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Malignant ureteral obstruction (MUO) is treated with kidney decompression by a percutaneous nephrostomy (PCN) or internal ureteral stents. The objective of this study was to compare quality of life (QoL) with a PCN compared to tandem ureteral stents (TUS) in cases of MUO.We reviewed the medical records of patients with MUO who were treated by PCN/TUS in our institution between June 2019 and May 2020. Patients were asked to fill out a QoL questionnaire, a tube-symptoms questionnaire, report a general health scale, and asked for a drain preference if they had experience with both drains. Scores of both groups were compared and predictors of all QoL and tube-symptoms measures were searched using multivariate analysis.Seventy-four patients with a PCN and 30 with TUS were included in the study. No statistically significant difference was found in all QoL and tube-symptoms measurements between the two drains. Type of drain was not found to be a predictor of QoL or tube-related symptoms. Eighty-four percent of patients (11/13) who have experience with both types of drains preferred TUS.TUS and PCN for relief of MUO have a negative and similar effect on various areas of QoL and urinary symptoms. Most patients who had experience with both types of drains preferred TUS over PCN. In this patient population with a grim prognosis, this negative effect must be communicated to patients, and calculated against the potential benefits of drainage.

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

Purpose Primary Ureteroscopy & Laser Lithotripsy is the treatment of choice for distal ureteral stones. However, in cases of proximal ureteral stones some urologists recommend preliminary insertion of a Double J ureteral stent (DJS) and deferred Ureteroscopy. We aim to evaluate the necessity of preliminary DJS insertion in proximal ureteral stones management, by comparing the surgical outcome of patients undergoing primary ureteroscopy and laser lithotripsy for proximal Vs. distal ureteral stones. Patients and Methods Medical records of patients who underwent ureteroscopy between January to December 2016 in our institution were reviewed. Data collected included: demographic data, stone size, renal function, intra and post-operative complications, stone free rate (SFR). Patients were divided into 2 groups: Proximal ureteral stones and Distal ureteral stones. Results This cohort included 241 patients who underwent ureteroscopy, among them 106 had a proximal ureteral stone. Median age was 51 years. Patients who underwent ureteroscopy for proximal ureteral stone were significantly older: 54.68 vs.49.2 (p = 0.007). The median stone maximal diameter was 7 mm, the proximal ureteral stones were larger with borderline statistical significance (p = 0.07). The complication rate and stone free rate (SFR) was similar among both groups (p = 0.657 and p = 1, respectively). The Prevalence of post procedural DJS insertion was higher among patients who underwent ureteroscopy for proximal ureteral stone: 92.5% Vs. 79.3% (p = 0.004). Conclusions Our study concludes that primary ureteroscopy and laser lithotripsy for proximal ureteral stones is a valid and feasible treatment with similar surgical outcome compared to distal ureteral stones. Preliminary DJS insertion seems to be unnecessary.

Background: Radical cystectomy (RC) is the standard treatment for muscle invasive bladder cancer (MIBC). Neoadjuvant chemotherapy (NAC) is associated with improved patient survival. The impact of NAC on nutritional status is understudied, while the association between malnutrition and poor surgical outcomes is well known. This study aims to examine the association between NAC, nutritional status impairment, and post-operative morbidity. Materials and Methods: We included MIBC patients who underwent RC and received NAC from multiple academic centers in Israel. Cross-sectional imaging was used to measure the psoas muscle area and normalized it by height (smooth muscle index, SMI). Pre- and post-NAC SMI difference was calculated (represents nutritional status change). The primary outcomes were post-RC ileus, infection, and a composite outcome of any complication. Logistic regression models were fit to identify independent predictors of the outcomes. Results: Ninety-one patients were included in the study. The median SMI change was −0.71 (−1.58, −0.06) cm2/m2. SMI decline was significantly higher in patients with post-RC complications (−18 vs. −203, p < 0.001). SMI change was an independent predictor of all complications, ileus, infection, and other complications. The accuracy of SMI change for predicting all complications, ileus, infection, and other complications was 0.85, 0.87, 0.75, and 0.86, respectively. Conclusions: NAC-related nutritional deterioration is associated with increased risk of complications after RC. Our results hint towards the need for nutritional intervention during NAC prior to RC.

