clinical Research Office of the Endourological Society (CROES) Global Renal Mass Study. Frequencies were gathered using descriptive statistics. Results: The majority of the 86 responders worked in a university hospital in Europe. Most of the urologists (97.7%) used the tumor-node-metastasis (TNM) classification, and 44% performed prognosis estimations in all patients. The main reason not to estimate prognosis was lack of accuracy (20.9%) and of additional benefit (11.6%). In addition, clinical, laboratory, or pathologic factors were used by 89.5% of the urologists and biomarkers by 16.3%. Preoperative models were used by 20.9%, postoperative models by 38.4%, and metastatic models by 38.4%. The Raj and Motzer models were the most used in preoperative and metastatic settings, while no predominance among the different postoperative models was seen. The most important reasons to skip the use of models were 'lack of additional value' and 'lack of familiarity' reported by 30.2% and 27.9% of the responders, respectively. Conclusions: The TNM is the mainstay for assessing prognosis in RCC. Our data indicate that penetration of prognostic systems is, at most, moderate, suggesting limited use outside original developmental settings. On the contrary, clinical, laboratory, and pathologic factors are used by almost all urologists for prognosis estimations. The most important reason not to use models is the lack of additional value. [ABSTRACT FROM AUTHOR]

The incidence of small renal masses is increasing, as a result of the wide adoption of imaging exams. Their management, however, is complicated, especially in patients with decreased life expectancy or comorbidities. Approximately 20% of small renal masses are benign and, even if malignant, just 10% show aggressive pathological features. Furthermore, competing cause mortality seems to exceed the cancer-specific mortality in patients aged over 70 years. The role of percutaneous tumor biopsy is still not well defined. All these observations raise the concern as to whether surgery might represent an overtreatment for some cases of small renal masses, calling into question the role of active surveillance. The aim of this review was to evaluate the current evidence pertaining to several hot questions that need to be addressed when contemplating active surveillance for small renal masses. The most relevant publications on this subject available in the literature were selected. Five representative series of active surveillance along with the main related variables were identified. Some relevant items surrounding the field of active surveillance were identified and submitted to an evidence-based discussion. According to the recent evidence, small renal masses under active surveillance tend to show an indolent course with a low probability of disease progression, the latter being triggered most of the time by a tendency to grow faster. Unfortunately, we are currently unable to predict those few cases with aggressive behavior. According to the current evidence, active surveillance is feasible and safe in elderly and comorbid patients. [ABSTRACT FROM AUTHOR]

Purpose: Stringent radiological follow-up is essential after renal tumor ablation. Drawbacks of postablation follow-up by contrast-enhanced computed tomography (CECT) are the associated ionizing radiation and nephrotoxic contrast agent. Contrast-enhanced ultrasound (CEUS) has shown potential to demonstrate microvasculature without using either ionizing radiation or toxic contrast agent. We assessed the concordance of enhancement patterns of CEUS and CECT/MRI in cryolesion assessment after laparoscopic renal cryoablation (LCA). Methods: From 01/2006 to 01/2009, a CEUS was performed before and after LCA (3 and 12 months) in addition to regular CECT/MRI. Using an enhancement score (0=no enhancement, 1=rim enhancement, 2=diffuse enhancement, 3=localized enhancement, 4=no enhancement defect), the cryolesion was assessed by both modalities, and concordance of enhancement score was assessed. Results: In total, 45 tumors were included (29 biopsy proven renal cell carcinoma (RCC), mean size 2.66 cm). One cryoablation failed, resulting in a nonenhancing cryolesion apart from the persisting renal tumor. There were no postablation recurrences during the study period. Pre-LCA: Both modalities were available in 26 cases. In 20 out of 26, there was concordance of enhancement score (77%, all cases score 3 or 4). Three