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Contains fulltext : 291600.pdf (Publisher’s version ) (Open Access) BACKGROUND: Innovations in imaging and molecular characterisation and the evolution of new therapies have improved outcomes in advanced prostate cancer. Nonetheless, we continue to lack high-level evidence on a variety of clinical topics that greatly impact daily practice. To supplement evidence-based guidelines, the 2022 Advanced Prostate Cancer Consensus Conference (APCCC 2022) surveyed experts about key dilemmas in clinical management. OBJECTIVE: To present consensus voting results for select questions from APCCC 2022. DESIGN, SETTING, AND PARTICIPANTS: Before the conference, a panel of 117 international prostate cancer experts used a modified Delphi process to develop 198 multiple-choice consensus questions on (1) intermediate- and high-risk and locally advanced prostate cancer, (2) biochemical recurrence after local treatment, (3) side effects from hormonal therapies, (4) metastatic hormone-sensitive prostate cancer, (5) nonmetastatic castration-resistant prostate cancer, (6) metastatic castration-resistant prostate cancer, and (7) oligometastatic and oligoprogressive prostate cancer. Before the conference, these questions were administered via a web-based survey to the 105 physician panel members ("panellists") who directly engage in prostate cancer treatment decision-making. Herein, we present results for the 82 questions on topics 1-3. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Consensus was defined as ≥75% agreement, with strong consensus defined as ≥90% agreement. RESULTS AND LIMITATIONS: The voting results reveal varying degrees of consensus, as is discussed in this article and shown in the detailed results in the Supplementary material. The findings reflect the opinions of an international panel of experts and did not incorporate a formal literature review and meta-analysis. CONCLUSIONS: These voting results by a panel of international experts in advanced prostate cancer can help physicians and patients navigate controversial areas of clinical management for which high-level evidence is scant or conflicting. The findings can also help funders and policymakers prioritise areas for future research. Diagnostic and treatment decisions should always be individualised based on patient and cancer characteristics (disease extent and location, treatment history, comorbidities, and patient preferences) and should incorporate current and emerging clinical evidence, therapeutic guidelines, and logistic and economic factors. Enrolment in clinical trials is always strongly encouraged. Importantly, APCCC 2022 once again identified important gaps (areas of nonconsensus) that merit evaluation in specifically designed trials. PATIENT SUMMARY: The Advanced Prostate Cancer Consensus Conference (APCCC) provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference aims to share the knowledge of international experts in prostate cancer with health care providers and patients worldwide. At each APCCC, a panel of physician experts vote in response to multiple-choice questions about their clinical opinions and approaches to managing advanced prostate cancer. This report presents voting results for the subset of questions pertaining to intermediate- and high-risk and locally advanced prostate cancer, biochemical relapse after definitive treatment, advanced (next-generation) imaging, and management of side effects caused by hormonal therapies. The results provide a practical guide to help clinicians and patients discuss treatment options as part of shared multidisciplinary decision-making. The findings may be especially useful when there is little or no high-level evidence to guide treatment decisions.

PURPOSE To generate and present survey results on important issues relevant to treatment and follow-up of localized and locally advanced, high-risk prostate cancer (PCa) focusing on developing countries. METHODS A panel of 99 PCa experts developed more than 300 survey questions of which 67 questions concern the main areas of interest of this article: treatment and follow-up of localized and locally advanced, high-risk PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up of localized and locally advanced, high-risk PCa in areas of limited resources discussed in this article. RESULTS The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion and not on a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations considered cost-effectiveness as well as the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. Results were tabulated in real time. CONCLUSION The voting results and recommendations presented in this article can guide physicians managing localized and locally advanced, high-risk PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment of localized and locally advanced, high-risk PCa in developing countries have not been defined, this article will serve as a point of reference when confronted with this disease.

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

We systematically evaluated the impact of positive surgical margins (PSM) on oncological outcomes after partial nephrectomy for renal cell carcinoma. Forty-two studies comprising 101,153 subjects were included and five distinct meta-analyses were performed. PSM was associated with increased risk of local recurrence (hazard ratio (HR) 6.11—high certainty), metastasis (HR 3.29—moderate certainty), overall relapse (HR 2.25—high certainty), overall mortality (HR 1.30—moderate certainty), and may be associated with increased cancer-specific mortality (HR 1.91—low certainty). Patients with PSM should be counseled for the possibility of additional surgery, novel adjuvant therapies, and more rigorous surveillance.

Objectives: Prostate cancer incidence is increasing in the Middle East (ME); however, the data of stage at the diagnosis and treatment outcomes are lacking. In developed countries, the incidence of de novo metastatic prostate cancer ranges between 4% and 14%. We hypothesized that the rates of presentation with advanced disease are significantly higher in the ME based on clinical observation. This study aims to examine the stage at the presentation of patients with prostate cancer at a large tertiary center in the ME. Methods: After Institutional Review Board approval, we identified the patients diagnosed with prostate adenocarcinoma and presented to a tertiary care center between January 2010 and July 2015. Clinical, demographic, and pathological characteristics were abstracted. Patients with advanced disease were stratified according to tumor volume based on definitions from practice changing clinical trials. Descriptive and Kaplan–Meier survival analysis was used. Results: A total of 559 patients were identified, with a median age at the diagnosis of 65 years and an age range of 39–94 years. Median prostate-specific antigen (PSA) at the presentation was 10 ng/ml, and almost a quarter of the men (23%) presented with metastatic disease. The most common site of metastasis was the bone (34/89, 38%). High-volume metastasis was present in 30.3%, 9%, and 5.2% of the cohort based on STAMPEDE, CHAARTED, and LATITUDE trial criteria, respectively. Conclusion: This is the first report showing the high proportion of men from ME presenting with de novo metastasis. This could be due to many factors, including the highly variable access to specialist multidisciplinary management, lack of awareness, and lack of PSA screening in the region. There is a clear need to raise the awareness about prostate cancer screening and early detection and to address the rising burden of advanced prostate cancer affecting men in the ME region.

Background The optimal surveillance method for recurrence of non-muscle invasive bladder cancer (NMIBC) after intravesical BCG treatment is unknown. The aim of this study is to assess the difference between two surveillance methods: cystoscopy with bladder biopsies and office-based flexible cystoscopy in detecting NMIBC recurrence and time to recurrence. Methods Charts of patients who underwent transurethral resection of bladder tumor with subsequent intravesical Bacillus Calmette–Guerin (BCG) treatment were reviewed between January 2015 and December 2018. Baseline demographics and oncological parameters were compared between the two methods of surveillance. Then, the role of the surveillance method for NMIBC recurrence and time to recurrence were evaluated in backward logistic regression and hazard ratios estimated in Cox regression models, respectively. Results Fifty-one patients (50.5%) underwent office-based flexible cystoscopy and 50 patients (49.5%) had bladder biopsies. The patients undergoing either surveillance methods were comparable for baseline demographic and oncological parameter. The predictors of recurrence and earlier BCG relapse were increased body mass index, the presence of multifocal tumors, the presence of concurrent carcinoma in situ, and tumor size at presentation. Bladder cancer recurrence was mostly affected by multifocality of the disease [OR 3.61 95%CI (1.17–11.15)] and the presence of concomitant carcinoma in situ [4.35 (1.29–14.68)]. Yet, the surveillance method neither predicted a higher recurrence yield nor earlier diagnosis. Conclusion In our cohort, there is neither difference in recurrence yield nor earlier diagnosis of recurrence between office-based flexible cystoscopy and bladder biopsies. Larger prospective studies are needed to assess the generalizability of these findings.

