Kidney-sparing surgery has equivalent oncological outcomes to radical nephroureterectomy for ureteral urothelial carcinoma

INTRODUCTION AND OBJECTIVE

Kidney-sparing surgery (KSS) for upper tract urothelial cancer (UTUC) has gained increasing interest recently. However, there is limited contemporary data regarding the role of KSS in ureteral urothelial carcinoma. Therefore, we investigated the survival outcomes of ureteral urothelial carcinoma after KSS from a large prospective international UTUC registry.

METHODS

The Clinical Research Office of the Endourology Society-Urothelial Carcinomas of the Upper Tract (CROES-UTUC) Registry included UTUC patients who received KSS or radical nephroureterectomy (RNU) between 2014 and 2019. In this study, we included patients with ureteral UTUC only. Study outcomes included overall survival (OS), cancer-specific survival (CSS), upper tract recurrence-free survival (RFS), intravesical RFS, progression-free survival (PFS), and metastasis-free survival (MFS). Propensity score matching (PSM) was performed to balance the tumour features' differences between groups.

RESULTS

Of 391 patients with ureteral UTUC, 309 (79.0%) received RNU, and 82 (21.0%) received KSS by ureteroscopy with laser ablation (n=28) or segmental resection (n=54). After PSM, there were no differences in OS (p=0.525), CSS (p=0.487), upper tract RFS (p=0.147), intravesical RFS (p=0.989), PFS (p=0.617), and MFS (p=0.336) between KSS and RNU. Both ureteroscopic ablation and segmental resection had similar OS, CSS, intravesical RFS, PFS, and MFS with RNU. Proximal ureteral UTUC had worse OS and CSS outcomes than other tumour locations following segmental resection.

CONCLUSIONS

In patients with ureteral UTUC, no significant differences in long-term survival outcomes were observed between KSS and RNU. Proximal ureteral UTUC had worse survival outcomes over other tumour locations following segmental resection.

Effect of Focal Zone Size on Treatment Outcomes and Renal Injury Following Extracorporeal Shockwave Lithotripsy of Renal Calculi: A Prospective Randomized Study

Background: The narrower focal zone (FZ) size of modern lithotripter was considered as one of the factors that resulted in suboptimal treatment result of extracorporeal shockwave lithotripsy (SWL). Therefore, we investigate the efficacy and safety of standard narrow or extended (FZ) sizes in SWL for patients with renal stones. Materials and Methods: In this prospective study conducted between April 2018 and October 2022, patients with renal stones were randomized to receive SWL with either standard or extended FZ. Treatment was delivered using a Modulith SLX-F2 lithotripter with a maximum of 3000 shocks at 1.5 Hz. The primary outcome was treatment success 12 weeks after a single SWL session, defined as the absence of a stone or stone fragment <4 mm on computed tomography. Secondary outcomes included the incidence of perinephric hematoma, stone-free rate (SFR), and changes in the urinary levels of acute renal injury markers. Results: A total of 320 patients were recruited, and 276 patients were randomized into the two groups. The two groups had similar baseline parameters. The treatment success rate was significantly better for standard FZ (74.3%) than the extended FZ group (59.3%) (p = 0.009). Standard FZ also had a significantly better SFR (Grade-A, 36.8% vs 23.0%, p = 0.013) and less pain after treatment. Both groups had similar perinephric hematoma formation rates, unplanned hospital admission rates, and changes in urinary acute renal injury markers. Conclusions: The standard narrow FZ has better treatment efficacy and similar safety compared with the extended FZ during SWL for renal stones. This clinical trial has been registered in the public domain (CCRBCTR) under trial number CUHK_CCRB00510.

Risk prediction of bladder cancer among person with diabetes: A derivation and validation study

AIMS

This study aimed to devise and validate a clinical scoring system for risk prediction of bladder cancer to guide urgent cystoscopy evaluation among people with diabetes.

METHODS

People with diabetes who received cystoscopy from a large database in the Chinese population (2009-2018). We recruited a derivation cohort based on random sampling from 70% of all individuals. We used the adjusted odds ratios (aORs) for independent risk factors to devise a risk score, ranging from 0 to 5: 0-2 'average risk' (AR) and 3-5 'high risk' (HR).

RESULTS

A total of 5905 people with diabetes, among whom 123 people with BCa were included. The prevalence rate in the derivation (n  = 4174) and validation cohorts (n  = 1731) was 2.2% and 1.8% respectively. Using the scoring system constructed, 79.6% and 20.4% in the derivation cohort were classified as AR and HR respectively. The prevalence rate in the AR and HR groups was 1.57% and 4.58% respectively. The risk score consisted of age (18-70: 0; >70: 2), male sex (1), ever/ex-smoker (1) and duration of diabetes (≥10 years: 1). Individuals in the HR group had 3.26-fold (95% CI = 1.65-6.44, p  = 0.025) increased prevalence of bladder than the AR group. The concordance (c-) statistics was 0.72, implying a good discriminatory capability of the risk score to stratify high-risk individuals who should consider earlier cystoscopy.

CONCLUSIONS

The risk prediction algorithm may inform urgency of cystoscopy appointments, thus allowing a more efficient use of resources and contributing to early detection of BCa among people planned to be referred.

A systematic review and meta-analysis of artificial intelligence diagnostic accuracy in prostate cancer histology identification and grading

BACKGROUND

Artificial intelligence (AI) is a promising tool in pathology, including cancer diagnosis, subtyping, grading, and prognostic prediction.

METHODS

The aim of the study is to assess AI application in prostate cancer (PCa) histology. We carried out a systematic literature search in 3 databases. Primary outcome was AI accuracy in differentiating between PCa and benign hyperplasia. Secondary outcomes were AI accuracy in determining Gleason grade and agreement among AI and pathologists.

RESULTS

Our final sample consists of 24 studies conducted from 2007 to 2021. They aggregate data from roughly 8000 cases of prostate biopsy and 458 cases of radical prostatectomy (RP). Sensitivity for PCa diagnostic exceeded 90% and ranged from 87% to 100%, and specificity varied from 68% to 99%. Overall accuracy ranged from 83.7% to 98.3% with AUC reaching 0.99. The meta-analysis using the Mantel-Haenszel method showed pooled sensitivity of 0.96 with I2 = 80.7% and pooled specificity of 0.95 with I2 = 86.1%. Pooled positive likehood ratio was 15.3 with I2 = 87.3% and negative - was 0.04 with I2 = 78.6%. SROC (symmetric receiver operating characteristics) curve represents AUC = 0.99. For grading the accuracy of AI was lower: sensitivity for Gleason grading ranged from 77% to 87%, and specificity from 82% to 90%.

CONCLUSIONS

The accuracy of AI for PCa identification and grading is comparable to expert pathologists. This is a promising approach which has several possible clinical applications resulting in expedite and optimize pathology reports. AI introduction into common practice may be limited by difficult and time-consuming convolutional neural network training and tuning.

The impact of body mass index on oncological and surgical outcomes of patients undergoing nephrectomy: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis to evaluate the impact of body mass index (BMI) on oncological (primary) and surgical (secondary) outcomes of patients who underwent nephrectomy, as obesity or high BMI is a known risk factor for renal cell carcinoma (RCC) and predictor of poorer outcomes.

METHODS

Studies were identified from four electronic databases from database inception to 2 June 2021, according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. The review protocol was registered in the International Prospective Register of Systematic Reviews with the identification number: CRD42021275124.

RESULTS

A total of 18 studies containing 13 865 patients were identified for the final meta-analysis. Regarding oncological outcomes, higher BMI predicted higher overall survival (BMI >25 vs BMI <25 kg/m2 : hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.58-0.85), cancer-specific survival (BMI >25 vs BMI <25 kg/m2 : HR 0.60, 95% CI 0.50-0.73; BMI 25-30 vs BMI <25 kg/m2 : HR 0.46, 95% CI 0.23-0.95; BMI >30 vs BMI <25 kg/m2 : HR 0.50, 95% CI 0.36-0.69), and recurrence-free survival rates (BMI >25 vs BMI <25 kg/m2 : HR 0.72, 95% CI 0.63-0.82; BMI 25-30 vs BMI <25 kg/m2 : HR 0.59, 95% CI 0.42-0.82). Those with a lower BMI fared better in surgical outcomes, such as operation time and warm ischaemic time, although the absolute difference was minimal and unlikely to be clinically significant. There was no difference between groups for length of hospital stay, intraoperative or postoperative complications, blood transfusion requirements, and conversion to open surgery.

