The Role of 99mTc-Sestamibi Single-photon Emission Computed Tomography/Computed Tomography in the Diagnostic Pathway for Renal Masses: A Systematic Review and Meta-analysis

CONTEXT

The diagnostic accuracy of current imaging techniques in differentiating benign from malignant neoplasms in the case of indeterminate renal masses is still suboptimal.

OBJECTIVE

To evaluate the diagnostic accuracy of 99mTc-sestamibi (SestaMIBI) single-photon emission tomography computed tomography (SPECT)/CT in characterizing indeterminate renal masses by differentiating renal oncocytoma and hybrid oncocytic/chromophobe tumor (HOCT) from (1) all other renal lesions and (2) all malignant renal lesions. Secondary outcomes were: (1) benign versus malignant; (2) renal oncocytoma and HOCT versus clear cell (ccRCC) and papillary (pRCC) renal cell carcinoma; and (3) renal oncocytoma and HOCT versus chromophobe renal cell carcinoma (chRCC).

EVIDENCE ACQUISITION

A literature search was conducted up to November 2022 using the PubMed/MEDLINE, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to identify eligible studies. Studies included were prospective and retrospective cross-sectional studies in which SestaMIBI SPECT/CT findings were compared to histology after renal mass biopsy or surgery.

EVIDENCE SYNTHESIS

Overall, eight studies involving 489 patients with 501 renal masses met our inclusion criteria. The sensitivity and specificity of SestaMIBI SPECT/CT for renal oncocytoma and HOCT versus all other renal lesions were 89% (95% confidence interval [CI] 70-97%) and 89% (95% CI 86-92%), respectively. Notably, for renal oncocytoma and HOCT versus ccRCC and pRCC, SestaMIBI SPECT/CT showed specificity of 98% (95% CI 91-100%) and similar sensitivity. Owing to the relatively high risk of bias and the presence of heterogeneity among the studies included, the level of evidence is still low.

CONCLUSIONS

SestaMIBI SPECT/CT has good sensitivity and specificity in differentiating renal oncocytoma and HOCT from all other renal lesions, and in particular from those with more aggressive oncological behavior. Although these results are promising, further studies are needed to support the use of SestaMIBI SPECT/CT outside research trials.

PATIENT SUMMARY

A scan method called SestaMIBI SPECT/CT has promise for diagnosing whether kidney tumors are malignant or not. However, it should still be limited to research trials because the level of evidence from our review is low.

Kidney stones in renal transplant recipients: A systematic review

INTRODUCTION

Lithiasis in renal graft recipients might be a dangerous condition with a potential risk of organ function impairment.

EVIDENCE ACQUISITION

A systematic literature search was conducted through February 2023. The primary objective was to assess the incidence of lithiasis in kidney transplant (KT) recipients. The secondary objective was to assess the timing of stone formation, localization and composition of stones, possible treatment options, and the incidence of graft loss.

EVIDENCE SYNTHESIS

A total of 41 non-randomized studies comprising 699 patients met our inclusion criteria. The age at lithiasis diagnosis ranged between 29-53 years. Incidence of urolithiasis ranged from 0.1-6.3%, usually diagnosed after 12 months from KT. Most of the stones were diagnosed in the calyces or in the pelvis. Calcium oxalate composition was the most frequent. Different treatment strategies were considered, namely active surveillance, ureteroscopy, percutaneous/combined approach, or open surgery. 15.73% of patients were submitted to extracorporeal shock wave lithotripsy (ESWL), while 26.75% underwent endoscopic lithotripsy or stone extraction. 18.03% of patients underwent percutaneous nephrolithotomy whilst 3.14% to a combined approach. Surgical lithotomy was performed in 5.01% of the cases. Global stone-free rate was around 80%.

CONCLUSIONS

Lithiasis in kidney transplant is a rare condition usually diagnosed after one year after surgery and mostly located in the calyces and renal pelvis, more frequently of calcium oxalate composition. Each of the active treatments is associated with good results in terms of stone-free rate, thus the surgical technique should be chosen according to the patient's characteristics and surgeon preferences.

Radial head prosthesis disassembly: case report and medico-legal implications

BACKGROUND

The aim of the treatment of radial head comminuted fractures is the restoration of anatomical normalcy to avoid the risk of several complications such as joint instability. Among the options for the treatment of such fractures, it is worth mentioning osteosynthesis, resection of the radial head or prosthetic replacement. In the presence of comminution or severe dislocation of the fracture's fragments, as in our patient's type III Mason fracture, prosthesis implantation is the treatment of choice.