Introduction: Renal cell carcinoma (RCC) has various histopathological tumor subtypes which have a significant implication on the oncological outcome of these patients. We aimed to evaluate the distribution of RCC subtypes presenting at a tertiary care center in the Middle East, in comparison to the distribution reported in different geographic areas worldwide. Methods: A retrospective chart review was conducted on all patients who underwent partial or radical nephrectomy for RCC at the American University of Beirut Medical Center between January 2012 and January 2018. Data on histologic subtypes were compiled and compared to representative series from different continents. Results: One hundred and seventy-nine patients with RCC were identified, of whom 122 (68.2%) were classified as clear cell, 30 (16.8%) as papillary, 17 (9.5%) as chromophobe, and 10 (5.6%) as unclassified. When compared to other regions of the world, this Middle Eastern series demonstrated a higher prevalence of the chromophobe subtype compared to Western populations (9.5% in the Middle East vs. 5.3% in the US and 3.1% in Europe) and a lower prevalence of clear cell subtype (68.2% in the Middle East vs. 78.7% in the US and 85.8% in Europe). Conversely, there was a higher prevalence of papillary RCC in the Middle East (16.8%) compared to North America (13.1%, 95% confidence interval [CI]: 12.7–13.6), Europe (11.1%, 95% CI: 10.0–12.1), and Australia (10.2%). The prevalence of chromophobe and clear cell RCC in the Middle East was similar to that reported in South America. Conclusions: The distribution of RCC subtypes in this Middle Eastern cohort was significantly different from that reported in the Western hemisphere (Europe and the US) but similar to that reported in South America and Australia. These findings may point to a possible genetic predisposition underlying the global variation in distribution.

Autosomal dominant polycystic kidney disease is the fourth most common single cause of end-stage renal disease worldwide with both renal and extrarenal manifestations, resulting in significant morbidity. Approaches to the management of this disease vary widely, with no broadly accepted practice guidelines. Herein, we reviewed the various surgical and interventional management options that are targeted toward treating the symptoms or addressing the resulting kidney failure. Novel treatment modalities such as celiac plexus blockade and renal denervation appear to be promising in pain relief; however, further studies are lacking. Renal cyst decortication seems to have a higher success rate in targeting cyst-related pain compared with aspiration only. In terms of requiring major surgical intervention, such as need and timing of native nephrectomy, there are several considerations when deciding on transplantation with or without a pretransplant native nephrectomy. Patients who are not candidates for native nephrectomy may consider transcatheter arterial embolization. Based on our review of the contemporary indications for genitourinary interventions in the management of autosomal dominant polycystic kidney disease, we propose an algorithm that depicts the decision-making process on assessing the indications and timing of native nephrectomy in patients with end-stage renal disease awaiting transplant.

Background: Innovations in treatments, imaging, and molecular characterisation in advanced prostate cancer have improved outcomes, but there are still many aspects of management that lack high-level evidence to inform clinical practice. The Advanced Prostate Cancer Consensus Conference (APCCC) 2019 addressed some of these topics to supplement guidelines that are based on level 1 evidence. Objective: To present the results from the APCCC 2019. Design, setting, and participants: Similar to prior conferences, experts identified 10 important areas of controversy regarding the management of advanced prostate cancer: locally advanced disease, biochemical recurrence after local therapy, treating the primary tumour in the metastatic setting, metastatic hormone-sensitive/naive prostate cancer, nonmetastatic castration-resistant prostate cancer, metastatic castration-resistant prostate cancer, bone health and bone metastases, molecular characterisation of tissue and blood, inter- and intrapatient heterogeneity, and adverse effects of hormonal therapy and their management. A panel of 72 international prostate cancer experts developed the programme and the consensus questions. Outcome measurements and statistical analysis: The panel voted publicly but anonymously on 123 predefined questions, which were developed by both voting and nonvoting panel members prior to the conference following a modified Delphi process. Results and limitations: Panellists voted based on their opinions rather than a standard literature review or formal meta-analysis. The answer options for the consensus questions had varying degrees of support by the panel, as reflected in this article and the detailed voting results reported in the Supplementary material. Conclusions: These voting results from a panel of prostate cancer experts can help clinicians and patients navigate controversial areas of advanced prostate management for which high-level evidence is sparse. However, diagnostic and treatment decisions should always be individualised based on patient-specific factors, such as disease extent and location, prior lines of therapy, comorbidities, and treatment preferences, together with current and emerging clinical evidence and logistic and economic constraints. Clinical trial enrolment for men with advanced prostate cancer should be strongly encouraged. Importantly, APCCC 2019 once again identified important questions that merit assessment in specifically designed trials. Patient summary: The Advanced Prostate Cancer Consensus Conference provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference, which has been held three times since 2015, aims to share the knowledge of world experts in prostate cancer management with health care providers worldwide. At the end of the conference, an expert panel discusses and votes on predefined consensus questions that target the most clinically relevant areas of advanced prostate cancer treatment. The results of the voting provide a practical guide to help clinicians discuss therapeutic options with patients as part of shared and multidisciplinary decision making. (C) 2020 The Authors. Published by Elsevier B.V. on behalf of European Association of Urology.

Patients with advanced prostate cancer (APC) may be at greater risk for severe illness, hospitalisation, or death from coronavirus disease 2019 (COVID-19) due to male gender, older age, potential immunosuppressive treatments, or comorbidities. Thus, the optimal management of APC patients during the COVID-19 pandemic is complex. In October 2021, during the Advanced Prostate Cancer Consensus Conference (APCCC) 2021, the 73 voting members of the panel members discussed and voted on 13 questions on this topic that could help clinicians make treatment choices during the pandemic. There was a consensus for full COVID-19 vaccination and booster injection in APC patients. Furthermore, the voting results indicate that the expert's treatment recommendations are influenced by the vaccination status: the COVID-19 pandemic altered management of APC patients for 70% of the panellists before the vaccination was available but only for 25% of panellists for fully vaccinated patients. Most experts (71%) were less likely to use docetaxel and abiraterone in unvaccinated patients with metastatic hormone-sensitive prostate cancer. For fully vaccinated patients with high-risk localised prostate cancer, there was a consensus (77%) to follow the usual treatment schedule, whereas in unvaccinated patients, 55% of the panel members voted for deferring radiation therapy. Finally, there was a strong consensus for the use of telemedicine for monitoring APC patients. Patient summary: In the Advanced Prostate Cancer Consensus Conference 2021, the panellists reached a consensus regarding the recommendation of the COVID-19 vaccine in prostate cancer patients and use of telemedicine for monitoring these patients., NA