CONCLUSION

Our study suggests that a higher BMI is associated with improved long-term oncological survival and similar perioperative outcomes as a lower BMI. More research into the underlying biological and physiological mechanisms will enable better understanding of the effect of BMI, beyond mere association, on post-nephrectomy outcomes.

Comparing Robotic-Assisted to Open Radical Cystectomy in the Management of Non-Muscle-Invasive Bladder Cancer: A Propensity Score Matched-Pair Analysis

BACKGROUND

For non-muscle-invasive bladder cancer (NMIBC) requiring radical surgery, limited data are available comparing robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) to open radical cystectomy (ORC). The objective of this study was to compare the two surgical techniques.

METHODS

A multicentric cohort of 593 patients with NMIBC undergoing iRARC or ORC between 2015 and 2020 was prospectively gathered. Perioperative and pathologic outcomes were compared.

RESULTS

A total of 143 patients operated on via iRARC were matched to 143 ORC patients. Operative time was longer in the iRARC group (p = 0.034). Blood loss was higher in the ORC group (p < 0.001), with a consequent increased post-operative transfusion rate in the ORC group (p = 0.003). Length of stay was longer in the ORC group (p = 0.007). Post-operative complications did not differ significantly (all p > 0.05). DFS at 60 months was 55.9% in ORC and 75.2% in iRARC with a statistically significant difference (p = 0.033) found in the univariate analysis.

CONCLUSION

We found that iRARC for patients with NMIBC is safe, associated with a lower blood loss, a lower transfusion rate and a shorter hospital stay compared to ORC. Complication rates were similar. No significant differences in survival analyses emerged across the two techniques.

Cross-cultural translation into Chinese and psychometric evaluation of a screening tool for nocturia: the Targeting the individual's Aetiology of Nocturia to Guide Outcomes (TANGO) questionnaire

INTRODUCTION

We conducted translation and psychometric validation of a self-administered, 22-item dichotomous response-based questionnaire to identify nocturia aetiologies and co-morbidities in adult patients.

METHODS

The Targeting the individual's Aetiology of Nocturia to Guide Outcomes (TANGO) questionnaire was forward- and backward-translated, then finalised using a standardised methodology. The resulting version, a Chinese version of the TANGO [TANGO (CV)], was evaluated for internal consistency, test-retest reliability, content validity, convergent validity, criterion validity, and discriminant validity via responses from 65 participants (46 men and 19 women; mean age, 67 years, range, 50-88), in comparison with other validated questionnaires and a 4-day bladder/sleep diary.

RESULTS

Only 0.4% of responses were missing; 3% of participants required assistance with comprehension. The Kuder-Richardson Formula 20 (KR-20) coefficient for the whole tool was 0.711. Kappa values for individual domains and the whole tool varied from 0.871 to 0.866, indicating satisfactory test-retest reliability. There was strong agreement between the sum of positive responses to each domain and the whole tool (intra-class correlation coefficient=0.878-1.000). Modest correlations (ρ=0.4-0.6) were detected between the tool and bladder/sleep diary-based parameters for convergent validity. Criterion validity was confirmed for each domain and the whole tool [ρ=0.287-0.687]. In receiver operating characteristic analysis, the tool could distinguish patients (≥2 nocturia episodes/night) from controls (≤1 nocturia episode/night) [Youden's J statistic=0.453, area under the curve=0.818, 95% confidence interval (CI)=0.683-0.953] and patients with significant nocturia distress from patients with mild nocturia distress (Youden's J statistic=0.398, area under the curve=0.729, 95% CI=0.581-0.878).

CONCLUSION

The TANGO (CV) was formally crossculturally adapted and translated. Its psychometric properties (except sensitivity to change) were validated.

Disease-related complications in patients with metastatic hormone-sensitive prostate cancer

INTRODUCTION

Prostate-specific antigen-based screening for prostate cancer reportedly does not improve cancer-specific survival. However, there remain concerns about the increasing incidence of advanced disease at initial presentation. Here, we investigated the incidences and types of complications that occur during the course of disease in patients with metastatic hormone-sensitive prostate cancer (mHSPC).

METHODS

This study included 100 consecutive patients who were diagnosed with mHSPC at five hospitals from January 2016 to August 2017. Analyses were conducted using patient data extracted from a prospectively collected database, along with information about complications and readmission obtained from electronic medical records.

RESULTS

The median patient age was 74 years and the median serum prostate-specific antigen level at diagnosis was 202.5 ng/mL. Ninety-nine patients received androgen deprivation therapy; 17 of these patients also received chemotherapy. During a mean follow-up period of 32.9 months, 41 patients reported bone pain; of these patients, 21 developed pathologic fractures and eight had cord compression. Twenty-eight patients developed retention of urine; of these patients, 10 (36%) required surgery and 11 (39%) required long-term urethral catheter use. Among 15 patients who developed ureteral obstruction, four (27%) required ureteral stenting and four (27%) required long-term nephrostomy drainage. Other complications included anaemia (41%) and deep vein thrombosis (4%). Fifty-nine (59%) patients had ≥1 unplanned hospital admission during the course of disease; 16% of such patients had >5 episodes of readmission.

CONCLUSION

Among patients with mHSPC, 70% experienced disease-related complications and unplanned hospital admissions, which substantially burdened both patients and the healthcare system.

Public awareness of preventive measures against COVID-19: an infodemiology study

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has led to an increase in global awareness of relevant public health preventive measures. This awareness can be explored using online search trends from major search engines, such as Google Trends. We investigated the relationship between public awareness of preventative measures and progression of the COVID-19 pandemic.

METHODS

Search data for five queries ('mask', 'hand washing', 'social distancing', 'hand sanitizer', and 'disinfectant') were extracted from Google Trends in the form of relative search volume (RSV). Global incidence data for COVID-19 were obtained from 1 January to 30 June 2020. These data were analysed and illustrated using a global temporal RSV trend diagram, a geographical RSV distribution chart, scatter plots comparing geographical RSV with average number of daily cases, and heat maps comparing temporal trends of RSV with average number of daily cases.

RESULTS

Global temporal trends revealed multiple increases in RSV, associated with specific COVID-19-related news events. The geographical distribution showed top regions of interest for various preventive measures. For the queries 'mask', 'hand washing', 'hand sanitizer', and 'disinfectant', heat maps demonstrated patterns of early RSV peaks in regions with lower average number of daily cases, when the temporal element was incorporated into the analysis.

CONCLUSION

Early public awareness of multiple preventive measures was observed in regions with lower average number of daily cases. Our findings indicate optimal public health communication regarding masks, hand washing, hand sanitiser, and disinfectant in the general population during early stages of the COVID-19 pandemic. Early public awareness may facilitate future disease control efforts by public health authorities.

Time for change? Feasibility of introducing micromodules into medical student education: a randomised controlled trial

INTRODUCTION

Didactic lectures have been the foundation of learning for many medical students. However, in recent years, the flipped classroom model has become increasingly popular in medical education. This approach enhances pre-class learning, allowing the limited contact time between clinicians and medical students to be focused on practical issues. This study evaluated the effectiveness and non-inferiority of online micromodule teaching in terms of knowledge transfer concerning specific urology topics.

METHODS

Medical students without prior exposure to the urology subspecialty were enrolled in the study, then randomised to a traditional didactic lecture group or an online micromodule group. Knowledge transfer was assessed by pre-intervention and post-intervention multiple-choice questions and objective structured clinical examinations that involved the acquisition of medical histories from real patients.

RESULTS

In total, 45 medical students were enrolled (22 in the traditional didactic group and 23 in the online micromodule group). In terms of knowledge transfer (assessed by objective structured clinical examinations), the efficacy of online micromodules was comparable to traditional didactic lectures, although the difference was not statistically significant (P=0.823). There were no significant differences in terms of knowledge acquisition, retention, or clinical application between the two groups.

CONCLUSION

In terms of acquiring, retaining, and applying foundational urological knowledge, online micromodules can help medical students to achieve outcomes comparable with the outcomes of didactic lectures. Online micromodules may be a viable alternative to traditional didactic lectures in urology education.