CASE REPORT

This clinical case reports a 22-year-old volleyball player, who during training suffered a comminuted fracture of the radial head, type III according to Mason's classification. A prosthesis was implanted. The post-operative course took place regularly. However, approximately three months after surgery, the patient experienced sudden pain and functional limitation following a normal elbow extension movement, so much so that he required medical attention in our emergency room. Following all the appropriate clinical-instrumental tests, a complete dissociation of the bipolar prosthesis of the radial head was found.

CONCLUSIONS

Our clinical case shows the disassembly of a bipolar radial head prosthesis, a rather rare complication. From a medicolegal perspective, the patients should be aware of the increased risk of requiring further surgery after radial head replacement. When patients are thoroughly informed, they can cooperate and comply with indications more effectively, thus taking an active role in recovery management.

Is there such a thing as an indispensable skills profile to be a good doctor? "Life skills" as essential capabilities in the medicoforensic professions

Abstract

This writing aims to convey the essential nature and features of a cultural tool based on a set of skills and capabilities generally referred to as "life skills", which allow for the proper management (in the medical and medical-forensic professional realms) of daily situations in an effective and rewarding fashion. Such a process is based on individual tools such as communication, problem solving, stress management, self-control, the ability to make timely decisions, empathy, creativity and the opportunity to work in a multidisciplinary setting. Life skills include everything the professional should rely on in order to minimize the risks of a professional error, through the acquisition of knowledge and behavioral traits which constitute the fundamental, experience-based starting point. The chief objective of this commentary is to outline the scope of a straightforward discussion by specifically defining such skills; that in turn will make it possible to identify all the technical issues to address during the medical-diagnostic assessment, also from a medico-legal perspective, in order to frame the residual life skills and evaluate the possibilities of recovery and any disabilities, based on observation and interactions with each patient aimed at weighing their psychophysical performance.

Consequences of COVID-19 restrictions on adolescent mental health and drug abuse dynamics

The COVID-19 pandemic has hit elderly people the hardest in terms of severity and mortality. However, it is also evident that children and adolescents have been significantly impacted and experienced major disruptions in their lives. The psychological, mental, and developmental repercussions have been major and have led to a reshaping of drug abuse dynamics and substance addiction. The authors have outlined a narrative review of the major issues affecting adolescents and their mental well-being by clarifying the lingering effects and pandemic aftermath, especially on drug abuse, developmental aspects, and behavioral addiction. The unique traits of adolescent risk factors have been outlined, in order to identify areas to be prioritized for future strategies. Possible repercussions on juvenile crime linked to social estrangedness and disrupted interactions have been briefly explored as well. All such aspects are highly meaningful and relevant from a medicolegal perspective as well. The looming mental health crisis involving youngsters will have to be confronted by fine-tuning and optimizing mental health care services, building on current experiences, raising awareness, and eliminating the stigma that often comes with mental issues. Healthcare systems should look at the current scenario as an opportunity to improve care delivery to eliminate access inequalities and stigmatization of mental issues and raise awareness for the benefit and well-being of all. Similarly, law enforcement, lawmakers, and the judiciary will have to account for such factors, too, as will economic policy-makers. In that regard, a set of defining criteria has been framed in order to provide a degree of objectivity when meeting the unique challenges of the pandemic for youth mental health, in a comprehensive and tailored fashion.

Pathological Fracture of the Proximal Humerus Occurred on Metastases of Probable Kidney Origin in the Absence of Primary Lesions: A Case Report

Cancer of unknown primary (CUP) origin represents a diagnostic and therapeutic challenge. These tumours spread to different parts of the body even if the site of origin has not been identified. When renal metastases are observed without an obvious primary lesion, it is important to exclude the possibility of a primary kidney tumour that may be unknown or too small to be detected. The diagnosis of CUP is established after a careful clinical evaluation and diagnostic tests, including blood chemistry and laboratory tests, instrumental exams (CT, MRI, PET, bone scan), biopsy, and molecular and cytogenetic analysis. Once the diagnosis of CUP with kidney metastases is confirmed, treatment depends on the location of the metastases, the patient's health status, and available treatment options. The latter includes surgery to remove metastases, radiation therapy, or systemic treatment such as chemotherapy or immunotherapy. It is important that patients with CUP are evaluated by a multidisciplinary team of specialists, who can contribute to planning the most appropriate treatment. In this article, we report the clinical case of a patient with a pathological fracture of the proximal humerus which occurred on metastases of probable renal origin in the absence of primary lesions.

Perioperative and oncological outcomes of distal ureter management during nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and meta-analysis

INTRODUCTION

The best approach of the bladder cuff (i.e., transvesical, extravesical, endoscopic) during radical nephroureterectomy (RNU) remains an unsolved question. The aim of this review is to compare the oncological and perioperative outcomes among three different approaches of the distal ureter during RNU.