Background: innovations in treatments, imaging, and molecular characterisation in advanced prostate cancer have improved outcomes, but various areas of management still lack high-level evidence to inform clinical practice. The 2021 Advanced Prostate Cancer Consensus Conference (APCCC) addressed some of these questions to supplement guidelines that are based on level 1 evidence. Objective: to present the voting results from APCCC 2021. Design, setting, and participants: the experts identified three major areas of controversy related to management of advanced prostate cancer: newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC), the use of prostate-specific membrane antigen ligands in diagnostics and therapy, and molecular characterisation of tissue and blood. A panel of 86 international prostate cancer experts developed the programme and the consensus questions. Outcome measurements and statistical analysis: The panel voted publicly but anonymously on 107 pre-defined questions, which were developed by both voting and non-voting panel members prior to the conference following a modified Delphi process. Results and limitations: the voting reflected the opinions of panellists and did not incorporate a standard literature review or formal meta-analysis. The answer options for the consensus questions received varying degrees of support from panellists, as reflected in this article and the detailed voting results reported in the Supplementary material. Conclusions: these voting results from a panel of experts in advanced prostate cancer can help clinicians and patients to navigate controversial areas of management for which high-level evidence is scant. However, diagnostic and treatment decisions should always be individualised according to patient characteristics, such as the extent and location of disease, prior treatment(s), comorbidities, patient preferences, and treatment recommendations, and should also incorporate current and emerging clinical evidence and logistic and economic constraints. Enrolment in clinical trials should be strongly encouraged. Importantly, APCCC 2021 once again identified salient questions that merit evaluation in specifically designed trials. Patient summary: the Advanced Prostate Cancer Consensus Conference is a forum for discussing current diagnosis and treatment options for patients with advanced prostate cancer. An expert panel votes on predefined questions focused on the most clinically relevant areas for treatment of advanced prostate cancer for which there are gaps in knowledge. The voting results provide a practical guide to help clinicians in discussing treatment options with patients as part of shared decision-making., National Health and Medical Research Council (NHMRC) Practitioner Fellowship; Prostate Cancer Foundation; Peter MacCallum Foundation; NHMRC Investigator Grant

Patients with advanced prostate cancer (APC) may be at greater risk for severe illness, hospitalisation, or death from coronavirus disease 2019 (COVID-19) due to male gender, older age, potential immunosuppressive treatments, or comorbidities. Thus, the optimal management of APC patients during the COVID-19 pandemic is complex. In October 2021, during the Advanced Prostate Cancer Consensus Conference (APCCC) 2021, the 73 voting members of the panel members discussed and voted on 13 questions on this topic that could help clinicians make treatment choices during the pandemic. There was a consensus for full COVID-19 vaccination and booster injection in APC patients. Furthermore, the voting results indicate that the expert’s treatment recommendations are influenced by the vaccination status: the COVID-19 pandemic altered management of APC patients for 70% of the panellists before the vaccination was available but only for 25% of panellists for fully vaccinated patients. Most experts (71%) were less likely to use docetaxel and abiraterone in unvaccinated patients with metastatic hormone-sensitive prostate cancer. For fully vaccinated patients with high-risk localised prostate cancer, there was a consensus (77%) to follow the usual treatment schedule, whereas in unvaccinated patients, 55% of the panel members voted for deferring radiation therapy. Finally, there was a strong consensus for the use of telemedicine for monitoring APC patients. Patient summary In the Advanced Prostate Cancer Consensus Conference 2021, the panellists reached a consensus regarding the recommendation of the COVID-19 vaccine in prostate cancer patients and use of telemedicine for monitoring these patients.

Objectives We aim to compare the outcomes of a 3-arm versus a 4-arm robotic assisted partial nephrectomy (RAPN) using the da Vinci Si model; as well as, illustrate the deployment of long ports to decrease arm collision during the 4-arm approach. Patients and Methods Results of RAPN in a Middle Eastern tertiary referral center from August 2013 to December 2017 are reported. Comparison between 3 versus 4-arm robotic approaches was done in regards to patient and tumor characteristics, operative parameters, and postoperative outcomes. Statistical analysis was performed with the Student's t-test and chi-squared test. Results Forty consecutive 3-arm RAPNs and 40 consecutive 4-arm RAPNs were retrospectively evaluated. Differences in tumor complexity between the two groups were statistically insignificant. Similarly, surgical margin positivity, mean ischemia time, estimated blood loss, length of hospital stay, and mean change in serum creatinine were statistically insignificant between the two groups. Mean operative time was significantly shorter by 42 minutes in the 4-arm vs 3-arm group (p=0.01). Conclusions The addition of a 4th arm in RAPN can be of benefit in centers that still rely on the da Vinci Si model. The ease of hilar dissection, retraction, and surgeon independence instigated a statistically significant decrease in operative time with 4-arm use.

Objective To report on the surgical, oncological and early functional outcomes of robot-assisted radical prostatectomy (RARP) at our tertiary care centre, as there is a scarcity of reports on outcomes of robotic surgery from the Middle East. Patients and methods We reviewed the electronic health records for patients undergoing RARP between 2013 and 2019 at the American University of Beirut Medical Center. We collected patients’ demographics and preoperative oncological factors including prostate-specific antigen (PSA), clinical oncological stage, and World Health Organization (WHO) grade. PSA persistence, biochemical recurrence (BCR) and positive surgical margin (PSM) were reported. Complications were categorised by Clavien–Dindo grade. Moreover, the postoperative oncological outcomes including the rates of adjuvant and salvage androgen-deprivation therapy (ADT) and external-beam radiation therapy (EBRT), chemotherapy, and metastasis were reported. Additionally continence and potency results were retrieved. Results For the designated period, 250 patients underwent RARP of which 182 (72.8%) underwent lymph node dissection. The median (interquartile range) anaesthesia time was 330 (285–371) min and the estimated blood loss was 200 (200–300) mL. The overall complication rate was 8%, with 2% Clavien–Dindo Grade III–IV complications. The PSM and BCR rates were 21.6% and 6.4%, respectively. Adjuvant ADT and EBRT was administered to 7.2% of the patients. Functional data was available for 112 patients. Continence was 68%, 82% and 97% of the patients at 3, 6 and 12 months, respectively. For 65 patients who had bilateral nerve sparing potency was 37%, 60% and 83% at 3, 6 and 12 months, respectively. Conclusion This is the largest RARP series from the Middle East. The surgical, oncological and functional outcomes are consistent with those published in the literature. This confirms the safety and efficacy of applying robotic technology in our region during the implementation phase. Abbreviations: ADT: androgen-deprivation therapy; AJCC: American Joint Committee on Cancer; AUBMC: American University of Beirut Medical Center; BCR: biochemical recurrence; CPT: Current Procedural Terminology; EBRT external beam radiation therapy; IQR, interquartile ranges; LOS: length of stay; PLND: pelvic lymph node dissection; PSM: positive surgical margin; (O)(RA)RP, (open) (robot-assisted) radical prostatectomy