Fragmentation landscape of cell-free DNA revealed by deconvolutional analysis of end motifs

Cell-free DNA (cfDNA) fragmentation is nonrandom, at least partially mediated by various DNA nucleases, forming characteristic cfDNA end motifs. However, there is a paucity of tools for deciphering the relative contributions of cfDNA cleavage patterns related to underlying fragmentation factors. In this study, through non-negative matrix factorization algorithm, we used 256 5' 4-mer end motifs to identify distinct types of cfDNA cleavage patterns, referred to as "founder" end-motif profiles (F-profiles). F-profiles were associated with different DNA nucleases based on whether such patterns were disrupted in nuclease-knockout mouse models. Contributions of individual F-profiles in a cfDNA sample could be determined by deconvolutional analysis. We analyzed 93 murine cfDNA samples of different nuclease-deficient mice and identified six types of F-profiles. F-profiles I, II, and III were linked to deoxyribonuclease 1 like 3 (DNASE1L3), deoxyribonuclease 1 (DNASE1), and DNA fragmentation factor subunit beta (DFFB), respectively. We revealed that 42.9% of plasma cfDNA molecules were attributed to DNASE1L3-mediated fragmentation, whereas 43.4% of urinary cfDNA molecules involved DNASE1-mediated fragmentation. We further demonstrated that the relative contributions of F-profiles were useful to inform pathological states, such as autoimmune disorders and cancer. Among the six F-profiles, the use of F-profile I could inform the human patients with systemic lupus erythematosus. F-profile VI could be used to detect individuals with hepatocellular carcinoma, with an area under the receiver operating characteristic curve of 0.97. F-profile VI was more prominent in patients with nasopharyngeal carcinoma undergoing chemoradiotherapy. We proposed that this profile might be related to oxidative stress.

Adverse metabolic consequences of androgen deprivation therapy (ADT) on Asian patients with prostate cancer: Primary results from the real-life experience of ADT in Asia (READT) study

BACKGROUND

Androgen deprivation therapy (ADT) use in prostate cancer (PCa) has seen a rising trend. We investigated the relationship between ADT and adverse changes in metabolic parameters in an Asian population.

METHODS

This is an international prospective multicenter single-arm cohort yielded from the real-life experience of ADT in Asia (READT) registry. Consecutive ADT-naïve patients diagnosed of PCa and started on ADT were prospectively recruited from 2016 and analyzed. Baseline patient characteristics, PCa disease status, and metabolic parameters were documented. Patients were followed up at 6-month interval for up to 5 years. Metabolic parameters including body weight, lipid profiles, and glycemic profiles were recorded and analyzed.

RESULTS

589 patients were eligible for analysis. ADT was associated with adverse glycemic profiles, being notable at 6 months upon ADT initiation and persisted beyond 1 year. Comparing to baseline, fasting glucose level and hemoglobin A1c level increased by 4.8% (p < 0.001) and 2.7% (p < 0.001), respectively. Triglycerides level was also elevated by 16.1% at 6th month and by 20.6% at 12th month compared to baseline (p < 0.001). Mean body weight was 1.09 kg above baseline at 18th month (p < 0.001).

CONCLUSION

ADT was associated with adverse metabolic parameters in terms of glycemic profiles, lipid profiles, and body weight in the Asian population. These changes developed early in the treatment and can persist beyond the first year. Regular monitoring of the biochemical profiles during treatment is paramount in safeguarding the patients' metabolic health.

Comparison of Low-Power vs High-Power Holmium lasers in pediatric RIRS outcomes

OBJECTIVES

to compare the outcomes of using low-power (up to 30W) vs high-power (up to 120W) holmium lasers in retrograde intrarenal surgery (RIRS) in children and to analyse if lasering techniques and the use of access sheath have any influence on the outcomes.

METHODS

We retrospectively reviewed data from 9 centres of children who underwent RIRS with holmium laser for the treatment of kidney stones between January 2015 and December 2020. Patients were divided into two groups: high-power and low-power holmium laser. Clinical, perioperative variables and complications were analysed. Outcomes were compared between groups using Student's T-test for continuous variables, and Chi-square and Fisher's exact test for categorical variables. A multivariable logistic regression analysis model was also performed.

RESULTS

314 patients were included. A high-power and low-power holmium laser was used in 97 and 217 patients, respectively. Clinical and demographic variables were comparable between both groups, except for stone size where the low-power group treated larger stones (mean 11.11 mm vs 9.70 mm; p 0.018). In the high-power laser group, a reduction in surgical time was found (mean 64.29 min vs 75.27 min; p 0.018) with a significantly higher stone-free rate (SFR) (mean 81.4% vs 59%; p <0.001). We found no statistical differences in complication rates. The multivariate logistic regression model showed lower SFR in the low-power holmium group, especially with larger (p = 0.011) and multiple stones (p < 0.001).

CONCLUSION

Our real-world pediatric multicenter study favours high-power holmium laser and establishes its safety and efficacy in children.  .

Systematic review and meta-analysis of ketamine-associated uropathy

INTRODUCTION

This systematic review and meta-analysis focused on the literature regarding ketamine-associated uropathy to summarise its clinical manifestations, the results of urological assessments, and current management.

METHODS

A literature search was conducted using keywords and MeSH terms related to ketamine abuse, urinary tracts, and urological examinations. Databases including Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched up to 26 June 2020.

RESULTS

In total, 1365 articles were retrieved; 45 articles (4921 patients) were included in the analysis of patient demographics, clinical manifestations, examination results, and treatments. Frequency was the most common manifestation (pooled prevalence 77.1%, 95% confidence interval [CI]=56.9%-92.2%), followed by urgency (69.9%, 95% CI=48.8%-87.3%) and suprapubic pain (60.4%, 95% CI=35.3%-82.9%). Upper urinary tract involvement was less common; the pooled prevalence of hydronephrosis was 30.2% (95% CI=22.0%-39.2%). Further workup revealed a pooled functional bladder capacity of 95.23 mL (95% CI=63.57-126.88 mL), pooled voided volume of 113.31 mL (95% CI=59.44- 167.19 mL), and pooled maximum urine flow rate of 8.69 mL/s (95% CI=5.54-11.83 mL/s). Cystoscopic examinations and bladder biopsy revealed frequent urothelial denudation, inflammatory changes, and inflammatory cell infiltration. Treatments included oral medications for symptomatic relief, intravesical therapy, and surgery (eg, hydrodistension and bladder reconstruction), but ketamine abstinence was necessary for improvement.

CONCLUSION

Ketamine-associated uropathy frequently involves frequency, urgency, and suprapubic pain; upper urinary tract involvement is less common. Affected patients showed reductions in bladder capacity and urine flow rate. Endoscopic and histological analyses often revealed cystitis. Despite variations in treatment, ketamine abstinence is important for all patients with ketamine-associated uropathy.

Reassessment of the Efficacy of Carboplatin for Metastatic Urothelial Carcinoma in the Era of Immunotherapy: A Systematic Review and Meta-analysis

CONTEXT

Platinum-based combination chemotherapy is the standard treatment for advanced or metastatic urothelial carcinoma (AMUC). However, data comparing the efficacy of different platinum agents are limited.

OBJECTIVE

This review aimed to assess the efficacy of carboplatin as a first-line treatment for AMUC using phase 3 randomized trial data.

EVIDENCE ACQUISITION

Multiple databases were searched for articles published until August 2021. Studies that compared overall survival (OS), complete response (CR), and objective response rates (ORRs) in chemotherapy-eligible patients with AMUC were deemed eligible.

EVIDENCE SYNTHESIS

Four studies were included. Compared with immune checkpoint inhibitor (ICI) monotherapy, neither cisplatin- nor carboplatin-based chemotherapy was associated with significant OS (hazard ratio [HR]: 0.97, 95% confidence interval [CI]: 0.85-1.11, p = 0.64 and HR: 0.90, 95% CI: 0.78-1.04, p = 0.16, respectively) and CR (odds ratio [OR]: 1.16, 95% CI: 0.70-1.92, p = 0.57 and OR: 0.89, 95% CI: 0.52-1.53, p = 0.67, respectively benefits, while both were associated with a favorable ORR (OR: 0.54, 95% CI: 0.40-0.74, p < 0.001 and OR: 0.58, 95% CI: 0.42-0.80, p < 0.001, respectively). A network meta-analysis (NMA)-based indirect comparison between carboplatin and cisplatin revealed that while cisplatin was slightly better than carboplatin in terms of OS, CR, and ORR, no significant difference was noted.

CONCLUSIONS

Cisplatin- and carboplatin-based chemotherapies offer similar OS/CR benefits to ICI monotherapy and elicit a greater ORR than ICI monotherapy. Moreover, our NMA demonstrated that both cisplatin- and carboplatin-based chemotherapy have a similar efficacy in terms of OS, CR, and ORR. Given that carboplatin-based chemotherapy is shown to be more effective in contemporary series than in historical controls, it is strongly recommended that carboplatin be re-examined for its value in the era of ICIs and beyond.

