E. Dalmasso

Prostate Cancer Detection Rate with Koelis Fusion Biopsies versus Cognitive Biopsies: A Comparative Study

Objective: Targeted fusion biopsies have led to an improved prostate cancer (PCa) detection rate (CDR). Our aim was to assess if device-assisted fusion biopsies are superior to cognitive ones in terms of CDR. The association between multiparametric MRI parameters and PCa was also evaluated. Methods: We retrospectively enrolled 50 patients who underwent transrectal biopsy with elastic fusion (Koelis; group KB, n = 25) or cognitive approach (group CB, n = 25). Targeted biopsies were done on targets, while a variable number of random biopsies were performed depending on the clinical case. Results: The groups did not significantly differ in terms of age, prostate-specific antigen, prostate volume and previous biopsies. Mean number of random cores was significantly inferior in KB group (8.4 vs. 12.1) and mean number of targeted biopsies was significantly higher (3.6 vs. 2.6). CDR was higher in fusion biopsies (64 vs. 40%), with the gap becoming significant when considering CDR of MRI targets only (59 vs. 27%). The difference was marked for lesions ≤10 mm, where CDR was 52% in KB against 21% in CB group. Conclusions: According to our study, elastic fusion biopsies performed with Koelis achieve an increased per-patient and per-lesion CDR as compared to cognitive biopsies, especially in the case of lesions ≤10 mm.

Prostate Cancer Treatment in Renal Transplant Recipients: A Systematic Review

The aim of this review was to summarize the current evidence and to highlight the main issues future research needs to address regarding prostate cancer (PCa) treatment in renal transpant recipients (RTRs). We conducted a search of AMED, Medline and Embase up to 17 November 2016 to investigate oncological and functional outcomes of PCa treatment in RTR. Type and use/protocols of immunosuppression and peri‐operative antibiotic drugs were also assessed. The search was implemented manually. Exclusion criteria were absence of full text or absence of information that allowed us to differentiate oncological and/or functional outcomes of each therapeutic approach used. We included 241 patients from 27 retrospective studies published between 1991 and 2016; seven of the studies were case–control and 20 were case series. We also considered nine case reports published between 1999 and 2016. Follow‐up ranged from 1 to 120 months. PCa was organ‐confined, with Gleason score ≤6 in 75.2% and 60.4% of patients. Surgery was the most frequent treatment used (n = 186), for which cancer‐specific (CSS) and overall survival (OS) rates were both 96.8%. Functional outcomes, including continence and erectile function, and complications were less frequently reported and were generally similar to those reported for radical prostatectomy (RP) in non‐RTRs. Other treatment methods in the patients included in the review were radiotherapy (RT) ± androgen deprivation therapy (ADT; n = 34; OS 88.2%; CSS 88.2%), ADT alone (n = 14; OS 42.9%; CSS 64.3%), brachytherapy (BT; n = 11; OS and CSS 100%), watchful waiting (n = 4) and active surveillance (n = 1). Overall no treatment‐related graft loss occurred. Immunosuppression and antibiotic schemes were poorly reported and inconsistent. Outcomes of PCa treatment in RTRs are encouraging and do not appear to be inferior to those of non‐RTR. RP was the most commonly assessed approach, whilst RT, BT and ADT were less frequent. Immunosuppression and antibiotic use were poorly reported and highly variable. High‐quality studies are needed because the current level of evidence is low, and our results should therefore be interpreted with caution.

Robot-assisted laparoscopic pyeloplasty in a pediatric patient with horseshoe kidney: surgical technique and review of the literature.

Objective The aim of this study was to describe the technical aspects of a robotic pyeloplasty in pediatric patients with uretero-pelvic junction obstruction (UPJO) in horseshoe kidney (HSK) through the report of our recent case, and to outline the state of the art of minimally invasive pyeloplasty (MIP) with a systematic review of the literature. Methods We describe all the steps of our surgery performed on an 11-year-old patient with left UPJO in HSK in detail. All the anatomic landmarks are clearly showed, with particular attention to trocar placement in a pediatric patient. A systematic review of the literature on the outcomes of MIP in HSK patients has been performed, including 16 articles. Results Our surgery was successful following a standardized approach. However, we recorded a rare complication, the herniation of a small portion of omentum through the 8 - mm defect used for the caudal robotic port. The evidence synthesis shows excellent postoperative outcomes for both laparoscopic and robot-assisted laparoscopic pyeloplasties in HSK patients. Probably, MIP should be preferred to the traditional open approach in these patients, when feasible. Conclusions Transperitoneal robotic pyeloplasty is an excellent minimally invasive choice for the treatment of UPJO in HSK pediatric patients. The pediatric setting should prompt attention to every detail to avoid unfortunate complications.

Urological consequences following renal transplantation: a review of the literature.