EVIDENCE ACQUISITION

A literature search was conducted through June 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The primary outcome was bladder recurrence-free survival and secondary outcomes included: perioperative outcomes, metastasis-free survival, and cancer-specific survival.

EVIDENCE SYNTHESIS

A total of 19 non-randomized studies comprising 6581 patients met our inclusion criteria. The risk of bladder recurrence, metastasis and cancer-related death did not differ significantly between each approach (all P>0.05). In subgroup analysis excluding patients with history of bladder cancer, the risk of bladder recurrence remained similar between each approach (all P>0.05). There was no significant difference in terms of operative time, estimated blood loss, length of hospital stay, and postoperative complications between each approach (all P>0.05). The main limitation is the retrospective design of 18/19 included studies.

CONCLUSIONS

The present systematic review and meta-analysis highlights the lack of high-level evidence on distal ureter management during RNU. On the basis of the available data, the present review supports the equivalence of different techniques of bladder cuff excision during RNU. The extravesical approach seems non-inferior to the transvesical approach in terms of oncological and perioperative outcomes.

Is There an Impact of Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted Biopsy in Clinically Significant Prostate Cancer Detection Rate? A Systematic Review and Meta-analysis

CONTEXT

It is unclear whether a magnetic resonance imaging (MRI)-targeted transperineal (TP) biopsy can improve the detection of clinically significant prostate cancer (csPCa).

OBJECTIVE

To compare the MRI-targeted TP and transrectal (TR) approaches for csPCa detection.

EVIDENCE ACQUISITION

A literature search was conducted using the PubMed/Medline, Embase, and Web of Science databases to identify reports published until February 2023. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The primary outcome was the detection of csPCa (Gleason grade group ≥2). Sensitivity analyses were performed to investigate csPCa detection rates according to tumor location, Prostate Imaging Reporting and Data System (PI-RADS) score, and type of fusion (cognitive or software based).

EVIDENCE SYNTHESIS

Eleven studies met our inclusion criteria, and data from 3522 and 5140 patients who underwent, respectively, TR and TP MRI-targeted biopsies were reviewed. No statistically significant difference in the detection of csPCa was observed between the TR and TP approaches (odds ratio [OR] 1.11, 95% confidence interval [CI] 0.98-1.25; p = 0.1). When stratifying patients according to lesion location, the TP approach was associated with higher csPCa detection in case of anterior (OR 2.17, 95% CI 1.46-3.22; p < 0.001) and apical (OR 1.86, 95% CI 1.14-3.03; p = 0.01) lesions. In the subgroup analysis based on PI-RADS score, the TP approach was associated with higher csPCa detection (OR 1.57, 95% CI 1.07-2.29; p = 0.02) in PI-RADS 4 lesions. Conversely, no difference was found in PI-RADS 3 and 5 lesions (p > 0.05). The main limitation was the retrospective design of most included studies.

CONCLUSIONS

No significant association was found between the prostate biopsy approach and csPCa detection rate when we considered all biopsy indications. The TP approach provides a detection advantage in anterior and apical tumors, arguing for a preferred use of the TP approach in these lesion locations.

PATIENT SUMMARY

The transperineal magnetic resonance imaging-targeted prostate biopsy approach appears to be more effective only for selected lesions. No clear benefit was seen for the transperineal approach in the overall population.

One-Stage Tricompartmental Hypoallergenic UKA for Tricompartmental Osteoarthritis: A Case Report

Osteoarthritis (OA) is a degenerative and progressive joint disease. When all three compartments are involved, end-stage OA is treated with a total knee arthroplasty (TKA). Unicompartmental knee arthroplasty (UKA) is a primary treatment for isolated osteoarthritis. UKA has a quicker recovery time than TKA, as well as less morbidity and more tissue sparing. At the time of surgery, 17% of patients have a tricompartmental disease and most patients with a Kellegren-Lawrence grade >3 have an intact anterior cruciate ligament (ACL). Conventional TKA sacrifices the ACL. Patients with concurrent medial and lateral osteoarthritis and a functional ACL may receive a primary bi-unicondylar arthroplasty. Combined partial knee arthroplasty (CPKA) is an established practice either in bicompartmental femoro-tibial OA or in OA progression after UKA, with the addition of another UKA. A conversion of a lateral UKA to a tricompartmental joint replacement has been reported in the literature. In our case report, we describe a one-stage hypoallergenic tricompartmental UKA, with improved clinical score and no sign of early failure at the last follow-up.