PATIENT SUMMARY

Cisplatin- as well as carboplatin-based chemotherapy is as effective as immune checkpoint inhibitors in terms of survival and eliciting a positive response. It is currently believed that cisplatin provides greater benefits than carboplatin; this requires re-evaluation.

Fragmentomics of urinary cell-free DNA in nuclease knockout mouse models

Urinary cell-free DNA (ucfDNA) is a potential biomarker for bladder cancer detection. However, the biological characteristics of ucfDNA are not well understood. We explored the roles of deoxyribonuclease 1 (DNASE1) and deoxyribonuclease 1-like 3 (DNASE1L3) in the fragmentation of ucfDNA using mouse models. The deletion of Dnase1 in mice (Dnase1^-/-) caused aberrations in ucfDNA fragmentation, including a 24-fold increase in DNA concentration, and a 3-fold enrichment of long DNA molecules, with a relative decrease of fragments with thymine ends and reduction of jaggedness (i.e., the presence of single-stranded protruding ends). In contrast, such changes were not observed in mice with Dnase1l3 deletion (Dnase1l3^-/-). These results suggested that DNASE1 was an important nuclease contributing to the ucfDNA fragmentation. Western blot analysis revealed that the concentration of DNASE1 protein was higher in urine than DNASE1L3. The native-polyacrylamide gel electrophoresis zymogram showed that DNASE1 activity in urine was higher than that in plasma. Furthermore, the proportion of ucfDNA fragment ends within DNase I hypersensitive sites (DHSs) was significantly increased in Dnase1-deficient mice. In humans, patients with bladder cancer had lower proportions of ucfDNA fragment ends within the DHSs when compared with participants without bladder cancer. The area under the curve (AUC) for differentiating patients with and without bladder cancer was 0.83, suggesting the analysis of ucfDNA fragmentation in the DHSs may have potential for bladder cancer detection. This work revealed the intrinsic links between the nucleases in urine and ucfDNA fragmentomics.

Cell-free DNA (cfDNA) in various bodily fluids, for example blood plasma and urine, is of great importance for noninvasive cancer detection and noninvasive prenatal testing. Many emerging studies on the fragmentation of plasma DNA (i.e., fragmentomics) have received much recent interest. However, the fragmentomics in urinary cfDNA (ucfDNA) remained much less explored. In this study, we explored the biological links between ucfDNA fragmentation and DNA nucleases, using mice for which either the Dnase1 or Dnase1l3 gene was genetically inactivated. Interestingly, we found that the deletion of Dnase1, but not Dnase1l3, caused dramatic alterations of ucfDNA fragmentation patterns, including the elevation of DNA concentration, lengthening of fragment size, disruptions of ucfDNA end motifs (i.e., nucleotide sequences at fragment end) and the jagged ends (i.e., the single-stranded protruding ends). The proportion of fragment ends within DNase I hypersensitive sites (DHSs) was greatly increased in mice with the Dnase1 deletion. Such ucfDNA fragmentation pattern surrounding DHSs holds potential for classifying the human subjects with and without bladder cancer. The analysis combining various fragmentomic features could further improve the performance for bladder cancer detection, with an AUC of 0.91. This study has shed mechanistic insights into fragmentomics of ucfDNA in urine and has opened up new possibilities for applying ucfDNA fragmentomics in a clinical context.

Correlation between transurethral interventions and their influence on type and duration of postoperative urinary incontinence: results from a systematic review and meta-analysis of comparative studies

Objective To perform a systematic review to assess the incidence of transient (<6-month) and persistent (>6-month) stress (SUI), urge (UUI), and mixed urinary incontinence (MUI) after transurethral surgeries for benign prostatic hyperplasia (BPH). Materials and Methods A systematic literature search was performed using Embase, PubMed, and Web of Science. We included studies comparing monopolar(M)/bipolar(B) TURP vs ablation vs enucleation procedures. Incidence of incontinence was assessed using Cochran-Mantel-Haenszel Method and reported as odds ratio (OR), 95% confidence interval (CI), and p-values. Statistical significance was set at p <0.05 Evidence synthesis 28 studies were included. Incidence of transient SUI was 4.6%, 6.0%, 3.0%, 2.4% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent SUI was 1.1% after ablation, 1.7%, after enucleation and M-TURP, 1.0% after B-TURP. Incidence of transient UUI was 2.0%, 7.3%, 4.4%, 2.8% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent UUI was 2.2% after M-TURP. The incidence of transient MUI was 5.1%, 0.8%, 5.4%, 0.9% after ablation, enucleation, M-TURP, and B-TURP, respectively. Incidence of persistent MUI was 3.1% after ablation, and 4.8% after M-TURP. Incidence of transient and persistent SUI and UUI did not differ after TURP vs enucleation. Incidence of transient (OR 3.32, 95% CI 0.41-26.65, p=0.26) and persistent SUI (OR 4.79, 95%CI 0.52-43.89,p=0.17) was not significantly higher after ablation. Incidence of transient UUI was not significantly higher after ablation (OR 2.62, 95%CI 0.04-166.01,p=0.65), whilst persistent UUI did not differ. Incidence of transient MUI was significantly higher after enucleation (OR 3.26, 95%CI 1.51-7.05,p=0.003). Incidence of transient and persistent MUI did not differ after TURP vs ablation. Conclusions Ablation, enucleation, and TURP have an impact on all forms of incontinence but this is transient in most cases with no difference between the groups, except for MUI which was higher after enucleation vs M-TURP.

A Global Survey of Ergonomics Practice Patterns and Rates of Musculoskeletal Pain Among Urologists Performing Retrograde Intrarenal Surgery

PURPOSE

Retrograde intrarenal surgery (RIRS) requires awkward body posture for long durations. Few urologists receive ergonomics training despite the availability of ergonomics best practices utilized by other surgical specialties. We characterize ergonomics practice patterns and rates of musculoskeletal (MSK) pain among urologists performing RIRS.

METHODS

A web-based survey was distributed via the Endourological Society, the EAU, and social media. Surgeon anthropometrics and ergonomic factors were compared to ergonomics best practices. Pain was assessed with the Nordic Musculoskeletal Questionnaire (NMQ).

RESULTS

Overall, 519 of 526 participants completed the survey (99% completion rate). Ninety-three percent of urologists consider ergonomic factors when performing RIRS to reduce fatigue (68%), increase performance (64%), improve efficiency (59%), and reduce pain (49%). Only 16% received ergonomics training. Residents/fellows had significantly lower confidence in ergonomic technique compared to attending surgeons of any career length. Adherence to proper ergonomic positioning for modifiable factors were highly variable. On NMQ, 12-month rates of RIRS-associated pain in ≥1 body part, pain limiting activities of daily living, and pain requiring medical evaluation were 81%, 51%, and 29%, respectively. Annual case volume >150 cases (OR 0.55 [0.35-0.87]) and higher adherence to proper ergonomic techniques (OR 0.67 [0.46-0.97]) were independently associated with lower odds of pain. Limitations include a predominantly male cohort which hindered the ability to assess gender disparities in pain and ergonomic preferences.

CONCLUSION

Adherence to ergonomics best practices during RIRS is variable and may explain high rates of MSK pain among urologists. These results underscore the importance of utilizing proper ergonomic techniques and may serve as a framework for establishing ergonomics guidelines for RIRS.

Systematic review: the learning curve for robot-assisted radical cystectomy. What do we know?

Background The aim of this systematic review is to assess the robot-assisted radical cystectomy (RARC) learning curve (LC), which is important to consider in both risk-benefit assessment and training.

MATERIALS AND METHODS

We performed a systematic literature search using 2 databases (Medline and Scopus) with the search query "learning AND cystectomy" and included all articles containing data on the assessment of the RARC LC. Our primary outcome was the surgeons' experience (a number of performed procedures) required to achieve the LC plateau. The secondary outcomes related to the methods for assessing the relevant LC.

RESULTS

Between 9 and 50 procedures were required to reduce the operation time significantly. The data on estimated blood loss during RARC is somewhat controversial. In order to optimize the lymph node yield, it was necessary to treat between 20 and 50 patients. The LC for positive surgical margin was described only in one study, it was completed after 24 - 30 cases. Between 10 and 15 cases were necessary to reduce LOS. Complications became less frequent after 10 to 75 patients but there was no clear plateau in the figures.

CONCLUSIONS

Based on the relevant assessment criteria, the RARC learning curve length varies from 10 to 50 cases. The most common criteria for evaluating the learning experience include operation time and the lymph node yield. Blood loss, length of hospital stay and complications rate show variable outcomes and may be harder to use systematically as a means of learning curve assessment.

