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Background: Prostate size estimation is a valuable clinical measure widely utilized in urology. This study evaluated the accuracy of preoperative transabdominal ultrasound (TAUS) compared to radica...

Aims Bariatric surgeries induce profound weight loss (decrease in body mass index, BMI), through a decrease in fat mass (FM) and to a much lesser degree of fat-free mass (FFM). Some reports indicate that the weight which is lost after gastric bypass (RYGB) and sleeve gastrectomy (SG) is at least partially regained 2 years after surgery. Here we compare changes in BMI and body composition induced by four bariatric procedures in a 5 years follow-up study. Methods We analyzed retrospectively modifications in BMI, FM and FFM obtained through Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), biliopancreatic diversion (BPD) and a long common limb revisional biliopancreatic diversion (reduction of the gastric pouch and long common limb; BPD + LCL−R). Patients were evaluated at baseline and yearly for 5 years. Of the whole cohort of 565 patients, a subset of 180 patients had all yearly evaluations, while the remaining had incomplete evaluations. Setting University Hospital. Results In a total of 180 patients evaluated yearly for 5 years, decrease in BMI and FM up to 2 years was more rapid with RYGB and SG than BPD and BPD + LCL−R; with RYGB and SG both BMI and FM slightly increased in the years 3–5. At 5 years, the differences were not significant. When analysing the differences between 2 and 5 years, BPD + LCL−R showed a somewhat greater effect on BMI and FM than RYGB, BPD and SG. Superimposable results were obtained when the whole cohort of 565 patients with incomplete evaluation was considered. Conclusions All surgeries were highly effective in reducing BMI and fat mass at around 2 years; with RYGB and SG both BMI and FM slightly increased in the years 3–5, while BPD and BPD + LCL−R showed a slight further decreases in the same time interval.

Greenlight photo-selective vaporization of the prostate (GL-PVP) has gained international acceptance as a safe and effective alternative procedure for the treatment of benign prostatic hyperplasia (BPH), especially in anticoagulated men. This descriptive analysis aims to characterize the current state of GL-PVP, pooling data from international centers. Data from 3627 patients who underwent GL-PVP with the XPS-180 W system in seven international centers performed by eight expert surgeons between 2011 and 2019 were retrospectively analyzed. Demographic, perioperative, and postoperative data were collected, including IPSS, QoL, Qmax, PVR, and PSA, and complications. At baseline, median age, prostate volume, PSA, and IPSS were 70 years (interquartile range 64–77), 64 (47–90), 3.1 ng/mL (1.8–6), and 22 (19–27), respectively. Median lasing and operative time were 34 (23–48) and 62 min (46–85), respectively. Median energy use was 250.0 kJ (168.4–367.9), with 92.6% of procedures being completed with one laser fiber. In 60.1% of cases, catheter was removed on postoperative day 1 with median length of 2 days. All-cause mortality within 30 days was 0.3%. Median PSA reduction at 3 months and 60 months compared to baseline was 43.9 and 46.4%, respectively (p

Most Canadian hospitals face significant reductions in operating room access during the summer. We sought to assess the impact of longer wait times on the oncological outcomes of localized prostate cancer patients following robotic-assisted radical prostatectomy (RARP). We conducted a retrospective review of a prospectively maintained RARP database in two high-volume academic centers, between 2010 and 2019. Assessed outcomes included the difference between post-biopsy UCSF-CAPRA and post-surgical CAPRA-S scores, Gleason score upgrade and biochemical recurrence rates (BCR). Multivariable regression analyses (MVA) were used to evaluate the effect of wait times. A total of 1057 men were included for analysis. Consistent over a 10 year period, summer months had the lowest surgical volumes despite above average booking volumes. The lowest surgical volume occurred during the month of July (7.1 cases on average), which was 35% less than the cohort average. The longest average wait times occurred for patients booked in June (93 ± 69 days, p

Testosterone replacement therapy (TRT) remains controversial in men with treated prostate cancer. We assessed its safety and functional impacts in patients after definitive surgical treatment with robotic-assisted radical prostatectomy (RARP). We performed a retrospective analysis of 1303 patients who underwent RARP during the years 2006–2019. We identified men with symptoms of andropause and low serum testosterone who received TRT post-RARP; then we divided the cohort into two groups accordingly for comparison. Biochemical recurrence (BCR) was the primary endpoint. Secondary endpoints included functional outcomes. Predictors of BCR, including the effect of TRT on BCR, were evaluated using univariable and multivariable logistic regression. Among the forty-seven men who received TRT, the mean age was 60.83 years with a median follow-up of 48 months. Three (6.4%) and 157 (12.56%) patients experienced BCR in TRT and non-TRT groups, respectively. Baseline characteristics were similar between both groups except for higher mean BMI in the TRT group (p = 0.03). In the multivariate analysis (MVA), higher pre-RARP prostate-specific antigen (PSA) (p = 0.043), higher International Society of Urological Pathology score (p

In this review, we will discuss the state of the literature regarding Rezūm and opportunities for its application in the treatment of BPH. A comprehensive review of original research on convective water vapor thermal therapy (Rezūm) was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, Aquablation, and greenlight photoselective vaporization of the prostate were reviewed for discussion. Rezūm distinguishes itself from other treatment options by its durable improvement in objective clinical outcomes such as IPSS and BPH Impact Index, while being cost-effective and versatile in its ability to treat a variety of prostate gland morphologies. This treatment option shows good lower urinary tract symptom relief, especially in small-to-moderate prostate sizes (30–80 cc). The use of convective heat transfer is unique and allows for localized treatment, avoiding damage to surrounding structures, thus providing an excellent safety profile and sexual function preservation. The current evidence on Rezūm warrants its consideration as a therapeutic alternative to transurethral surgery in selected patients.