Beneficial effects of music in the healing process of traumatic injuries: perceptual control of suffering and possible abatement of disability conditions

Abstract

Numerous scientific studies report that listening to music can beneficially affect physical and mental health, and even expedite the healing process of traumatic conditions. One of the most noteworthy positive effects of music lies in its ability to control stress and anxiety by lowering heart rate, blood pressure and blood cortisol levels. Furthermore, music can help improve mood especially in traumatized people who are faced with a wide range of negative emotions, reducing symptoms of depression and stimulating the production of dopamine in the brain, favorably inducing sleep quality, thanks to the their relaxing action. Listening to music can stimulate brain activity and improve short-term memory and concentration, having positive effects on the healing process of traumatic pathologies. Therefore, music should be considered a complementary treatment option for people facing treatment for traumatic pathologies, also stimulating the production of endorphins in the brain and intervening on pain control, resulting in positive effects on the quality of life of the traumatized. Furthermore, music can help people express their emotions and communicate with others, providing a way to connect with the world and share similar experiences, reducing social isolation and improving emotional well-being.

A new machine-learning model to predict long-term renal function impairment after minimally invasive partial nephrectomy: the Fundació Puigvert predictive model

PURPOSE

To provide a new model to predict long-term renal function impairment after partial nephrectomy (PN).

METHODS

Data of consecutive patients who underwent minimally invasive PN from 2005 to 2022 were analyzed. A minimum of 12 months of follow-up was required. We relied on a machine-learning algorithm, namely classification and regression tree (CART), to identify the predictors and associated clusters of chronic kidney disease (CKD) stage migration during follow-up.

RESULTS

568 patients underwent minimally invasive PN at our center. A total of 381 patients met our inclusion criteria. The median follow-up was 69 (IQR 38-99) months. A total of 103 (27%) patients experienced CKD stage migration at last follow-up. Progression of CKD stage after surgery, ACCI and baseline CKD stage were selected as the most informative risk factors to predict CKD progression, leading to the creation of four clusters. The progression of CKD stage rates for cluster #1 (no progression of CKD stage after surgery, baseline CKD stage 1-2, ACCI 1-4), #2 (no progression of CKD stage after surgery, baseline CKD stage 1-2, ACCI ≥ 5), #3 (no progression of CKD stage after surgery and baseline CKD stage 3-4-5) and #4 (progression of CKD stage after surgery) were 6.9%, 28.2%, 37.1%, and 69.6%, respectively. The c-index of the model was 0.75.

CONCLUSION

We developed a new model to predict long-term renal function impairment after PN where the perioperative loss of renal function plays a pivotal role to predict lack of functional recovery. This model could help identify patients in whom functional follow-up should be intensified to minimize possible worsening factors of renal function.

Robot-assisted radical cystectomy and ileal conduit with HugoTM RAS system: feasibility, setting and perioperative outcomes

INTRODUCTION

Robotic approach has shown its feasibility and safety with respect to open approach for radical cystectomy (1). The performances of HugoTM RAS system (Medtronic, Minneapolis, USA) have been demonstrated in several clinical scenarios (2-5). We report the feasibility and surgical settings of the first series of robot-assisted radical cystectomy (RARC) with intracorporeal ileal-conduit performed with HugoTM RAS system.

METHODS

Two patients were submitted to RARC with ileal conduit at our institution. The trocar placement scheme and the operating room setting with docking angles of the four arms were already described (6). A 12-mm and a 5-mm trocar for the assistant were placed. In both cases, an ileal-conduit with a Wallace type-1 uretero-enteric derivation was performed intra-corporeally.

RESULTS

The first patient was a 71-year-old male with a very-high risk non-muscle invasive bladder cancer(BC), and the second patient was a 64-year-old male with a diagnosis of T2 high-grade BC. Operative times were 360 and 420 minutes with a docking time of 12 and 9 minutes, respectively. No intraoperative complications occurred. The estimated blood loss was 200ml and 400ml, respectively. The second patient developed an ileus on postoperative day 4 (Clavien-Dindo grade 2). No positive surgical margins were recorded. No recurrence nor progression occurred during follow-up.

CONCLUSION

RARC with intracorporeal ileal conduit urinary diversion is feasible with HugoTM RAS system. We provided insight into the surgical setting using this novel robotic platform to help new adopters to face this challenging procedure. These findings may help a wider distribution of robotic programs for BC treatment.

New technologies for nephron-sparing surgery in upper urinary tract cancers

PURPOSE OF REVIEW

Nephron-sparing surgery (NSS) is the preferred treatment in patients with low-risk upper tract urothelial carcinoma (UTUC). Improving both instruments and topical chemotherapy regimens efficacy is crucial to achieve better outcomes. The purpose of this review is to summarize the most recent evidence on technological advances for the conservative management of UTUC with implications on diagnosis and treatment.

RECENT FINDINGS

Novel diagnostic tools, lasers, and topical chemotherapy systems delivery have been implemented to optimize NSS outcomes for UTUC.