Background: Data from the Middle East regarding second primary malignancy (SPM) after radical prostatectomy are limited. Our objective was to estimate the overall risk of developing second primary malignancy (SPM) among Middle Eastern men with prostate cancer who underwent surgical extirpation of their prostate. Materials and methods: We conducted a retrospective study of 406 patients who underwent radical prostatectomy in a tertiary centre and who had no evidence of previous malignancy from 1998 to 2012. Standardized incidence ratios (SIRs) and 95% confidence interval (CI) were calculated to analyze the risk of SPM in our population compared with the general population. Cox-regression models were also conducted to correlate the clinicopathological factors with the development of SPM. Results: After 14 years of follow-up, the incidence rate of SPM was 100.9 per 1,000 person-years. The most frequent SPMs were bladder cancer (n = 11, 27%) followed by hematological malignancies (n = 9, 22%) and lung cancer (n = 7, 17%). The overall risk for men with prostate cancer to develop SPM is lower than the men in the general population (standardized incidence ratios = 0.19; 95% CI: 0.14–0.25). A multivariate analysis failed to correlate any of the clinicopathological factors with the development of SPM. Conclusion: Patients with prostate cancer who underwent surgical expiration of their prostate are at lower risk of developing SPM compared with the general population. Keywords: Prostate Cancer, Radical Prostatectomy, Second Primary Malignancies, Standardized Incidence Ratios

Background: The aim of the study was to evaluate the utility of multiparametric magnetic resonance imaging (mp-MRI)-transrectal ultrasound (TRUS) cognitively targeted biopsy in identifying the most significant cancerous lesion in the prostate to decrease the incidence of pathologic upgrading after radical prostatectomy. Methods: We conducted a retrospective review of all radical prostatectomies at the American University of Beirut Medical Center between January 2016 and 2017. Pathology reports for both, TRUS biopsy and surgically resected specimens were analyzed and compared using SPSS. Results: Among 66 patients who underwent radical prostatectomy, 44 patients underwent a standard random 12-core biopsy of the prostate, while 22 patients underwent 4 - 5 cognitively targeted biopsies. Biopsy Gleason scores were compared to surgically resected specimens. Of mp-MRI targeted biopsies, 86% were identical to the surgical specimen, while 14% were upgraded. Of the random biopsy, 55% patients upgraded after surgery, while 38% were concordant with the random biopsy result. Moreover, 13/24 patients who upgraded after random biopsy, did so from Gleason 6 (3+3) to Gleason 7 (3+4). The difference in pathological upgrading among both groups is statistically significant, and confirms the importance of MRI-TRUS cognitively targeted biopsy in identifying the highest risk lesion. This may have significant implications on the choice of treatment prior to embarking on surgical resection of prostate cancer. Conclusion: MRI-TRUS targeted biopsy is more accurate than random biopsy in identifying the most significant cancerous lesion, resulting in a decreased incidence of pathologic upgrading after prostatectomy. This may have significant implications on the choice of treatment especially in low risk prostate cancer. Larger scale multicenter studies are required. World J Nephrol Urol. 2018;7(1):12-16 doi: https://doi.org/10.14740/wjnu285w

A common health-care problem worldwide, urinary tract infection (UTI), represents a disease of significant impact on every country's economy, being the most common cause of hospitalization among elderly people and the most common cause of antibiotic prescription in primary care. Diagnosing and managing upper and lower UTI have always been a challenge to physicians, given its high prevalence, risk of recurrence and improper treatment, and the fact of worldwide increase in antibiotic resistance, necessitating implementation of a proper antibiotic stewardship. Urinary infections are twice more likely to occur in females compared to males and its prevalence increases with increasing age. The following is a comprehensive review paper about UTI in females, discussing the various factors leading to a complicated infection. The various etiologies and microbiologies of UTI are also highlighted. In addition to various usual antibiotic regimens for treating UTI, a significant number of nonantimicrobial treatment modalities are highlighted and described in this manuscript, including the novel use of intravesical antibiotics and vaccines for suppression treatment. Finally, a pathway is suggested for the proper diagnosis and treatment that ensures antibiotic stewardship in order to decrease long-term complications.

Purpose Prostate cancer care in the Middle East is highly variable and access to specialist multidisciplinary management is limited. Academic tertiary referral centers offer cutting-edge diagnosis and treatment; however, in many parts of the region, patients are managed by non-specialists with limited resources. Due to many factors including lack of awareness and lack of prostate-specific antigen (PSA) screening, a high percentage of men present with locally advanced and metastatic prostate cancer at diagnosis. The aim of these recommendations is to assist clinicians in managing patients with different levels of access to diagnostic and treatment modalities. Methods The first Advanced Prostate Cancer Consensus Conference (APCCC) satellite meeting for the Middle East was held in Beirut, Lebanon, November 2017. During this meeting a consortium of urologists, medical oncologists, radiation oncologist and imaging specialists practicing in Lebanon, Syria, Iraq, Kuwait and Saudi Arabia voted on a selection of consensus questions. An additional workshop to formulate resource-stratified consensus recommendations was held in March 2019. Results Variations in practice based on available resources have been proposed to form resource-stratified recommendations for imaging at diagnosis, initial management of localized prostate cancer requiring therapy, treatment of castration-sensitive/naïve advanced prostate cancer and treatment of castration-resistant prostate cancer. Conclusion This is the first regional consensus on prostate cancer management from the Middle East. The following recommendations will be useful to urologists and oncologists practicing in all areas with limited access to specialist multi-disciplinary teams, diagnostic modalities and treatment resources. Electronic supplementary material The online version of this article (10.1007/s00345-019-02872-x) contains supplementary material, which is available to authorized users.

Background: Prostate cancer (PCa) is the second most frequent cause of cancer-related death in men worldwide. It is a heterogeneous disease at molecular and clinical levels which makes its prognosis and treatment outcome hard to predict. The epithelial-to-mesenchymal transition (EMT) marks a key step in the invasion and malignant progression of PCa. We sought to assess the co-expression of epithelial cytokeratin 8 (CK8) and mesenchymal vimentin (Vim) in locally-advanced PCa as indicators of EMT and consequently predictors of the progression status of the disease. Methods: Co-expression of CK8 and Vim was evaluated by immunofluorescence (IF) on paraffin-embedded tissue sections of 122 patients with PCa who underwent radical prostatectomies between 1998 and 2016 at the American University of Beirut Medical Center (AUBMC). EMT score was calculated accordingly and then correlated with the patients' clinicopathological parameters and PSA failure. Results: The co-expression of CK8/Vim (EMT score), was associated with increasing Gleason group. A highly significant linear association was detected wherein higher Gleason group was associated with higher mean EMT score. In addition, the median estimated biochemical recurrence-free survival for patients with < 25% EMT score was almost double that of patients with more than 25%. The validity of this score for prediction of prognosis was further demonstrated using cox regression model. Our data also confirmed that the EMT score can predict PSA failure irrespective of Gleason group, pathological stage, or surgical margins. Conclusion: This study suggests that assessment of molecular markers of EMT, particularly CK8 and Vim, in radical prostatectomy specimens, in addition to conventional clinicopathological prognostic parameters, can aid in the development of a novel system for predicting the prognosis of locally-advanced PCa.

