Surveillance or Dynamic Sentinel Lymph-Node Biopsy in Low-Risk Clinically N0 Penile Squamous Cell Carcinoma: Single-Institution Real World Data

INTRODUCTION

Surveillance is the standard management in low-risk cN0 penile squamous cell carcinoma (peSCC) patients. However, no previous analysis focused on early and long-term outcomes of these patients. We report on main oncological outcomes of a large series of low-risk cN0 peSCC patients.

PATIENTS AND METHODS

Between 1980 and 2017 included, 93 evaluable consecutive low-risk (ie, pT1a G1 cN0M0) peSCC patients underwent primary tumor surgery and either observation (74) or dynamic sentinel node biopsy (DSNB) (19) following a clinical diagnosis of T1 in 66 (71%), T2 in 15 (16.1%) and Tx in 12 (12.9%) patients, respectively. The statistical significance of differences in medians and proportions was tested with the Kruskal-Wallis and chi-square tests. Kaplan-Meier plots illustrated 5-year inguinal relapse (IR)-free survival rates.

RESULTS

Median age was 60 years (IQR: 50-69 years). Median follow-up was 92 months (IQR 54-133 months). Surveillance was more frequently adopted in clinical (c)T1 than in cT2 tumors (79.7% vs. 36.8%). None of 19 patients who had DSNB had nodal metastasis. Overall, 7 (7.5%) out of 93 pT1aG1cN0 peSCC patients had IR after a median interval of 9 months. Of note, 1 patient only relapsed after 12 months of surveillance. After stratification according to IR, relapses occurred more frequently in younger patients (59 vs. 64 years, P < .001). The 5-year IR-free survival rates for the entire cohort was 92% (95% Confidence interval [CI] 87-98%).

CONCLUSIONS

Observation is a safe and effective management for low-risk peSCC patients. Younger patients may be offered a mini-invasive staging as an alternative.

Perioperative and Survival Outcomes of Patients Treated With Robot-Assisted Partial Nephrectomy and Percutaneous Microwave Ablation for Small Renal Masses: A Single Center Experience

BACKGROUND

Robot assisted partial nephrectomy (RAPN) and microwave ablation (MWA) are 2 of the most advanced techniques for the management of localized small renal masses.

PURPOSE

To compare the perioperative, functional and oncological results of RAPN and MWA.

MATERIALS AND METHODS

Data from 171 consecutive patients undergoing either RAPN or MWA for a localized small renal mass at a single academic center was retrospectively collected. Baseline features included patients' demographics and masses' characteristics. Procedures were compared in terms of perioperative outcomes and renal function variation Progression of a persistent lesion or local recurrence after a complete treatment defined local tumor progression. Descriptive statistics and survival analysis tested the association between predictors and local tumor progression.

RESULTS

Of all, 109 and 62 patients underwent RAPN and MWA. Patients in the MWA group were older (P = .002) had higher Charlson Comorbidity Index (CCI) (P < .001) and higher frequency of preoperative chronic kidney disease (P < .001). MWA led to a shorter postoperative hospitalization time (P < .001) and lower incidence of medical complications (6.5% vs. 22.9%, P = .02) than RAPN. GFR decline was similar between groups both at discharge (P = .39) and at the time of last follow up (P = 1.00). A lower rate of secondary interventions (11.7% vs. 2.8%, P = .037) and a better disease-free survival (83.2% vs. 96.5%, P = .027) were reported after RAPN. Conversely, cancer specific and overall survival were comparable (P > .05). At univariate regression analysis, MWA was associated with local tumor progression (HR 3.46, P = .040).

CONCLUSION

MWA displayed a lower perioperative impact, while functional outcomes were similar after each intervention. RAPN resulted superior in terms of tumor eradication, but no difference was noted regarding cancer specific survival. Thus, MWA represents a valid alternative in frail patients, though less radical than RAPN.

Advanced Age Impacts Survival After Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma

INTRODUCTION

Upper tract urothelial carcinoma is rare but has a poor prognosis. Prognostic factors have been extensively studied in order to provide the best possible management for patients. We have aimed to investigate commonly available factors predictive of recurrence and survival in this patient population at high risk of death and recurrence, with an emphasis on the effects of age (using a cutoff of 70 years) on survival outcomes.

PATIENTS AND METHODS

From 1387 patients with clinically nonmetastatic upper tract urothelial carcinoma treated with radical nephroureterectomy at 21 academic hospital centers between 2005 and 2021, 776 patients were eligible and included in the study. Univariable and multivariable Cox regression models were built to evaluate the independent prognosticators for intravesical and extravesical recurrence, overall survival, and cancer-specific survival according to age groups. A P value of <.05 was considered statistically significant.

RESULTS

We did not find an association between groups aged <70 and >70 years old and preoperatively clinical or histopathological characteristics. Kaplan-Meier analysis was found no statistical significance between the 2 age groups in terms of intravesical or extravesical recurrence (P = .09 and P = .57). Overall survival (P = .0001) and cancer-specific survival (P = .0001) have been found to be statistically significantly associated with age as independent predictors (confounding factors: gender, tumor size, tumor side, clinical T stage, localization, preoperative hydronephrosis, tumor localization, type of surgery, multifocality of the tumor, pathological grade, lymphovascular invasion, concomitant CIS, lymph node status, necrosis, or history of previous bladder cancer).

CONCLUSION

This research confirms that patients aged 70 and above who undergo radical nephroureterectomy may have worse outcomes compared to younger patients, older patients needing an improved care and management of UTUC to improve their outcomes in the setting of an increase in this aged population group.

Extended pelvic lymph node dissection during robotic prostatectomy: antegrade versus retrograde technique

BACKGROUND

Robot-assisted radical prostatectomy (RARP) with extended lymphadenectomy (ePLND) is the gold standard for surgical treatment of prostate cancer (PCa). Recently, the en-bloc ePLND has been proposed but no studies reported on the standardization of the technique. The aim of the study is to describe different standardized en-bloc ePLND, the antegrade and the retrograde ePLND, and to compare their surgical and oncological outcomes.

MATERIALS & METHODS

From January 2018 to September 2019, all patients subjected to RARP plus ePLND by one single surgeon were enrolled. ePLND was performed in a retrograde fashion by starting laterally to the medial umbilical ligament from the internal inguinal ring proceeding towards the ureter, or in an antegrade way by starting from the ureter at its crossing with the common iliac artery and proceeding towards the femoral canal. Patients' demographic data, clinical and surgical data were collected. Each en-bloc ePLND was categorized as "efficient" or "inefficient" by the operator, as surrogate of surgeon's satisfaction.

RESULTS

Antegrade and retrograde ePLND were performed in 41/105 (group A) and 64/105 (group R) patients, respectively. The two groups (A vs R) had similar median (IQR) number of lymph nodes retrieved [20 (16.25-31.5) vs 19 (15-26.25); p = 0.18], ePLND time [33.5 (29.5-38.5) min vs 33.5 (26.5-37.5) min; p = 0.4] and post-operative complications [8/41 (19.5%) vs 9/64 (14.1%); p = 0.61]. In group A, 3/41 (7.3%) clinically significant lymphoceles were reported, while 1/64 (1.6%) in group R (p = 0.3). 33/41 (80.5%) and 28/64 (44%) procedures were scored as efficient 59 in group A and R, respectively (p = 0.01). On multivariate regression, only BMI (B = 0.93; 95% CI 0.29-1.56; p = 0.005) was associated with a longer ePLND time.