SUMMARY

Photodynamic ureteroscopy has been reported to improve cancer detection rate as compared with conventional imaging or ureteroscopy, especially in case of carcinoma in situ . However, refinements in photosensitizer administration and dedicated instruments are needed. The armamentarium of lasers for UTUC ablation is composed of several devices with peculiar characteristics. Together with Ho:YAG and Tm:YAG lasers, the Thulium Fiber Laser (TFL) is gaining momentum in UTUC ablation. Strengths and weaknesses of each laser must be considered to maximize oncological and safety outcomes. Several novel endocavitary chemotherapy delivery systems have been tested to reduce tumor recurrence and progression after NSS. Administration of gel-based chemotherapeutic agents has been proven to be effective in humans; conversely, drug-eluting ureteral stent systems are still conceptual.

The posterior interosseus artery flap (piaf) in reconstructive surgery of the hand: strategies of use and medico-legal implications

Background and aim

The fascio-cutaneous posterior interosseus artery flap (PIAF) is used in hand reconstruction, especially to repair skin or tissue defects such as burn injuries, open fractures, gunshot wounds or traumatic amputations. The aim of this study is to examine the anatomical features of this flap, to describe the surgical harvesting technique and the difficulties associated with the dissection.

Methods

From January 2016 to January 2022, we performed PIAF in 10 patients (3 women and 7 men) with a mean age of 28 years (range 22-44). This flap is taken from the back of the forearm, between the extensor carpi ulnaris (ECU) muscle and the extensor digitorum common (EDC) muscle.

Results

We analyzed retrospectively our patients indicating the failures of this reconstructive surgery, the complications that have arisen and the results using DASH score with the related clinical and medico-legal implications.

Conclusions

Due to its location and structure, PIAF is one of the most versatile fascio-cutaneous flaps in upper limb reconstructive surgery and can be used to reconstruct parts of the hand, wrist, or elbow, allowing to restore limb function and improve the quality of life of patients even if there could be some medico-legal implications.

Robot-assisted oncologic pelvic surgery with Hugo™ robot-assisted surgery system: A single-center experience

Objective

To report the outcomes of intra- and extra-peritoneal robot-assisted radical prostatectomy (RARP) and robot-assisted radical cystectomy (RARC) with Hugo™ robot-assisted surgery (RAS) system (Medtronic, Minneapolis, MN, USA).

Methods

Data of twenty patients who underwent RARP and one RARC at our institution between February 2022 and January 2023 were reported. The primary endpoint of the study was to report the surgical setting of Hugo™ RAS system to perform RARP and RARC. The secondary endpoint was to assess the feasibility of RARP and RARC with this novel robotic platform and report the outcomes.

Results

Seventeen patients underwent RARP with a transperitoneal approach, and three with an extraperitoneal approach; and one patient underwent RARC with intracorporeal ileal conduit. No intraoperative complications occurred. Median docking and console time were 12 (interquartile range [IQR] 7-16) min and 185 (IQR 177-192) min for transperitoneal RARP, 15 (IQR 12-17) min and 170 (IQR 162-185) min for extraperitoneal RARP. No intraoperative complications occurred. One patient submitted to extraperitoneal RARP had a urinary tract infection in the postoperative period that required an antibiotic treatment (Clavien-Dindo Grade 2). In case of transperitoneal RARP, two minor complications occurred (one pelvic hematoma and one urinary tract infection; both Clavien-Dindo Grade 2).

Conclusion

Hugo™ RAS system is a novel promising robotic platform that allows to perform major oncological pelvic surgery. We showed the feasibility of RARP both intra- and extra-peritoneally and RARC with intracorporeal ileal conduit with this novel platform.

The importance of second-look ureteroscopy implementation in the conservative management of upper tract urothelial carcinoma

PURPOSE

The purpose of the study was to evaluate the effect of second-look ureteroscopy (SU) in the endoscopic operative work-up of patients with upper tract urothelial carcinoma (UTUC).

MATERIALS AND METHODS

Patients with UTUC who underwent SU between 2016 and 2021 were included. Cancer detection rate (CDR) at SU was defined as endoscopic visualization of tumor. The effect of SU on recurrence-free survival (RFS), radical nephroureterectomy-free survival (RNU-FS), bladder cancer-free survival (BC-FS), and cancer-specific survival (CSS) was estimated using the Kaplan-Meier method. Multivariate logistic regression analysis (MLR) assessed predictors of negative SU. Finally, we evaluated the effect of SU timing on oncological outcomes, classifying SUs as "early" (≤ 8 weeks) and "late" (> 8 weeks).