In this review, we will discuss the state of the literature regarding Aquablation, its limitations, and opportunities for its application in the treatment of benign prostatic enlargement (BPE). A comprehensive review of original research on Aquablation was conducted. Articles related to transurethral resection of the prostate, holmium laser enucleation of the prostate, greenlight photoselective vaporization of the prostate, and simple prostatectomy were reviewed for discussion. For small–medium prostates (30–80 mL), Aquablation’s main advantages include better ejaculatory function and similar functional outcomes compared to TURP. For large prostates (80–150 mL), Aquablation demonstrates shorter operative time and superior ejaculatory function when compared to simple prostatectomy, HoLEP, and Greenlight PVP. In addition, Aquablation displays shorter hospital stays than simple prostatectomy. The integration of software programming and semi-automatic technology increases the reproducibility of the procedure and helps standardize overall outcomes, while also accelerating the learning curve. Its ability to preserve antegrade ejaculation makes Aquablation a very compelling option for sexually active patients. However cost and postoperative bleeding risks remain a concern. The current evidence suggests that Aquablation is a safe and effective alternative for BPE for small to large prostates. Further prospective clinical trials, with comparisons to other BPE modalities, and data from longer follow-up periods are still required.

We aimed to compare postoperative functional outcomes following robotic-assisted radical prostatectomy (RARP) in elderly men with localized prostate cancer. A retrospective review of a prospectively maintained database of men who underwent RARP between January 2007 and November 2018 was performed. Patients over 65 years of age were selected (N = 302) and then stratified by age group: 66–69 years old (N = 214) and ≥ 70 years old (N = 88). Full continence was defined as strict 0-pad per day usage. Preoperative potency included those with a Sexual Health Inventory for Men score ≥ 17. Preoperative and postoperative functional outcomes were assessed. Kaplan–Meier analysis was used to estimate time to recovery of continence in both groups. Both groups had comparable preoperative parameters. Continence rates at 1, 3, 6, 9, 12, 18 and 24 months in the 66–69-year-old group were 6%, 34%, 61%, 70%, 74%, 80% and 87%, respectively. Comparatively in the ≥ 70-year-old group, continence rates were significantly lower at all time points (3%, 22%, 50%, 56%, 66%, 69% and 75%, respectively). Men in the 66–69-year-old group were significantly more likely to be continent after RARP when compared to patients 70 years of age and above [(Hazards ratio (HR) 0.73; 95%confidence interval 0.54–0.97, (p = 0.035)]. Our results suggest that RARP is feasible in elderly patients. Nevertheless, elderly patients in the ≥ 70-year-old group had significantly inferior postoperative continence rates compared to patients aged 66–69 years. Such information is valuable when counselling men during preoperative RARP planning to ensure that they have realistic postoperative expectations.

Background. Gestational trophoblastic disease (GTD) defines a spectrum of proliferative disorders of trophoblastic epitheli- um of the placenta. Incidence, risk factors, and outcome may differ from one country to another. Objective. To describe incidence, patient characteristics, treatment modalities, and outcome of GTD at Mansoura University which is a referral center of Lower Egypt. Methods. An observational prospective study was conducted at the GTD Clinic of Mansoura University. The patients were recruited for 12 months from September 2015 to August 2016. The patients’ characteristics, management, and outcome were reported. Results. We reported 71 clinically diagnosed GTD cases, 62 of them were histologically confirmed, 58 molar (33 CM and 25 PM) in addition to 4 initially presented GTN cases. Mean age of the studied cases was 26.22 years ± 9.30SD. Mean pre-evacu- ation hCG was 136170 m.i.u/ml ±175880 SD. Most of the cases diagnosed accidentally after abnormal sonographic findings (53.2%). Rate of progression of CM and PM to GTN was 24.2% and 8%, respectively. Conclusion. The incidence of molar pregnancy and GTN in our locality was estimated to be 13.1 and 3.2 per 1000 live births respectively. We found no significance between CM and PM regarding hCG level, time to hCG normalization, and progression rate to GTN. Keywords. Molar pregnancy; incidence; outcome.

INTRODUCTION AND OBJECTIVE:This study aims to report age-stratified potency outcomes in Canadian men undergoing robot-assisted radical prostatectomy (RARP).METHODS:A retrospective review was perfor...

