Florian Fuller

Attitude to nephrolithiasis in the potential living kidney donor: a survey of the German kidney transplant centers and review of the literature

Abstract:  Living donor kidney transplantation (LD‐KTX) is increasing worldwide. With the prevalence of urolithiasis ranging between 4% and 15%, the number of donors with current nephrolithiasis or a history of the disease will increase as well. A questionnaire was sent to all German centers with LD‐KTX programs (urologists and general surgeons). Answers were compared for differences between urological and surgical kidney transplant centers. Response rate was 74%. Nephrolithiasis at the time of KTX is an exclusion criterion at 36% of the German centers (58% urological/19% surgical, χ2 = 4.65, p = 0.03, Fishers exact p = 0.05), 96% of the centers accept kidney donors with a history of nephrolithiasis. The length of the stone‐free episode is regarded as relevant by 42% of all centers (58% urological vs. 32% surgical centers, p = ns). Stone composition is a criterion for 54% of centers (66% vs. 44%, p = ns). More than half of the centers accept a history of cystine stones, almost all centers of struvite and urate stones. Donors with current nephrolithiasis were less commonly accepted by urologists than by general surgeons. For almost all centers history of nephrolithiasis does not preclude living kidney donation. Stone composition proved to be of little relevance for decision making.

Intermittent vs continuous docetaxel therapy in patients with metastatic castration-resistant prostate cancer - a phase III study (PRINCE).

To investigate non‐inferiority of intermittent docetaxel compared to continuous docetaxel in patients with metastatic castration‐resistant prostate cancer (mCRPC).

Validation of Prostate Imaging Reporting and Data System Version 2 for the Detection of Prostate Cancer

Purpose: The second version of the PI‐RADS™ (Prostate Imaging Reporting and Data System) was introduced in 2015 to standardize the interpretation and reporting of prostate multiparametric magnetic resonance imaging. Recently low cancer detection rates were reported for PI‐RADS version 2 category 4 lesions. Therefore the aim of the study was to evaluate the cancer detection rate of PI‐RADS version 2 in a large prospective cohort. Materials and Methods: The study included 704 consecutive men with primary or prior negative biopsies who underwent magnetic resonance imaging/ultrasound fusion guided targeted biopsy and 10‐core systematic prostate biopsy between September 2015 and May 2017. All lesions were rated according to PI‐RADS version 2 and lesions with PI‐RADS version 2 category 3 or greater were biopsied. An ISUP (International Society of Urological Pathology) score of 2 or greater (ie Gleason 3 + 4 or greater) was defined as clinically significant prostate cancer. Results: The overall cancer detection rate of PI‐RADS version 2 categories 3, 4 and 5 was 39%, 72% and 91% for all prostate cancer, and 23%, 49% and 77% for all clinically significant prostate cancer, respectively. If only targeted biopsy had been performed, 59 clinically significant tumors (16%) would have been missed. The PI‐RADS version 2 score was significantly associated with the presence of prostate cancer (p <0.001), the presence of clinically significant prostate cancer (p <0.001) and the ISUP grade (p <0.001). Conclusions: PI‐RADS version 2 is significantly associated with the presence of clinically significant prostate cancer. The cancer detection rate of PI‐RADS version 2 category 4 lesions was considerably higher than previously reported. When performing targeted biopsy, the combination with systematic biopsy still provides the highest detection of clinically significant prostate cancer.

Assessing venous thrombus in renal cell carcinoma: preliminary results for unenhanced 3D-SSFP MRI

AIM To test the potential of unenhanced cardiac- and respiratory-motion-corrected three-dimensional steady-state free precession (3D-SSFP) magnetic resonance imaging (MRI) for the assessment of inferior vena cava (IVC) thrombus in patients with clear-cell renal cell carcinoma (cRCC), compared to standard contrast-enhanced (CE)-MRI and CE-computed tomography (CT). MATERIALS AND METHODS Eighteen patients with cRCC and IVC thrombus, who received CE-MRI and 3D-SSFP at 1.5 T between June 2015 and December 2017, were included. The diagnostic performance of 3D-SSFP in determining the level of thrombus extension, contrast-to-noise ratio (CNR), and image quality were compared with standard MRI/CT and validated against intraoperative and histopathology results. RESULTS There was 100% agreement between 3D-SSFP, 83.3% agreement between CE-MRI, and 71.4% agreement between CE-CT and surgical findings regarding the level of IVC thrombus. In addition, 3D-SSFP showed a slightly superior estimate of pathological IVC volume. 3D-SSFP reached a significantly higher CNR in the supra- and infrarenal IVC compared to the morphological sequence T2-weighted half-Fourier axial single-shot fast spin-echo (T2-HASTE) and all phases of CE-MRI. More specifically, 3D-SSFP showed a significantly higher CNR in the infrarenal IVC (mean CNR of 10.09±5.74 versus 4.21±2.33 in the delayed phase, p≤0.001) and in the suprarenal IVC (mean CNR of 9.22±4.11 versus 4.84±5.74 in the late arterial phase, p=0.015). CE-CT also was significantly inferior to 3D-SSFP (p≤0.01) and slightly inferior to CE-MRI (p>0.05). The thrombus delineation score for 3D-SSFP (4.38±0.67) was higher compared to CE-MRI (3.76±0.56, p=0.005). CONCLUSION This preliminary study indicates that 3D-SSFP can achieve an accurate assessment of IVC thrombus in cRCC patients without the need for contrast medium administration, being superior to standard MRI and CT.