RESULTS

Overall, 85 patients underwent SU. The CDR at SU was 44.7%. After a median follow-up was 35 (IQR: 15-56) months, patients with positive SU had a higher rate of UTUC recurrence (47.4% vs 19.1%, p = 0.01) and were more frequently radically treated (34.2% vs 8.5%, p = 0.007). Patients with high-grade disease (hazard ratio [HR]: 3.14, 95% CI 1.18-8.31; p = 0.02) had a higher risk of UTUC recurrence, while high-grade tumor (HR: 3.87, 95%CI 1.08-13.77; p = 0.04) and positive SU (HR: 4.56, 95%CI 1.05-22.81; p = 0.04) were both predictors of RNU. Low-grade tumors [odds ratio (OR): 5.26, 95%CI 1.81-17.07, p = 0.003] and tumor dimension < 20 mm (OR: 5.69, 95%CI 1.48-28.31, p = 0.01) were predictors of negative SU. Finally, no significant difference emerged regarding UTUC recurrence, RNU, BC-FS, and CSM between early vs. late SUs (all p > 0.05).

CONCLUSIONS

SU may help in identifying patients with UTUC experiencing an early recurrence after conservative treatment. Patients with low-grade and small tumors are those in which SU could be safely postponed after 8 weeks.

A Plea for the Use of Video-recorded Cystoscopy for Blinded Independent Central Review of Tumor Response in Open-label Non-muscle invasive Bladder Cancer Trials

Given that most of non-muscle invasive bladder cancer trials available in the literature share the same limitation of an open-label design, they are likely prone to detection bias. Indeed, tumor response is currently assessed by unblinded investigators, mainly via follow-up cystoscopy, which has well-known intraobserver and interobserver variability. Thus, we believe that the use of video-recorded cystoscopy for blinded independent central review of tumor response could help to minimize detection bias in open-label NMIBC trials.

Novel single-stage preputial spiral graft for panurethral stricture: a step-by-step description of the technique

PURPOSE

To report the 12-month results of a novel urethroplasty technique relying on a spiral preputial graft for panurethral stricture disease.

MATERIALS AND METHODS

Twenty consecutive patients were treated between May and October 2021 at our center. A spiral preputial mucocutaneous graft is a foreskin-based graft, developed from a 5-cm-wide preputial skin, which is harvested using a helicoidal shape and can reach up to 20 cm in length. Stricture characteristics were assessed through preoperative retrograde and voiding cystourethrogram and maximum uroflowmetry data (Qmax). Complications were collected up to 30 days after surgery and graded using the Clavien-Dindo (C-D) classification. The patients were followed up to 12 months.

RESULTS

Preoperative median Qmax was 6.5 ml/s [interquartile range (IQR): 4.0-8.7]. After a median follow-up of 12 months (IQR 12-13), six patients experienced at least one complication. Of them, two patients had grade 2 C-D complications, while only one developed a grade 3a C-D complication. The median postoperative Qmax was 16 ml/s (IQR: 13-18). Only one patient had early urethral stricture recurrence treated with dilatation after catheter removal. At one-year follow-up, no other patients had urethral stricture recurrence with an overall median Qmax of 15.1 ml/s (IQR 13.5-16.4).

CONCLUSIONS

Our novel single-stage spiral preputial graft urethroplasty for panurethral stricture treatment appears to be safe and could be used as a valid alternative to two-stage procedures or even to single-stage buccal mucosa graft augmentation.

Long-Term Oncologic Outcomes of Endoscopic Management of High-Risk Upper Tract Urothelial Carcinoma: The Fundació Puigvert's Experience

Objectives: Many patients with upper tract urothelial carcinoma (UTUC) outside of the low-risk criteria may possess low absolute risks of distant progression. Herein, we hypothesized that careful selection of high-risk patients undergoing an endoscopic approach could result in acceptable oncologic outcomes. Materials and Methods: Patients with high-risk UTUC managed endoscopically between 2015 and 2021 were retrospectively identified from a prospectively maintained single academic institution database. Elective and imperative indications for endoscopic treatment were considered. Regarding elective indications, the decision to perform endoscopic treatment was systematically proposed to high-risk patients in whom macroscopically complete ablation was deemed feasible, excluding invasive appearance on CT scan, and without histologic variant. Results: A total of 60 patients with high-risk UTUC met our inclusion criteria (29 imperative and 31 elective indications). The median follow-up in patients without any event was 36 months. At 5 years, the estimated overall survival, cancer-specific survival, metastasis-free survival, UTUC recurrence-free survival, radical nephroureterectomy-free survival, and bladder recurrence-free survival were 57% (41-79), 75% (57-99), 86% (71-100), 56% (40-76), 81% (70-93), and 69% (54-88), respectively. All oncologic outcomes were similar between patients with elective and imperative indications (all log-rank p > 0.05). Conclusions: In conclusion, we report the first large series of endoscopic treatment in patients with high-risk UTUC, arguing that promising oncologic outcomes can be achieved in properly selected candidates. We encourage multi-institutional collaborative work as a large cohort of high-risk patients treated endoscopically may allow subgroup analyses to define the best candidates.

