The definition of ideal training of a urology resident from two different perspectives: trainees vs professors. Is there agreement in their idea of good training?

Introduction

At the end of their residency program, urology trainees should reach the minimum skills required to be able to work by themselves and within a team. To achieve this objective, it is fundamental that the training involves not only surgical activities, but also theoretical, academic, and relational ones. What is the perfect balance between these activities within the ideal urological training? This study aims to evaluate the concordance in different concepts of good urological training between different perspectives (trainees vs professors).

Material and methods

Between January and December 2020 the same survey was distributed via email to 967 urology trainees and urology tutors. The survey investigated 5 educational fields: theoretical, clinical, surgical, relational, and simulation. For each field, specific questions investigated the importance of different activities and the training outcomes considered fundamental to be reached by a resident. The questions were evaluated by responders through a Likert 10-point scale.

Results

The survey was completed by 155 trainees (58.9%, Group A) and 108 tutors (41.1%, Group B) from 26 different countries. Relative to the tutors, residents assigned statistically significantly lower scores to prostate biopsy (median score 9.11 vs 9.24), robotic simulator training (5.66 vs 5.93), on-call duties with consultants (6.85 vs 7.99), as well as all aspects of relational training (e.g., proper dialogue with colleagues: 7.95 vs 8.88). Conversely, residents assigned statistically significantly higher scores, albeit below sufficiency, to the performance of robotic prostatectomy as a first operator (4.45 vs 4.26). Finally, no discrepancies between residents' and tutors' scores were recorded regarding the remaining items of clinical training (e.g., urodynamics, outpatient clinic, ward duties) and surgical training (e.g., major open, laparoscopic and endoscopic surgical training; all p values >0.05).

Conclusions

There was partial concordance between trainees and tutors regarding the activities that should be implemented and the skills that should be achieved during a urological residency. The residents aimed for more surgical involvement, while the tutors and professors, although giving importance to surgical and theoretical training, considered clinical practice as the fundamental basis on which to train future urologists.

Clinical impact of ERG and PTEN status in prostate cancer patients underwent radical prostatectomy

OBJECTIVES

Phosphate and tensin homolog gene (PTEN) acts as a regulator of PI3-KAkt molecular pathway. ETS Related gene (ERG), an oncogene located in chromosome 21q22.2, is involved in prostate cancer (PCa) by serine 2 (TMPRSS2), a protein encoded by TMPRSS2 gene. The aim of this study is to evaluate the clinical impact of PTEN loss and ERG rearrangement in terms of oncologic results in patients diagnosed with localized PCa who underwent radical prostatectomy.

MATERIALS AND METHODS

Prospective data were collected from a total of 74 patients who underwent open radical retropubic prostatectomy for localized PCa and immunohistochemical study was performed in tissue samples. The primary antibodies for anti-ERG antibody as well as anti-PTEN antibody were obtained from DAKO. ERG was considered positive if at least 20% of the evaluated cells were stained at least with medium intensity. PTEN protein loss was considered when the intensity of cytoplasmic and nuclear staining was mild or entirely negative across > 10% of tumor cells.

RESULTS

Homogenous loss of PTEN was associated with higher clinical International Society of Urological Pathology (ISUP) grade (p = 0.018) while no statistical significant association was present regarding the presence of ERG rearrangement with either ISUPc or ISUPp. After a median follow up of 34 months, 24 patients developed biochemical recurrence. No statistical significant correlation of ERG status with biochemical recurrence was noted while PTEN was associated with biochemical recurrence development in a statistical significant way. Lastly the combination of PTEN loss with ERG rearrangement presence was detected more often in higher ISUPc and ISUPp as well as biochemical recurrence development, although in a non statistical significant way.

CONCLUSIONS

Homogenous and heterogenous PTEN loss was associated with biochemical recurrence. No association of ERG and biochemical recurrence was noted. The combination of PTEN loss and ERG rearrangement presented a trend for higher ISUPc and ISUPp as well as biochemical recurrence but not in a statistical significant way.