Renal transplant (RT) represents the treatment of choice for end-stage renal disease (ESRD) but harbours a wide range of possible complications and therapeutic challenges of urological competence. Dialysis years and clinical medical background of these patients are risk factors for sexual dysfunction and lower urinary tract symptoms (LUTS). On the contrary, RT itself may have a number of possible surgical complications such as ureteral stenosis and urinary leakage, while immunosuppressive treatment is a known risk factor for de-novo malignancies. The present review describes the main urologic problems of RT patients and their up-to-date treatment options according to the most recently available literature evidences.

Intraoperative superselective embolization of a biopsy-related arteriocalyceal fistula during a kidney transplantation.

A lthough macroscopic hematuria occurs in 3.4% to 10% of patients after renal transplant biopsies, major complications requiring invasive procedures are rare (1%). An arteriocalyceal fistula associated with severe gross hematuria has been reported in less than 0.1% of graft biopsies (1, 2). In such cases, an angiographic evaluation is indicated, and a superselective arterial embolization should be considered to save the kidney (3Y5). In the literature, some case reports describe the successful selective arterial embolization in arteriocalyceal fistulas caused by diagnostic biopsies performed for renal function impairment in transplanted kidneys (4, 6). To our knowledge, the case that we present is the first intraoperative treatment by superselective arterial embolization during a kidney transplantation of an arteriocalyceal fistula caused by a scoring biopsy on the graft performed at the moment of organ recovery.

How bothersome double-J ureteral stents are after semirigid and flexible ureteroscopy: a prospective single-institution observational study

PurposeTo evaluate in details the actual extent of double-J stent-related symptoms after semirigid (URS) and flexible (RIRS) ureteroscopy using a validated questionnaire.MethodsWe asked to complete the Ureteric Stent Symptoms Questionnaire (USSQ) to all stone patients undergoing URS or RIRS with stent placement from 2010 to 2015. Stent-related symptoms’ prevalence, severity, and impact on daily life were analyzed using descriptive statistics and five-order Likert scales. Subgroups analyses were performed.Results232 patients completed the USSQ. Stents had a deep impact on urinary symptoms (daily frequency ≥ 1 per hour 59.1%, ≥ 1 nocturnal micturition 90.1%, urgency 86.6%, burning 82.3%) that represented a problem for 88.4% of patients. 83.2% complained of pain, mostly in the kidney (67.9%) or in the bladder area (31.3%), particularly during physical activity (72.9%) and micturition (77.0%). Pain interfered with everyday life in 92.2%. General health, working, and sexual activity were also affected. 62.0% of patients would be dissatisfied (51.6% unhappy or terrible) if further ureteral stenting was proposed in future. Younger patients and females were more affected. Limitations include observational design and lack of baseline evaluation.ConclusionsUreteral stents are responsible for significant urinary symptoms and pain after semirigid and flexible ureteroscopy. They also considerably affect general health, working and sexual activity. Urologists should consider it carefully before stenting, inform patients about stent-related symptoms, and minimize stent indwelling time.

De Novo Bladder Urothelial Neoplasm in Renal Transplant Recipients: A Retrospective, Multicentered Study

Background and Objectives: Renal transplant recipients (RTRs) have a 2- to 7-fold risk of developing a neoplasm compared to general population. Bladder urothelial neoplasms in this cohort has an incidence of 0.4–2%. Many reports describe a more aggressive behavior. The objective of this study is to describe oncologic characteristics of bladder urothelial neoplasms in RTRs and to evaluate its recurrence, progression, and survival rates. Methods: A retrospective multicentered study was performed evaluating all de novo bladder urothelial neoplasms cases in RTRs from 1988 to 2014. Descriptive statistical analysis and evaluation of recurrence, progression, and survival rates were performed. Results: A total of 28 de novo bladder transitional cell carcinomas (TCCs) were identified (incidence rate 0.64%). Cancer-specific survival rates were 100, 75, and 70% after 1, 5, and 10 years, respectively. Age at diagnosis superior to 60 years was found to be a statistically significant variable for recurrence risk. Progression rate was 14%. Presence of CIS was significantly associated with progression. All cancer-specific deaths were in the high-risk group and all were progressions from non-muscle invasive to muscle invasive bladder cancer. Conclusions: Bladder urothelial neoplasms following renal transplant is associated with a trend toward worst prognosis. Early aggressive treatments, such as early radical cystectomy, might be advisable to reduce cancer-specific deaths.

Role of perioperative dynamic sentinel node biopsy for cN0 penile cancer management: experience from an Italian tertiary referral center