Autonomous cortisol secretion (ACS) is common in patients with adrenal incidentalomas (AI). ACS is associated with increased cardiovascular morbidity and mortality. Data regarding the association between radiological characteristics of adrenal adenomas, their hormonal functionality and metabolic outcomes, are scarce and inconclusive. In this study, we aim to delineate the association between radiological characteristics of AI, ACS and metabolic status.A cross-sectional study of 77 patients with AI who underwent a comprehensive hormonal evaluation. Radiological assessments were performed by an independent radiologist blinded to the clinical and hormonal phenotype of each case. Linear regression models were used to evaluate the association between post dexamethasone suppression test (DST) cortisol levels, metabolic indices and radiological measurements.Mean maximal adenoma diameter was greater in patients with versus without ACS (20.35 ± 6 vs. 27.09 ± 9.3 mm, respectively, p .01). Maximal adenoma diameter was found to be positively and linearly correlated with post-DST morning cortisol levels across their entire range (R = .474, p .01). Linear correlations between maximal adenoma diameter and indices of glycemic control showed a correlation coefficient (R) of .481 and .463 for fasting plasma glucose (FPG) and haemoglobin A1c (HbA1c), respectively, p .01. When analysis included only patients with ACS, an R = .584 and R = .565 was observed for FPG and HbA1c, respectively (p .01 for both). The association between maximal adenoma diameter and both FPG and post-DST morning cortisol intensified in patients with metabolic syndrome.There is a quantitative positive mild correlation between AI size and both cortisol autonomy and metabolic parameters.

Heart transplantation (HT) success rate is limited by a high incidence of cancer post-HT. Data on kidney cancer following solid organ transplantation, especially HT, are limited, and only a few cases have been reported.To report a unique case series of detected kidney cancer following HT.Between 1997 and 2018, 265 patients who underwent HT were enrolled and prospectively followed in the HT registry of the Sheba Medical Center.The series included 5 patients, 4 men and a woman (age range 35-50 years at HT). The patients were diagnosed with kidney tumors 6-11 years after HT (age range at diagnosis 40-72 years). Two of the men were identical twin brothers. At HT four patients received induction therapy with anti-thymocyte globulin and all received an initial immunosuppressive regimen based on cyclosporine. All male HT recipients had a history of heavy smoking. Two male patients developed allograft vasculopathy, but all had preserved heart function. The 72-year-old woman developed a kidney tumor of the native kidney 5 years after re-HT and kidney transplantation. Two patients had features of multifocal papillary renal cell carcinoma (RCC) and eventually underwent bilateral nephrectomy, while another patient underwent left partial nephrectomy with preserved renal function.To the best of our knowledge, this is the first case series study describing kidney tumors following HT. With the improving outcomes and life expectancy of HT patients, a better understanding of the factors that determine cancer risk is of the utmost importance and may have a major impact on the non-cardiac surveillance.

Radiotherapy to the prostate bed is used to eradicate residual microscopic disease following radical prostatectomy for prostate cancer. Recommendations are based on historical series.To determine outcomes and toxicity of contemporary salvage radiation therapy (SRT) to the prostate bed.We reviewed a prospective ethics committee-approved database of 229 patients referred for SRT. Median pre-radiation prostate-specific antigen (PSA) was 0.5 ng/ml and median follow-up was 50.4 months (range 13.7-128). Treatment was planned and delivered using modern three-dimensional radiation techniques. Mean bioequivalent dose was 71 Gy (range 64-83 Gy). Progression was defined as two consecutive increases in PSA level0.2 ng/ml, metastases on follow-up imaging, commencement of anti-androgen treatment for any reason, or death from prostate cancer. Kaplan-Meier survival estimates and multivariate analysis was performed using STATA.Five year progression-free survival was 68% (95%CI 59.8-74.8%), and stratified by PSA was 87%, 70% and 47% for PSA0.3, 0.3-0.7, and0.7 ng/ml (P0.001). Metastasis-free survival was 92.5%, prostate cancer-specific survival 96.4%, and overall survival 94.9%. Low pre-radiation PSA value was the most important predictor of progression-free survival (HR 2.76, P0.001). Daily image guidance was associated with reduced risk of gastrointestinal and genitourinary toxicity (P0.005).Contemporary SRT is associated with favorable outcomes. Early initiation of SRT at PSA0.3 ng/ml improves progression-free survival. Daily image guidance with online correction is associated with a decreased incidence of late toxicity.