Outcomes of radical cystectomy in pT4 bladder cancer frail patients: Α high-volume single center study

Objectives:

This study aims to evaluate the effect of frailty in patients undergoing radical cystectomy (RC) for locally advanced bladder cancer.

Methods:

In this retrospective, single center study we evaluated 51 patients with pT4 bladder cancer treated with radical cystectomy between 2016-2020. Patient frailty was assessed with the Clinical Frailty Scale (CFS). Furthermore, six separate parameters (early mortality index within 30 days after surgery, death after one year, length of stay, respiratory complications, readmission index, total hospital charges) were also evaluated. The patients were categorized on three groups (Group 1, 2, 3) based on the CFS.

Results:

A total of 51 pT4 RC patients were included in the study. Mean age was 75.6 years. Early mortality rate at 30 days after surgery was low all the groups. One year mortality rate was higher in Group 2 (22%) and 3 (69%). The length of stay and the number of patients with respiratory complications were also higher in the frailer groups. 30 days readmission rate was 22% in Group 2 and 38% in Group 3.

Conclusions:

Preoperative frailty is associated with worse postoperative results after RC. CFS is an objective tool for patient risk stratification and can predict postoperative complications and mortality.

Juxtaglomerular cell tumour of the kidney: a rare cause of resistant hypertension

SUMMARY

Juxtaglomerular cell tumour (JGCT) is an unusually encountered clinical entity. A 33-year-old man with severe long-standing hypertension and hypokalaemia is described. The patient also suffered from polyuria, polydipsia, nocturia and severe headaches. On admission, laboratory investigation revealed hypokalaemia, kaliuresis, high aldosterone and renin levels, and the abdomen CT identified a mass of 4 cm at the right kidney. Kidney function was normal. Following nephrectomy, the histological investigation revealed the presence of a JGCT. Immunostaining was positive for CD34 as well as for smooth muscle actin and vimentin. Following surgery, a marked control of his hypertension with calcium channel blockers and normalization of the serum potassium, renin or aldosterone levels were reached. According to our findings, JGCT could be included in the differential diagnosis of secondary hypertension as it consists of a curable cause. The association of JGCT with hypertension and hypokalaemia focusing on the clinical presentation, diagnostic evaluation and management is herein discussed and a brief review of the existing literature is provided.

LEARNING POINTS

Juxtaglomerular cell tumours (JGCT), despite their rarity, should be included in the differential diagnosis of secondary hypertension as they consist of a curable cause of hypertension. JGCT could be presented with resistant hypertension along with hypokalaemia, kaliuresis and metabolic alkalosis. Early recognition and management can help to prevent cardiovascular complications. Imaging (enhanced CT scans) may be considered as the primary diagnostic tool for the detection of renal or JGCT. For the confirmation of the diagnosis, a histopathologic examination is needed.

Relugolix: A new kid on the block among gonadotrophin-releasing hormone antagonists

Androgen-deprivation therapy (ADT) is the cornerstone of metastatic prostate cancer treatment. ADT can be achieved through surgical castration, or it may be induced either by gonadotrophin-releasing hormone (GnRH) agonists or GnRH antagonists. GnRH antagonists provide a more rapid castration alongside with a safer profile regarding adverse events. Degarelix is the sole GnRH antagonist used in clinical practice. Injection site reactions are the commonest adverse events related to the use of degarelix. Relugolix, a novel molecule, represents the first orally administered United States Food and Drug Administration approved GnRH antagonist, with clinical efficacy equal to that of the established ADT regimens. The main advantages of relugolix are the avoidance of the injection site reactions of GnRH antagonists such as degarelix alongside its patient-friendly oral administration. The aim of the present review article is to present novel data regarding the role of relugolix as ADT for the treatment of prostate cancer.