Defining the morbidity of Robotic-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: adoption of the Comprehensive Complication Index

BACKGROUND & OBJECTIVE

The Clavien-Dindo Classification (CDC) only reports the post-operative complication of highest grade. It is thus of limited value for radical cystectomy after which patients usually experience multiple complications. The CCI is a novel scoring system which incorporates all post-operative events in one single value. To adopt the Comprehensive Complication Index (CCI) for the evaluation of complications in patients undergoing Robot-Assisted Radical Cystectomy (RARC) with Intra-Corporeal Urinary Diversion (ICUD) and explore its advantages in the analysis of the morbidity of RARC with ICUD.

PATIENTS AND METHODS

Multicentric cohort of 959 patients undergoing RARC+ICUD between 2015-2020, whose complications are encoded in local prospective registries. Post-operative complications at 30 days were assessed using both the CDC and CCI. The CCI was calculated using an online tool (assessurgery.com). Risk factors for overall, major complications (CDC≥III) and CCI were evaluated using uni- and multivariable logistic and linear regressions. To analyse the potential advantage of using the CCI in clinical trials, a sample size calculation of a hypothetic clinical trial was performed using as endpoint reduction of morbidity with either the CDC or CCI.

RESULTS

Overall, 885 post-operative complications were reported in 507 patients (53%). The CCI improved the definition of post-operative morbidity in 22.6% of patients. Male sex and neobladder were associated to major complications and to a significant increase in CCI on adjusted regressions. In a hypothetical clinical trial, 80 patients would be needed to demonstrate a ten point reduction in CCI, compared to 186 needed to demonstrate an absolute risk reduction of 20% in overall morbidity using the CDC.

CONCLUSION

CCI improves the evaluation of post-operative morbidity by considering the cumulative aspect of complications compared to the CDC. Implementing the CCI for radical cystectomy would help reducing sample sizes in clinical trials.

Role of pre-operative ureteral stent on outcomes of retrograde intra-renal surgery (RIRS): systematic review and meta-analysis of 3831 patients and comparison of Asian and non-Asian cohorts

PURPOSE

To evaluate the outcomes of pre-stented (PS) versus non-pre-stented (NPS) patients who have undergone retrograde intrarenal surgery (RIRS) for renal calculi with subgroup analysis of Asian and non-Asian cohorts.

METHODS

Protocol is registered in PROSPERO, CRD42021261123. Eligible studies identified from four electronic databases. Meta-analysis was done to enumerate the outcomes of RIRS in between PS and NPS. Secondary sub-analysis was done to look for differences in outcomes in Asian and non-Asian cohorts.

RESULTS

Fourteen studies involving 3831 patients (4 prospective, 10 retrospective studies) were included. PS patients experienced higher success rates of ureteral access sheath (UAS) insertion than NPS (RR 1.09, 95% CI 1.05-1.13, p < 0.00001). PS patients had lower risk of ureteral injuries from UAS placement (RR 0.69, 95% CI 0.50-0.96, p = 0.03). No significant differences in intra- and postoperative complications between two groups were found. Stone-free rate (SFR) outcomes for residual fragment (RF) cut-off of < 1 mm and < 4 mm favoured the PS patients (RR 1.10, 95% CI 1.04-1.17, p = 0.002 for < 4 mm, RR1.10, 95% CI 1.02-1.19, p = 0.02 for < 1 mm). In the subgroup analysis, PS Asian patients had similar SFR as NPS patients for SFR(< 4 mm) but non-Asian population showed better outcomes in the PS patients for SFR(< 4 mm) (RR 1.31, 95% CI 1.13-1.52, p = 0.0005).

CONCLUSIONS

This meta-analysis suggests that pre-stenting results in a higher success for UAS placement, minimising intraoperative ureteric injury, with higher overall SFR for any RF cut-off in PS cohorts. In non-Asian cohort, significant differences occurred at SFR < 4 mm but not for SFR < 1 mm. No difference was seen in our Asian cohort for any SFR cut-off in both PS and NPS patients.

Defining Factors Associated with High-quality Surgery Following Radical Cystectomy: Analysis of the British Association of Urological Surgeons Cystectomy Audit

Background

Radical cystectomy (RC) is associated with high morbidity.

Objective

To evaluate healthcare and surgical factors associated with high-quality RC surgery.

Design setting and participants

Patients within the prospective British Association of Urological Surgeons (BAUS) registry between 2014 and 2017 were included in this study.

Outcome measurements and statistical analysis

High-quality surgery was defined using pathological (absence of positive surgical margins and a minimum of a level I lymph node dissection template with a minimum yield of ten or more lymph nodes), recovery (length of stay ≤10 d), and technical (intraoperative blood loss <500 ml for open and <300 ml for minimally invasive RC) variables. A multilevel hierarchical mixed-effect logistic regression model was utilised to determine the factors associated with the receipt of high-quality surgery and index admission mortality.

Results and limitations

A total of 4654 patients with a median age of 70.0 yr underwent RC by 152 surgeons at 78 UK hospitals. The median surgeon and hospital operating volumes were 23.0 and 47.0 cases, respectively. A total of 914 patients (19.6%) received high-quality surgery. The minimum annual surgeon volume and hospital volume of ≥20 RCs/surgeon/yr and ≥68 RCs/hospital/yr, respectively, were the thresholds determined to achieve better rates of high-quality RC. The mixed-effect logistic regression model found that recent surgery (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.11-1.34, p < 0.001), laparoscopic/robotic RC (OR: 1.85, 95% CI: 1.45-2.37, p < 0.001), and higher annual surgeon operating volume (23.1-33.0 cases [OR: 1.54, 95% CI: 1.16-2.05, p = 0.003]; ≥33.1 cases [OR: 1.64, 95% CI: 1.18-2.29, p = 0.003]) were independently associated with high-quality surgery. High-quality surgery was an independent predictor of lower index admission mortality (OR: 0.38, 95% CI: 0.16-0.87, p = 0.021).

Conclusions

We report that annual surgeon operating volume and use of minimally invasive RC were predictors of high-quality surgery. Patients receiving high-quality surgery were independently associated with lower index admission mortality. Our results support the role of centralisation of complex oncology and implementation of a quality assurance programme to improve the delivery of care.

Patient summary

In this registry study of patients treated with surgical excision of the urinary bladder for bladder cancer, we report that patients treated by a surgeon with a higher annual operative volume and a minimally invasive approach were associated with the receipt of high-quality surgery. Patients treated with high-quality surgery were more likely to be discharged alive following surgery.

A propensity score-matching study on retzius-sparing robotic-assisted radical prostatectomy: Evidence of continence advantage in the early learning curve

OBJECTIVES

To investigate the outcome of retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) compared with conventional RARP in the early learning curve.

METHODS

Consecutive patients with prostate cancer who underwent RS-RARP were included to compare against conventional RARP of the same period. Propensity-score matching was performed based on age, prostate size, nerve-sparing approach, and final pathological risk categories. All patients were re-admitted to undergo trial without Foley catheter from post-operative day 7-10. Clinical follow-up was performed with monitoring of continence (day 0, 3 months, and the latest continence during the study period) and surveillance of PSA level.

RESULTS

Between July 2017 and August 2019, 24 consecutive patients received RS-RARP in our centre. Propensity score matching was performed with the best matched 24 controls receiving conventional RARP. Overall median follow-up duration was 15.5 months. A majority of the patients belonged to the intermediate-risk group, with most of them harbouring pT2 disease (RS-RARP: 87.5%; conventional RARP: 79.2%). More patients in RS-RARP group achieved day-0 continence (33.3% vs 0%, p = 0.002) and 3-month continence (66.7% vs 12.5%, p = 0.001). During the whole study period, more RS-RARP achieved continence with 0 pad (91.7% vs 66.7%, p = 0.033). The mean months to continence is shorter in RS-RARP group (4.0 months vs 13.6 months, p = 0.002). No statistically significant differences between the two groups with respect to surgical margins, post-operative PSA detection, and the use of adjuvant radiotherapy.

CONCLUSIONS

RS-RARP showed better continence rates when compared to conventional RARP even during the learning curve phase.

Inherited Mutations in Chinese Men With Prostate Cancer

BACKGROUND

Although China accounts for 7.8% of worldwide new prostate cancer (PCa) cases and 14.5% of new deaths according to GLOBOCAN 2020, the risk of PCa associated with germline mutations is poorly defined, hampered in part by lack of nationwide evidence. Here, we sequenced 19 PCa predisposition genes in 1,836 Chinese patients with PCa and estimated disease risk associated with inherited mutations.