INTRODUCTION AND OBJECTIVE:Incontinence after robot-assisted radical prostatectomy (RARP) significantly impacts quality of life. This study aims to compare the age-stratified continence outcomes in...

Introduction and Objectives: The GreenLight™ MoXy® laser fiber has been used since 2010 for benign prostatic hyperplasia procedures. We tested a novel principle to increase the saline irrigation fl...

Background: Survival after hospital admission has been evaluated as a possible risk factor for long-term mortality in selected classes of diseases. The aim of this study was to evaluate survival after hospital admission in all patients admitted as in-patients in a general hospital of Milano, Italy. Methods: 2,580 consecutive patients admitted at Ospedale San Paolo, July1-December 31, 2012, for several classes of diseases (internal medicine, cancer, infectious diseases, trauma and surgery, pneumonia, and heart diseases) were studied; age, total diseases, type of admission, length of admission, age-adjusted Charlson index, prognostic nutritional index (PNI), and full blood count were evaluated. Results: At univariate analysis, all investigated variables, except sex and lymphocytes, were associated with death of patients. At stepwise regression analysis, Charlson index or age plus total diseases, type of admission, number of admissions, and PNI were significant risk factors in the whole sample and in the majority of classes of diseases. Conclusion: Pre-existing conditions and nutritional state represent the major risk factor for mortality in most classes of disease, and possibly influence other predictors, such as type of admission, length of stay. This suggests that the current model of hospital admission might be improved, for instance through comprehensive care at home, instead of hospital admission, or before admission. Funding Information: This study received only institutional funds from Universita degli Studi di Milano and from IRCCS Multimedica; a grant by the Italian Ministry of Health (Ministero della Salute), was issued to IRCCS Multimedica (Ricerca Corrente). Declaration of Interests: LL, FG, ASZ, MF, AV, AEP, and ET declare no conflict of interest with the content of this paper. Ethics Approval Statement: The protocol of the study was approved by the local Ethics in 2013 (original study) and in 2020 (follow-up study).

Previous analyses of the impact of median lobe presence on Greenlight photoselective vaporization of the prostate (PVP) outcomes were limited by their small sample size and the ability to adjust for important confounders. As such, we sought to investigate the impact of prostate median lobe presence on the operative outcomes of 180 W XPS GreenLight PVP using a large international database. Data were obtained from the Global GreenLight Group (GGG) database which pools data of eight high-volume, experienced surgeons, from a total of seven international centers. All men with established benign prostatic hyperplasia who underwent GreenLight PVP using the XPS-180 W system between 2011 and 2019 were eligible for the study. Patients were assigned to two groups based on presence or absence of median lobes. Analyses were adjusted for patient age, prostate volume, body mass index, and American Society of Anesthesia (ASA) score. A total of 1650 men met the inclusion criteria. A median lobe was identified in 621 (37.6%) patients. Baseline prostate volume, patient age, and ASA score varied considerably between the two groups. In adjusted analyses, the operative and lasing time of patients with median lobes was 6.72 (95% CI 3.22–10.23; p

The aim of the study is to evaluate the impact of having a nadir and persistently detectable ultrasensitive prostate-specific antigen (uPSA) between 0.01 and 0.1 ng/ml post-robot-assisted radical prostatectomy (RARP), on future biochemical recurrence (BCR). We conducted a retrospective analysis of a prospectively maintained cohort of 1359 men who underwent RARP, between 2006 and 2019. Patients were followed with uPSA at 1, 3, 6, 9, 12, 18, 24, 30, 36 months and annually thereafter. We included patients with PSA nadir values between 0.01 and 0.1 ng/ml within 6 months of surgery and with at least 2 follow-up measurements within the same range. We divided patients based on their BCR status and analyzed uPSA changes. Multivariable Cox-regression models (CRMs) were used to analyze variables predicting BCR-free survival (BCR-FS). We identified 167 (12.3%) patients for analyses, with a mean follow-up time of 60.2 ± 31.4 months. In our cohort, 5-year BCR-FS rate was 86%. Overall, 32 (19.1%) patients had BCR, with a mean time to BCR of 43.7 ± 24.3 months. BCR-free patients had stable mean uPSA values ≤ 0.033 ng/ml, while patients who developed BCR showed a slowly rising trend over time, with a significant difference between groups starting at 9 months (p

In the current review, we will discuss the state of the literature of vaporization of the prostate for the treatment of benign prostatic enlargement (BPE). We discuss two methods of vaporization of the prostate: Transurethral Vaporization of the Prostate (TUVP) and Greenlight Photo-selective Vaporization of the Prostate (PVP). A comprehensive review of the literature was performed on TUVP and PVP. The literature on transurethral resection of the prostate (TURP) was also extensively reviewed as a comparative surgical method. The evidence shows that TUVP appears to be the safer choice, as compared to TURP due to less intra- and peri-operative complications. PVP was associated with less bleeding complications than TURP with outpatient discharge. Importantly, PVP was not associated with serious bleeding events requiring blood transfusions or medical treatment in patients under anticoagulation or antiplatelet therapies. PVP was also shown to be a cost-effective option compared to TURP. Prostate vaporization for the treatment of BPE appears to be an efficient and safer alternative to TURP. Vaporization techniques, particularly Greenlight PVP, should be offered to most men, especially those under anticoagulation therapy, as well as patients at risk of bleeding complications.

