Yuval Freifeld

Does the use of ureteral stents with extraction strings increase urinary infection rates

PurposeTo assess the effect of ureteral stents with extraction string on the rate of postoperative UTI after ureteroscopies.MethodsRetrospective analysis of patient records who underwent ureteroscopy from January 2011 to August 2014 was performed. Patients were grouped into three groups according to postoperative stent status: non-stented or ureteral catheter for up to 24xa0h (NS), ureteral stent without extraction string (US) and ureteral stent with an extraction string (US-E).ResultsThere were 144, 133 and 282 cases in the NS, US and US-E groups, respectively. Overall infection rate was 4.7%; NS—2.1%, US—3.0% and US-E—6.7% (pxa0=xa00.057). Four percentage of men and 6.6% of women had postoperative UTI (pxa0=xa00.22). Within the group of men infection rates were 0, 2.4 and 6.4% for the NS, US and US-E groups, respectively (pxa0=xa00.01). For women, UTI rates were 7.5, 4.0 and 8.5% in the NS, US and US-E groups, respectively (pxa0=xa00.6). Infection rates were 20 and 3.9% (pxa0=xa00.001) for patients with extraction strings for >8 and <8xa0days. In multivariate analysis the presence of an extraction string was found to be a risk factor for infection OR 7.7 (1.01–58.9, 95% CI, pxa0=xa00.049) along with renal stone location OR 5.09 (2.1–12.05, 95% CI, pxa0<xa00.001).ConclusionsNo statistically significant difference was found between overall infections rates for patients with and without extraction strings, and such difference was found within the male group, suggesting extraction strings in men may increase the risk of infection.

Adjuvant Methods to Improve Results of Local Bladder Irrigations by Chemotherapy for NMIBC

Non-muscle-invasive bladder cancer is characterized by frequent recurrences requiring repeated transurethral resections and carries a risk of progression to muscle-invasive disease. The routinely used, passive diffusion irrigation of the bladder with mitomycin C has achieved limited success in avoiding these events. We review two methods that may improve penetration of mitomycin C into the bladder wall, thus leading to better results in terms of recurrence rate and bladder preservation.

Multi-institutional evaluation of the prognostic significance of EZH2 expression in high-grade upper tract urothelial carcinoma

PURPOSEnEnhancer of zeste homolog 2 is a methyltransferase encoded by the EZH2 gene, whose role in upper tract urothelial carcinoma (UTUC) is poorly understood. We sought to evaluate the prognostic value of EZH2 expression in UTUC.nnnMETHODSnWe reviewed a multi-institutional cohort of patients who underwent radical nephroureterectomy for high-grade UTUC from 1990 to 2008. Immunohistochemistry for EZH2 was performed on tissue microarrays. Percentage of staining was evaluated, and the discriminative value of EZH2 was tested, with EZH2 positivity defined as>20% staining present. Clinicopathologic characteristics and oncologic outcomes (recurrence-free (RFS), cancer-specific (CSS), and overall survival (OS)) were compared, stratified by EZH2 positivity. The prognostic role of EZH2 was assessed using Kaplan-Meier, univariate (UVA), and multivariate (MVA) Cox regression analyses. Significance was defined for P<0.05.nnnRESULTSnA total of 376 patients were included for analysis, with median follow-up 36.0 months. Overall, 78 (20.7%) were EZH2-positive. EZH2 expression was more often associated with ureteral location, lymphovascular invasion, sessile architecture, necrosis, and concomitant carcinoma in situ. On UVA, increased EZH2 expression was a significant predictor for inferior RFS (HR 1.63, P = 0.033), CSS (HR 2.03, P = 0.003), and OS (HR 2.11, P<0.001). On MVA EZH2 remained a significant predictor of worse CSS (HR 1.99 [95% CI: 1.21-3.27], P = 0.007) and OS (HR 1.54 [95% CI: 1.06-2.24], P = 0.024), while significance was lost for RFS.nnnCONCLUSIONnIncreased EZH2 expression is associated with adverse pathologic features and inferior oncologic outcomes in patients with high-grade UTUC. The role of EZH2 biology in UTUC pathogenesis remains to be further elucidated.