Background: Several studies have alluded to a detrimental impact of the surgeon’s “learning curve” on outcomes of minimally invasive surgery. In this study, we evaluated the outcomes of robotic-assisted partial nephrectomy (RAPN) versus open partial nephrectomy (OPN) for kidney tumors, during the introduction of Robotic Urologic Oncology at our institution. Methods: A retrospective review of all consecutive partial nephrectomies (PN), RAPN and OPN, performed at the American University of Beirut Medical Center since the inception of the robotic program in July 2013 until July 2015. Thirty-four consecutive patients underwent PNs, 19 OPN and 15 RAPN. Preoperative variables (patient characteristics, tumor size, and RENAL score) and perioperative renal functional/patient outcomes (% change in glomerular filtration rate (GFR), ischemia time, blood loss, need for blood transfusions, total operating time, and length of hospital stay) were compared using SPSS. Results: Preoperative variables, including the size and RENAL score of the tumor were analyzed. The difference in the median size of the tumor between OPN and RAPN was not statistically significant (4.5 ± 2.7 cm vs. 3.6 ± 1.7 cm, respectively, P = 0.25). RENAL score was significantly higher for OPN compared to RAPN (7.3 ± 2.3 vs. 4.9 ± 1.5, respectively, P < 0.05). Mean operative time was significantly shorter for OPN vs. RAPN (178 ± 52 min vs. 296 ± 86 min, respectively, P < 0.05). Cold ischemia time was 24 ± 3 min in OPN, and warm ischemia time was 17.5 ± 2 min for RAPN; 10 out of the total 15 robotic cases were performed with a warm ischemia time of < 20 min. Intraoperative blood loss was comparable for both approaches (225 ± 132 mL in OPN vs. 243 ± 192 mL in RAPN), and there was no need for blood transfusions in either group. Hospital stay was significantly longer for OPN vs. RAPN (6 ± 1.6 days vs. 4 ± 0.9 days, respectively, P = 0.01). The change in GFR was comparable among both procedures (OPN = -9% vs. RAPN = -7%); pathological margin status was also comparable among both procedures, with 1/19 (5%) positive focal margins in OPN vs. 0/14 in RAPN. None of the robotic procedures required conversion to the laparoscopic or open approach. Conclusions: RAPN is currently an established approach for the treatment of kidney tumors with the advantages of decreased crude ischemia time and a shorter hospital stay, with comparable intraoperative blood loss and risk of GFR reduction. Our data show that tumor characteristics were not equivalent, with higher RENAL scores noted in patients allocated to OPN vs. RAPN, thus limiting a fair comparison of outcomes. However, the data confirm that with proper selection of patients for RAPN, outcomes were equivalent to OPN and were not jeopardized during the initial robotic learning curve. Larger prospective studies are needed to validate our results. World J Nephrol Urol. 2016;5(4):79-82 doi: https://doi.org/10.14740/wjnu286w

Background Radical cystectomy (RC) remains the standard of care for muscle-invasive bladder cancer (MIBC). Because of the higher overall risks associated with RC, particularly in the elderly patients with multiple comorbidities, other less invasive bladder preservation strategies have been considered. Methods This is a retrospective chart review of patients diagnosed with MIBC, pT2–4N0–2M0, at the American University of Beirut Medical Center between 2007 and 2017. Results 98 patients, 85 (86.7%) males and 13 (13.3%) females, were included. Of the 98 patients, 19 (19.3%) patients were treated with upfront CRT, 35 (35.7%) were treated with upfront RC and 44 (45%) were treated with NAC. 26 (26.5%) patients underwent RC after NAC and 18 (18.4%) received CRT after NAC. The mean overall survival (OS) for the different treatment modalities was 69.4, 60.4, 56.1 and 44.2 months for RC, CRT, RC post-NAC and CRT post-NAC, respectively (p = 0.83). The median disease-free survival (DFS) was 29, 22, 21 and 16 months for RC, CRT, RC post-NAC and CRT post-NAC, respectively (p = 0.49). Patients with pT3/T4 had a higher risk of death by 3.335 folds compared to pT2 (95% CI [1.321–8.422], p Conclusions No difference was noted in the OS and DFS between the groups who underwent RC post-NAC and CRT post-NAC. These findings further support the possibility of bladder preservation after the treatment with NAC for MIBC. The pathologic T stage at diagnosis is an important prognostic factor regardless of treatment modality.

Background Positive surgical margin (PSM) is a predictor of biochemical recurrence (BCR) following radical prostatectomy (RP). Attempts to stratify PSM based on linear length, Gleason score, location and number have failed to add to predictive models using margin status alone. We evaluated the prognostic significance of Ki-67 expression in this setting. Methods Immunohistochemical staining for Ki-67 was done on prostatectomy specimens from 117 patients who had a PSM. Ki67 expression was measured at the margin and in the index lesion. Patients were dichotomized based on Ki-67 expression into three groups. Group 1 with no Ki-67 expression, Group 2 with Ki-67 ≤ 2%, and Group 3 with Ki-67 ≥ 3%. To eliminate the impact of the adjuvant treatment (AT) on the outcome, data were analyzed by the Cox proportional hazards in which AT was Considered as a time-dependent covariate. Results The discordance rate of Ki-67 expression between matched index lesion and margin specimens was 44/117 (37.6%). There was a trend for higher risk of BCR (HR:2.06, (0.97–4.43), P = 0.06) in patients expressing high Ki67 at the surgical margin although this was not statistically significant. However High Ki-67 expression in the index lesion was an independent predictive factor for BCR in this subset of patients. (HR:4, (1.64–9.80), P = 0.002). Conclusion High Ki67 expression in the index prostate cancer lesion is an independent predictor of BCR in patients with positive surgical margin following radical prostatectomy. Our findings need to be validated in a larger cohort.

Background: In advanced prostate cancer (APC), successful drug development as well as advances in imaging and molecular characterisation have resulted in multiple areas where there is lack of evidence or low level of evidence. The Advanced Prostate Cancer Consensus Conference (APCCC) 2017 addressed some of these topics. Objective: To present the report of APCCC 2017. Design, setting, and participants: Ten important areas of controversy in APC management were identified: high-risk localised and locally advanced prostate cancer; "oligometastatic" prostate cancer; castration-naïve and castration-resistant prostate cancer; the role of imaging in APC; osteoclast-targeted therapy; molecular characterisation of blood and tissue; genetic counselling/testing; side effects of systemic treatment(s); global access to prostate cancer drugs. A panel of 60 international prostate cancer experts developed the program and the consensus questions. Outcome measurements and statistical analysis: The panel voted publicly but anonymously on 150 predefined questions, which have been developed following a modified Delphi process. Results and limitations: Voting is based on panellist opinion, and thus is not based on a standard literature review or meta-analysis. The outcomes of the voting had varying degrees of support, as reflected in the wording of this article, as well as in the detailed voting results recorded in Supplementary data. Conclusions: The presented expert voting results can be used for support in areas of management of men with APC where there is no high-level evidence, but individualised treatment decisions should as always be based on all of the data available, including disease extent and location, prior therapies regardless of type, host factors including comorbidities, as well as patient preferences, current and emerging evidence, and logistical and economic constraints. Inclusion of men with APC in clinical trials should be strongly encouraged. Importantly, APCCC 2017 again identified important areas in need of trials specifically designed to address them. Patient summary: The second Advanced Prostate Cancer Consensus Conference APCCC 2017 did provide a forum for discussion and debates on current treatment options for men with advanced prostate cancer. The aim of the conference is to bring the expertise of world experts to care givers around the world who see less patients with prostate cancer. The conference concluded with a discussion and voting of the expert panel on predefined consensus questions, targeting areas of primary clinical relevance. The results of these expert opinion votes are embedded in the clinical context of current treatment of men with advanced prostate cancer and provide a practical guide to clinicians to assist in the discussions with men with prostate cancer as part of a shared and multidisciplinary decision-making process. At the Advanced Prostate Cancer Consensus Conference, 10 important areas of controversy in advanced prostate cancer management were identified, discussed, and the experts voted on 150 predefined consensus questions. The full report of the results is summarised here.