INTRODUCTION AND OBJECTIVE:Amongst the surgical treatment modalities available, Greenlight photo-selective vaporization of the prostate (GL-PVP) has gained international acceptance as a safe and ef...

INTRODUCTION AND OBJECTIVE:Most Canadian hospitals face significant reductions (20-50%) in operative room access during summer months due to nursing shortages, leading to increased surgical delays....

INTRODUCTION AND OBJECTIVE:Ultrasensitive PSA assays is widely used in the early detection of biochemical recurrence (BCR) after RARP, setting a value of

Introduction: In light of the recent Canadian Urological Association (CUA) and other urological association (America Urological Association, European Association of Urology) recommendations for the treatment of benign prostate hyperplasia (BPH) with lower urinary tract symptoms (LUTS), open simple prostatectomy (OSP) remains the recommended approach for large prostates with measured volumes over 80 cc.1 We sought to assess the current state of OSP and other BPH surgical training across Canadian urology residency programs and the use of guideline-recommended imagery prior to BPH surgery. Methods: A survey was distributed among Canadian urology program directors in June 2019. We identified the various surgical modalities available for the treatment of BPH offered by each program and obtained the annual number of OSP performed at each academic residency program. Additionally, we evaluated if preoperative transrectal ultrasound (TRUS) of the prostate was routinely performed to obtain the prostate volume during patient counselling as recommended by 2018 CUA guidelines. Results: All 13 program directors from the Canadian urology programs responded to our survey. OSP and monopolar transurethral resection of the prostate (TURP) remain the most common across programs and are practiced in all centers. Greenlight photo-vaporization, bipolar TURP, holmium laser enucleation of the prostate and robot-assisted simple prostatectomy were practiced in 76.8%, 69.2%, 23.1%, and 23.1% of centers, respectively. The mean number of OSP per academic training program was 4.7 cases annually. Moreover, only five (38%) academic centers routinely performed a preoperative TRUS to evaluate prostate volume for BPH counselling. Conclusions: Although recognized and referenced as the BPH gold standard for the treatment of prostates over 80 cc, Canadian urology trainees’ annual OSP exposure remains extremely limited. Considering the degree of importance given (category A) to the direct observation (of a minimum of five) of this intervention during residency training in the new Royal College's practice guidelines, it may be unrealistic to reach these national standards considering the annual case OSP volumes in Canadian academic urology faculties.

Background and aims: Bariatric surgery (BS) reduces long-term mortality in comparison with medical treatment of obesity. Some studies indicate that this effect is significant for patients above mean age in different cohorts, but not for younger patients. These findings raise the question whether morbid obese patients should undergo BS as soon as possible, or whether patients might undergo surgery later in their life. Methods: We performed a post hoc analysis of two studies; we evaluated surgery-related long-term mortality in: (1) the whole cohort [857 surgery patients (163 diabetes) vs. 2086 controls (512 diabetes)]; (2) patients above mean age [> 43 years, 427 surgery patients (133 diabetes) vs. 1054 controls (392 diabetes)]; (3) patients below mean age [≤ 43 years, 432 surgery patients (30 diabetes) vs. 1032 controls (120 diabetes]. Then, we analyzed age-related long-term mortality in the whole cohort, as well as in surgery patients and in controls. Finally, we analyzed incident diseases (diabetes, cardiovascular disease, and cancer) as a function of surgery versus no-surgery and of mean age. Results: Surgery patients, compared with controls receiving standard medical/dietary treatment, had reduced mortality in the whole cohort (HR = 0.45, 95% CI 0.33–0.62, p = 0.001) and in the study group aged > 43 years (HR = 0.39, 95% CI 0.28–0.56, p = 0.001), but not in the study group aged ≤ 43 years (HR = 0.87, 95% CI 0.42–1.80, p = 0.711). Reduced mortality was observed in non-diabetic and diabetic patients aged > 43 years (HR = 0.37, 95% CI 0.23–0.62, p = 0.001 and HR = 0.45, 95% CI 0.27–0.74, p = 0.002, respectively) who underwent bariatric surgery. In contrast, in patients aged ≤ 43 years, no significant protective effect of bariatric surgery appeared in non-diabetic patients (HR = 0.64, 95% CI 0.24–1.71, p = 0.371), and mortality increased, almost significantly, in diabetic patients aged < 43 years (HR = 2.87, 95% CI 0.96–8.56, p = 0.058), and even more in diabetic patients aged 33–43years; HR = 4.99, 95% CI 1.18–21.09, p = 0.029). As expected, age-related mortality was increased in the whole cohort (HR = 7.23, 95% CI 5.14–10.17, p = 0.001), in non-diabetic and diabetic controls (HR = 8.55, 95% CI 5.77–12.68, p = 0.001, and HR = 3.76, 95% CI 1.97–7.18, p = 0.001, respectively). The effect of aging was slightly reduced in surgery patients (HR = 3.76, 95% CI 1.87–7.58, p = 0.001), while it was not significant in diabetic surgery patients (HR = 0.70, 95% CI 0.26–1.90, p = 0.88), further emphasizing that diabetes per se has a strong negative effect on survival, also with concomitant bariatric surgery. In a supplementary analysis, HRs did not change when surgery and control parents were matched for the presence of diabetes. Incident diseases (cardiovascular, diabetes, and cancer) were less frequent in surgery than in control patients, irrespective of age. Conclusion: Bariatric surgery reduces long-term mortality in comparison with medical treatment when performed in patients aged > 43 years, but not in younger patients, where it is neutral or could even increase mortality; reduction in morbidity occurs at any age.