Risks and benefits of partial nephrectomy performed with limited or with zero ischaemia time

OBJECTIVE

To test the hypothesis that longer warm ischaemia time (WIT) might have a marginal impact on renal functional outcomes and might, in fact, reduce haemorrhagic risk intra-operatively.

PATIENTS AND METHODS

Data from 1140 patients treated with elective partial nephrectomy (PN) for a cT1-2 cN0 cM0 renal mass were prospectively collected. WIT was defined as the duration of clamping of the main renal artery with no refrigeration and was tested as a continuous variable. The primary outcome of the study was evaluation of the effect of WIT on renal function (estimated glomerular filtration rate [eGFR]) postoperatively, at 6 months and in the long term (measured between 1 and 5 years after surgery). The secondary outcome of the study was haemorrhagic risk, defined as estimated blood loss (EBL) or peri-operative transfusions. Multivariable linear, logistic and Cox regression analyses, accounting for age, Charlson comorbidity index, clinical size, preoperative eGFR and year of surgery, were used and the potential nonlinear relationship between WIT and the study outcomes was modelled using restricted cubic splines.

RESULTS

A total of 863 patients (76%) underwent PN with WIT and 277 (24%) without. The baseline median eGFR was 87.3 (68.8-99.2) mL/min/1.73m2 for the on-clamp population and 80.6 (63.2-95.2) mL/min/1.73m2  for the off-clamp population. The median duration of WIT was 17 (13-21) min. At multivariable analyses predicting renal function, longer WIT was associated with decreased postoperative eGFR (estimate: -0.21, 95% confidence interval [CI] -0.31; -0.11 [P < 0.001]). Conversely, no association between WIT and eGFR was recorded at 6-month or long-term follow-up (all P > 0.8). At multivariable analyses predicting haemorrhagic risk, clampless resection with no ischaemia time and PN with short WIT was associated with an increased EBL (estimate: -21.56, 95% CI -28.33; -14.79 [P < 0.001]) and peri-operative transfusion rate (estimate: -0.009, 95% CI -0.01; -0.003 [P = 0.002]). No association between WIT and positive surgical margin status was recorded (all P = 0.1).

CONCLUSION

Patients and clinicians should be aware that performing PN with very limited or even with zero WIT might increase bleeding and the need for peri-operative transfusion while not improving long-term renal function outcomes.

Metabolism Study of Anamorelin, a GHSR1a Receptor Agonist Potentially Misused in Sport, with Human Hepatocytes and LC-HRMS/MS

Anamorelin, developed for the treatment of cancer cachexia, is an orally active medication that improves appetite and food intake, thereby increasing body mass and physical functioning. It is classified as a growth hormone secretagogue and strictly monitored by the World Anti-Doping Agency (WADA), owing to its anabolic enhancing potential. Identifying anamorelin and/or metabolite biomarkers of consumption is critical in doping controls. However, there are currently no data available on anamorelin human metabolic fate. The aim of this study was to investigate and identify biomarkers characteristic of anamorelin intake using in silico metabolite predictions with GLORYx, in vitro incubation with 10-donor-pooled human hepatocytes, liquid chromatography-high-resolution tandem mass spectrometry (LC-HRMS/MS) analysis, and data processing with Thermo Scientific's Compound Discoverer. In silico prediction resulted in N-acetylation at the methylalanyl group as the main transformation (score, 88%). Others including hydroxylation at the indole substructure, and oxidation and N-demethylation at the trimethylhydrazino group were predicted (score, ≤36%). Hepatocyte incubations resulted in 14 phase I metabolites formed through N-demethylation at the trimethylhydrazino group, N-dealkylation at the piperidine ring, and oxidation at the indole and methylalanyl groups; and two phase II glucuronide conjugates occurring at the indole. We propose four metabolites detected as specific biomarkers for toxicological screening.

Differential Prognostic Value of Extrarenal Involvement in Patients With Non-Metastatic Renal Cell Cancer

INTRODUCTION

A better definition of the prognostic significance of non-metastatic pT3a stage RCC subcategories is crucial to select the best candidate for adjuvant treatment. The aim of the study is to investigate the differential prognosis of extrarenal involvement in patients with non-metastatic pT3a RCC.

MATERIALSAND METHODS

From a single institutional prospective database, 451 consecutive patients treated for pT3aN0/NxM0 RCC were selected and stratified according to pT3a subtypes (perirenal fat invasion, sinus fat invasion, segmental/renal vein thrombus, ≥ 2 features). Cancer specific survival (CSS), metastasis free survival (MFS) and relapse free survival (RFS) were primary endpoints of multivariable Cox regression models.