Background The aim of this study is to investigate the effect of tumor characteristics and parameters of treatment response in predicting biochemical disease-free survival (BFS) for patients with intermediate or high risk prostate cancer treated by combined definitive external beam radiation therapy (EBRT) and androgen deprivation therapy (ADT). Methods Between June 1995 and January 2015, 375 patients with localized prostate cancer and a National Comprehensive Cancer Network (NCCN) intermediate or high risk categories were treated by definitive EBRT and ADT. Median duration of androgen blockade was 10 months (range: 3–36 months); Median radiation dose was 72 Gy (Range: 70–78 Gy). Median follow-up time was 5.8 years (range: 0.8–16.39 years). The main study endpoint was biochemical disease free survival (BFS). Results Forty seven patients (12.5%) developed biochemical recurrence (BCR) during the observation period. Monovariate analysis identified baseline PSA (bPSA) (p = 0.024), T-stage (p = 0.001), Gleason’s score (GS) (p = 0.042), radiation dose (p = 0.045), PSA pre-radiation therapy (p = 0.048), and nadir PSA (nPSA), (p

Gallium-68 prostate-specific membrane antigen positron emission tomography-computed tomography (Ga-68 PSMA PET/CT) is an imaging modality that promises improved sensitivity and specificity of detection of prostate cancer lesions based on their increased uptake of PSMA-based radiotracers. It remains an emerging modality that has not yet been endorsed in the guidelines for the management of prostate cancer pending more established evidence to prove its efficacy. The objective of the study is to assess the value of Ga-68 PSMA PET/CT in the detection and localization of patients diagnosed with intermediate or high risk prostate cancer. Twenty three patients with intermediate or high risk prostate cancer had undergone Ga-68 PSMA PET/CT imaging prior to robotic assisted radical prostatectomy. Surgical specimens were then submitted for histological examinations. Lesions visualized on PET/CT and histology were independently mapped unto a 36-segment (Prostate Imaging Reporting and Data System version 2 [PI-RADS v.2]) map of the prostate. Concordance of visualization on PET/CT as compared to the histology as gold standard reference was then assessed. Lesions visualized on PET/CT and histology were independently mapped unto a 36-segment (PI-RADS v.2) map of the prostate. Concordance of visualization on PET/CT as compared to the histology as gold standard reference was then assessed. Sensitivity for all lesions identified on Ga-68 PSMA PET/CT was 42.37%; specificity was 88.61%. Both parameters were higher when considering only index lesions for which sensitivity was 68.42% and specificity was 98.23%. Sensitivity for the index lesions in intermediate risk group was 53.2% and was higher in the high risk group reaching 83.33%. Ga-68 PSMA PET/CT provides accurate localization of tumor lesions in patients with intermediate and high risk prostate cancer.

In this chapter we review the standard and most commonly performed surgical incisions and highlight some tips while performing these open surgical approaches to the pelvis in urological surgery.

Prostate cancer is a key health concern for men with its etiology still under investigation. Recently, the role of dietary supplements has been noted to have a major inhibitory effect on prostate cancer and numerous studies have been conducted in this regard. This review provides a summary on numerous recent studies conducted in this field. Some of the studies reviewed revealed a protective role for supplements, and others showed no correlation while some even had an adverse effect. The mechanism of how these supplements act on the prostate is still not clear. Further studies are warranted especially for supplements that have been shown to have a potential inhibitory role in prostate cancer.

Objectives: Multiple factors may result in an elevation in serum creatinine level after kidney transplantation, mimicking rejection. It is crucial to differentiate between a true rejection and other conditions inducing a ‘pseudorejection', in order to avoid overtreatment, or worse, mistreatment. Our goal was to review and classify true rejections and pseudorejections and their clinical significance. Material and Methods: This was a retrospective review of articles published in the USA and Europe, from 1976 to the present. The sites from which information was retrieved included PubMed, Clinical Imaging, Histopathology, Archives of Surgery, JACS, the American Urological Association, Medline and Springer Link. The importance of the resistive index will also be emphasized. Results: We reviewed 61 articles regarding the causes of renal graft dysfunction, which may be classified into true rejections and pseudorejections, the latter including the following 6 factors: hyperglycemia, ureteral obstruction, lymphocele, arterial stenosis, infection and recurrence of primary pathology. Conclusions: ‘Pseudorejection' has been described only once, for the first time in 1976 in the USA, and there have been no other reports since then. Multiple factors, mainly hyperglycemia, may induce a pseudorejection, presenting with an elevation of serum creatinine level and leading the clinician to an erroneous diagnosis of true rejection initially, resulting in inappropriate management.

Objectifs La nephrectomie partielle robotique constitue la deuxieme indication urologique du robot Da Vinci apres la prostatectomie radicale. Elle permet des resultats oncologiques similaires a la chirurgie ouverte dans les tumeurs de stade T1 avec moins de morbidite et une recuperation plus rapide. Nous decrivons les resultats preliminaires durant la phase d’adoption de la technologie robotique dans notre centre. Methodes Apres accord du Comite d’ethique de l’hopital americain de Beyrouth, les donnees de 57 malades ayant beneficie d’une nephrectomie partielle robotique entre mars 2014 et mars 2017 ont ete recueillis. Les parametres peri- et postoperatoires, le score RENAL de nephrometrie et les resultats anatomopathologiques ont ete analyses. Resultats L’âge moyen des patients etait de 58 ans (24–84), et l’IMC etait de 31 kg/m2 (19–52). Le score RENAL de nephrometrie etait bas (4–6), moyen (7–9) et eleve (10 + ) chez 51 %, 45 % et 4 % des malades respectivement. Le diametre moyen des tumeurs etait de 3 cm (1,4–6), le temps operatoire total etait de 241 min (140–480). Le saignement est evalue a 250 mL en moyenne (50–1200) avec un taux de transfusion de 5 %. Le temps d’ischemie chaude etait de 17 min en moyenne (12–30). Les resultats anatomopathologiques ont revele 80 % de tumeurs malignes et 20 % de tumeurs benignes ( Tableau 1 ). Les marges etaient saines sauf pour un cas ou la resection etait rendue difficile par un clampage arteriel incomplet. La duree d’hospitalisation etait de 3,7 jours (2–6). Le taux moyen de variation de la filtration glomerulaire a un mois de suivi etait de–8,2 mL/min. Conclusion La nephrectomie partielle robotique permet d’excellents resultats oncologiques et fonctionnels meme durant la phase d’adoption. Une bonne formation en robotique, la selection des cas et le travail d’equipe sont des elements cles pour le succes du programme de chirurgie robotique.