PATIENTS AND METHODS

Patients were recruited from 4 tertiary cancer centers (n=1,160) and a commercial laboratory (n=676). Germline DNA was sequenced using a multigene panel, and pathogenic/likely pathogenic (P/LP) mutation frequencies in patients with PCa were compared with populations from the gnomAD (Genome Aggregation Database) and ChinaMAP (China Metabolic Analytics Project) databases. Clinical characteristics and progression-free survival were assessed by mutation status.

RESULTS

Of 1,160 patients from hospitals, 89.7% had Gleason scores ≥8, and 65.6% had metastases. P/LP mutations were identified in 8.49% of Chinese patients with PCa. Association with PCa risk was significant for mutations in ATM (odds ratio [OR], 5.9; 95% CI, 3.1-11.1), BRCA2 (OR, 15.3; 95% CI, 10.0-23.2), MSH2 (OR, 15.8; 95% CI, 4.2-59.6), and PALB2 (OR, 5.9; 95% CI, 2.7-13.2). Compared with those without mutations, patients with mutations in ATM, BRCA2, MSH2, or PALB2 showed a poor outcome with treatment using androgen deprivation therapy and abiraterone (hazard ratio, 2.19 [95% CI, 1.34-3.58] and 2.47 [95% CI, 1.23-4.96], respectively) but similar benefit from docetaxel.

CONCLUSIONS

The present multicenter study confirmed that a significant proportion of Chinese patients with PCa had inherited mutations and identified predisposition genes in this underreported ethnicity. These data provide empirical evidence for precision prevention and prognostic estimation in Chinese patients with PCa.

1459 Intravesical Chemohyperthermia Versus Bacillus Calmette-Guerin Instillation for Intermediate- And High-Risk Non-Muscle Invasive Bladder Cancer: A Systematic Review and Meta-Analysis

Introduction

Traditional intravesical chemotherapy instillations under room temperature post trans-urethral resection (TUR) of non-muscle invasive bladder cancer (NMIBC) have lower efficacies than maintenance BCG installations. Intravesical chemo-hyperthermia (CHT) at higher temperatures is developed to improve the efficacy of chemotherapy instillation. This systematic review aims to compare the use of CHT and BCG instillation post-TUR.

Method

The protocol of this review is registered on PROSPERO(CRD42020223277). A comprehensive literature search was performed on Medline, EMBASE, and Cochrane CENTRAL to identify studies comparing CHT and BCG post-TUR for intermediate- or high-risk NMIBC. Primary outcomes include recurrence-free survival (RFS) and progression-free survival (PFS). Secondary outcomes include adverse events (AE).

Results

From 2,375 identified records, four randomised control trials incorporating 327 patients were included for meta-analysis. The use of CHT was found to be non-inferior to BCG in RFS, PFS and AEs (Grades 1-3) (p &gt; 0.05). Sensitivity analysis, excluding patients with BCG failures, show 24-36 months recurrence rate to be significantly lower in CHT group (RR 0.64, 95% CI 0.42-0.98, p = 0.04) compared to the BCG group. In patients without carcinoma in situ (CIS), RFS is also significantly better in CHT patients (HR 0.52, 95% CI 0.32- 0.85, p &lt; 0.01). Safety profile remains non-inferior to the BCG group in sensitivity analyses. Quality of evidence across all outcomes ranged from moderate to low.

Conclusions

In well-selected patients, intravesical CHT has superior oncological outcomes and non-inferior safety profile when compared to BCG maintenance therapy for patients with intermediate- and high-risk NMIBC. CHT is a possible alternative treatment during BCG shortage.

Influence of webinar based learning on practice of percutaneous nephrolithotomy: Outcomes of a global survey

Background With webinars looking to be the mainstay post-pandemic, it is important to demonstrate if webinars are indeed effective educational tools for professional training and skill acquisition. We aim to demonstrate, via a global survey, the efficacy of webinars on PCNL and how this knowledge transforms clinical practice. Methods A structured online survey covering the following sections: (1) Demographics, (2) PCNL techniques, (3) PCNL equipment, was circulated. The target study population were practicing urologists and residents. Categorical data were presented with counts and percentages, and compared using Chi-square test. Continuous data was analysed with non-parametric methods. Respondents were dichotomised according to attendance of webinars type, attendees of dedicated PCNL webinars (Group A) or attendees of endourological webinars that discussed some aspects of PCNL (Group B). Results A total of 303 respondents participated from 38 countries. 91.7% (n=278) were in Group A with 8.3% (n=25) in Group B. 77.9% were under the age of fifty years while 51.8% had more than 10 years of urology experience. In group A, urologists of all ages, in academic institutions and private practitioners, significantly benefitted in gaining knowledge about the merits of newer devices and the role of suction assisted devices in modern PCNL; Majority of group A also reflected that by attending a dedicated PCNL based webinar they benefited in learning newer positions for PCNL access, especially supine, and how to effectively use laser as energy devices for lithotripsy. In Group B, the only area of benefit was in lasing techniques and the use of newer lasers like the TFL. Conclusion Our survey positively validates the two proposed hypothesis i.e. webinars as a medium of education do benefit practicing urologists in knowledge and the clinical practice domains. Age, experience or place of practice is no barrier to adopting newer mediums of education like webinars.

The impact of lasers in percutaneous nephrolithotomy outcomes: results from a systematic review and meta-analysis of randomized comparative trials

Background Percutaneous nephrolithotomy (PCNL) is the first choice treatment of renal stones larger than 2 cm. We aimed to evaluate if lasers perform as equal as non-laser devices in patients with kidney stones candidate to PCNL. Materials and methods A comprehensive literature search was performed in MEDLINE via PubMed, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) to assess the differences in the perioperative course, incidence of postoperative complications, and stone free-rate (SFR) in patients with kidney stones undergoing laser versus non-laser PCNL in randomized studies. The incidences of complications were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and expressed as Risk Ratios (RR), 95% Confidence Intervals (CI), and p-values. Surgical time and length of stay were pooled using the inverse variance of the mean difference (MD) with a random effect, 95% CI, and p-values. Analyses were two-tailed, with a significance set at p ≤0.05. Results Six papers including 732 patients (311 patients undergoing holmium laser and 421 non-laser PCNL) were included in meta-analysis. Surgical time and postoperative stay were shorter in the non-laser group (MD:11.14, 95% CI:2.32-19.96, p=0.002; MD:-0.81, 95%CI:-2.18-0.57 p=0.25, respectively). SFR was significantly higher in the non-laser group (RR:1.08, 95% CI:1.01-1.15, p=0.03). Patients undergoing laser PCNL had a non-significant higher risk of postoperative fever >38°C (RR:0.64, 95%CI: .31-1.30, p=0.22). Transfusion rate did not differ between the two groups (RR:1.02, 95% CI:0.50-2.11 p=0.95). The need for stent positioning due to urine extravasation was higher risk in the laser group but the difference did not reach significance (RR:0.49, 95% CI:0.17-1.41 p=0.19). Conclusions Non-laser PCNL showed better perioperative outcomes and SFR as compared to holmium laser PCNL.

Assessing the optimal urine culture for predicting systemic inflammatory response syndrome after percutaneous nephrolithotomy and retrograde intrarenal surgery: results from a systematic review and meta-analysis

Background Systemic inflammatory response syndrome (SIRS) is a dangerous complication after percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). We aimed to review the diagnostic accuracy of mid steam urine culture (MSUC), pelvic urine culture (PUC) and stone culture (SC) derived from the same cases to predict SIRS after PCNL and/or RIRS. Materials and methods A comprehensive literature search was performed, using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. Sensitivity and specificity were calculated for MSUC, PUC, and SC. The diagnostic odds ratio (DOR) was estimated for each study with a random effect and hierarchical summary receiver operating characteristic (HSROC) model leading to a corresponding 95% Confidence Interval (CI). Overall test accuracy was measured by finding the area under the curve (AUC). An AUC value >0.70 stands for adequate overall accuracy Results The search retrieved 537 papers. After screening, 21 studies involving 5238 patients were included for the meta-analysis. The pooled sensitivity for MSUC was 0.322 (95% CI 0.2228-0.432), and pooled specificity 0.854 (95% CI 0.810-0.889). The DOR was low at 2.780 (95% CI 1.769-4.368), showing poor overall diagnostic accuracy. The pooled sensitivity for PUC was 0.323 (95% CI 0.224-0.440) and specificity 0.931 (95% CI 0.896-0.954). The DOR was 6.377 (95% CI 4.065-10.004), showing a mild overall diagnostic accuracy. The pooled sensitivity for SC was 0.552 (95% CI 0.441-0.658) and specificity 0.847 (95%CI 0.798-0.886). The DOR was 6.820 (95%CI 4.435-10.488), showing mild overall diagnostic accuracy. The AUC for HSROC for MSUC was 0.65, 0.73, and 0.75 for PUC and SC, respectively. Conclusion MSUC is a poor predictor for postoperative SIRS. PUC or SC should be collected during lithotripsy to better predict the possibility of developing postoperative SIRS after PCNL and RIRS.