CONCLUSIONS

The study indicates that antegrade and retrograde en-bloc extended pelvic lymph node dissection (ePLND) have comparable surgical and oncologic outcomes, supporting the importance of standardizing the procedure rather than focusing on the direction. Although both techniques aligned with current evidence regarding lymph node invasion and complications, the antegrade approach was subjectively perceived as safer due to early isolation of critical anatomical landmarks. Encouragement for the use of en-bloc ePLND, regardless of direction, is emphasized to improve prostate cancer staging accuracy and procedural standardization.

Transient ureteral obstruction after mini-percutaneous nephrolithotomy is associated with stone volume and location: results from a single-center, real-life study

PURPOSE

To evaluate the rate of and predictors of ureteral obstruction after mini-percutaneous nephrolithotomy (mPCNL) for kidney stones.

METHODS

We analyzed data from 263 consecutive patients who underwent mPCNL at a single tertiary referral academic between 01/2016 and 11/2022. Patient's demographics, stone characteristics, and operative data were collected. A nephrostomy tube was placed as the only exit strategy in each procedure. On postoperative day 2, an antegrade pyelography was performed to assess ureteral canalization. The nephrostomy tube was removed if ureteral canalization was successful. Descriptive statistics and logistic regression models were used to identify factors associated with a lack of ureteral canalization.

RESULTS

Overall, median (IQR) age and stone volume were 56 (47-65) years and 1.7 (0.8-4.2) cm3, respectively. Of 263, 55 (20.9%) patients showed ureteral obstruction during pyelography. Patients without ureteral canalization had larger stone volume (p < 0.001), longer operative time (p < 0.01), and higher rate of stones in the renal pelvis (p < 0.01) than those with normal pyelography. Length of stay was longer (p < 0.01), and postoperative complications (p = 0.03) were more frequent in patients without ureteral canalization. Multivariable logistic regression analysis revealed that stone volume (OR 1.1, p = 0.02) and stone located in the renal pelvis (OR 2.2, p = 0.04) were independent predictors of transient ureteral obstruction, after accounting for operative time.

CONCLUSION

One out of five patients showed transient ureteral obstruction after mPCNL. Patients with a higher stone burden and with stones in the renal pelvis are at higher risk of inadequate ureteral canalization. Internal drainage might be considered in these cases to avoid potential complications.

Prevalence and predictors of stone passage after double J stenting for symptomatic ureteral stones: a cross-sectional, real-life study

PURPOSE

To evaluate the rate of and predictors of stone passage (SP) after urgent retrograde stenting for symptomatic ureteral stones.

METHODS

We retrospectively analysed data from 249 consecutive patients presenting to the emergency department for symptomatic ureteral stones and treated with retrograde stenting. Demographic, clinical and laboratory characteristics were collected. Stones parameters were collected before stenting and SP was evaluated at 1 month with computerized tomography. Descriptive statistics and logistic regression models tested the association between predictors and SP.

RESULTS

Overall, median (IQR) age and stone diameter were 56 (45-68) years and 7.1 (4.4-9.8) mm, respectively. Stones were located in the proximal, mid and distal ureter in 102 (41.0%), 48 (19.3%) and 99 (39.8%) cases. SP was observed in 65 (26.2%) individuals. Stone diameter (3.2 vs. 7.7 mm, p < 0.001) and stone density (416 vs. 741, p < 0.001) were lower and a higher rate of distal stones (76.9% vs. 26.7%, p < 0.001) was found in the SP group compared to that with persistent stones. Multivariable logistic regression analysis showed that distal ureteral stone location (OR 7.9, p < 0.01) and lower HU (OR 0.9, p < 0.01) were associated with SP, after accounting for stone volume. Patients with a distal stone of 500 HU had a 75% probability of SP.

CONCLUSION

Stone passage occurred in 26% of patients with indwelling stent due to symptomatic ureteral stones. Lower stone density and distal stone location were independent predictors of stone passage. Patients with these criteria should be managed with follow-up imaging and stent removal instead of ureteroscopy.

Diagnosis of prostate cancer with magnetic resonance imaging in men treated with 5-alpha-reductase inhibitors

PURPOSE

The primary aim of this study was to evaluate if exposure to 5-alpha-reductase inhibitors (5-ARIs) modifies the effect of MRI for the diagnosis of clinically significant Prostate Cancer (csPCa) (ISUP Gleason grade ≥ 2).

METHODS

This study is a multicenter cohort study including patients undergoing prostate biopsy and MRI at 24 institutions between 2013 and 2022. Multivariable analysis predicting csPCa with an interaction term between 5-ARIs and PIRADS score was performed. Sensitivity, specificity, and negative (NPV) and positive (PPV) predictive values of MRI were compared in treated and untreated patients.

RESULTS

705 patients (9%) were treated with 5-ARIs [median age 69 years, Interquartile range (IQR): 65, 73; median PSA 6.3 ng/ml, IQR 4.0, 9.0; median prostate volume 53 ml, IQR 40, 72] and 6913 were 5-ARIs naïve (age 66 years, IQR 60, 71; PSA 6.5 ng/ml, IQR 4.8, 9.0; prostate volume 50 ml, IQR 37, 65). MRI showed PIRADS 1-2, 3, 4, and 5 lesions in 141 (20%), 158 (22%), 258 (37%), and 148 (21%) patients treated with 5-ARIs, and 878 (13%), 1764 (25%), 2948 (43%), and 1323 (19%) of untreated patients (p < 0.0001). No difference was found in csPCa detection rates, but diagnosis of high-grade PCa (ISUP GG ≥ 3) was higher in treated patients (23% vs 19%, p = 0.013). We did not find any evidence of interaction between PIRADS score and 5-ARIs exposure in predicting csPCa. Sensitivity, specificity, PPV, and NPV of PIRADS ≥ 3 were 94%, 29%, 46%, and 88% in treated patients and 96%, 18%, 43%, and 88% in untreated patients, respectively.

CONCLUSIONS

Exposure to 5-ARIs does not affect the association of PIRADS score with csPCa. Higher rates of high-grade PCa were detected in treated patients, but most were clearly visible on MRI as PIRADS 4 and 5 lesions.

TRIAL REGISTRATION

The present study was registered at ClinicalTrials.gov number: NCT05078359.

Clinical and time-related predictors of sepsis in patients with obstructive uropathy due to ureteral stones in the emergency setting

PURPOSE

Well-defined clinical predictors of sepsis after upper tract drainage for obstructive uropathy due to ureteral stones are needed. We aim to determine whether sepsis after decompression of the upper urinary tract may be predicted by clinical and time-related factors, specifically delay time from symptom onset to hospital presentation (StH) and from hospital presentation to surgical decompression (HtD).

METHODS

In this single-center retrospective study, data from 196 consecutive patients presenting to the emergency department for obstructive uropathy due to ureteral stones and submitted to surgical decompression were evaluated. Postoperative sepsis was defined as an acute increase in ≥ 2 SOFA points and documented blood or urine cultures.