Bariatric surgeries such as gastric banding (LAGB), gastric bypass (RYGB), vertical banded gastroplasty (VBG), and sleeve gastrectomy (LSG) decrease body weight in morbid obesity, leading to the resolution of coexisting diabetes mellitus and arterial hypertension in the majority of cases as well as improvements of renal function and liver steatosis. BS (LAGB, RYGB, VBG, and LSG) also reduce incident cases of diabetes, of cardiovascular diseases, and of cancer; these therapeutic and preventive effects on comorbidities of obesity have not been analyzed for malabsorptive surgeries such as biliopancreatic diversion (BPD) or biliointestinal bypass (BIBP). The aim of this study was to analyze the incidence of comorbidities, i.e., diabetes, cardiovascular diseases, and cancer, in obese subjects undergoing BPD and BIBP, in comparison with standard medical treatment of obesity. Medical records of 1983 obese patients (body mass index (BMI) > 35 kg/m2, aged 18–65 years, undergoing surgery (n = 472, of which 111 with diabetes) or medical treatment (n = 1511, of which 422 with diabetes), during the period 1999–2008 (visit 1)) were collected; incident cases of comorbidities were ascertained through December 31, 2016. Observation period was 12.0 ± 3.48 years (mean ± SD). Compared to non-surgical patients matched for age, body mass index, and blood pressure, malabsorptive surgeries were associated with reduced new incident cases of diabetes (p = 0.001), cardiovascular diseases (p = 0.001), hyperlipidemia (p = 0.001), oculopathy (p = 0.021), and cancer (p = 0.001). The preventive effect of BS was similar in both nondiabetic and diabetic patients for cardiovascular diseases and hyperlipidemia (both p = 0.001). The preventive effect was significant in nondiabetic subjects for coronary heart disease and for cancer, not significant in diabetic subjects. Patients undergoing malabsorptive bariatric surgery show less incident cases of diabetes, cardiovascular diseases, hyperlipidemia, oculopathy, and cancer than controls receiving medical treatment.

Long-term comparisons between bariatric surgical techniques have been performed for gastric bypass (RYGB), sleeve gastrectomy (LSG), and biliopancreatic diversion (BPD) vs gastric banding (LAGB), but short-term studies (6 months–4 years) have only compared biliointestinal bypass (BIBP) and LAGB. The participating institutions regularly perform both BIBP and LAGB with a common protocol, and the aim of this retrospective study was to compare long-term effects of the two procedures on body weight, on clinical and metabolic variables, and on resolution of obesity and of diabetes. All procedures performed between 01/01/1998 and 31/12/2005 were considered; 73 out of 91 patients undergoing BIBP, and 154 out of 249 patients undergoing LAGB were evaluable up to 9 years. BIBP was significantly more effective than LAGB in terms of weight loss and of resolution of obesity (BMI

To characterize testosterone profile changes over time in a cohort of prostate cancer (PCa) patients managed with active surveillance (AS) and to assess its correlation with the initial disease characteristics and further progression. We conducted retrospective chart review of PCa patients managed with AS. Patients were followed with PSA, total, free and bioavailable testosterone measurements, physical examination, and by repeat biopsies or periodic magnetic resonance imaging. Disease progression was identified by follow-up biopsy changes or by imaging. A Cox proportional hazard regression models were used to assess the association between testosterone profile at baseline and the risk of progression. For the 122 patients included in analyses, the mean age at diagnosis was 65.8 years; the mean follow-up time was 7.8 years. At baseline, 108 (88.5%) patients had a Gleason score of ≤ 6. In all, 45 (36.8%) patients had disease progression, with a mean time to progression of 4.6 years. During follow-up, PSA levels showed a rising trend, while testosterone profile levels showed a trend of decrease over time. There was no significant correlation between PSA and testosterone profile (total, free, and bioavailable) level changes over time (ρ = − 0.14, − 0.11 and − 0.16, P = 0.16, 0.34, and 0.20, respectively). In addition, multivariable analysis showed that serum-free testosterone was an independent predictor of disease progression (HR 0.93, 95% CI 0.88–0.99, P = 0.029). Our study results showed that testosterone profile measurements tended to decrease over time in PCa patients managed with AS. Free testosterone was a significant independent variable of disease progression.