Prognostic value of the preoperative albumin-globulin ratio in patients with upper urinary tract urothelial carcinoma treated with radical nephroureterectomy: results from a large multicenter international collaboration

OBJECTIVE

To assess the value of preoperative albumin to globulin ratio for predicting pathologic and oncological outcomes in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy in a large multi-institutional cohort.

MATERIALS AND METHODS

Preoperative albumin to globulin ratio was assessed in a multi-institutional cohort of 2492 patients. Logistic regression analyses were performed to assess the association of the albumin to globulin ratio with pathologic features. Cox proportional hazards regression models were performed for survival endpoints.

RESULTS

The optimal cut-off value was determined to be 1.4 according to a receiver operating curve analysis. Lower albumin to globulin ratios were observed in 797 patients (33.6%) compared with other patients. In a preoperative model, low preoperative albumin to globulin ratio was independently associated with nonorgan-confined diseases (odds ratio 1.32, P = 0.002). Patients with low albumin to globulin ratios had worse recurrence-free survival (P < 0.001), cancer-specific survival (P = 0.001) and overall survival (P = 0.020) in univariable and multivariable analyses after adjusting for the effect of standard preoperative prognostic factors (recurrence-free survival: hazard ratio (HR) 1.31, P = 0.001; cancer-specific survival: HR 1.31, P = 0.002 and overall survival: HR 1.18, P = 0.024).

CONCLUSIONS

Lower preoperative albumin to globulin ratio is associated with locally advanced disease and worse clinical outcomes in patients treated with radical nephroureterectomy for upper tract urothelial carcinoma. As it is difficult to stage disease entity, low preoperative serum albumin to globulin ratio may help identify those most likely to benefit from intensified care, such as perioperative systemic therapy, and the extent and type of surgery.

Role and importance of ergonomics in retrograde intrarenal surgery (RIRS): outcomes of a narrative review

BACKGROUND

With recent technological advancement, new and improved endoscopic instruments and laser devices have catapulted flexible ureteroscopy (fURS) to the forefront, hence making retrograde intrarenal surgery (RIRS) a popular choice for the management of renal stones. However, RIRS has also resulted in an increasing number of work-related musculoskeletal disorders, which can have a detrimental impact on surgeons' physical health and operative lifespan. The aim of our review is to examine the impact and feasibility of ergonomic adjustments, and outline future directions and recommendations in order to improve the awareness of and reduce the prevalence of musculoskeletal injuries among urologists.

METHODS

This study was carried out according to the PRISMA guidelines. A thorough literature review was conducted of several databases using the following keywords and Medical Subject Headings (MeSH) terms to generate a search strategy: nephrolithiasis, kidney calculus, renal calculus, staghorn calculus, ergonomics, position, fatigue, comfort, tire, physical strain, visual strain, muscle, ureteroscopy (URS), retrograde intrarenal surgery (RIRS), laser, and lithotripsy. Studies were chosen for inclusion by reviewers independently, and the data was consolidated for analysis.

RESULTS

A total of 1446 articles were identified on initial literature search; 23 were included in the final analysis. The impact of various ergonomic modifications on operative outcomes, surgeons, surgical equipment, and patients, was analysed. In addition, we summarized all the improvements that resulted in better ergonomics in RIRS.

CONCLUSION

Ergonomics in RIRS is poorly understood and there are currently no formal guidelines for this aspect. While modern endourology armamentarium seems to help with procedural ergonomics, more needs to be done to enhance surgeon comfort, protect surgeon longevity, and prioritize the health and safety of endourologists.

979 Delayed Surgery for Localised and Metastatic Renal Cell Carcinoma: A Systematic Review and Meta-Analysis for the COVID-19 Pandemic

Introduction

COVID-19 have delayed treatments for cancer; hence we performed a systematic review on the oncological effects of active surveillance (AS), delayed intervention (DI) and sequencing of cytoreductive nephrectomy (CN) and target therapy (TT) on localised and metastatic renal cell carcinoma (RCC). PROSPERO: CRD42020190882

Method

Both randomised controlled trials and observational studies related to the study were included in this review after a comprehensive search and screening.

Results

A total of 2065 potential eligible records were identified. 23 studies were included for quantitative analysis. In meta-analysis, no significant difference was found between the patients who underwent AS/DI and PN/RN for overall survival (OS) (HR 1.36, 95% CI 0.99-1.87, p = 0.06), while cancer-specific survival is significantly worsened (CSS) (HR 1.67, 95% CI 1.23-2.27, p &lt; 0.01) in AS/DI patients. In other localised stages, results are contradicting amongst literature. Upfront TT followed by deferred CN is associated with better OS when compared to upfront CN followed by deferred TT (HR 0.53, 95% CI 0.41-0.69, p = 0.00) in metastatic patients.

Conclusions

Based on low quality evidence, AS and DI is no inferior to immediate surgical intervention in well selected T1a patient’s OS but not CSS. Upfront TT followed by deferred CN improves OS and progression free survival.

Effect of SARS and COVID-19 outbreaks on urology practice and training

INTRODUCTION

The objective was to investigate the changes in urology practice during coronavirus disease 2019 (COVID-19) pandemic with a perspective from our experience with severe acute respiratory syndrome (SARS) in 2003.

METHODS

Institutional data from all urology centres in the Hong Kong public sector during the COVID-19 pandemic (1 Feb 2020-31 Mar 2020) and a non-COVID-19 control period (1 Feb 2019-31 Mar 2019) were acquired. An online anonymous questionnaire was used to gauge the impact of COVID-19 on resident training. The clinical output of tertiary centres was compared with data from the SARS period.

RESULTS

The numbers of operating sessions, clinic attendance, cystoscopy sessions, prostate biopsy, and shockwave lithotripsy sessions were reduced by 40.5%, 28.5%, 49.6%, 44.8%, and 38.5%, respectively, across all the centres reviewed. The mean numbers of operating sessions before and during the COVID-19 pandemic were 85.1±30.3 and 50.6±25.7, respectively (P=0.005). All centres gave priority to cancer-related surgeries. Benign prostatic hyperplasia-related surgery (39.1%) and ureteric stone surgery (25.5%) were the most commonly delayed surgeries. The degree of reduction in urology services was less than that during SARS (47.2%, 55.3%, and 70.5% for operating sessions, cystoscopy, and biopsy, respectively). The mean numbers of operations performed by residents before and during the COVID-19 pandemic were 75.4±48.0 and 34.9±17.2, respectively (P=0.002).

CONCLUSION

A comprehensive review of urology practice during the COVID-19 pandemic revealed changes in every aspect of practice.

Jagged Ends of Urinary Cell-Free DNA: Characterization and Feasibility Assessment in Bladder Cancer Detection

BACKGROUND

Double-stranded DNA in plasma is known to carry single-stranded ends, called jagged ends. Plasma DNA jagged ends are biomarkers for pathophysiologic states such as pregnancy and cancer. It remains unknown whether urinary cell-free DNA (cfDNA) molecules have jagged ends.

METHODS

Jagged ends of cfDNA were detected by incorporating unmethylated cytosines during a DNA end-repair process, followed by bisulfite sequencing. Incorporation of unmethylated cytosines during the repair of the jagged ends lowered the apparent methylation levels measured by bisulfite sequencing and were used to calculate a jagged end index. This approach is called jagged end analysis by sequencing.

RESULTS

The jagged end index of urinary cfDNA was higher than that of plasma DNA. The jagged end index profile of plasma DNA displayed several strongly oscillating major peaks at intervals of approximately 165 bp (i.e., nucleosome size) and weakly oscillating minor peaks with periodicities of approximately 10 bp. In contrast, the urinary DNA jagged end index profile showed weakly oscillating major peaks but strongly oscillating minor peaks. The jagged end index was generally higher in nucleosomal linker DNA regions. Patients with bladder cancer (n = 46) had lower jagged end indexed of urinary DNA than participants without bladder cancer (n = 39). The area under the curve for differentiating between patients with and without bladder cancer was 0.83.