months: Both modalities were available in 32 cases. Enhancement score corresponded in 23 out of 32 cases (72%). Seven cases showed enhancement on CECT/MRI ('1' in six cases, '4' in one case) with enhancement score '0'on CEUS. Two cases showed enhancement on CEUS without enhancement on CECT/MRI (specificity 92%, negative predictive value [NPV] 77%). Except one case, all enhancement resolved on subsequent imaging. Twelve months: Both modalities were available in 21 tumors. Enhancement score corresponded in 19 out of 21 cases (91%). Two cases showed enhancement on CEUS without enhancement on CECT/MRI (specificity 90%, NPV 100%). Conclusion: This pilot study shows that CEUS is a safe imaging technique with high concordance of enhancement score between CEUS and CECT/MRI. While cross-sectional imaging seems sensible to demonstrate successful ablation at first follow-up, CEUS might be used to diminish the burden of contrast-enhanced cross-sectional imaging in the long-term follow-up. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Optical Coherence Tomography (OCT) was developed in the early 1990s for ophthalmological application and is currently widely accepted in ophthalmology for retinal imaging purposes. In kidneys, the first experiments were performed on transplant kidneys to investigate the ability of OCT to assess ischaemic damage of kidneys. An ex vivo pilot study on the ability of OCT to differentiate normal renal tissue from malignant renal tissue, showed positive results and here we present the results of the first in vivo experiment. The study shows for the first time that in vivo OCT is feasible and safe to perform in humans and that a significant different attenuation coefficient (as a quantitative measurement of the OCT images) is found between normal renal tissue and malignant renal tumours with a clear trend towards significance in the difference between benign and malignant renal tumours in a small pilot study. This suggests potential use of OCT in different clinical settings for diagnostic purposes in the course of renal tumours, and justifies further research. OBJECTIVE To determine the ability of optical coherence tomography (OCT) in differentiating human renal tumours in an in-vivo setting by assessing differences in attenuation coefficient (µOCT; mm-1) as a quantitative measurement., METHODS Consecutive patients undergoing nephrectomy (partial/radical) or cryoablation for an enhancing solid renal tumour were included in our centre between October 2010 and May 2011., In vivo OCT images were obtained from renal tumour and normal parenchyma during surgery. Ex vivo OCT images of internal (subcapsular) tissue were obtained after longitudinal dissection of the extirpated specimen., Attenuation coefficients of the OCT images were determined off-line and compared between normal renal parenchyma and renal tumours (grouped per tissue type and per individual patient); and between OCT images recorded from tissue surface vs internal (subcapsular) tissue., RESULTS In vivo OCT was performed in 16 cases (11 renal cell carcinoma, three benign tumours, one non-diagnostic biopsy and one not-accessible tumour)., Median attenuation coefficient of normal renal parenchyma was 5.0 mm−1 vs 8.2 mm−1 for tumour tissue ( P < 0.001) with normal parenchyma differing significantly from malignant tumour (9.2 mm−1, P < 0.001) and non-significantly from benign tumour (7.0 mm−1, P= 0.050). The attenuation coefficient of benign tumours did not differ significantly from that of malignant tumours (7.0 vs 9.2 mm−1, P= 0.139)., Using patients as their own control, attenuation coefficients of normal renal parenchyma differed significantly from malignant tumour ( P < 0.001) and non-significantly from benign tumour ( P= 0.109)., Assessed in 10 patients, there was no significant difference between attenuation coefficients of tumour surface and internal tumour (8.5 vs 9.7 mm−1 respectively, P= 0.260)., CONCLUSIONS In this first in vivo study on OCT for differentiation of renal tumours in humans the attenuation coefficients (as a quantitative assessment) differed significantly between normal renal parenchyma and malignant tumour., Tumour surface and internal tumour did not differ significantly, suggesting that a superficial OCT attenuation coefficient reliably assesses tissue composition inside the tumour., These results justify further research on OCT for various clinical applications in the diagnosis of renal tumours. [ABSTRACT FROM AUTHOR]