RESULTS

Median StH and HtD were 24 (6-48) and 17 (10-30) hours, respectively. Thirty-three (16.8%) patients developed sepsis. Septic patients were more frequently female (75.8% vs. 37.4%, p < 0.001), had higher preoperative max body temperature (p < 0.001), white blood cells (WBC) count (p < 0.01), C-reactive protein (CRP) values (p < 0.001) and larger stone diameter (7.2 vs. 6 mm, p = 0.02). StH and HtD did not differ according to sepsis status. Time for WBC normalization and CRP halving were longer for septic patients (all p < 0.02). At multivariable logistic regression analysis, max body temperature ≥ 38 °C (OR 21.5; p < 0.001), female gender (OR 3.6; p = 0.02) and higher CRP (OR 1.1; p < 0.001) were independently associated with sepsis status.

CONCLUSION

Clinical and laboratory parameters are associated with an increased risk of sepsis after decompression. StH and HtD timing are not associated with higher sepsis rates. In selected patients, urinary decompression could be delayed or primary ureteroscopy could be considered.

Artificial Intelligence in the Advanced Diagnosis of Bladder Cancer-Comprehensive Literature Review and Future Advancement

Artificial intelligence is highly regarded as the most promising future technology that will have a great impact on healthcare across all specialties. Its subsets, machine learning, deep learning, and artificial neural networks, are able to automatically learn from massive amounts of data and can improve the prediction algorithms to enhance their performance. This area is still under development, but the latest evidence shows great potential in the diagnosis, prognosis, and treatment of urological diseases, including bladder cancer, which are currently using old prediction tools and historical nomograms. This review focuses on highly significant and comprehensive literature evidence of artificial intelligence in the management of bladder cancer and investigates the near introduction in clinical practice.

Bilateral inguinal lymph-node dissection vs. unilateral inguinal lymph-node dissection and dynamic sentinel node biopsy in clinical N1 squamous cell carcinoma of the penis

INTRODUCTION

To evaluate the role of unilateral inguinal lymph-node dissection (ILND) plus contralateral dynamic sentinel node biopsy (DSNB) vs. bilateral ILND in clinical N1 (cN1) penile squamous cell carcinoma (peSCC) patients.

MATERIAL AND METHODS

Within our institutional database (1980-2020, included), we identified 61 consecutive cT1-4 cN1 cM0 patients with histological confirmed peSCC who underwent either unilateral ILND plus DSNB (26) or bilateral ILND (35).

RESULTS

Median age was 54 years (Interquartile range [IQR]: 48-60 years). Median follow-up was 68 months (IQR 21-105 months). Most patients had pT1 (23 %) or pT2 (54.1%), as well as G2 (47.5%) or G3 (23%) tumors, while lymphovascular invasion (LVI) was present in 67.1% of cases. Considering a cN1 and a cN0 groin, overall 57 out of 61 patients (93.5%) had nodal disease in the cN1 groin. Conversely, only 14 out of 61 patients (22.9%) had nodal disease in the cN0 groin. 5-year IR-free survival was 91% (Confidence interval [CI] 80%-100%) for bilateral ILND group and 88% (CI 73%-100%) for the ipsilateral ILND plus DSNB group (P-value 0.8). Conversely, 5-year CSS was 76% (CI 62%-92%) for bilateral ILND group and 78% (CI 63%-97%) for the ipsilateral ILND plus contralateral DSNB group (P-value 0.9).

CONCLUSIONS

In patients with cN1 peSCC the risk of occult contralateral nodal disease is comparable to cN0 high risk peSCC and the gold standard, namely bilateral ILND, may be replaced by unilateral ILND and contralateral DSNB without affecting positive node detection, IRRs and CSS.

Radiation Exposure and Surgical Outcomes after Antegrade Sclerotherapy for the Treatment of Varicocele in the Paediatric Population: A Single Centre Experience

INTRODUCTION

Antegrade sclerotherapy (Tauber) effectively treats varicocele. However, fluoroscopy exposes young males to ionizing radiation. We aimed to evaluate radiation exposure and surgical outcomes after the Tauber procedure.

MATERIALS AND METHODS

We retrospectively analysed data from 251 patients. Dose area product (DAP) and fluoroscopy time were recorded. The effective dose was calculated with the PCXMC software. Descriptive statistics and linear regression tested the association between clinical predictors and radiation exposure.

RESULTS

Median (IQR) age and body mass index (BMI) were 14 (13-16) years and 20.1 (17.9-21.6) kg/m². Five (2.1%) patients developed clinical recurrence and two (0.81%) developed complications. Median fluoroscopy time and DAP were 38.5 (27.7-54.0) s and 89.6 (62.5-143.9) cGy*cm². The effective dose was 0.19 (0.14-0.31) mSv. Fluoroscopy time was higher in patients with collateral veins (41 (26-49) s vs. 36 (31-61) s, p = 0.02). The median amount of sclerosing agent (SA) used was 3 (3-4) ml. DAP was higher when SA > 3 mL was used (101.4 (65-183) cGy*cm² vs. 80.5 (59-119) cGy*cm²; p < 0.01). At univariable linear regression, age, BMI, operative time and SA > 3 mL were associated with higher DAP (all p < 0.01). At multivariable linear regression, only BMI (beta 12.9, p < 0.001) and operative time (beta 1.9, p < 0.01) emerged as predictors of higher DAP, after accounting for age and SA > 3 mL.

CONCLUSIONS

The Tauber procedure is safe and associated with low effective doses. Operative time and the patient's BMI independently predict a higher radiation dose.

Cone Beam Computed Tomography Image Fusion with Cross Sectional Images for Percutaneous Renal Tumor Ablation: Preliminary Data

PURPOSE

Percutaneous ablative treatments in the kidney are now standard options for local cancer therapy. Multimodality image guidance, combining two 3D image sets, may improve procedural images and interventional strategies. We aimed to assess the value of intra-procedural cone beam computed tomography (CBCT) with magnetic resonance (MR) or CT imaging fusion technique in the guidance of percutaneous microwave ablation (MWA) of renal neoplasms.

MATERIALS AND METHODS

Fifteen patients (eight males, seven females, median age 65 years, median lesion size 20 mm) underwent percutaneous MWA for 15 renal tumors. All the procedures were performed in a dedicated angiography room setting; CBCT ablation planning capabilities included multimodality image fusion. Preoperative contrast-enhanced CT was available in 12 patients, whereas magnetic resonance imaging in the remaining. All patients were considered inoperable due to comorbidities, advanced age, and/or refusal to undergo surgery. Exclusion criteria were: tumors visible at unenhanced CBCT, metastatic disease, and uncorrected coagulopathy. Technical success and technical effectiveness were calculated. Procedural time, complications and recurrences were registered.

RESULTS

MWA under CBCT-guidance with fusion technique was technically successful in 14 out of 15 cases (93%). The median procedural time was 45 min. No procedure-related complications were reported. No enhancing tissue was visualized in the area of ablation at 1-month follow-up. All 15 cases were recurrence-free at last follow-up assessment (median follow-up of 12 months); no cancer-specific deaths were registered.

CONCLUSION

CBCT-CT/MR image fusion is technically feasible and safe in achieving correct targeting and complete ablation of renal lesions. This approach bears the potential to overcome most of the limitations of unenhanced CBCT guidance alone; larger series are needed to validate this technique.