CONCLUSIONS

Jagged ends represent a property of urinary cfDNA. The generation of jagged ends might be related to nucleosomal structures, with enrichment in linker DNA regions. Jagged ends of urinary DNA could potentially serve as a new biomarker for bladder cancer detection.

Telemedicine Usage Among Urologists During the COVID-19 Pandemic: Cross-Sectional Study

BACKGROUND

Prior to the COVID-19 pandemic, urology was one of the specialties with the lowest rates of telemedicine and videoconferencing use. Common barriers to the implementation of telemedicine included a lack of technological literacy, concerns with reimbursement, and resistance to changes in the workplace. In response to the COVID-19 pandemic declared in March 2020, the delivery of urological services globally has quickly shifted to telemedicine to account for the mass clinical, procedural, and operative cancellations, inadequate personal protective equipment, and shortage of personnel.

OBJECTIVE

The aim of this study was to investigate current telemedicine usage by urologists, urologists' perceptions on the necessity of in-person clinic appointments, the usability of telemedicine, and the current barriers to its implementation.

METHODS

We conducted a global, cross-sectional, web-based survey to investigate the use of telemedicine before and after the COVID-19 pandemic. Urologists' perceived usability of telemedicine was assessed using a modified Delphi approach to create questions based on a modified version of the validated Telehealth Usability Questionnaire (TUQ). For the purposes of this study, telemedicine was defined as video calls only.

RESULTS

A total of 620 urologists from 58 different countries and 6 continents participated in the survey. Prior to COVID-19, 15.8% (n=98) of urologists surveyed were using telemedicine in their clinical practices; during the pandemic, that proportion increased to 46.1% (n=283). Of the urologists without telemedicine experience, interest in telemedicine usage increased from 43.7% (n=139) to 80.8% (n=257) during the COVID-19 pandemic. Among urologists that used telemedicine during the pandemic, 80.9% (n=244) were interested in continuing to use it in their practice. The three most commonly used platforms were Zoom, Doxy.me, and Epic, and the top three barriers to implementing telemedicine were patients' lack of technological comprehension, patients' lack of access to the required technology, and reimbursement concerns.

CONCLUSIONS

This is the first study to quantify the use, usability, and pervading interest in telemedicine among urologists during the COVID-19 pandemic. In the face of this pandemic, urologists' usage of telemedicine nearly tripled, demonstrating their ability to adopt and adapt telemedicine into their practices, but barriers involving the technology itself are still preventing many from utilizing it despite increasing interest.

Effect of androgen deprivation therapy on cardiovascular function in Chinese patients with advanced prostate cancer: a prospective cohort study

Androgen deprivation therapy (ADT) is the standard treatment for advanced prostate cancer, but its effect on cardiovascular and metabolic function in Asian patients is still inconclusive. We prospectively assess the effects of ADT on 36 patients with advanced prostate cancer, with reference to another 24 prostate cancer patients not requiring ADT, for 2 years. Patients’ anthropometric, metabolic and vascular parameters were assessed every six-monthly. The baseline parameters of the two groups were comparable. There was a significant negative effect of the usage of ADT on the changes in BMI (p = 0.020), waist to hip ratio (p = 0.005), body fat percentage (p = 0.012), and high-density-lipoprotein (p = 0.012). ADT-patients were 4.9 times more likely to have metabolic syndrome at 24 months. (CI 0.889–27.193, p = 0.068). The Framingham risk score (p = 0.018) and pulse-wave-velocity (p = 0.024) for ADT-group were also significantly higher than controls, which signified increase in cardiovascular risk. Although there was no statistically significant difference in ischemic cardiovascular events between two groups, a trend for more events in ADT-group was observed. Therefore, Asian patients have increased cardiovascular and metabolic risks after being treated with ADT for two years. Appropriate counselling and monitoring of associated complications with ADT are essential.

Attitudes, acceptance, and registration in relation to organ donation in Hong Kong: a cross-sectional study

INTRODUCTION

The objective of this study was to investigate the discrepancy between individuals with positive attitudes towards organ donation and the actual number of registered organ donors in Hong Kong, and to investigate the best modalities for promoting more organ donor registrations.

METHODS

This cross-sectional telephone survey was conducted in Hong Kong. Telephone numbers were selected randomly. Upon successful contact with a household, the eligible household member who had the most recent birthday was selected to participate in the telephone interview.

RESULTS

A total of 1000 Hong Kong Chinese residents were interviewed successfully. The response rate was 53.8%. The majority of the respondents were female (68.3%) and were aged 51 to 60 years (24%) or ≥61 years (43.6%). Among the respondents, 31.3% were willing to donate their organs after death; 43.3% were indecisive, and 25.4% refused. Among those who were willing to donate organs after death, only 34.2% had registered with the Centralised Organ Donation Register (CODR). Among those who were willing to donate organs after death but had not yet registered on CODR, 52.2% said they were not determined enough to take action, 47.8% said they were too busy, 37.8% said they were too lazy, and 20.4% said they were always forgetful about registering. In all, 32.8% of the interviewees were not aware of the ways to register as a prospective organ donor. Among non-messenger social media platforms, Facebook, YouTube, and Instagram were the most commonly used. Most participants believed that Facebook and YouTube were effective for engaging audiences.

CONCLUSIONS

More effort should be made to facilitate organ donor registration in face-to-face settings via promotional booths and in online settings via appropriate social media platforms.

Patient-reported outcomes after surgery or radiotherapy for localised prostate cancer: a retrospective study

INTRODUCTION

To compare the intermediate-term outcomes and patient-reported outcomes of robot-assisted laparoscopic prostatectomy (RALP) and radical external beam radiotherapy (RT) in Chinese patients with localised prostate cancer.

METHODS

This was a retrospective study of patients with localised prostate cancer diagnosed between 2010 and 2011 and treated with either RALP or RT. Baseline patient and disease characteristics, post-treatment complications, and latest disease status were retrospectively collected from hospital records. For assessment of patient-reported outcomes, the Chinese version of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire was completed by the patients.

RESULTS

Ninety three patients aged 58 to 84 years were recruited. Thirty patients were treated by RALP (32.3%), whereas 63 received RT (67.7%). The RALP group had significantly lower baseline prostate-specific antigen levels than the RT group (P<0.001). More patients who underwent RALP reported urinary incontinence (70.0% vs 3.2%, P<0.001), whereas more patients who underwent RT reported other voiding symptoms (87.3% vs 50.0%, P<0.001) and perirectal bleeding (36.5% vs 0%, P<0.001) during follow-up. Of the 85 patients who were still alive at the time of the study, 52 (61.2%) returned completed questionnaires. Patients who underwent RALP had poorer median (interquartile range) EPIC urinary summary scores than patients who underwent RT [81.5 (18.3) vs 88.9 (17.9), P=0.016]. Urinary function [75.9 (20.4) vs 93.6 (16.2), P<0.001] and incontinence [60.5 (31.8) vs 91.8 (14.5), P<0.001] were also significantly worse in the RALP group. The bowel and sexual domain scores were similar between the two groups.

CONCLUSIONS

We found that RALP and RT were associated with different patterns of complications and patient-reported outcomes. Urinary incontinence was much more prevalent in the patients treated surgically. This may significantly affect patients' quality of life.

Global incidence of prostate cancer in developing and developed countries with changing age structures

To investigate the global incidence of prostate cancer with special attention to the changing age structures. Data regarding the cancer incidence and population statistics were retrieved from the International Agency for Research on Cancer in World Health Organization. Eight developing and developed jurisdictions in Asia and the Western countries were selected for global comparison. Time series were constructed based on the cancer incidence rates from 1988 to 2007. The incidence rate of the population aged ≥ 65 was adjusted by the increasing proportion of elderly population, and was defined as the “aging-adjusted incidence rate”. Cancer incidence and population were then projected to 2030. The aging-adjusted incidence rates of prostate cancer in Asia (Hong Kong, Japan and China) and the developing Western countries (Costa Rica and Croatia) had increased progressively with time. In the developed Western countries (the United States, the United Kingdom and Sweden), we observed initial increases in the aging-adjusted incidence rates of prostate cancer, which then gradually plateaued and even decreased with time. Projections showed that the aging-adjusted incidence rates of prostate cancer in Asia and the developing Western countries were expected to increase in much larger extents than the developed Western countries.