Abstract: Context: Thermal ablation of small renal tumours is an established treatment modality in selected cases. Many groups have published their experiences. However, a major drawback of most of the previously published reviews and meta-analyses is their retrospective nature, the heterogeneity of included studies, and the limitations of a short-term oncologic follow-up. For those reasons, firm conclusions are still lacking. Objective: To assess the best combination of ablation technique and approach in those renal tumours deemed suitable for ablation. Evidence acquisition: A PubMed search was performed (up to December 2010) of the world literature on thermal ablation of renal tumours. To assess oncologic outcomes, we selected reports with a minimum follow-up of 36 mo and with appropriately documented pathologic results specifying the number of biopsy-proven renal cell carcinomas (RCCs). To assess perioperative complications we selected series with substantial caseloads of at least 70 cases and comparative series among techniques. Evidence synthesis: All long-term series of thermal ablation for small renal masses show a recurrence-free survival (RFS) of 84–94% with a cancer-specific survival (CSS) of 89–100%. Some cases with previous (partial) nephrectomy for RCC are included in the series with lowest RFS and CSS. No distinct differences exist between radiofrequency ablation (RFA) and cryoablation (CA). Initial failure and overall complication rates are higher for the percutaneous approach compared with laparoscopy. The major complication rate is slightly lower, ultimate survival is comparable, and length of stay and patient convalescence are favourable for the percutaneous approach, regardless of the modality. Conclusions: Low-quality evidence shows that CA or RFA modalities have a low major-complication rate, preserve renal function, and provide acceptable, oncologic, long-term outcomes. The percutaneous approach has a high rate of initial failure, but seems to be less costly. [Copyright &y& Elsevier]

Purpose: To define in which patients who present with microscopic or macroscopic hematuria CT urography (CTU) is indicated as an imaging mode for the upper urinary tract (UUT). Patients and Methods: We conducted a prospective study on consecutive patients who attended a modern protocol-driven hematuria clinic from January 2006 to February 2010. Standard tests (history taking, physical examination, urinalysis via dipstick method, ultrasonography of kidneys and bladder performed by urologists, cystoscopy, and cytology) were directed to all patients, whereas the mode of additional UUT imaging (ultrasonography by a radiologist or four-phase CTU/magnetic resonance (MR) urography (MRU) when CTU was contraindicated) was selected according to a risk factor-based management algorithm. The added value of cross-sectional urography (CTU/MRU) supplementary to ultrasonography (by urologists) to detect renal masses, UUT tumors, and stones was assessed. Univariate and multivariate analysis on predictive factors for cross-sectional urography result were performed. Results: From the total of 841 patients, lesions that might account for hematuria could not be identified in 462 (54.9%), whereas in 250 (29.7%) and 124 (14.7%) patients, hematuria was from benign and malignant disease, respectively. Cross-sectional urography revealed relevant UUT lesions in 73 of 525 (13.9%) patients. Only result of ultrasonography (odds ratio [OR] 7.7, 95% confidence interval [CI] 4.0-14.9), P<0.001) and type of hematuria (OR 2.6, 95% CI 1.3-5.1, P=0.01) were significant predictors for cross-sectional urography result. In 44 of 456 (9.6%) patients with no abnormalities on ultrasonography, CTU/MRU revealed that these were false negatives, with most lesions missed being stones. In 253 of 309 (81.9%) patients with macroscopic hematuria, no lesions were detected in the UUT on CTU/MRU, in contrast to 199 of 216 patients (92.1%) with microscopic hematuria. Conclusion: For patients who present with microscopic hematuria, ultrasonography is sufficient to exclude significant UUT disease. For patients with macroscopic hematuria, the likelihood of finding UUT disease is higher, and a CTU as a first-line test seems justified. [ABSTRACT FROM AUTHOR]