Purpose: Inguinal lymphadenectomy (iLAD) reduces mortality in patients with cN0 penile cancer but yields high complication rates. Thus, its prophylactic role has been questioned and dynamic sentinel node biopsy (DSNB) was introduced to select men who should undergo the procedure. Our aim was to investigate the accuracy of a contemporary DSNB cohort. Methods: We performed a retrospective analysis of ≥T1 or ≥G2 cN0 penile cancer undergoing perioperative DSNB from June 2009 to June 2015 at a tertiary referral center. We excluded men with <18 months follow-up or with local recurrence after primary curative treatment. Complications were graded according to the Clavien-Dindo classification. Results: Thirty-five men underwent DSNB; 85.71% had ≤T2 penile cancer with ≤G2a histology. Per groin detection rate was 80% (scintigraphy being positive bilaterally in 60% and unilaterally in 20.0%). In no cases did DSNB prolong the postoperative course compared to primary surgery. Nine men (n = 15/109 nodes removed) had positive results, 8 of whom underwent iLAD. Among negative DSNB patients, 2 developed nodal penile cancer recurrence; none of them had node biopsy due to inconclusive scintigraphy. At a median follow-up of 42 months (interquartile range 30-78 months), if considering only men with scintigraphy detected inguinal nodes, per-patient sensitivity and specificity were 50% and 80% whereas positive predictive value and negative predictive value were 25% and 92.3%, respectively. Conclusions: Perioperative DSNB is a safe procedure, yielding promising results when performed at a tertiary referral center. Future prospective large studies are needed to investigate how to optimize detection rate and reduce false-negative rates.

MP75-06 A PROSPECTIVE OBSERVATIONAL STUDY ABOUT STENT-RELATED SYMPTOMS AFTER URETEROSCOPY ASSESSED THROUGH A VALIDATED QUESTIONNAIRE.

RESULTS: We identified 22,577 patients (12,942 ESWL, 9,635 URS) treated during our study period. Forty percent of ESWL and 43% of URS patients filled an opioid prescription following their procedure. Among those patients, the median dose was 150 MME (interquartile range [IQR] 128-225). This corresponds to twenty 5mg oxycodone tablets with a range of 17 to 30 tablets. Hydrocodone (57%) was the most frequently prescribed opioid for ESWL and oxycodone (59%) for URS. Surgeons varied widely in the average dose of opioids prescribed, ranging from 89 to 675 MME (p<0.001), or eleven to ninety 5mg oxycodone tablets (Figure). CONCLUSIONS: Most patients did not fill an opioid prescription after ESWL or URS. There was no significant difference between ESWL and URS in terms of frequency or amount of opioids prescribed. There was wide variation in opioid prescribing at both the patient and urologist level. Given that these patients were opioid naive, patient variables are not likely to account for this variation. As such, urologists appear to be well positioned to reduce excess opioid prescribing.

PD21-08 IS ENDOSCOPIC EVALUATION AT THE END OF RETROGRADE INTRA-RENAL SURGERY A RELIABLE PREDICTOR OF POST-OPERATIVE SIGNIFICANT RESIDUAL FRAGMENTS?

INTRODUCTION AND OBJECTIVES: Minimally Invasive PCNL (MIP) is a promising modality in the treatment of small size renal calculi. There is no consensus regarding ideal size of Nephrostomy Tract/Sheath for minimally invasive treatment modality. We prospectively compared outcomes in use of three different sizes of Sheaths (7.5, 12, 15.5 F ) during MIP for 10-20 mm size Renal Calculi. METHODS: A total of 153 patients having Renal Calculi of 10-20 mm size were treated at our center between July 2015 and April 2016. Computer generated randomization Schedule was used to assign the use of Outer sheath size during MIP. 7.5 F sheath(n1⁄442), 12F (n1⁄466), and 15.5 F( n1⁄445) was used in our study, where mean stone size was 13.4, 14.6, and 14.1 mm respectively. Rest of the patient demographics were comparable in each group. Hardness of all calculi were evaluated by the use of House Field Units on CT Scan. Pressure Irrigation pump was used for irrigation and Holmium Laser(20-40W) Lithotripsy with quartz fiber was used for stone fragmentation. OR time, Stone free rates, Post-operative Analgesic Use, Clavien Complication rate, Hospital Stay and Ancillary procedure requirement was noted in each group. X-ray KUB, Sonography and non-contrast CT Scan was used on post-operative day 3 to confirm stone free status. Use of DJ stent or Nephrostomy tube was decided as per merits of the case. RESULTS: Primary Stone free rate was defined as complete clearance on Non contrast CT scan on postoperative day 3. There was no significant difference (p1⁄4.124) in Primary stone free rate in 7.5 F (83.4%) and 12 F(84.9%) sheath group. 15.5F(96.5%) sheath group stone free rate was significantly higher(p>0.05) and OR Time(38 5) was lower (p1⁄40.004) compared to other two groups. There was no significant difference in postoperative complications (Clavien Grade I &II) in either groups. Analgesic use in all groups was similar. 2 patients in 7.5 F sheath group and 4 in 12 F Sheath group needed ancillary procedure for complete stone clearance. Mean hospital stay was not significantly different in either groups. Primary stone free rate was 99% in Calculi with Housfield Unit <790 32 compared to those (81.5%) with Housefield Unit of >1150 89 in all groups. CONCLUSIONS: Efficacy of miniaturized equipment with 7.5 F, 12 F and 15.5 F outer Sheath in treatment of 10-20 mm renal calculi is similar and has lower morbidity. Higher Primary Stone free rate with lower OR Time in 15.5 F Sheath group, irrespective of hardness of calculus, makes it more preferred size of equipment in Minimally Invasive PCNL.