Allogeneic perioperative blood transfusions (PBT) have been associated with higher rates of postoperative complications and tumour recurrence in a number of malignancies. This study evaluates the risk factors for PBT in patients undergoing partial nephrectomy (PN), in order to identify patients who could benefit from alternatives to allogenic blood.Data on 822 patients who underwent elective PN between 1988 and 2013 were analysed. Patient demographics and clinicopathologic variables were collected retrospectively. PBT was defined as transfusion of allogeneic red blood cells during PN (in the operating-room) or postoperative hospitalization.Of the 822 patients, 122 (14.8%) received PBT. Of these, 45.9% were transfused intraoperatively and 47.5% in the postoperative period. Only 14.3% of the patients who were transfused intraoperatively required additional postoperative transfusions. On multivariable analysis, age ≥65 (P 0.01), lower preoperative haemoglobin levels (P 0.001), larger renal masses (P 0.001), central lesions (P 0.01) and cumulative surgical experience (P 0.001) were found to be associated with higher rate of PBT.Age, low preoperative haemoglobin level, lesion size, surgeons' experience and central renal lesions are independent pre-operative risk factors for PBT in patients undergoing PN. Evaluation of these risk factors prior to surgery may be helpful in constituting guidelines for a more responsible use of allogeneic blood and its alternatives.

Interleukin-2 (IL-2) shows encouraging clinical results in metastatic renal cell carcinoma (RCC) patients, but is limited by substantial toxicity. Cell-based therapy holds a promise, but past attempts in RCC were unsuccessful. Advances in tumor-infiltrating lymphocytes (TIL) generation technology and modified clinical protocols recently yielded a 50% response in refractory melanoma patients.RCC-derived TIL and tumor cells were processed by current protocols from tumor specimens in a clean laboratory. The expanded TIL were characterized and tested in functional assays.The TIL cultures were efficiently generated and massively expanded. Virtually all the expanded cells were T-cells, but a considerable variability in the CD4/CD8 ratio and a frequent CD4-CD8-phenotype were observed. The TIL exerted cytotoxic or IFNgamma-release activities against autologous targets in major histocompatibility (MHC) class I-restricted and -independent functional patterns. The functional results were superior to former technologies.Recent developments in TIL generation technology and clinical patient conditioning protocols indicate that the TIL-based approach for RCC could be revisited.

Hypokalemic periodic paralysis is a familial autosomal dominant trait. The paralytic attacks are precipitated by large carbohydrate-rich meals, cold, mental or surgical stress, infections, exercise, drugs, electrolytes and endocrine abnormalities. Death may occur from respiratory arrest, infections, aspiration or cardiac arrhythmias. Anesthesia and surgical procedures may induce an attack and complicate the perioperative patient condition. Guidelines for anesthetic management should include preventive measures i.e. reduce mental stress and carbohydrate intake and correction of electrolytes and endocrine abnormalities. During the operation, measures should include prevention of cold and monitoring of muscle relaxants and ECG. When paralysis is diagnosed, slow (50 mEq/hr) i.v. infusion of potassium is suggested, while monitoring plasma levels of potassium ECG, and facial nerve conduction. We present two patients with hypokalemic periodic paralysis who underwent uneventful orthopedic procedures under i.v. regional block.

We evaluated the clinical significance and cost of routine preoperative laboratory screening in young healthy patients in a public hospital. Three hundred consecutive young (aged 18-40 years), healthy (ASA I) patients undergoing minor elective surgical procedures were enrolled in this prospective study. A preoperative test was considered to be significant if its result lead to a new diagnose or to cancellation of surgery. The lab tests revealed only one new diagnosis. None of the procedures were cancelled. The total cost of the lab tests was NIS 114,000. Of this amount, NIS 104,000 could have been saved if the tests were ordered as required by the patients medical history and physical examination and not performed routinely.This study suggests that routine preoperative laboratory screening is not recommended prior to minor, elective surgery in young, healthy patients.