Abstract: Context: The increasing incidence of localised renal cell carcinoma (RCC) over the last 3 decades and controversy over mortality rates have prompted reassessment of current treatment. Objective: To critically review the recent data on the management of localised RCC to arrive at a general consensus. Evidence acquisition: A Medline search was performed from January 1, 2004, to May 3, 2011, using renal cell carcinoma, nephrectomy (Medical Subject Heading [MeSH] major topic), surgical procedures, minimally invasive (MeSH major topic), nephron-sparing surgery, cryoablation, radiofrequency ablation, surveillance, and watchful waiting. Evidence synthesis: Initial active surveillance (AS) should be a first treatment option for small renal masses (SRMs) <4cm in unfit patients or those with limited life expectancy. SRMs that show fast growth or reach 4cm in diameter while on AS should be considered for treatment. Partial nephrectomy (PN) is the established treatment for T1a tumours (<4cm) and an emerging standard treatment for T1b tumours (4–7cm) provided that the operation is technically feasible and the tumour can be completely removed. Radical nephrectomy (RN) should be limited to those cases where the tumour is not amenable to nephron-sparing surgery (NSS). Laparoscopic radical nephrectomy (LRN) has benefits over open RN in terms of morbidity and should be the standard of care for T1 and T2 tumours, provided that it is performed in an advanced laparoscopic centre and NSS is not applicable. Open PN, not LRN, should be performed if minimally invasive expertise is not available. At this time, there is insufficient long-term data available to adequately compare ablative techniques with surgical options. Therefore ablative therapies should be reserved for carefully selected high surgical risk patients with SRMs <4cm. Conclusions: The choice of treatment for the patient with localised RCC needs to be individualised. Preservation of renal function without compromising the oncologic outcome should be the most important goal in the decision-making process. [Copyright &y& Elsevier]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Laparoscopic Cryoablation of renal masses has a low persistence and recurrence rates at short term follow-up albeit higher than Partial Nephrectomy. Long term results are scarcely reported. It is however a NSS technique suitable for high-risk that preserves renal function. The study provides (1) mid-term oncological outcomes of laparoscopic cryoablation of renal masses stratified by primary pathology (RCC, benign mass or undetermined biopsy) and (2) data on renal function evolution up to one year of follow-up supporting the fact that the only predictor of (moderate)renal insufficiency development after Laparoscopic cryoablation is the eGFR at baseline. OBJECTIVE To present the functional and oncological mid-term results of laparoscopic cryoablation of renal masses using third generation ultrathin (17-gauge[G]) cryoprobes. PATIENTS AND METHODS • Consecutive patients with small renal masses treated by cryoablation from September 2003 to September 2008 were prospectively evaluated. The cryoablation was performed using multiple third generation 17-G cryoprobes after intraoperative mass biopsy. • Data on serum creatinine measurements and cross sectional imaging (computed tomography/magnetic resonance imaging) were regularly collected according to a previously determined protocol. Follow-up was censored in October 2009. • Renal function analysis was based on estimated glomerular filtration rate (eGFR) at 1 year compared with baseline. Residual (or persistent tumour) and recurrence were defined as the presence of residual enhancement at first follow-up and 'd e novo' enhancement of a non-enhancing cryolesion at any time during follow-up. • Survival data were analysed using the Kaplan-Meier method. Best estimates for the overall survival (OS), recurrence-free survival (RFS), cancer-specific survival (CSS) and metastatic-free survival (MFS) were made for patients with renal cell carcinoma (RCC) and for patients with RCC or non-diagnostic biopsy. RESULTS • A total of 92 patients (100 tumours; mean size 2.5 ± 0.8 cm) were treated in 95 sessions. The mean follow-up was 30.2 ± 16.6 months (Mean values are ±SD). • Intraoperative biopsy showed RCC in 51 patients (53.7%), benign lesion in 23 patients (24.2%) and was non-diagnostic in 21 patients (22.1%). Three tumour persistences and four radiological recurrences were detected. • The estimated mean RFS time and 3-year OS and RFS in patients with RCC exclusively were 47.8 (95% confidence interval [CI]: 44.1-51.1) months, 86.1% (95% CI: 71.2-93.6) and 91.8% (95% CI: 76.3-97.3), respectively. The figures were slightly higher in the group of patients with RCC or unknown pathology. The actual CSS and MFS rates were 100%. • Renal function was preserved in 84.5% of patients with normal preoperative eGFR. • Baseline eGFR was the only predictor of renal insufficiency development at 1-year follow-up. CONCLUSION Laparoscopic cryoablation with multiple ultrathin cryoprobes is oncologically and functionally effective at mid-term follow-up. [ABSTRACT FROM AUTHOR]