Abbreviations: ADT: androgen-deprivation therapy; FDA: United States Food and Drug Administration

Association of metabolic syndrome with prostate cancer diagnosis and aggressiveness in patients undergoing transrectal prostate biopsy

INTRODUCTION AND OBJECTIVE

Even though the only established risk factors for prostate cancer (PCa) are age, ethnic origin and family history, there are data suggesting that environmental factors, such as the presence of metabolic syndrome (MetS), may also play a role in the etiology of the disease. The aim of this study is to correlate MetS with PCa diagnosis and Gleason score (GS) in patients undergoing transrectal ultrasound guided prostate biopsy.

MATERIALS AND METHODS

This is a prospective, single-center study including 378 patients who underwent transrectal ultrasound guided prostate biopsy in our department during the years from 2018 to 2019. Patients were divided into two groups according to the presence of PCa. Group A included 197 patients diagnosed with PCa while Group B consisted of 181 patients without PCa in their biopsy result. Multiple variables such as the presence of MetS and its components were evaluated in correlation to the presence of PCa and PCa characteristics. Statistical analysis was performed using the IBM SPSS Statistics v.23 program.

RESULTS

Mean PSA value was 8.7 ng/dl in the PCa group and 7.1 ng/dl in the non PCa group, respectively. MetS was diagnosed in 108 patients (54.8%) with PCa and 80 patients (44.2%) without PCa and the difference was statistically significant. Hypertriglyceridemia was the MetS component with statistically higher frequency in PCa patients. Furthermore, the prevalence of MetS was higher in higher Gleason score PCa (GS ≥ 4+3) patients vs lower Gleason score PCa (GS ≤ 3+4) patients. More specifically, MetS, hypertriglyceridemia, and low HDL levels were independent factors associated with higher Gleason score PCa (GS ≥ 4+3).

CONCLUSIONS

Patients suffering from MetS who undergo prostate biopsy present with higher rates of PCa diagnosis and higher GS in comparison with patients with a normal metabolic profile.

Novel treatments in BCG failure. Where do we stand today?

Most patients at first diagnosis of bladder cancer (BC) present with non muscle invasive disease (NMIBC). BCG intravesical therapy after transurethral resection of the bladder tumor is the gold standard in intermediate and high risk NMIBC patients. However, it is estimated that approximately 50% of these patients will present with BCG failure which increases their risk for progression to muscle invasive disease. Currently, the best option for these patients is radical cystectomy. Thus, it is of great interest to pursue new, therapeutic options for BCG failure patients to avoid the necessity of radical cystectomy. We hereby review novel treatment modalities for BCG failure patients. METHODS: This is a narrative review. Keywords for the search were BCG failure, BCG unresponsive, BCG refractory, BCG relapsing and BCG intolerance. Evidence was identified through a search for publications with a ''BCG unresponsive'' tag through 2020. Studies were selected if they contained clinical data on BCG unresponsive therapeutics with near-term availability. Clinical trial landscape evaluation for emerging therapies was performed by searching ClinicalTrials.gov for recruiting/ open interventional trials in 2020. RESULTS: Novel treatment modalities for BCG failure include intravesical chemotherapy, BCG re-challenge or combination of BCG with IFN-α2β, valrubicin, radiotherapy, electromotive drug administration, vicinium, chemohyperthermia, photodynamic therapy, gene therapy, vaccine therapy and immunotherapy. For patients in whom BCG has once failed a repeat course of BCG or BCG plus interferon appears to be a reasonable practice. Likewise, single agent gemcitabine may be considered a treatment modality. However, after 2 or more BCG failures, especially in patients with earlier relapses or cancer persistence, single agent intravesical chemotherapy with valrubicin, gemcitabine or docetaxel appears to be less active than doublet/triplet intravesical chemotherapy or mitomycin chemothermotherapy. Gene therapy or conjugated antibodies may play a role upon further relapse. Single agent pembrolizumab is unlikely to be used as first line, but may be useful, along with multiple new immunotherapeutics, as part of a multimodal approach towards BCG unresponsive disease. CONCLUSIONS: Results from ongoing trials will provide us useful information about many of the existing regimens and probably new drugs will soon be available for this group of patients.