Nephrogenic adenoma is a rare metaplastic benign lesion of the urinary tract caused by chronic irritation to the urinary epithelium. The appearance of this lesion is usually characterized by hematuria and irritative symptoms. Nephrogenic adenoma may be found most commonly in the bladder and the urethra and less frequently in the renal pelvis and ureters. We present 5 patients who underwent surgery due to bladder or urethral nephrogenic adenoma. Despite the fact that nephrogenic adenoma is a benign lesion, long term follow-up is needed due to the high recurrence rate and the potential, though rare, malignant transformation.

Item does not contain fulltext BACKGROUND: Radiotherapy to the prostate bed is used to eradicate residual microscopic disease following radical prostatectomy for prostate cancer. Recommendations are based on historical series. OBJECTIVES: To determine outcomes and toxicity of contemporary salvage radiation therapy (SRT) to the prostate bed. METHODS: We reviewed a prospective ethics committee-approved database of 229 patients referred for SRT. Median pre-radiation prostate-specific antigen (PSA) was 0.5 ng/ml and median follow-up was 50.4 months (range 13.7-128). Treatment was planned and delivered using modern three-dimensional radiation techniques. Mean bioequivalent dose was 71 Gy (range 64-83 Gy). Progression was defined as two consecutive increases in PSA level > 0.2 ng/ml, metastases on follow-up imaging, commencement of anti-androgen treatment for any reason, or death from prostate cancer. Kaplan-Meier survival estimates and multivariate analysis was performed using STATA. RESULTS: Five year progression-free survival was 68% (95%CI 59.8-74.8%), and stratified by PSA was 87%, 70% and 47% for PSA < 0.3, 0.3-0.7, and > 0.7 ng/ml (P < 0.001). Metastasis-free survival was 92.5%, prostate cancer-specific survival 96.4%, and overall survival 94.9%. Low pre-radiation PSA value was the most important predictor of progression-free survival (HR 2.76, P < 0.001). Daily image guidance was associated with reduced risk of gastrointestinal and genitourinary toxicity (P < 0.005). CONCLUSIONS: Contemporary SRT is associated with favorable outcomes. Early initiation of SRT at PSA < 0.3 ng/ml improves progression-free survival. Daily image guidance with online correction is associated with a decreased incidence of late toxicity.

To verify whether bladder dysfunction detected by urodynamic studies prior to radical prostatectomy can predict postoperative continence status.Twenty patients diagnosed with prostate cancer had multichannel subtracted filling and voiding videocystometry before undergoing radical retropubic prostatectomy. Postoperatively, all patients had periodic clinical assessment of continence status.On preoperative filling cystometry, detrusor instability with a maximal detrusor pressure greater than 15 cm H2O was demonstrated in 12/20 patients (60%). Postoperatively, 11/20 patients (55%) were continent, 4 (20%) had mild stress incontinence and 5 (25%) complained of episodic urge incontinence. However, only 5 of the 12 patients with preoperatively diagnosed detrusor instability manifested clinical urge incontinence after surgery (positive predictive value = 41.6%).The incidence of preoperative detrusor instability in our series was high, but little correlation was found between this finding and postoperative incontinence.

Extensive necrosis is rare in primary renal cell carcinoma. This finding may reflect the biological characteristics of the carcinoma and therefore could be of prognostic and clinical value.To assess the incidence of necrosis in renal cell carcinoma and its potential prognostic value.We conducted a consecutive retrospective study of 173 patients after radical nephrectomy for renal cell carcinoma. Clinical and pathological data were collected from hospital medical records and compiled into a computerized database.Extensive necrosis was found in 31 tumor specimens (17.9%). Univariate analysis showed that the specimens with extensive necrosis were significantly larger and manifested more perirenal and venous extension than the tumors without necrosis. The size of the renal tumor was the only parameter that remained significant in multivariate analysis (P = 0.0001). Overall disease-free survival did not differ significantly between patients with necrotic tumors and those without (68% and 66% respectively).The finding of extensive necrosis in renal cell carcinoma specimens does not seem to be related to tumor biology but rather may reflect the relation between size and vascularity of the tumor.