Abstract: The diagnostic problems in the subtyping of renal tumors were evaluated by a panel of five pathologists studying a set of selected tumors. Five pathologists independently assessed a single hematoxylin-and-eosin (HE)-stained slide from 28 selected renal tumors. After this independent assessment, the pathologists reevaluated and discussed all discordant cases. Additional HE-stained sections and immunohistochemically (IHC) stained slides were available. The generalized kappa for interobserver agreement was calculated. After independent assessment of the HE-stained slides, the five pathologists unanimously reached an agreement in the decision between malignant and benign in 82% of the cases. Fifty percent of the cases were correctly subclassified. The overall generalized kappa value for the five pathologists was 0.320 (CI 95% 0.090–0.551), which is considered a moderate agreement. A 100% agreement was reached for all 28 cases after examination of more slides from different tumor areas and IHC-stained sections. An accurate histologic distinction between benign and malignant renal tumors is possible on one HE-stained section. Correct assignment of the subtype is difficult on one slide alone and relies on IHC-markers and additional slides. Tumors composed of an eosinophilic cell type and tumors with a papillary growth pattern were the major causes of an incorrect diagnosis on an HE-stained section alone. [Copyright &y& Elsevier]

Abstract: Background: Fine needle aspiration (FNA) cytology is under consideration as an auxiliary preoperative diagnostic technique in the diagnosis of renal masses. However, reports for FNA are contradictory with regard to diagnostic accuracy and applicability. Objective: To evaluate the diagnostic accuracy and reproducibility of FNA from renal masses. Design: FNAs performed in-bench (hematoxylin and eosin [H&E] stains) from 66 consecutive renal tumours (58 malignant and 8 benign tumours) were presented twice with a 6-mo interval to five pathologists with little experience in renal cytology. Pathologists were blinded for the results of the first round as well for the surgical specimen. The FNAs were stained for Papanicolaou and Giemsa. Measurements: Diagnostic accuracy, concordance between smears and surgical specimens, and the generalized kappa for interobserver/intraobserver agreement were calculated. Results and limitations: The number of nondiagnostic and nonconclusive cases ranged from 5–14% in the first and 3–8% in the second round. Overall accuracy varied between 73–89% and 71–91% for the first and second round, respectively. Sensitivity (72–97%) and positive predictive value (PPV) (93–100%) to classify a malignant tumour in both rounds was high. Sensitivity (25–100%) and PPV (28–100%) to classify a benign tumour was lower with a wide confidence interval. Overall concordance in subtyping ranged from 39–70% in the first, and from 52–74% in the second round. Interobserver agreement ranged from fair (κ =0.039) to substantial (κ = 0.540) for the different subtypes. The intraobserver agreement (mean κ = 0.357, CI 95%=0.304–0.411) was moderate for all pathologists. The low number of benign tumours in this study precludes sound statements regarding the diagnostic accuracy of FNA to classify benignity. Conclusion: Despite the lack of experience in renal cytology, all pathologists showed a high diagnostic yield and good overall accuracy in distinguishing between malignant and benign tumours. Concordance in subtyping varied widely among pathologists and was reliable only for clear cell renal cell carcinoma (ccRCC). These results suggest that FNA may have a potential role in the diagnosis of renal tumours although its value in subtyping was limited in our setting. [Copyright &y& Elsevier]