Urology residency training in Greece. Results from the first national resident survey

BACKGROUND AND OBJECTIVES

This is the first national survey assessing Greek Urology residency programs. The main objective of this study is to assess the level of confidence and perception of Greek Urology residents regarding their educational program and detect areas of improvement.

MATERIAL AND METHODS

A 51-question survey was developed via an electronic platform and answered by 91 out of 104 Greek residents from March 2019 until May 2019. Fisher's exact test, chi-squared test and Kruskal-Wallis test were used with statistical significance set at p=.05.

RESULTS

The median overall satisfaction regarding surgical training was 6/10 regardless of working schedule, working in a University Department, PGY or number of residents in clinic. Most residents have not performed any scrotal ultrasound or pressure-flow-studies; however, they are more familiar with KUB ultrasound. Double-J stent insertion and cystoscopy were common procedures for residents. Bureaucracy was reported as a major issue by 70.4% of residents. ESWL has not been performed by 80.2% of residents, 58.2% residents performed less than 10 ureteroscopies, and only the last year trainees performed more than 10 TURBT and TURP. Most residents mentioned to rarely perform basic steps in many open or laparoscopic urological procedures. Surprisingly, 59.3% of residents have not published any study in peer-reviewed journals. Regarding satisfaction, 44% rarely feel satisfied at work and 59.3% sometimes suffer from burnout. Response rate reached 87.5%.

CONCLUSIONS

Considering the results from this survey, regulatory authorities should join forces to establish a structured curriculum of clinical, surgical and research training in Urology across Europe.

Conservative management of grade 4 and 5 renal injuries: A high-volume trauma center experience

INTRODUCTION

Traumatic renal injuries represent a major public health issue concerning mostly young men. Over the last decades there is growing debate regarding the management of high-grade renal injuries due to the emerging role of conservative treatment. The aim of this study is to present our experience in the conservative management of patients presenting with grade 4 or grade 5 renal injuries in our department.

MATERIAL AND METHODS

In this retrospective, single center study we evaluated data from a total of 57 hemodynamically stable patients who were managed conservatively for grade 4 or grade 5 renal injuries from 2015 to 2019 in our high-volume trauma center. Grading was based on contrast enhanced abdominal computed tomography (CT) scans. Patients managed with immediate nephrectomy due to hemodynamic instability and patients who underwent immediate laparotomy due to concomitant injuries or penetrating wounds were excluded from the study.

RESULTS

A total of 54 patients diagnosed either with grade 4 or grade 5 renal trauma were finally successfully managed conservatively and included in the study. Median age was 34 years. Most patients presented with grade 4 renal trauma while five patients presented with grade 5 renal injury. Concomitant injuries not requiring surgical intervention were present in 48 patients. Continuous renal bleeding was detected in 15 patients (27.8%) and subsequent arterial embolization was performed with no further intervention required. Urine leak was diagnosed in 12 patients treated either by double j stent or by nephrostomy tube.

CONCLUSIONS

Grade 4 and selected cases of grade 5 renal trauma can be treated conservatively with close monitoring and CT scan protocols in hemodynamic stable patients. In cases of continuous bleeding, arterial embolization can be performed. In cases of severe urine leak conservative management is also feasible either by inserting a double j stent or a nephrostomy tube.

Incidental prostate cancer in patients who underwent radical cystectomy for high risk non muscle invasive bladder cancer: Is it clinically significant?

INTRODUCTION AND OBJECTIVE

Non muscle invasive, high-risk, bladder cancer is an entity which is usually treated with radical cystectomy. Incidental prostate cancer refers to prostate cancer detected in radical cystectomy specimens in patients with no signs of the disease. Objective of this study is to report the prevalence, characteristics, and clinical significance of incidental prostate cancer in non-muscle invasive bladder cancer patients treated with radical cystectomy in our department.