Laparoscopic retroperitoneal lymph-node dissection in metastatic nonseminomatous germ-cell tumors

OBJECTIVES

To support laparoscopic post-chemotherapy retroperitoneal lymph-node dissection (L-PC-RPLND) as a potential new standard, we report on a large dataset of patients systematically undergoing L-PC-RPLND.

PATIENTS AND METHODS

Patients with unilateral residual mass (≥1 cm), normalized markers, limited encasement (<30%) of gross retroperitoneal vessels underwent unilateral L-PC-RPLND with no adjuvant chemotherapy. Surgical performances, histology, hospital stay, complications within 30 days and follow-up visits were recorded. Multivariable linear and logistic regression models were used.

RESULTS

Between February 2011 and January 2021, 151 consecutive patients underwent L-PC-RPLND. Median size of the residual mass was 25 mm (interquartile range [IQR] 20-35 mm). Overall median operative time was 208 min (IQR 177-241) and was 51 min longer (p-value <0.001) for right L-PC-RPLNDs. Eleven procedures were converted to open surgery. Median number of removed and positive nodes was 11 (IQR 8-16) and 1 (IQR 1-2), respectively. Mean hospital stay was 2 days (IQR 2-3). Nine complications (6%) occurred: two were Clavien-Dindo grade III. Definitive pathology revealed post-pubertal teratoma in 65.6%, fibro-necrotic tissue in 23.8%, teratoma with malignant somatic component in 6.6% and viable tumour in 4.0% patients. In multivariable linear regression models, fibro-necrotic tissue (32 min, CI 8.5-55.5; p < 0.01) and residual volume (1.05 min, CI 0.24-1.85; p < 0.01) achieved independent predictor status for longer operative time. All patients, but one, are alive and disease-free after a median follow-up of 22 months (IQR 10, 48).

CONCLUSION

L-PC-RPLND, when adequately planned, is safe and effective for most patients with low to medium volume residual masses.

Artificial intelligence and radiomics in evaluation of kidney lesions: a comprehensive literature review

Radiomics and artificial intelligence (AI) may increase the differentiation of benign from malignant kidney lesions, differentiation of angiomyolipoma (AML) from renal cell carcinoma (RCC), differentiation of oncocytoma from RCC, differentiation of different subtypes of RCC, to predict Fuhrman grade, to predict gene mutation through molecular biomarkers and to predict treatment response in metastatic RCC undergoing immunotherapy. Neural networks analyze imaging data. Statistical, geometrical, textural features derived are giving quantitative data of contour, internal heterogeneity and gray zone features of lesions. A comprehensive literature review was performed, until July 2022. Studies investigating the diagnostic value of radiomics in differentiation of renal lesions, grade prediction, gene alterations, molecular biomarkers and ongoing clinical trials have been analyzed. The application of AI and radiomics could lead to improved sensitivity, specificity, accuracy in detecting and differentiating between renal lesions. Standardization of scanner protocols will improve preoperative differentiation between benign, low-risk cancers and clinically significant renal cancers and holds the premises to enhance the diagnostic ability of imaging tools to characterize renal lesions.

Percutaneous Microwave Ablation is Comparable to Cryoablation for the Treatment of T1a Renal Masses: Results From a Cross-Sectional Study

INTRODUCTION

Percutaneous microwave ablation (MWA) of renal masses (RM) is still considered experimental as opposed to established procedures such as cryoablation (CA). We aimed to compare perioperative, functional and oncological outcomes of patients with RM treated with CA and MWA.

MATERIALS AND METHODS

Data from 116 (69.9%) and 50 (30.1%) patients treated with CA and MWA for RM were analyzed. Patients' demographics and perioperative data were collected including nephrometry scores, complications, pre- and postprocedural renal function. Tumor persistence and recurrence were recorded. Descriptive statistics compared functional outcomes between groups. Cox regression analyses tested risk factors associated with recurrence.

RESULTS

Groups were similar in terms of RM diameter, nephrometry scores and histology distribution. Median follow-up was 26 (13-46) and 24 (14-36) months for CA and MWA, respectively. The rate of overall (36.2% for CA vs. 24% for MWA, P= .1) and major (Clavien ≥ 3a) complications (1.7% vs. 5.4%, P = .1) were similar among groups. The median decline of renal function after 6 months follow-up did not differ between CA and MWA (P = .8). Tumor persistence [4.3% vs. 12%] and recurrence [9.5% and 7.1%] rates were similar for CA and MWA. Three years recurrence free and overall survival were 91% versus 95% (log-rank P = .77) and 80 versus 88% (log-rank P = .23) in the CA and MWA groups, respectively. At Cox analysis no predictors were found associated with recurrence.

CONCLUSION

Despite being considered still experimental, MWA showed comparable outcomes relative to CA in terms of safety, preservation of renal function and oncological efficacy.

Outcomes and predictive factors of successful salvage microdissection testicular sperm extraction (mTESE) after failed classic TESE: results from a multicenter cross-sectional study

Microdissection testicular sperm extraction (mTESE) has been proposed as a salvage treatment option for men with a previously failed classic TESE (cTESE), but data are scarce. We aimed to assess the outcome of and potential predictors of successful salvage mTESE in a cohort of men previously submitted to unfruitful cTESE. Data from 61 men who underwent mTESE after a failed cTESE between 01/2014 and 10/2020, at 6 tertiary-referral centres in Italy were analysed. All men were investigated with semen analyses, testicular ultrasound, hormonal and genetic blood testing. Pathological diagnosis from TESE was collected in every man. Descriptive statistics and logistic regression models were used to investigate potential predictors of positive sperm retrieval (SR+) after salvage mTESE. Baseline serum Follicle-Stimulating hormone (FSH) and total testosterone levels were 17.2 (8.6-30.1) mUI/mL and 4.7 (3.5-6.4) ng/mL, respectively. Sertoli-cell-only syndrome (SCOS), maturation arrest (MA) and hypospermatogenesis were found in 24 (39.3%), 21 (34.4%) and 16 (26.2%) men after cTESE, respectively. At mTESE, SR+ was found in 30 (49.2%) men. Patients with a diagnosis of hypospermatogenesis had a higher rate of SR+ (12/16 (75%)) compared to MA (12/21 (57.1%)) and SCOS (6/24 (25%)) patients at mTESE (p < 0.01). No clinical and laboratory differences were observed between SR+ and SR- patients at mTESE. There were no significant complications after mTESE. At multivariable logistic regression analysis, only hypospermatogenesis (OR 9.5; p < 0.01) was independently associated with SR+ at mTESE, after accounting for age and FSH.In conclusion, salvage mTESE in NOA men with previous negative cTESE was safe and promoted SR+ in almost 50%. A baseline pathology of hypospermatogenesis at cTESE emerged as the only independent predictor of positive outcomes at salvage mTESE.