Abstract: Context: Laparoscopic retroperitoneal lymph node dissection (L-RPLND) is not recommended as standard tool in European Association of Urology (EAU) guidelines. Objective: To update the role of L-RPLND in patients with clinical stage I nonseminomatous germ cell tumour (NSGCT) compared to open retroperitoneal lymph node dissection (O-RPLND). Evidence acquisition: A systematic literature search from 1992 to 2008 was performed in Medline, EMBASE, and Cochrane. The largest series from each group was considered. Comparative analysis was based on raw data of series published in 2000 and later. Evidence synthesis: Results of >800 patients treated by L-RPLND reported in 34 articles were analyzed. Lymph node dissection (LND) was based on modified templates, removing an average of 16 (5–36) lymph nodes. At experienced centres, complication rates were 15.6% (9.4–25.7), including 2% (0–5) retrograde ejaculation and 1.7% (0–6) reintervention. Operating room times are longer compared to O-RPLND (204 vs 186min). Five publications with a follow-up of 63 (36–89) mo include 557 patients. One hundred twenty-six of 140 (90%) patients with positive nodes (25%, range: 17–38) received adjuvant chemotherapy, resulting in a local relapse rate of 1.4% (0.7–2.3) with no in-field recurrence; rate of distant relapses was 3.3% (1.8–4.6), including one port-site metastasis; and rate of biochemical failure was 0.9% (0.7–2.3). Two of 14 patients with positive nodes (pN1) who did not receive adjuvant chemotherapy relapsed, both 8 mo after surgery, and were salvaged by chemotherapy. Compared with O-RPLND, there was no difference in relapse rates, percentage of patients receiving chemotherapy (29% vs 31%), chemotherapy (CTx) cycles per cohort (0.6), rate of salvage surgery (1.2% vs 1.5%), and patients with no evidence of disease (NED; 100% vs 99.7%). Conclusions: L-RPLND offers similar staging accuracy and long-term outcome to O-RPLND. In a late series of experienced L-RPLND centres, there was a trend towards fewer complications. L-RPLND represents a valuable tool for experienced laparoscopic surgeons. Further studies must focus on the curative potential of the procedure in pathologic stage IIA. [Copyright &y& Elsevier]

OBJECTIVE To evaluate changes in the pathological characteristics, stage of primary renal tumours and their surgical management in the Netherlands during the period 1995–2005. METHODS Extracts from the records of all patients who had surgery for primary renal tumours in the Netherlands during the period 1995–2005 were reviewed. Data were collected from PALGA, the nationwide network and archive of histocytopathology. The 2002 Tumour-Node-Metastasis and the three-tier Fuhrman grade were used for staging and grading. RESULTS In all there were 12 471 operations for primary renal masses during the study period. The incidence of surgically removed renal cancers increased from 6.2 in 1995 to 7.5 cases per 100 000 inhabitants ( P = 0.005) in 2005. The mean (sd, median) age of the patients was 63.3 (11.9, 65.0) years, with a male-to-female ratio of 3:2. The mean (sd) tumour size of malignant tumours decreased from 7.3 (3.6) to 6.9 (3.7) cm ( P = 0.301). The percentage of benign removed tumours remained relatively stable ( P = 0.056), with a mean of 5.4% of all resected tumours. There was an increase of grade 1 tumours; the incidence of T1 tumours increased from 36.6% to 44.2%, and advanced tumours decreased from 46.4% to 33.7%, respectively. The percentage of nephron-sparing surgery increased from 3.5% in 1995 to 10.1% ( P = 0.003) in 2005, mainly in the T1a tumours. CONCLUSIONS During the last decade there was an increase in the incidence of surgically treated renal tumours in the Netherlands. Tumours with favourable histopathological characteristics, low stage and grade, accounted for most of this increase. The percentage of surgically removed benign tumours remained stable. The use of nephron-sparing surgery increased during the last decade, especially in T1a tumours. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The diagnostic accuracy of in-bench core biopsies (CBs) from renal masses, and the interobserver and intraobserver variability in pathological subtyping of renal tumors were assessed. Methods: We performed two CBs in 62 consecutive renal masses suspected for renal cell carcinoma (RCC), obtained after radical or partial nephrectomy and, in one case, after autopsy. Routine hematoxylin-eosin (HE)–stained sections from each CB were evaluated by five pathologists on two occasions. The surgical specimen was the reference standard. Diagnostic accuracy and the generalized kappa for intraobserver and interobserver agreement were calculated. Results: Five tumors were benign and 57 malignant. Eight percent to 16% of the CBs were considered inadequate for diagnosis. In 0–8% of the cases, the pathologist could not discriminate between a benign or malignant tumor. Overall accuracy ranged from 77% to 90%. Sensitivity (79–100%) and positive predictive value (100%) were high with narrow 95% confidence interval (95%CI). Specificity (100%) was high but negative predictive value (29%–100%) varied, with wide 95% CI. Interobserver agreement was fair to almost perfect (κ=−0.010 to 0.830) for the different subtypes. In 64–81% of the CBs, the subtype was correctly classified. Intraobserver agreement was substantial (mean κ=0.628) for all pathologists. Conclusion: Diagnostic accuracy of CBs was high, with a diagnostic yield varying between 84% and 92%. Pathological subtyping of CBs was highly reproducible with the exception of the chromophobe renal cell carcinoma, which was problematic on HE-stained sections only. [Copyright &y& Elsevier]

Abstract: Objective: To up-date the 2001 version of the EAU testicular cancer guidelines. Methods: A non-structured literature review until January 2005 using the MEDLINE database has been performed. Literature has been classified according to evidence-based medicine levels. Results: Testicular cancer is a highly curable disease. Excellent cure rates have been achieved by standardization of treatment, interdisciplinary management, and tremendous success in performing clinical trials. Currently, the aims of testicular cancer treatment are as follows: for patients with low-stage disease, a reduction in treatment is proposed to improve long-term toxicity in these patients with unaltered life expectancy; for about 10% of patients with advanced disease and poor prognosis, intensification of treatment (including high-dose chemotherapy and new drugs as well as aggressive surgical approaches) is being investigated to improve long-term cure rates. Conclusion: Guidelines will improve clinical practice only if they are regularly updated. This update presents the state-of-the-art management of testicular cancer patients in 2005. [Copyright &y& Elsevier]

Objectives: To assess the efficacy and safety of the thermoexpandable hourglass-shaped nitinol prostatic stent in the treatment of patients with lower urinary tract symptoms due to bladder outlet obstruction.Methods: The stents were inserted in an outpatient setting under local anesthesia and direct vision. Five different stent lengths (2.0 to 4.0 cm) were used, depending on the length of the prostatic urethra. Assessment of voiding function and symptom scores was performed at baseline, directly after stent insertion, at 14 days, and 1, 3, 6, and 12 months after stent placement.Results: We enrolled 35 men in the trial. In 5 patients, insertion of the stent failed, mainly because of anatomical limitations. After all placement procedures, minimal temporary hematuria was observed. Spontaneous voiding was achieved in all patients, with immediate significant improvements in voiding parameters and symptom scores. The median indwelling time of the stent was 70 days. Kaplan-Meier survival analysis showed that at 14 days and at 3, 6, and 12 months, the stent was still in situ in 73%, 40%, 33%, and 23% of the patients, respectively. The main reason for removal of the stent was migration (93%), in most cases toward the bladder. Removal was uneventful in all but 1 case.Conclusions: The placement of the thermoexpandable hourglass-shaped nitinol stent results in relief of outflow obstruction and improvement of symptom scores. Because of the high migration rate, however, this stent design needs further improvement to be suitable for clinical practice. [ABSTRACT FROM AUTHOR]