MATERIAL AND METHODS

We retrospectively reviewed data from 41 patients who underwent radical cystectomy for non-muscle invasive, high risk, bladder cancer during the years 2016-2020 in our department. Prostate cancer was described as clinically significant when there were positive surgical margins, extraprostatic extension, Gleason score >6, or tumor volume ⩾0.5 cm³. Two groups of patients were formed according to the presence or absence of clinically significant prostate cancer.

RESULTS

Incidental prostate cancer in the cystectomy specimens was detected in 21 of the 35 patients investigated. Clinically significant prostate cancer was detected in five patients. Positive surgical margins and extraprostatic extension were present in one patient, respectively. Gleason score was more than six in four of the five patients and PCa tumor volume was above 0.5 cm³ in three patients. Two patients with clinically significant prostate cancer were diagnosed with biochemical recurrence during their follow up.

CONCLUSIONS

In non-muscle invasive, high-risk patients undergoing radical cystectomy, clinically significant incidental PCa is an important issue as it may affect prognosis, quality of life, metastasis free survival, and overall survival.

Fragility index of urological literature regarding medical expulsive treatment

INTRODUCTION

The role of medical expulsive treatment (MET) is controversial. Fragility index is an additional metric to assess randomized controlled trials (RCTs) outcome validity and indicates how many patients would be required to convert a trial from being statistically significant, to not significant. The larger is the FI, the better the trial's data. The aim of this study is to assess FI of RCTs regarding MET for ureteral stones.

MATERIALS AND METHODS

A systematic literature search was performed. RCTs, reporting stone expulsion as a dichotomous outcome, showing statistical significance were eligible. FI (the number of patients needed to change from a non-event to event group, to lose statistical significance) and Fragility quotient (FI divided by total sample size), were calculated while Pearson's correlation and Mann-Whitney U test were used as appropriate.

RESULTS

Thirty-six RCTs were eligible, with median FI = 3.5 and fragility quotient = 0.042, median sample size = 81, median journal impact factor = 1.73 and median reported p value = 0.008. In 33.3% of the studies, number of patients lost during follow-up was larger than FI, while in 13.89% of the studies, FI was 0, indicating use of inappropriate statistical method. Pearson's correlation showed significant positive association between FI and sample size (r = 0.981), number of events (r = 0.982) and impact factor (r = 0.731), while no association was found with p value or publication year.

CONCLUSIONS

In this analysis, a calculated FI of 3.5 indicates that findings from RCTs on MET for ureteral stones are fragile and should be interpreted in combination with clinical thinking and expertise.

Clinical impact of combined PTEN and ERG rearrangements in localized prostate cancer

To the Editor, Prostate cancer (PCa) is nowadays the second most common malignancy diagnosed among men and is responsible for one of the leading causes of cancer mortality. Clinically localized disease may present with a wide variety of clinical behavior including tumors of low clinical significance as well as highly aggressive ones. Among patients treated with either radical prostatectomy or radiotherapy there is a risk of biochemical failure (BF). As a result, it is of outmost interest to develop new markers predicting the risk of BF development.

Oncology and complications

This collection of cases describes some unusual urological tumors and complications related to urological tumors and their treatment. Case 1: A case of uretero-arterial fistula in a patient with long-term ureteral stenting for ureteral oncological stricture and a second case associated to retroperitoneal fibrosis were described. Abdominal CT, pyelography, cystoscopy were useful to show the origin of the bleeding. Angiography is useful for confirming the diagnosis and for subsequent positioning of an endovascular prosthesis which represents a safe approach with reduced post-procedural complications. Case 2: A case of patient who suffered from interstitial pneumonitis during a cycle of intravesical BCG instillations for urothelial cancer. The patient was hospitalized for more than two weeks in a COVID ward for a suspected of COVID-19 pneumonia, but he did not show any evidence of SARS-CoV-2 infection during his hospital stay. Case 3: A case of a young man with a functional urinary bladder paraganglioma who was successfully managed with complete removal of the tumor, leaving the urinary bladder intact. Case 4: A case of a 61 year old male suffering from muscle invasive bladder cancer who was admitted for a radical cystectomy and on the eighth postoperative day developed microangiopathic hemolytic anemia and thrombocytopenia, which clinically defines thrombotic microangiopathy.