Metastatic “Burned Out” Seminoma Causing Neurological Paraneoplastic Syndrome—Not Quite “Burned Out”

A 44-year-old man presented with cerebellar ataxia and limbic encephalitis and was ultimately diagnosed with metastatic germ cell neoplasm resulting from a “burned out” primary testicular tumor. The patient had progressive ataxia, leading to a thorough investigation for infectious, autoimmune, metabolic, and malignant causes of acquired cerebellar ataxia that revealed no significant findings. Testicular sonography demonstrated a possible right testicular lesion that was not confirmed on radical inguinal orchiectomy. F18-FDG positron emission tomography/computerized tomography scan revealed a solitary retroperitoneal lesion, concerning for metastatic disease but not amenable to percutaneous biopsy. A robotic retroperitoneal lymph node dissection was performed and pathology revealed a CD117-positive metastatic seminoma leading to appropriate germ cell tumor-directed chemotherapy. After completing chemotherapy and during 1u2009year of follow-up, there has been a gradual improvement of the patient’s neurological manifestations.

Therapeutic strategies for upper tract urothelial carcinoma

ABSTRACT Introduction: Many controversies exist regarding the appropriate management of patients with upper tract urothelial carcinoma (UTUC), including staging, surgical management, use of systemic therapy, and prevention of bladder recurrence. Due to the rarity of this condition, high-level evidence is often lacking and in many cases guidelines are extrapolated from existing evidence on urothelial bladder cancer. Areas covered: This review paper summarizes the evidence on proper diagnosis and staging, surgical techniques, prevention of bladder recurrences, the use of local or systemic treatments in both neoadjuvant and adjuvant settings as well as special consideration for hereditary UTUC. Expert commentary: UTUC is a rare malignancy and slow progress is being made in the acquisition of high-quality evidence in this field. Treatments that facilitate preservation of the kidney are being explored such as advanced endoscopic techniques or partial resection of ureteral disease with seemingly acceptable oncological results. Further prospective evidence is needed.

A New Model to Predict Benign Histology in Residual Retroperitoneal Masses After Chemotherapy in Nonseminoma

BACKGROUNDnPostchemotherapy retroperitoneal lymph node dissection (pcRPLND) is indicated in testicular cancer patients with normalised or plateaued serum tumour markers and residual retroperitoneal lesions >1cm. Challenges remain in predicting postchemotherapy residual mass (pcRM) histology, which may lead to unnecessary surgery.nnnOBJECTIVEnTo develop an accurate model to predict pcRM histology in patients with nonseminomatous germ cell tumours (NSGCTs).nnnDESIGN, SETTING, AND PARTICIPANTSnA retrospective review of 335 patients undergoing pcRPLND for metastatic NSGCTs to develop a model to predict benign histology in retroperitoneal pcRM. Our model was compared with others and externally validated.nnnINTERVENTIONnChemotherapy and pcRPLND.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnMultivariable logistic regression to evaluate the presence of benign histology, and fractional polynomials to allow for a nonlinear association between continuous variables and the outcome. The final Princess Margaret model (PMM) was selected based on the number of variables used, reliability, and discriminative capacity to predict benign pcRM.nnnRESULTS AND LIMITATIONSnPMM included the presence of teratoma in the orchiectomy, prechemotherapy α-fetoprotein, prechemotherapy mass size, and change in mass size during chemotherapy. Model specificity was 99.3%. Compared with Vergouwe et als model, PMM had significantly better accuracy (C statistic 0.843 vs 0.783). PMM appropriately identified a larger number of patients for whom pcRPLND can safely be avoided (13.9% vs 0%). Validated in external cohorts, the model retained high discrimination (C statistic 0.88 and 0.80). Larger and prospective studies are needed to further validate this model.nnnCONCLUSIONSnOur clinical model, externally validated, showed improved discriminative ability in predicting pcRM histology when compared with other models. The higher accuracy and reduced number of variables make this a novel and appealing model to use for patient counselling and treatment strategies.nnnPATIENT SUMMARYnPrincess Margaret model accurately predicted postchemotherapy benign histology. These results might have clinical impact by avoiding unnecessary retroperitoneal lymph node dissection and consequently changing the paradigm of advanced testicular cancer treatment.