Renal Cell Carcinoma as a Metabolic Disease: An Update on Main Pathways, Potential Biomarkers, and Therapeutic Targets

Clear cell renal cell carcinoma (ccRCC) is the most frequent histological kidney cancer subtype. Over the last decade, significant progress has been made in identifying the genetic and metabolic alterations driving ccRCC development. In particular, an integrated approach using transcriptomics, metabolomics, and lipidomics has led to a better understanding of ccRCC as a metabolic disease. The metabolic profiling of this cancer could help define and predict its behavior in terms of aggressiveness, prognosis, and therapeutic responsiveness, and would be an innovative strategy for choosing the optimal therapy for a specific patient. This review article describes the current state-of-the-art in research on ccRCC metabolic pathways and potential therapeutic applications. In addition, the clinical implication of pharmacometabolomic intervention is analyzed, which represents a new field for novel stage-related and patient-tailored strategies according to the specific susceptibility to new classes of drugs.

Clinically Meaningful Improvements in Sperm DNA Fragmentation Severity in Infertile Men Treated with Superoxide Dismutase Supplementation: A Single-Center Experience

Background. Antioxidants are commonly used for the treatment of idiopathic male infertility. Previous studies have shown that antioxidants are able to improve sperm quality, but little is known about their impact on sperm DNA fragmentation (SDF). Preliminary findings showed that superoxide-dismutase (SOD)-based antioxidant plus hydroxytyrosol and carnosol (FertiPlus® SOD) therapy was associated with SDF improvement in a small cohort of infertile men. Therefore, we aimed to assess rates of and predictors of semen parameters and SDF improvements in infertile men treated with FertiPlus® SOD therapy (SOD+) or with other antioxidants without SOD (SOD−) in the real-life setting. Methods. Data from 60 consecutive infertile men with baseline SDF ≥ 30% and treated with SOD+ or SOD− for at least three months were analyzed. Clinical parameters and serum hormones were collected. Sperm parameters and SDF were requested at baseline and after SOD+ or SOD− treatment. Clinically meaningful SDF change after treatment was defined as SDF improvement >20% compared to baseline. Propensity score matching was performed to adjust for baseline differences between groups. Descriptive statistics were used to compare clinical and hormonal characteristics between SOD+ and SOD− groups. Semen characteristics were compared before and after treatment. Logistic regression models investigated the association between clinical variables and SDF improvement. Results. Groups were similar in terms of clinical, serum hormones and semen parameters at baseline after matching. Compared to baseline, sperm progressive motility (17 (10−36)% vs. 27 (12−41)%) and normal morphology (2 (1−6)% vs. 4 (2−6)%) significantly improved after SOD+ treatment (all p < 0.01), but not after SOD−. SDF values significantly improved after treatment in both groups, compared to the baseline evaluation (all p < 0.01). However, SDF values were lower after SOD+ than SOD− treatment (30 (22−36)% vs. 37 (31−42)%, p = 0.01). Similarly, a clinically meaningful improvement in SDF at follow-up was more frequently found after SOD+ than SOD− treatment (76.7% vs. 20.0%, p = 0.001). Multivariable logistic regression analysis showed that SOD+ treatment (OR 5.4, p < 0.001) was an independent predictor of clinically meaningful SDF improvement, after accounting for age and baseline FSH values. Conclusions. This cross-sectional study showed that, in a cohort of primary infertile men with SDF ≥ 30%, SOD-based treatment was significantly effective in improving SDF compared to antioxidants without SOD. Approximately 80% of men treated with SOD+ achieved clinically meaningful improvement in SDF after three months of treatment. Sperm progressive motility and normal morphology also improved after SOD+ therapy but not after SOD−. These results suggest that SOD+ treatment could be considered an effective option for the management of idiopathic infertile men with elevated SDF.

Coenzyme Q10 and Melatonin for the Treatment of Male Infertility: A Narrative Review

BACKGROUND

Lifestyle and environmental factors can negatively impact fertility by means of oxidative stress. In this context, antioxidant supplementation therapy has gained much interest in recent years, and different molecules, alone or in combination, have been studied.

OBJECTIVE

The purpose of the present review is to investigate the evidence regarding the efficacy of coenzyme Q10 (CoQ10) and melatonin on male infertility.

METHODS

A literature search using PUBMED database from 2000 to October 2022 was performed to explore the role of CoQ10 and melatonin on male reproductive function.

CONCLUSIONS

The analysis involved a narrative synthesis. CoQ10, alone or in combination, appears to reduce testicular oxidative stress and sperm DNA fragmentation and to improve sperm parameters; particularly sperm motility. Moreover, CoQ10 treatment is associated with higher pregnancy rates, both naturally and through assisted reproductive technology (ART). Larger studies are needed to precisely determine its clinical efficacy. Melatonin is a known antioxidant and preclinical studies have shown its ability to modulate reproductive function through hormonal and immune system regulation and sperm cell proliferation. Regardless, clinical studies are necessary to assess its potential in male infertility.

Reducing the Frequency of Follow-up Cystoscopy in Low-grade pTa Non-muscle-invasive Bladder Cancer Using the ADXBLADDER Biomarker

BACKGROUND

Non-muscle-invasive bladder cancer (NMIBC) is one of the most expensive cancers owing to frequent follow-up cystoscopies for detection of recurrence.

OBJECTIVE

To assess if the noninvasive ADXBLADDER urine test could permit a less intensive surveillance schedule for patients with low-grade (LG) pTa tumor without carcinoma in situ (CIS) at the previous diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

In a prospective, double-blind, multicenter study, 629 patients underwent follow-up cystoscopy, transurethral resection of bladder tumor/biopsy of suspect lesions, and ADXBLADDER testing.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Diagnostic test accuracy and decision curve analysis were used to evaluate the impact of ADXBLADDER on decision-making on whether to perform follow-up cystoscopy. The primary endpoint was the negative predictive value (NPV) of ADXBLADDER for detection of high-grade and/or CIS (HG/CIS) recurrence and its impact on reducing unnecessary cystoscopies.

RESULTS AND LIMITATIONS

ADXBLADDER had sensitivity of 66.7% (95% confidence interval [CI] 34.9-90.1%) and an NPV of 99.15% (95% CI 97.8-99.8%) for detection of HG/CIS recurrence. The probability of HG/CIS recurrence was 5.0% for ADXBLADDER-positive patients and 0.85% for ADXBLADDER-negative patients. For HG/CIS recurrence threshold probabilities between 0.85% and 5.0%, ADXBLADDER yields a net benefit with omission of cystoscopy for ADXBLADDER-negative patients. The corresponding net reduction in unnecessary cystoscopies ranges from 11 to 62 per 100 patients.

CONCLUSIONS

Patients with LG pTa tumor at the previous diagnosis, for which the risk of HG/CIS recurrence is low and the ADXBLADDER NPV for ruling out HG/CIS recurrence is 99.15%, are ideally suited for a less intensive, personalized follow-up surveillance strategy using ADXBLADDER, with omission of cystoscopy for ADXBLADDER-negative patients.

PATIENT SUMMARY

ADXBLADDER is a urine test that can predict the probability of recurrence of bladder cancer. Patients diagnosed with low-grade cancer confined to the bladder mucosa are ideally suited for less intensive follow-up using this test, which could reduce unnecessary cystoscopy procedures for those with a negative result, potentially improve quality of life, and reduce overall health care costs.