To compare the costs and outcome of high-energy transurethral microwave thermotherapy of the prostate (HE-TUMT) with transurethral resection of the prostate (TURP), as the former is considered to be the best minimally invasive method for managing lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Between January 1996 and March 1997, 144 patients were randomized to treatment with HE-TUMT (78) using the Prostatron device and Prostasoft 2.5 software (EDAP Technomed, Lyon, France), or TURP (66). At baseline and during the annual follow-up, patients were evaluated by the International Prostate Symptom Score and uroflowmetry (maximum flow rate and postvoid residual volume). Kaplan-Meier survival analyses were used to calculate the cumulative risk of re-treatment. A cost-consequences analysis was performed based on the prospective measurement of healthcare use, with costs expressed as Netherland guilders (NLG). During a 3-year follow-up period, the mean (95% confidence interval) risk of re-treatment was 22.9 (12.5–33.2)% and 13.2 (4.5–21.9)% for HE-TUMT and TURP, respectively ( P = 0.215). The mean direct cost of treatment was 3450 (3444–3456) and 6560 (5992–7128) NLG for HE-TUMT and TURP, respectively. The mean total (including re-treatments), discounted (4%) 3-year cost for the HE-TUMT and TURP group was 5300 (4692–5908) and 7800 (7118–8482) NLG, respectively. In this prospective randomized trial, HE-TUMT and TURP had a comparable 3-year risk of re-treatment. Healthcare expenditure on HE-TUMT, mainly because it is an outpatient treatment, was significantly lower than for TURP. [ABSTRACT FROM AUTHOR]

Contemporary minimally invasive surgical (MIS) treatment options of patients with male Lower Urinary Tract Symptoms (LUTS) in men with prostate glands >80 mL include Holmium Laser Enucleation Prostate (HoLEP), Thulium laser VapoEnucleation Prostate (ThuVEP), and Laparoscopic (LSP) or Robotic-Assisted Simple Prostatectomy (RASP). Implementing new laser technologies is costly, and the steep learning curve of these laser techniques limit their wide range use. This promoted the use of LSP and RASP in centers with readily established laparoscopy or robotic surgery programs. The aim of this study is to review case and comparative series of RASP. We systematically reviewed published data from 2008 to 2020 on RASP and have identified 26 non-comparative and 9 comparative case series. RASP has longer operation time but less time spent in hospital and less blood loss. The outcomes of improvements in symptom score, post-voiding residual urine (PVR), postoperative PSA decline, complications, and cost are similar when compared to open and laser enucleation techniques. These outcomes position RASP as a viable MIS treatment option for patients with male LUTS needing surgical treatment for enlarged prostates. Nevertheless, prospective, randomized controlled trials (RCTs) with multicenter and large sample size are needed to confirm the findings of this systematic review. [ABSTRACT FROM AUTHOR]

Purpose: Longitudinal assessment of health-related quality of life (HRQoL) differences in patients with localized renal masses according to treatment strategy.Methods: Consecutive patients ≥ 18 years with localized renal masses treated with different approaches (open [O], laparoscopic [L], and percutaneous [P]) and modalities (radical nephrectomy [RN], nephron sparing surgery [NSS] and cryoablation [CA]). The SF-36, Functional Assessment of Cancer Therapy-Kidney Symptom Index-15 questionnaires and pain visual analog scale were completed pretreatment and at 1, 3, and 12 months posttreatment. Questionnaire results were stratified according to approach and treatment modality using a longitudinal multilevel linear regression model. Clinical patient and tumor characteristics, complications, and histopathology results were tested as confounders.Results: Ninety eight patients completed baseline and at least one follow-up questionnaires; 27.5%, 16.3%, 22.5%, 9.2%, 13.3%, and 11.2% patients received LNSS, ONSS, LRN, ORN, LCA, and PCA, respectively. Higher baseline SF-36 (3 domains) and Functional Assessment of Cancer Therapy-Kidney Symptom Index-15 scores were reported in L group compared with the O approach. Overall, HRQoL decreased at 1 month and gradually normalized to baseline level or higher at 1 year. For treatment modality at baseline, higher mean visual analog scale was observed in CA than RN group. A trend to decreased HRQoL was observed at 1 month for RN and NSS; thereafter, scores normalized to baseline levels or higher. Approach or treatment modality HRQoL did not change substantially when corrected for confounders.Conclusion: At short-term, HRQoL outcome favored minimally invasive treatment of RCC; at mid-term, these advantages were no longer apparent. This suggest that in selecting the best surgical treatment for the patient, oncological outcome should be the primary consideration as both approach and treatment modality result in similar HRQoL outcomes. [ABSTRACT FROM AUTHOR]