Introduction/Background Gestational trophoblastic disease (GTD) defines a spectrum of proliferative disorders of trophoblastic epithelium of the placenta. Incidence, risk factors, and outcome may differ from a country to another. Methodology An observational prospective study was conducted at the GTD Clinic of Mansoura University. The patients were recruited for 12 months from September 2015 to August 2016. The patients9 characteristics, management, and outcome were reported. Results We reported 71 clinically diagnosed GTD cases, 62 of them were histologically confirmed, 58 molar (33 CM and 25 PM) in addition to 4 initially presented GTN cases. Mean age of the studied cases was 26.22 years ± 9.30SD. Mean pre-evacuation hCG was 136170 m.i.u/ml ±175880 SD. Most of the cases diagnosed accidentally after abnormal sonographic findings (53.2%). Rate of progression of CM and PM to GTN was 24.2% and 8%, respectively. Conclusion The incidence of molar pregnancy and GTN in our locality was estimated to be 13.1 and 3.2 per 1000 live births respectively. We found no significance between CM and PM regarding hCG level, time to hCG normalization, and progression rate to GTN. Disclosure Nothing to disclose

BACKGROUND AND OBJECTIVES We evaluated the short- and long-term outcome in bladder cancer (BC) patients treated with radical cystectomy (RC) in Quebec (Canada). METHODS Data were collected from provincial registries on all BC patients who underwent RC in Quebec province in 2000-2015. Outcomes were hospitalization rates and survival. Survival analyses were conducted using log-rank tests and Cox proportional hazards models. RESULTS In total, 4450 patients were included in our analysis. RC was increasingly conducted by higher-volume surgeons in larger, higher-volume, academic hospitals. Comparing patients treated in 2010-2015 to 2000-2009, recently treated patients had shorter postoperative hospital stays (absolute difference, 0.9 days, P

Introduction and Objectives: The aim of this study was to assess if there is a difference in survival after radical cystectomy (RC) when examined in relation to prior non-muscle invasive bladder cancer (NMIBC) disease vs. invasive cancer de novo at time of diagnosis. Methods: We conducted a retrospective study of all patients who underwent RC within Quebec health insurance medical services database during the years (2000-2009). Overall survival (OS) outcome was assessed with Kaplan-Meier curves and hazard ratios (HRs) adjusted for age and gender. Results: A total of 2,671 subjects met the eligibility criteria. Among them, 19.8% had presumed prior NMIBC that further progressed to invasive disease. Median survival after RC for patients with presumed prior NMIBC was 4.3 years as compared to patients with presumed invasive disease de novo 3.7 years (p = 0.007, Wilcoxon test). Patients with presumed NMIBC at the time of diagnosis had a 16% decrease in the risk of mortality after RC, when compared to patients with presumed invasive BC de novo (HR 0.84, 95% CI 0.73-0.96 (p = 0.0166)). Conclusion: Our results suggest a slightly better prognosis, regarding OS after RC for patients with presumed NMIBC who progressed to invasive disease, when compared to patients with presumed invasive disease de novo at the time of diagnosis.

Aim of this study was to analyze long-term mortality in obese patients receiving malabsorptive bariatric surgery (BS)[biliopancreatic diversion (BPD) and biliointestinal bypass (BIBP)] in comparison to medical treatment of obesity. Medical records of 1877 obese patients [body mass index (BMI) > 35 kg/m2, aged 18–65 years, undergoing BS (n = 472, 111 with diabetes) or non-surgical medical treatment (n = 1405, 385 with diabetes), during the period 1999–2008 (visit 1)] were collected; non-surgical patients were matched for age, sex, BMI, and blood pressure, and life status and causes of death were ascertained through December 2016. Survival was compared across surgery patients and non-surgical patients using Kaplan–Meier plots and Cox regression analyses. Observation period was 12.1 ± 3.41 years (mean ± SD). Compared to non-surgical patients, BS patients had reduced all-cause mortality (34/472 (7.2%) vs 181/1,405 (12.9%) patients, χ2 = 11.25, p = 0.001; HR = 0.64, 95% C.I. 0.43–0.93, p = 0.019). Cardiovascular and cancer causes of death were significantly less frequent in surgery vs no-surgery (HR = 0.26, 95% C.I. 0.09–0.72, p = 0.003; HR = 0.21, 95% C.I. 0.09–0.45, p

Objectives To document radical cystectomy (RC) outcomes in patients over 80 years old across Quebec during the years 2000–2009 and to examine potentially related factors. Methods Within Quebec health insurance medical services database, we identified patients over 80 years who underwent RC. The outcomes analyzed were post-operative complications, mortality rates at 30, 60 and 90 days and overall survival. Results A total of 275 patients over 80 years old had RC performed in 38 hospitals across Quebec. Among them, 33% had major post-operative complications with 16% having more than one complication. Mortality rates at 30, 60 and 90 days were 5.8%, 9.8% and 13% respectively. 44.3% of RCs were performed in seven academic hospitals with mortality rates of 2.5%, 6.5% and 9% respectively. Community hospitals had mortality of 8.5%, 12.4% and 16.3% respectively (P