Renal cell carcinoma with venous extension: prediction of inferior vena cava wall invasion by MRI

BackgroundRenal cell carcinoma (RCC) are accompanied by inferior vena cava (IVC) thrombus in up to 10% of the cases, with surgical resection remaining the only curative option. In case of IVC wall invasion, the operative procedure is more challenging and may even require IVC resection. This study aims to determine the diagnostic performance of contrast-enhanced magnetic resonance imaging (MRI) for the assessment of wall invasion by IVC thrombus in patients with RCC, validated with intraoperative findings.MethodsData were collected on 81 patients with RCC and IVC thrombus, who received a radical nephrectomy and vena cava thrombectomy between February 2008 and November 2017. Forty eight patients met the inclusion criteria. Sensitivity and specificity as well as the positive and negative predictive values were calculated for preoperative MRI, based on the assessments of the two readers for visual wall invasion. Furthermore, a logistic regression model was used to determine if there was an association between intraoperative wall adherence and IVC diameter.ResultsComplete occlusion of the IVC lumen or vessel breach could reliably assess IVC wall invasion with a sensitivity of 92.3% (95%-CI: 0.75–0.99) and a specificity of 86.4% (95%-CI: 0.65–0.97) (Fisher-test: p-value< 0.001). The positive predictive value (PPV) was 88.9% (95%-CI: 0.71–0.98) and the negative predictive value reached 90.5% (95%-CI: 0.70–0.99). There was an excellent interobserver agreement for determining IVC wall invasion with a kappa coefficient of 0.90 (95%CI: 0.79–1.00).ConclusionsThe present study indicates that standard preoperative MR imaging can be used to reliably assess IVC wall invasion, evaluating morphologic features such as the complete occlusion of the IVC lumen or vessel breach. Increases in IVC diameter are associated with a higher probability of IVC wall invasion.

Primary magnetic resonance imaging/ultrasonography fusion-guided biopsy of the prostate

To examine the performance of a primary magnetic resonance imaging (MRI)/ultrasonography (US) fusion‐guided targeted biopsy (TB), and in combination with an added systematic biopsy (SB).

MP59-19 OUTCOME OF KIDNEY FUNCTION AFTER ISCHAEMIC AND ZERO-ISCHAEMIC LAPAROSCOPIC AND OPEN NEPHRON-SPARING SURGERY FOR RCC

INTRODUCTION AND OBJECTIVES: Adhesive perinephric fat (APF) increases the complexity of robot-assisted partial nephrectomy (RAPN). The Mayo adhesive probability (MAP) score is an index for quantifying APF and predicting prolonged operation time or increased surgical complication rate. However, the part of the operation influenced by increased MAP score remains unclear. METHODS: The study subjects were 311 patients who underwent RAPN between January 2013 and June 2016 in our institute. MAP score was calculated to quantify APF. The perinephric fat thickness and stranding were used to calculate the MAP score. Operation time was divided into a dissection phase (from robotic manipulation to hilar clamping) and resection phase (from hilar clamping to robotic surgery completion). RESULTS: The patients’ mean age, body mass index (BMI), total operation time, console time, dissection phase time, and resection phase time were 60 13 years, 23.5 3.5 kg/m2, 180.8 40.7 minutes, 132.6 36.5 minutes, 84.9 27.6 minutes, and 47.6 18.3 minutes, respectively. The MAP score was 0 in 98 patients (32%), 1 in 86 (28%), 2 in 21 (7%), 3 in 48 (15%), 4 in 44 (14%), and 5 in 14 (4%). The dissection and resection phase times significantly increased as the MAP scores increased (Figure 1). The dissection phase times were 71.2, 79.1, 88.9, 97.0, 99.7, and 118.8 minutes as the MAP score increased by 1 point from 0 to 5 (p<0.001). The influence of MAP score was more remarkable to the prolongation of the dissection phase than to that of the resection phase. In the patients with MAP scores of 1⁄43, the dissection phase time was not significantly influenced by the learning curve (100.8 25.2, 103.7 29.4, and 98.2 31.4 minutes in 1st100th, 101st-200th, and 201st-311th, respectively). We further examined the factors that influenced the dissection phase time of 100 minutes by using the logistic regression model. In the multivariate analysis, left side, early surgical experience (first 100 cases), the number of the renal arteries to be clamped and MAP score (1⁄43) were the independent factors of prolonged dissection phase. CONCLUSIONS: MAP score is an independent predictive factor of prolonged RAPN dissection phase. The complexity of RAPN in the patients with high MAP scores was still high even for experienced surgeons. Source of Funding: none