Renal tumor biopsy in patients with cT1b-T4-M0 disease susceptible to radical nephrectomy: analysis of safety, accuracy and clinical impact on definitive management

PURPOSE

Renal tumor biopsy was provided in patients candidate to radical nephrectomy for a renal mass ≥4 cm, to evaluate treatment deviation.

METHODS

Between 2008 and 2017, 102 patients with a solid renal mass ≥4 cm with no distant metastases underwent preliminary renal tumor biopsy. We investigated the proportion of patients who proceeded with radical nephrectomy, variables predicting non-renal cell carcinoma (RCC) and concordance between biopsy findings and definitive pathology.

RESULTS

Median tumor size was 70 mm (IQR 55-110). Clinical stage was cT1b in 41, cT2 in 33, cT3 in 25 and cT4 in three patients. A median of three (IQR 2-3) renal tumor biopsies were taken with 16/18 Gauge needles in 97% of cases. Clavien grade I complications occurred in five cases. Malignant tumors were documented in 84 patients: 78 RCCs and six non-RCCs. Fifteen biopsies documented oncocytoma and three were non-diagnostic. Grade was reported in 50 RCCs: 42 (84%) were low and eight (16%) high grade. Eighty-three patients proceeded with radical nephrectomy; six non-RCC malignant tumors underwent combined and/or intensified treatment; 13 of 15 patients with oncocytoma did not undergo radical nephrectomy (eight underwent observation). Definitive pathology confirmed diagnosis in all cases. Grade concordance was 84%, considering two tiers (high vs low grade). No preoperative clinical variable predicted definitive pathology.

CONCLUSIONS

Renal tumor biopsy is a safe procedure that leads to radical nephrectomy in most tumors ≥4 cm. Nonetheless, 20% of patients exhibited non-RCC histology. Renal tumor biopsy should be considered in this setting.

Accuracy of the European Association of Urology (EAU) NMIBC 2021 scoring model in predicting progression in a large cohort of HG T1 NMIBC patients treated with BCG

BACKGROUND

Recently, the European Association of Urology Guidelines Panel updated the prognostic factor risk groups model for non-muscle-invasive bladder cancer (NMIBC) with the introduction of a new group of patients at very high risk (VHR). Furthermore, three additional clinical risk factors (i.e., age>70 years, multiple papillary tumors; tumor diameter >3 cm) were proposed. However, the new scoring model was created by analyzing data from patients who did not receive BCG intravesical therapy.

METHODS

This is a retrospective multicenter study analyzing data of 920 patients with HGT1 NMIBC that underwent ReTUR e following BCG intravesical therapy. Patients were stratified into risk groups according to the 2021 new EAU NMIBC prognostic factor risk groups model. This study aimed to identify variables related to disease progression in a large cohort of HGT1 NMIBC patients who underwent both Re-TURB and BCG intravesical immunotherapy.

RESULTS

Median follow-up was 51 months (IQR 41-75), according to EAU NMIBC 2021 scoring model 179 (19.5%) patients were at VHR. Progression-free survival at 5 years was 68.2% and 59.9% for the whole sample and the VHR group, respectively. At multivariable regression model size >3 cm, multifocal tumor, concomitant CIS and LVI were identified as independently associated with disease progression.

CONCLUSIONS

Although patients at VHR are more likely to experience disease progression during follow-up, the European Association of Urology (EAU) NMIBC 2021 scoring model appears to be suboptimal in patients who underwent ReTUR and intravesical BCG therapy.

Is There Still a Place for Percutaneous Nephrolithotomy in Current Times?

Background: Percutaneous nephrolithotomy (PCNL) and its miniaturized modifications are usually considered the standard surgical options for large (>20 mm) staghorn and infected stones. Moreover, PCNL is a viable alternative to retrograde intrarenal surgery (RIRS) for smaller stones (<20 mm) in the presence of anatomical malformations or inaccessible lower pole stones. However, due to the advancements in laser and scope technology, RIRS is expanding its indications with the potential benefits of lower complications and a shorter hospital stay. Methods: A literature search using the PUBMED database from inception to June 2022 was performed to explore the current role of PCNL in endourology. The analysis involved a narrative synthesis. Results: PCNL confirmed its role in the treatment of large and complex stones; moreover, miniaturized PCNL has become more competitive, gaining space among classic indications of flexible ureteroscopy. Conclusions: considering all the evaluated subgroups, we can conclude that PCNL is an old fascinating procedure and is here to stay.

Urologists are optimistic surgeons: prevalence and predictors of discordance between intraoperative stone-free rate and cross-sectional imaging evaluation after vacuum-assisted mini-percutaneous nephrolithotomy

Purpose

To assess how accurate are urologists in predicting stone-free status (SFS) after vacuum-assisted mini-PCNL (vamPCNL) compared to computed tomography (CT) and clinical predictors of discordant SFS.

Methods

Data from 235 patients who underwent vamPCNL were analysed. Patient’s demographics, stones’ characteristics and operative data were recorded. SFS was evaluated intraoperatively by the treating urologist (iSFS) and with non-contrast CT 3 months after vamPCNL (ctSFS). SFS was defined as no residual stones. Stone complexity was scored with the Guy’s score. Descriptive statistics and logistic regression models were used to identify clinical factors associated with discordant SFS (namely iSFS not confirmed at CT).

Results

iSFS and ctSFS were 88.5% and 65.5%, respectively, with 54 (23%) cases resulting in discordant evaluation of SFS between the surgeon and CT imaging. Patients with discordant SFS had larger stone volume (p < 0.001), higher rate of multiple stones (p = 0.03) and higher rate of multiple calyceal groups affected by stones (p < 0.001) than those with concordant SFS. The use of flexible ureteroscopes to look for residual stones after lithotripsy was more frequently reported in cases with concordant SFS (p = 0.001). Multivariable logistic regression analysis revealed that stones in > 2 calyceal groups (OR 10.2, p < 0.001), Guy’s score II (OR 5.8, p < 0.01) and not using flexible ureteroscopes after lithotripsy (OR 2.9, p = 0.02) were independent predictors of discordant SFS.

Conclusion

One out of five patients is erroneously considered SF after vamPCNL. Urologist should carefully evaluate patients with multiple calyceal stones and consider using flexible ureteroscopes to complete lapaxy of migrated fragments in order to improve their prediction of SFS.

The comprehensive complication index as a tool for reporting the burden of complications after mini-percutaneous nephrolithotomy: is it time to leave the Clavien–Dindo classification behind?

Purpose

To validate the comprehensive complication index (CCI) for mini-percutaneous nephrolithotomy (mPCNL).

Methods

Data from 287 patients who underwent mPCNL were analyzed. Complications after mPCNL were classified using both the CCI and the Clavien–Dindo classification (CDC). Descriptive statistics and linear/logistic regression analyses detailed the association between clinical predictors and mPCNL outcomes.

Results

After mPCNL, 83 (28.9%) patients had complications, of which 12 (4.2%) patients with multiple complications had a higher CCI score compared to the traditional CDC system accounting only for the highest grade. The CCI enabled a more accurate prediction of length of stay (LOS) than CDC (CCI: r = 0.32; p < 0.01 vs. CDC: r = 0.26; p = 0.01). Patients with multiple complications had higher stone volume (p = 0.02), longer operative time and LOS (all p < 0.01). A higher rate of post-operative hospital readmission (33.3% vs. 9.9%, p = 0.02) and lower rate of stone free (33.3% vs. 64.7%, p = 0.04) were found in patients with multiple complications than in those with single complication. Linear regression analysis revealed that multiple complications were associated with longer LOS (p < 0.001) after accounting for BMI and stone volume. Similarly, having multiple complications was associated with fivefold higher risk of readmission (p = 0.02).