Introduction Late locoregional complications in prostate cancer (PCa) affect quality of life and require medical interventions. Our objective was to compare late locoregional complications in men dying of castration-resistant PCa (CRPC) who previously received external-beam radiotherapy (EBRT) to radical prostatectomy (RP). No group without previous primary local treatment was included. Patients and Methods The cohort consists of CRPC patients who died between 2001 and 2013 and who underwent previous EBRT or RP. The Regie de l'assurance maladie du Quebec administrative databases were used to identify late locoregional complications (urologic procedures, minor rectal procedures, and other major surgical procedures) and PCa-related hospitalizations occurring in the last 2 years of life. Multivariable logistic regression and negative binomial regression analyses were performed. Results The cohort comprised 1189 patients; 535 (45%) and 654 (55%) received EBRT and RP, respectively. Overall, 46.4% of patients experienced at least 1 late locoregional complication. Primary local treatment type was not associated with the odds of late locoregional complications (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.72, 1.16). RP was associated with greater odds of PCa-related hospitalization (OR, 1.63; 95% CI, 1.23, 2.17) relative to EBRT, as were the usage of a CRPC treatment (OR, 3.96; 95% CI, 2.83, 5.53) and the occurrence of a late locoregional complication (OR, 2.76; 95% CI, 2.05, 3.69). For the number of PCa-related hospitalization days, RP was not found to be significant (rate ratio, 1.09; 95% CI, 0.90, 1.32). Conclusion In this population-based cohort, the risk of late locoregional complications in CRPC was not associated with the type of primary local treatment (RP or EBRT).

Introduction and objectives Management of bladder cancer imposes a great economic challenge on the health care system; with the greatest share of this burden attributed to radical cystectomy (RC) and prolonged postoperative follow-up. Our aim was to characterize health care services utilization and evaluate associated cost predictors during the last 6 months of life in patients who had RC. Methods We conducted a retrospective study within a cohort of 2,988 patients who had RC from 2000 to 2009. Data were obtained from the Quebec health insurance medical services database. We included patients who deceased during the study period, and survived at least 6 months after the first 90 postoperative days. Services billing codes were used to retrieve hospital, outpatient and imaging services. Linear regression models were used to assess predictors of costs. Results From the 1,355 patients who deceased during the study period, we analyzed data of 799 subjects. Men formed 77.3% and 52.8% of patients were between 60 and 75 years of age at the time of RC. In their last 6 months of life, 17.2% of patients had surgery for major urinary tract complications, 25% had chemotherapy whereas 27.6% had radiotherapy. Also, 3.5% of patients had hemodialysis. Imaging was performed in 94.6% of patients. Urologist (specialist) visits ranked first where 72.3% of patients had 3,481 visits (average = 6 visits/pt) followed by medical subspecialist where 69% of patients had 10,010 visits (average = 18 visits/pt). For supportive care, 97% of patients had 25,560 family physician visits (average = 31 visits/pt) whereas only 16% of them had highly specialized care. Services utilization kept increasing with time especially during the last 2 months before death. Post-RC complications were significant predictor associated with increased costs at all assessed services ( P Conclusion Our study results suggest that health care services utilization varies in the assessed period. Urologists involvement in the process of care tends to decrease over time, in favor of other medical specialties, however, some health care services, such as highly specialized supportive care, may be underutilized.

Lent et al. (1) report on mortality in patients with and without diabetes undergoing gastric bypass or medical treatment. After a mean follow-up period of 5.8 years, they show that the benefit of gastric bypass versus medical treatment is confined to patients with diabetes. A few articles, analyzed in a meta-analysis by our group (2), have shown that long-term mortality is reduced with bariatric surgery in comparison with nonsurgical treatment; these studies …

Viability testing can be used to avoid the transplantation of nonheart beating donor organs that are likely to have primary nonfunction. Such testing also identifies a second group of kidneys which, although unsuitable for solitary transplantation, may be considered for dual transplantation. In kidneys in this group solitary transplants would be unlikely to produce a sufficient glomerular filtration rate to support the recipient. However, if used together as a dual transplant, they have the potential to produce sufficient renal function in 1 patient.The group at our unit has performed 23 dual nonheart beating donor renal transplants from 2003 to date. Using 3 and 12-month post-transplantation recipient glomerular filtration rates as primary end points we compared our dual transplant group with our series of 115 single nonheart beating donor transplants from 1998 to 2006.At 3 and 12 months mean glomerular filtration rates in the dual group were 46.2 and 45.5 ml per minute per 1.73 m(2), respectively. These values were not significantly different from the mean glomerular filtration rates of 40.7 and 43.0 ml per minute per 1.73 m(2), respectively, in the single transplant group.We have observed that a subset of nonheart beating donor kidneys that do not satisfy the viability criteria for single organ transplantation may become successful dual organ grafts, thus, avoiding unnecessary organ nonuse and maximizing organ resources.