RESULTS

Overall, 67 (15%) patients presented with renal/segmental vein thrombus only, 185 (41%) with perirenal fat invasion, 101 (22%) with sinus fat invasion and 98 (22%) with ≥ 2 features. The presence of ≥ 2 pT3a features was associated with a higher risk of metastasis (HR=2.36; 95%CI 1.30-4.27; P value = .005), recurrence (HR=2.41; 95%CI 1.36-4.28; P value=.003) and cancer specific mortality (HR=3.54; 95%CI 1.45-8.63; P value = .005) compared to only 1 pT3a feature. Moreover, the presence of perirenal fat invasion was associated with lower CSS (HR=2.82; 95% CI 1.19-6.69; P value = .02) compared to sinus fat invasion or tumoral thrombus only.

CONCLUSION

The concurrent presence of ≥ 2 pT3a features is associated to a higher risk of distant progression, relapse and cancer specific mortality, implying potential role for adjuvant therapy or a more stringent follow-up. Moreover, perirenal fat invasion is associated with worse CSS compared to other pT3a patterns taken alone.

Circulating miRNAs as a Tool for Early Diagnosis of Endometrial Cancer-Implications for the Fertility-Sparing Process: Clinical, Biological, and Legal Aspects

This review article explores the possibility of developing an integrated approach to the management of the different needs of endometrial cancer (EC) patients seeking to become pregnant. Life preservation of the woman, health preservation of the baby, a precocious and-as much as possible-minimally invasive characterization of the health and fertility parameters of the patient, together with the concerns regarding the obstetric, neonatal, and adult health risks of the children conceived via assisted reproductive techniques (ART) are all essential aspects of the problem to be taken into consideration, yet the possibility to harmonize such needs through a concerted and integrated approach is still very challenging. This review aims to illustrate the main features of EC and how it affects the normal physiology of pre-menopausal women. We also focus on the prospect of a miR-based, molecular evaluation of patient health status, including both EC early diagnosis and staging and, similarly, the receptivity of the woman, discussing the possible evaluation of both aspects using a single specific panel of circulating miRs in the patient, thus allowing a relatively fast, non-invasive testing with a significantly reduced margin of error. Finally, the ethical and legal/regulatory aspects of such innovative techniques require not only a risk-benefit analysis; respect for patient autonomy and equitable health care access allocation are fundamental issues as well.

Bladder-sparing strategies in patients with clinically localized muscle-invasive bladder cancer

PURPOSE OF REVIEW

Radical cystectomy is the standard of care for patients with localized muscle-invasive bladder cancer (MIBC). In this context, bladder-sparing strategies (BSS) have been investigated as viable alternatives for patients who are unfit for radical cystectomy or aim to preserve their bladder without compromising oncological outcomes. This review aims to provide the most up-to-date evidence on BSSs as an alternative treatment for patients with MIBC.

RECENT FINDINGS

Different studies have highlighted the long-term efficacy of trimodal therapy or chemoradiation protocols. However, due to the lack of randomized controlled trials, there is still a lack of high-level evidence on BSS efficacy as compared to radical cystectomy. Consequently, the adoption of these approaches is still limited. A possible turning point could be represented by the introduction of immunotherapy, as several studies are investigating the potential combination with chemoradiotherapy or radiotherapy alone. Patient selection, together with the implementation of new predictive biomarkers and imaging tools, may improve the efficacy of BSS in the near future.

SUMMARY

Radical cystectomy with perioperative chemotherapy remains the gold standard treatment for MIBC patients. Nevertheless, BSS can be considered a viable option in selected patients who desire to preserve their bladder. Further evidence is needed to clearly state the role of BSS in MIBC.

COVID-19 and its aftermath, new drivers of infertility?

Abstract

Law 40/2004, the Italian piece of legislation governing access to assisted reproductive technologies (ART), is relatively young, compared to the number of years that have passed since the first attempts at ART in the world. Still, such a law has undergone several revisions in recent years, mostly by court rulings, and such changes are indeed necessary in light of the constant evolution in ART innovations. Then, the COVID-19 pandemic struck on a global scale, disrupting virtually all aspects of social and economic life. COVID-19's impact on fertility has to do, although it is not limited to, the distribution and function of ACE2 in the female reproductive system: such receptors are in fact expressed extensively in the ovaries, uterus, vagina and placenta. We point out that overcoming the "demographic winter" Italy has been going through, compounded by the pandemic, will require major adjustments in the way we ensure access to ART services in an equitable, sustainable and affordable fashion for all who wish to fulfill their reproductive potential and have been prevented to do so by legal, regulatory and financial factors.