Oncological cases and complications in Urology

This collection of cases describes some unusual urological tumors and complications related to urological tumors and their treatment. Case 1: A case of left hydronephrosis referred four years after a right radical mastectomy for lobular breast carcinoma was described. Computed tomography scan revealed a left hydronephrosis with dilated ureter up to the proximal third. An exploratory laparoscopy was performed and the definitive histopathology examination showed a recurrence of the carcinoma with a right tubal metastasis and peritoneal carcinosis. Case 2: A rare case of an extensive penile squamous cell carcinoma in a young man. The patient was treated with radical surgery and modified inguinal lymphadenectomy. No recurrence was noticed so far. Case 3: A rare case of left sided Inferior Vena Cava (IVC) in a patient diagnosed with renal cell cancer who underwent open left partial nephrectomy. Case 4: A case of urethrorrhagia, caused by a recent trauma from an urinary catheter placed in a patient submitted to gastric resection due to a neoplastic pathology. Urethrorrhagia only temporarily responded to conservative treatment and ultimately resolved by coagulation with an endoscopic approach.

Collision kidney tumor with clear cell renal cell carcinoma and papillary type 1 renal cell carcinoma. A case report and review of the literature

INTRODUCTION

The most common renal neoplasms include clear cell, papillary, and chromophobe renal cell carcinomas. The simultaneous occurrence of different histological types of adjacent neoplasms in the same organ is known as a collision tumor. Collision kidney tumors have already been described but only in rare cases.

CASE DESCRIPTION

In this case report we present a 68-year-old man with chronic kidney insufficiency under dialysis who underwent an open right nephrectomy in our department with the histological diagnosis of a collision kidney tumor consisting of clear cell and papillary type 1 renal cell carcinoma.

CONCLUSION

To the best of our knowledge, our case of a collision kidney tumor consisting of clear cell RCC and papillary type 1 RCC, is unique in literature.

"Lock-down'' for COVID-19 has ''locked up'' Urological emergencies in Greece

Over the last couple of months physicians world wide are struggling to prevent the novel coronavirus (COVID-19) spread all over the world. It has become obvious that our health care systems should under go modifications in order to successfully confront similar pandemics, since this is considered the ''century of pandemics'', due to the high incidence of new virus attacks with expressly high virulence (Hong Kong flu in 1968, AIDS, SARS in 2002, H1N1 pandemic in 2009, MERS in 2012 and COVID-19 in 2020) (1).

Does radical prostatectomy result in lower urinary tract symptom improvement in high-risk and locally advanced prostate cancer? A Single-center experience

PURPOSE

Radical prostatectomy represents the most popular method of prostate cancer treatment, including cases with high-risk and locally advanced cancer. Besides, men with this disease often experience lower urinary tract symptoms (LUTS) and report high International Prostate Symptom Scores (IPSS), pathological post-void residual (PVR) urine volumes and low levels of maximum urinary flow rates (Qmax). In this study we assessed the effect of radical prostatectomy on the above parameters in patients with high-risk and locally advanced disease.

METHODS

A number of 240 individuals were enrolled in the study. Patients that required any post-operative manipulation up to the completion of 12 months after surgery were excluded. All patients were assessed pre- and post-operatively at 3, 6 and 12 months. Evaluation included IPSS, Qmax and PVR.

RESULTS

Mean age was 66.8 years. Mean PSA value was 12.7 ng/ml and mean Gleason score was 7.9. At baseline 41.3% of the patients had Qmax ⩽10 and 42.5% had IPSS >8. There was a significant increase in Qmax during the follow-up (median value was 12 at baseline and increased to 21 at 12 months). Also, IPSS and PVR decreased significantly during the follow-up. IPSS median value decreased from 9 at baseline to 5 at 12 months. Improvement was observed in all grades of symptoms.