Conclusion

The CCI is a valuable metric for assessing post-operative complications after mPCNL. The cumulative CCI is a better predictor of LOS than the CDC for mPCNL. Minor complications not captured by the highest CDC score are relevant since patients with multiple complications have longer LOS and higher rate of readmission than those with single ones.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-022-04045-9.

Prostatic artery embolization in people with spinal cord injury: a safe and effective technique to ease intermittent catheterization in case of concomitant benign prostatic hyperplasia

STUDY DESIGN

Case series.

OBJECTIVES

To assess the safety and efficacy of prostatic artery embolization (PAE) to reduce prostate volume (PV) and facilitate intermittent catheterization (IC) in individuals with concurrent benign prostatic hyperplasia (BPH) and spinal cord injury (SCI).

SETTING

Italian tertiary referral center for people with SCI.

METHODS

We retrospectively collected all data of individuals undergoing PAE from 2015 to 2020 because of BPH-related problems during IC. PAE was performed under local anesthesia with superselective catheterization of the prostatic arteries. Technical success was defined as bilateral embolization. We determined pre- and post-procedural PV by magnetic resonance imaging.

RESULTS

We considered 10 cases with tetraplegia (n = 5) and paraplegia (n = 5). Nine (90%) procedures were technically successful, while we performed monolateral PAE in one case. The median pre-procedural PV was 61 mL. After 6 months, all patients experienced significant PV reduction (median: 19.6%), and 7/7 patients with indwelling urinary catheter started successfully IC. Neither intra- nor post-procedural complications occurred within a median follow-up of 33 months.

CONCLUSIONS

PAE proved to be a safe and effective treatment for BPH to facilitate IC in people with SCI. Considering the minimal morbidity of PAE, further multi-center studies are mandatory to draw definitive conclusions and warrant its widespread adoption in this population.

External validation of the computerized analysis of TRUS of the prostate with the ANNA/C-TRUS system: a potential role of artificial intelligence for improving prostate cancer detection

PURPOSE

Prostate cancer (PCa) imaging has been revolutionized by the introduction of multi-parametric Magnetic Resonance Imaging (mpMRI). Transrectal ultrasound (TRUS) has always been considered a low-performance modality. To overcome this, a computerized artificial neural network analysis (ANNA/C-TRUS) of the TRUS based on an artificial intelligence (AI) analysis has been proposed. Our aim was to evaluate the diagnostic performance of the ANNA/C-TRUS system and its ability to improve conventional TRUS in PCa diagnosis.

METHODS

We retrospectively analyzed data from 64 patients with PCa and scheduled for radical prostatectomy who underwent TRUS followed by ANNA/C-TRUS analysis before the procedure. The results of ANNA/C-TRUS analysis with whole mount sections from final pathology.

RESULTS

On a per-sectors analysis, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and accuracy were 62%, 81%, 80%, 64% and 78% respectively. The values for the detection of clinically significant prostate cancer were 69%, 77%, 88%, 50% and 75%. The diagnostic values for high grade tumours were 70%, 74%, 91%, 41% and 74%, respectively. Cancer volume (≤ 0.5 or greater) did not influence the diagnostic performance of the ANNA/C-TRUS system.

CONCLUSIONS

ANNA/C-TRUS represents a promising diagnostic tool and application of AI for PCa diagnosis. It improves the ability of conventional TRUS to diagnose prostate cancer, preserving its simplicity and availability. Since it is an AI system, it does not hold the inter-observer variability nor a learning curve. Multicenter biopsy-based studies with the inclusion of an adequate number of patients are needed to confirm these results.

Accuracy of sonography for non-invasive detection of ovarian and deep endometriosis using #Enzian classification: prospective multicenter diagnostic accuracy study

OBJECTIVE

To compare the preoperative detection of endometriosis using transvaginal sonography (TVS) supplemented by transabdominal sonography (TAS) with surgical assessment of disease, using the #Enzian classification for endometriosis.

METHODS

This was a prospective multicenter diagnostic accuracy study of women undergoing TVS/TAS and radical surgery for deep endometriosis (DE) at different tertiary referral centers. The localization and grade of severity of the endometriotic lesions and adhesions were described according to the criteria of the #Enzian classification, both at preoperative ultrasound examination and during surgery. According to the #Enzian classification, the small pelvis is divided into three compartments for DE: A (rectovaginal septum and vagina); B (uterosacral and cardinal ligaments, parametrium and pelvic sidewalls); and C (rectum). In addition, further locations (F) are classified as adenomyosis (FA), urinary bladder involvement (FB) and ureteric involvement with signs of obstruction (FU). Other intestinal locations (FI) and other extragenital locations (FO) are also included. Ovarian endometriosis and adhesions at the level of the tubo-ovarian unit are listed as O and T, respectively. The #Enzian grade of severity (Grade 1-3) was determined for #Enzian compartments O, T, A, B and C based on the size of the lesion or the severity of the adhesions. Concordance between preoperative assessment using TVS/TAS and evaluation at surgery was assessed. The sensitivity, specificity, positive and negative predictive values and accuracy of TVS/TAS in the detection of endometriotic lesions/adhesions in the different #Enzian compartments were calculated.

RESULTS

In total, 745 women were included in the analysis. Preoperative TVS/TAS and surgical findings showed a concordance rate ranging between 86% and 99% for the presence or absence of endometriotic lesions/adhesions, depending on the evaluated #Enzian compartment. The concordance rate between TVS and surgery ranged between 71% and 92% for different severity grades, in #Enzian compartments O, T, A, B and C. Determining the presence or absence of adhesions at the level of the tubo-ovarian unit and classifying them accurately as Grade 1, 2 or 3 on TVS was more difficult than determining the presence and severity of endometriotic lesions in #Enzian compartments O, A, B and C. The sensitivity of TVS/TAS for the detection of endometriotic lesions ranged from 50% (#Enzian compartment FI) to 95% (#Enzian compartment A), specificity from 86% (#Enzian compartment T_left ) to 99% (#Enzian compartment FI) and 100% (#Enzian compartments FB, FU and FO), positive predictive value from 90% (#Enzian compartment T_right ) to 100% (#Enzian compartment FO), negative predictive value from 74% (#Enzian compartment B_left ) to 99% (#Enzian compartments FB and FU) and accuracy from 88% (#Enzian compartment B_right ) to 99% (#Enzian compartment FB).

CONCLUSIONS

The localization and severity of endometriotic lesions/adhesions, as described and classified according to the #Enzian classification, can be diagnosed accurately and non-invasively using TVS/TAS. The #Enzian classification provides a uniform classification system for describing endometriotic lesions, which can be used both at TVS/TAS and during surgical evaluation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Varicocele embolization with sclerosing agents leads to lower radiation exposure and procedural costs than coils: Data from a real-life before and after study

Objectives

To investigate clinical outcomes, radiation exposure and procedural costs associated with percutaneous varicocoele embolization using coils and sclerosing agents (SAs) in a cohort of young‐adult men.