Background Lipomatous tumours of the adrenals are almost always benign. The importance of recognising their characteristic radiological features, leading to their correct treatment, is fundamental, as there has been an increase in the identification of these lesions. Our goal was to review all lipomatous tumours of the adrenal glands, particularly myelolipomas, their imaging methods and surgical management, updated in 2011. Methods This was a retrospective review of articles published in the USA and Europe, from 1979 to date. The sites from which information was retrieved covered PubMed, Medscape, Clinical Imaging , Histopathology , Urologia Internationalis , Archives of Surgery , JACS , the American Urological Association, BMJ , Medline, and Springer Link. We report areas of controversies in addition to well established guidelines. Results We reviewed 45 articles, that confirmed, with a high level of evidence-based medicine, that the diagnosis of a lipomatous adrenal tumour is made by various imaging procedures, particularly computed tomography (CT). We emphasise the importance to their management of the initial size of the adrenal mass, its increase in size over time, in addition to the presence of symptoms. Conclusion Lipomatous tumours of the adrenals are most frequently benign. The diagnosis is usually made by various techniques, in particular CT. The fundamental characteristics indicating the necessity of surgical intervention are the symptoms presented, volume of the tumoral mass (>5 cm), and the increase in size of the tumour as shown in two consecutive imaging studies.

We studied the effects of HLA disparity, immunosuppressive regimen used, and the type of kidney allograft on production of anti-HLA antibodies after transplant and the occurrence of rejection episodes. Five living-unrelated donors and 4 living-related donors kidney recipients received quadruple therapy (including sirolimus and mycophenolate mofetil). Fifteen living-unrelated donors and 19 living-related donors received triple therapy (excluding sirolimus). A single bolus of 4 to 6 mg/kg rabbit anti-human T-lymphocyte immune serum was included with both regimens. Recipients were studied over a 3-year period. Human leukocyte antigen profiles were determined by DNA (SSP) typing, and anti-HLA class-I antibodies were determined by the complement-dependent microcytotoxicity assay and an enzyme-linked immunosorbent assay. The degree of HLA disparity did not appear to affect anti-HLA antibody production or the occurrences of rejection episodes. None of the patients who received quadruple therapy developed anti-HLA class-I antibodies. Two living-unrelated donors and 2 living-related donors recipients who received triple therapy developed anti-HLA class-I antibodies. One of the 2 living-unrelated donors antibody-positive patients rejected the kidney and returned to dialysis, and the other patient has normal graft function 3 years after the transplant. The 2 living-related donors patients with normal graft function were antibody-positive 1 year after the transplant but were antibody-negative at 2 and 3 years after transplant. Sirolimus appeared to inhibit production of antibodies after transplant. Moreover, use of present day immunosuppressive agents diminishes the role of HLA matching in relation to the occurrence of rejection episodes.

Few issues in medicine create as much debate and controversy as the need for routine circumcision. With one-third of the world male population and at least 60% (and up to 80%) of males in the USA being circumcised circumcision remains the most commonly performed surgical procedure. In 1971 the American Academy of Pediatrics (AAP) Task Force on circumcision considered the procedure unnecessary. With the accumulation of data in support of circumcision the AAP revisited this issue twice in 1989 and 1999 stating that circumcision definitely has potential benefits. Nevertheless no recommendation for routine circumcision was made. Today there is no consensus and circumcision remains a personal decision that should be preceded by an informed consent. For this review we found ample evidence pointing towards the advantages of circumcision. (excerpt)

The rates of prostate cancer vary by more than 50-fold across different international populations. The aim of this review was to explore the differences in epidemiology and risk factors between the Middle Eastern Arab countries and some of the developed countries in Europe and North America. The age-standardized incidence rate of prostate cancer in the Arab countries is still lower than that in the Western countries, but is steadily increasing with time. Several factors come into play to explain this difference. There are health care systems-related factors such as the lack of good population-based registries, and population-related factors. The latter include the relatively young age structure in the Arab countries, lower reported androgen and prostate-specific antigen levels in Arab men, the effect of genetic differences on prostate cancer risk, the metabolic syndrome paradox, and the protective effect of the Mediterranean diet on a subset of the Arab population. In conclusion, the study of prostate cancer in the Arab world represents a challenge with the currently available cancer care systems and the increase in the burden of the disease. A multinational prospective study to investigate the epidemiology of prostate cancer in the Middle East, with specific attention to country/geographic variability along with a comparative analysis to that of the Western hemisphere is needed.

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Objective: Transrectal ultrasound (TRUS)-guided prostate needle biopsy is the standard procedure to diagnose prostate cancer. It can be associated with significant discomfort and pain. We evaluated if periprostatic infiltration with local anesthetic reduces this discomfort. Material and methods: 72 patients underwent TRUS-guided prostate needle biopsy. All patients had 12 cores, with four prostatic zones of biopsies. In 25 consecutive patients (G1) with a median prostate size of 47 cc, no anesthesia was given; while in 47 sequential patients (G2) with a median prostate size of 50 cc, 2 ml of 2% lidocaine was infiltrated in the periprostatic area around the neurovascular bundle using 20-cm-long, 22-gauge needle on both sides as guided by color Doppler. Biopsies were performed in standard fashion. Discomfort was graded on a scale from 0 to 10 with 0 meaning no discomfort , 1–3 mild , 4–6 moderate , and 7–10 severe . Results: 12/25 (48%) of G1 patients reported no discomfort compared to 70% in G2 ( P =.025). Mild discomfort was reported in 5/25 (20%) patients of G1 and 9/47 (19%) patients of G2. Moderate or severe discomfort was reported in 8/25 (32%) patients and 5/47 (11%) patients in G2 ( P =.039). Prostate size did not affect degree of discomfort within each group and between both subgroups. No adverse reactions were observed secondary to lidocaine infiltration. Conclusion: Periprostatic infiltration with local anesthesia at the time of TRUS-guided prostate needle biopsy significantly reduces discomfort. It is easy to perform, safe, and should be considered in all patients irrespective of the prostate size.

e552 Background: Current data suggest that prostate cancer incidence is increasing in the Middle East and North Africa (MENA) region however remains significantly lower than the United States and Europe. No data are available regarding stage at diagnosis or treatment. SEER data from the US suggest that only 4% of patients present with metastatic disease. We hypothesized that rates of presentation with stage 4 disease are significantly higher in the MENA region. Methods: After IRB approval, a review of prostate cancer cases presenting to the leading tertiary referral center in Lebanon from January 2010 to July 2015 was undertaken. From September 2014 these data were collected prospectively. The American University of Beirut Medical Center sees approximately one third of all cancer cases in the country and is a major referral center for Syria and Iraq. Results: 582 cases were identified, median age at diagnosis was 68 (range 43-97); median PSA at diagnosis was 10.2ng/ml (range 2.3 – 3490), median Gleason score was 7. 480 patients had staging data available; 77.4% (449) presented with organ-confined disease, 22.6% (136) presented with stage 4 disease at diagnosis. 12% of this cohort were from Iraq, 57.6% presenting with stage 4 disease. Increasing age correlated with higher stage at presentation in this cohort. In patients presenting with PSA > 20, 62.3% were found to have stage 4 disease. Conclusions: This is the first report of prostate cancer stage at diagnosis from a large cohort of patients from the Middle East showing a median age at diagnosis of 68 and 22.6% presenting with stage 4 disease. These data highlight the importance of multi-disciplinary management and health-care system planning for the rising burden of prostate cancer affecting the MENA population.