Imaging for Screening and Surveillance of Patients with Hereditary Forms of Renal Cell Carcinoma

Purpose of ReviewTo summarize the literature providing the basic genetic and clinical characteristics of renal cell carcinoma (RCC) familial syndromes, as well as to describe associated unique imaging characteristics and appropriate imaging protocols.Recent FindingsAt least 5–8% of RCC cases are associated with hereditary syndromes. These patients are prone to developing multiple renal tumors or associated malignancies and require more intense diagnostic and follow-up imaging studies. New familial types of RCC are continuously discovered, vis-à-vis recent characterization of BAP1 associated RCC and MITF associated cancer syndrome.SummaryWith increasing number of recognizable familial syndromes associated with RCC, physicians should be familiar with the different syndromes, the associated risks of malignancy and appropriate imaging protocols.

Incidence and Outcomes of Delayed Targeted Therapy After Cytoreductive Nephrectomy for Metastatic Renal-Cell Carcinoma: A Nationwide Cancer Registry Study

Background: The optimal timing of targeted therapy (TT) initiation for metastatic renal‐cell carcinoma (mRCC) is not clear. We used a nationwide cancer registry to determine clinical and social factors associated with delayed TT and to evaluate the association of a delayed approach with overall survival (OS). Patients and Methods: We performed a retrospective observational study utilizing the National Cancer Data Base from 2006 to 2012 for patients diagnosed with mRCC (clear‐cell histology) treated with cytoreductive nephrectomy and TT. Time to initiation of TT was defined as early (within 2 months), moderately delayed (2‐4 months), delayed (4‐6 months), and late (> 6 months). Results: Of the 2716 patients included in the analysis, the median (interquartile range) time from diagnosis to initiation of TT was 2.1 (1.3‐3.23) months. A total of 1255 patients (46.2%) had early TT, 1072 patients (39.5%) had moderately delayed TT, 284 patients (10.5%) had delayed TT, and 105 patients (3.9%) had late TT. Delay in TT initiation was not independently associated with OS in multivariable analysis. The time interval from diagnosis to TT initiation was not correlated with time from initiation of TT to death (r = 0.04, P = .08). Conclusion: We found that delayed initiation of TT was not an independent predictor of worse OS. Although this study is subject to limitations of observation study design and selection bias, the results are consistent with the notion that in carefully selected patients, outcomes might not be compromised with initial observation.

Effect of blue-light cystoscopy on contemporary performance of urine cytology

To evaluate the performance of urine cytology based on contemporary data, including the effect of enhanced cystoscopic techniques.

Retrospective Analysis of Laparoscopic Partial Nephrectomies Using the Zero Ischemia Technique

Purpose: To report a series of 89 off-clamp laparoscopic partial nephrectomies (LPN) performed without using any additional “nephron sparing” manipulations. Methods: Retrospective analysis of surgical characteristics, complications, postoperative results, and renal function changes. Results: Between March 2008 and May 2014, 89 LPN using zero ischemia technique were performed. Most of the patients (61.8%) were male. The median age was 62 years (23-88). The mean BMI was 27.5 kg/m2 (20.8-54.2). The median tumor size was 3.0 cm (1.0-8.0). Tumor location was upper, middle, and lower part of the kidney in 33 (37.0%), 42 (47.2%), and 14 (15.7%) of patients, respectively. The median operative time was 154 min (58-289). The median hemoglobin change was -1.6 g/dL (0.5-5.5). The transfusion rate was 7.9%. The mean preoperative glomerular filtration rate was 96.6 mL/min (21.5-180.0) with a mean postoperative decline of 6.52 mL/min. The mean creatinine elevation after LPN was 0.09 mg/dL. The median hospital stay was 6 days (2-24). The intraoperative complications rate was 2.3%. Early postoperative complication rate was 33.7%. Late complications occurred in 6.7%. In 7 cases (7.9%), the surgical margins were microscopically involved by tumor cells. Conversion rate was 3.4%. Conclusion: Data obtained in the current series show that laparoscopic partial nephrectomy can be successfully performed without hilar clamping. Our results are comparable with contemporary data. Larger prospective studies would be helpful in assessing the evidence-based advantages of the “zero ischemia” technique.