Materials and methods

Data from consecutive men treated with percutaneous varicocoele embolization using coils and SA between 2017 and 2021 were analyzed. The allocation was based on a change of policy occurred in June 2020 with the substitution of coils with SA (before and after study). Semen analysis values were based on 2010 WHO reference criteria. Anatomic variants of gonadal veins were categorized according to Jargiello et al. Intraoperative radiation dose and procedural costs were collected for each patient. Descriptive statistics and linear regression models were used to describe the association between clinical parameters with procedural costs and radiation exposure.

Results

One hundred sixteen men were included, of whom 76 (65.5%) received coils, and 40 (34.5%) received SA. Baseline characteristics of the two study groups did not differ. A type 3 Jargiello anatomic variation of left gonadal vein was found in 45.7% of cases. Radiation dose was lower in the SA group as compared to the coils one (13.2 [7–43] vs. 19.8 [12–57] Gy/cm²; p < 0.001). Similarly, procedural costs were lower for the SA group (169.6 [169–199] € vs. 642.5 [561–775] €; p < 0.001). At follow‐up, pain and sperm variables significantly improved in both groups (p < 0.01), without differences among the embolic materials. Linear regression model revealed that coils use was associated with higher radiation exposure (beta 8.8, p = 0.02) than SA after accounting for anatomic variation of gonadal vein, body mass index, and vascular access.

Conclusions

SA and coils for varicocoele embolization are equally safe and effective. The use of SA was associated with lower radiation exposure and procedural costs than coils. These results should be considered in terms of public health cost and patient's safety.

Adulterants in drugs of abuse: a recent focus of a changing phenomenon

The adulteration of drugs of abuse is a well-known practice with alarming public health implications. In fact, the presence of other substances than those declared by the drug dealers may expose the consumers to unexpected adverse effects, even potentially fatal ones depending on the adulterant. Various adulterants are often added during the manufacturing process as cutting agent for deliberate underdosing, such as in case of levamisole for cocaine, or to strengthen the drug ef-fect, as in case of fentanyl for heroin. The authors aimed to elaborate on such unfolding dynamics and concluded that continuous development of effective analytical tools, along with a closely focused evaluation of each case by the medical doctor is essential to clarify the origin of the intoxications, so as to undertake the best therapeutic pathway.

Pediatric Urolithiasis: Current Surgical Strategies and Future Perspectives

New technological innovations and cutting-edge techniques have led to important changes in the surgical management of pediatric urolithiasis. Miniaturized technologies and minimally invasive approaches have been increasingly used in children with urinary stones to minimize surgical complications and improve patient outcomes. Moreover, the new computer technologies of the digital era have been opening new horizons for the preoperative planning and surgical treatment of children with urinary calculi. Three-dimensional modeling reconstructions, virtual, augmented, and mixed reality are rapidly approaching the surgical practice, equipping surgeons with powerful instruments to enhance the real-time intraoperative visualization of normal and pathological structures. The broad range of possibilities offered by these technological innovations in the adult population finds increasing applications in pediatrics, offering a more detailed visualization of small anatomical structures. This review illustrates the most promising techniques and devices to enhance the surgical treatment of pediatric urolithiasis in children, aiming to favor an early adoption and to stimulate more research on this topic.

Changes in renal function after nephroureterectomy for upper urinary tract carcinoma: analysis of a large multicenter cohort (Radical Nephroureterectomy Outcomes (RaNeO) Research Consortium)

PURPOSE

To investigate prevalence and predictors of renal function variation in a multicenter cohort treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

METHODS

Patients from 17 tertiary centers were included. Renal function variation was evaluated at postoperative day (POD)-1, 6 and 12 months. Timepoints differences were Δ1 = POD-1 eGFR - baseline eGFR; Δ2 = 6 months eGFR - POD-1 eGFR; Δ3 = 12 months eGFR - 6 months eGFR. We defined POD-1 acute kidney injury (AKI) as an increase in serum creatinine by ≥ 0.3 mg/dl or a 1.5 1.9-fold from baseline. Additionally, a cutoff of 60 ml/min in eGFR was considered to define renal function decline at 6 and 12 months. Logistic regression (LR) and linear mixed (LM) models were used to evaluate the association between clinical factors and eGFR decline and their interaction with follow-up.

RESULTS

A total of 576 were included, of these 409(71.0%) and 403(70.0%) had an eGFR < 60 ml/min at 6 and 12 months, respectively, and 239(41.5%) developed POD-1 AKI. In multivariable LR analysis, age (Odds Ratio, OR 1.05, p < 0.001), male gender (OR 0.44, p = 0.003), POD-1 AKI (OR 2.88, p < 0.001) and preoperative eGFR < 60 ml/min (OR 7.58, p < 0.001) were predictors of renal function decline at 6 months. Age (OR 1.06, p < 0.001), coronary artery disease (OR 2.68, p = 0.007), POD-1 AKI (OR 1.83, p = 0.02), and preoperative eGFR < 60 ml/min (OR 7.80, p < 0.001) were predictors of renal function decline at 12 months. In LM models, age (p = 0.019), hydronephrosis (p < 0.001), POD-1 AKI (p < 0.001) and pT-stage (p = 0.001) influenced renal function variation (ß 9.2 ± 0.7, p < 0.001) during follow-up.

CONCLUSION

Age, preoperative eGFR and POD-1 AKI are independent predictors of 6 and 12 months renal function decline after RNU for UTUC.

Drug-induced gynecomastia: A systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

To review the evidence concerning treatment-related gynecomastia in patients taking spironolactone, antiandrogens, 5 alpha-reductase inhibitors, lipid-lowering and psychotropic drugs.

MATERIAL AND METHODS

A search of Medline and EMBASE was performed up to 30 June 2021. We included randomized controlled trials comparing the effects of a drug belonging to these classes versus placebo or versus a drug of the same class.

RESULTS

A total of 32 randomized controlled trials were included in the final review. There was an increased odds of gynecomastia in men receiving antiandrogens (OR = 17.38, 95% CI: 11.26 to 26.82; 6 trials, 9599 participants) and 5 alpha-reductase inhibitors compared to controls (OR = 1.77, 95% CI: 1.53 to 2.06; 7 series out of 6 trials, 34860 participants). The use of spironolactone in mixed gender populations was characterized by significantly higher odds of having gynecomastia compared to controls (OR = 8.39, 95% CI: 5.03 to 13.99; 14 trials, 3745 participants). No placebo-controlled trials focusing on the risk of gynecomastia in patients taking antipsychotic drugs was available, although there was a significant difference in the odds of having gynecomastia in a comparison between risperidone and quetiapine (OR = 4.32, 95% CI: 1.31 to 14.27; 3 trials, 343 participants). Limited evidence about the effects of statins on mammary glands was found.

CONCLUSIONS

Antiandrogens and to a lesser extent 5 alphareductase inhibitors and spironolactone are associated with an increased risk of developing gynecomastia. Such effect can be explained by a modification of the testosterone to estradiol ratio. Gynecomastia (and galactorrhea) associated to the use of conventional and certain atypical antipsychotics can be related to high prolactin levels.