The continued success of renal transplantation has provided a higher quality of life for properly selected patients with ESRD. It is also a much more cost-effective and efficient treatment of ESRD compared with chronic dialysis. Innovative urologic reconstructive surgery using enteric segments for both continent and incontinent urinary diversions has permitted this therapeutic modality to be offered to the recipient with lower urinary tract disease not previously amenable to renal transplantation. These same reconstructive techniques using ileal segments have also permitted preservation of renal allografts with previously nonreconstructable renal pelvic or ureteral disease.

The updated data on 61 consecutive cadaveric transplants performed at our institution from 1987 to 1990 (followup 31 to 82 months, median 54 months) were analyzed with emphasis on cyclosporine monitoring and long-term results. All patients received triple therapy with cyclosporine induction, azathioprine and prednisone regardless of graft function, and they were preferentially placed on the calcium blocker nifedipine. We monitored 12-hour cyclosporine trough levels in whole blood using high performance liquid chromatography and the dose was adjusted to maintain levels at 150 ng./ml. or greater for the first 3 months. In 17 of 61 patients (28 percent) 22 rejection episodes occurred and 20 nephrotoxicity episodes occurred in 17 of 61 patients (28 percent). There was no significant difference in the mean cyclosporine levels among 32 rejection, nonrejection, nephrotoxic and nonnephrotoxic cases at any interval. Rejection occurred by 1 month in 13 (76 percent) and by 3 months in 15 (88 percent) of 17 p...

The aim of this manuscript is to review the subject of urethral dilation (UD) in female patients and to conduct a critical appraisal of the available evidence for its use. We used an online search of electronic databases. UD has been cited as a treatment option for various conditions that do not share common etiologies and that affect the lower urinary tract in female patients. Outcome measurement was not consistent, even when performed for the same conditions. A total of six randomized controlled trials failed to prove any benefit for UD in repetitive urinary tract infections (UTI), urethral syndrome, and overactive bladder. Conflicting results and diverse opinions have characterized the use of UD until present time. Professional societies are urged to attend to this issue, and to identify possible areas where UD could be potentially investigated.

Introduction: Docetaxel has become the standard chemotherapy for patients with castration-resistant prostate cancer (CRPC). We wanted to assess the efficacy and safety of a weekly high-dose calcitriol, docetaxel and zoledronic acid combination in CRPC. Patients and Methods: Thirty patients were enrolled to receive calcitriol 0.5 µg/kg orally in 4 divided doses over 4 h on day 1 of each treatment week, docetaxel 36 mg/m2 i.v. infusion on day 2 of each treatment week and zoledronic acid 4 mg i.v. on day 2 of the first and fifth week of each cycle. Treatment was administered weekly for 6 consecutive weeks on an 8-week cycle. Results: Out of 23 evaluable patients, there was a response of prostate-specific antigen (PSA) in 11 patients (47.8%); 6 (26.1%) had a stable PSA level for a median of 4.2 months. The median survival time was 15 months (95% confidence interval 13.9–16.1 months). The regimen was generally tolerated; anemia was the only grade 3/4 hematological toxicity in 2 patients. Conclusions: This regimen was tolerated, and half of the patients had a PSA response. Although our response rates are inferior to some studies using docetaxel, we believe our response rates are acceptable knowing that we are treating CRPC, which still has variable outcomes.

In an earlier study, we compared the duration of kidney graft survival between two groups of recipients; one on triple (cyclosporine, prednisone and mycophenolate mofetil) and the other on quadruple (cyclosporine, prednisone, mycophenolate mofetil, and sirolimus) immunosuppressive therapy.The aim of this study was to examine the impact of antiviral and statin therapy on graft longevity.One hundred five kidney allograft recipients were preoperatively assessed for serological markers of infection with various viral agents. All patients were on a prophylactic antiviral regimen of acyclovir and gancyclovir. Seventeen patients were on a statin. Patients were monitored for viral infections and graft rejection or loss for period of 3 years posttransplantation.We detected a high preoperative prevalence rate of IgG immunoglobulins versus the latency-establishing Herpesviridae viruses. Two patients who were preoperatively IgG positive for CMV had cytomegalovirus disease after transplantation. One patient who was preoperatively IgG positive for VZV had shingles after the surgery. No other confirmed viral infections were reported. Thirteen of 88 patients (14.77%) whose treatment regimen did not include a statin suffered a rejection episode or lost the graft whereas 1 of 17 patients (5.88%) on a statin had a rejection episode.The low rate of viral infections observed in our study population supports the utility of prophylactic administration of antiviral agents to transplant recipients. However, statins seem to have a protective effect on graft longevity (odds ratio [OR] = 0.361, 95% confidence interval [CI] = 0.044-2.957).

High risk renal transplant recipients experience excess graft loss despite overall improvements in the results of cadaveric renal transplantation. We evaluated a novel immunosuppression regimen consisting of simultaneous administration of OKT3, cyclosporine, azathioprine and prednisone. Of the 12 high risk patients studied 5 received 2 transplants, 1 received 3 transplants and 8 had peak panel reactive antibodies of greater than 60%. The protocol consisted of cyclosporine (7 mg./kg. orally or 3 mg./kg. intravenously per day) starting from the day of transplant regardless of graft function; 5 mg. OKT3 per day for 10 to 14 days starting intraoperatively; 5 mg./kg. azathioprine per day for 2 days, then 1.5 mg./kg. per day and adjusted according to white blood cell counts, and prednisone taper at 2 to 0.4 mg./kg. per day on day 10. The dose of cyclosporine was increased to 14 mg./kg. per day orally when serum creatinine was less than 3 mg./dl. The cyclosporine whole blood levels (measured by high performance liquid chromatography) were maintained between 250 and 400 ng./ml. in the first 3 months. Followup evaluations ranged from 3 to 28 months (median 8.5). Seven patients (58.3%) had acute tubular necrosis and required dialysis support for 2 to 5 weeks. Six patients (including 5 with acute tubular necrosis) experienced 1 episode of acute rejection in the first 3 months (2 of these were due to accelerated vascular rejection). Two rejections responded to pulse steroid treatment, while 4 (including 2 with vascular rejection) were treated with antilymphoblast globulin rescue therapy for 10 to 14 days. Symptomatic cytomegalovirus pneumonia occurred in 3 patients (25%). There were no deaths or graft losses. No case of malignancy was observed to date. The serum creatinine is less than 2 mg./dl. in 9 patients, and 2.5 to 2.9 mg./dl. in the remaining 3. We conclude that simultaneous quadruple immunosuppressive regimen that includes induction cyclosporine and OKT3 is a highly effective therapy for high risk patients, yielding excellent short-term and intermediate success rates. Long-term results of this regimen, including neoplastic potentiation, cannot be addressed because of the limited followup of these patients.