Background and aim Aim of this retrospective study was to compare long-term mortality and incidence of new diseases [diabetes and cardiovascular (CV) disease] in morbidly obese diabetic and nondiabetic patients, undergoing gastric banding (LAGB) in comparison to medical treatment. Patients and methods Medical records of obese patients [body mass index (BMI) > 35 kg/m2 undergoing LAGB (n = 385; 52 with diabetes) or medical treatment (controls, n = 681; 127 with diabetes), during the period 1995–2001 (visit 1)] were collected. Patients were matched for age, sex, BMI, and blood pressure. Identification codes of patients were entered in the Italian National Health System Lumbardy database, that contains life status, causes of death, as well as exemptions, drug prescriptions, and hospital admissions (proxies of diseases) from visit 1 to September 2012. Survival was compared across LAGB patients and matched controls using Kaplan–Meier plots adjusted Cox regression analyses. Results Observation period was 13.9 ± 1.87 (mean ± SD). Mortality rate was 2.6, 6.6, and 10.1 % in controls at 5, 10, and 15 years, respectively; mortality rate was 0.8, 2.5, and 3.1 % in LAGB patients at 5, 10, and 15 years, respectively. Compared to controls, surgery was associated with reduced mortality [HR 0.35, 95 % CI 0.19–0.65, p

Limited information is available on weight loss, metabolic control, cardiovascular disease and diabetic complications in morbidly obese patients undergoing gastric banding (LAGB) compared with morbidly obese patients receiving medical treatment.To assess the long-term effects of laparoscopic adjustable gastric banding (LAGB) on glucose tolerance, arterial hypertension, and cardiovascular disease and prevention of diabetic complications (retinopathy and renal function) in morbidly obese patients.University hospitals, Italy.In this retrospective study, 87 morbidly obese patients who underwent LAGB (20 with diabetes) and 87 morbidly obese patients who did not undergo surgery (36 with diabetes) for the treatment of obesity during the period 1995 to 2003 consented for re-examination after a mean (±standard deviation) period of 13.8±2.04 years. At baseline, all mobidly obese patients had a body mass index (BMI)≥35 kg/m(2) and were aged 18 to 65 years.At follow-up, LAGB patients maintained a lower weight compared with baseline values and demonstrated significant decreases in both blood pressure and heart rate measurements compared with control patients. LAGB patients also experienced greater improvement of glucose tolerance than did control patients (28% versus 10%, respectively; P.01) and reduction of insulin and homeostasis model assessment for insulin resistance. Fewer LAGB patients developed carotid plaques than did control patients (10% versus 26%, respectively; P.01). Intensification of antihypertensive therapy was required in 31% of surgery versus 60% of control patients (P.05). Among diabetic patients, improved glucose tolerance occurred in 55% of surgery patients versus 0% in the control group (P.01). In addition, insulin treatment was necessary in 9 control patients versus 0 in the surgery group (P.05), and carotid plaques occurred in 10% of LAGB patients versus 50% of control patients (P.01). Creatinine levels and the estimated glomerular filtration rate improved in LAGB diabetic patients but not in control patients (P.05).Despite a very small weight loss over the long term (i.e., 2.2 kg/m(2)), improvement of glucose tolerance persisted for long periods after LAGB, with no unfavorable effect on kidney function and retinopathy. In contrast, no effect was observed on prevention of arterial hypertension or cardiovascular disease.

Previous studies reported improved outcomes for bladder cancer patients who had radical cystectomy (RC) performed by surgeons and hospitals with high annual RC volumes. The objective of this study was to determine the effect of high hospital and surgeon volume on overall survival after RC for bladder cancer in Quebec. We conducted a retrospective cohort study using data of patients who underwent RC for bladder cancer from 2000 to 2009. The cohort was obtained with the linkage of two health databases: the RAMQ database (data on medical services) and the ISQ database (vital status data). Hospital and surgeon volumes were defined as the average annual number of RC performed at an institution or by surgeon, respectively, during the study period. We considered high hospital and surgeon volume those found in the third and fourth quartiles of the distribution of hospital and surgeon volumes. The effect of high hospital and surgeon volume on survival was assessed by multivariate Cox proportional hazards models. We analyzed a total of 2,778 patients who met inclusion criteria (75 % males). High hospital volume and surgeons were found to be significantly associated with improved overall survival (HR = 0.87, 95 % CI: 0.78–0.97 and HR = 0.81, 95 % CI: 0.71–0.91, respectively). The combined effect of high-volume hospital and high-volume surgeon decreased by 20 % the risk of long-term mortality (HR = 0.80, 95 % CI: 0.70–0.91). Compared to low-volume providers, having RC for bladder cancer performed in high-volume hospitals or by high-volume surgeon was associated with improved overall survival.

Even if limited to one biopsy core, most urologists and radiation oncologists use the highest Gleason score (GS) to guide therapy. To evaluate the suitability of using biopsy characteristics to predict tumor characteristics at radical prostatectomy (RP) in men with high biopsy GS (BGS) cancer to better select men who will most benefit from various local therapies, we retrospectively reviewed the biopsy and RP findings of 144 men with a BGS 8-10. One hundred six and 38 patients with a BGS of 8 and 9-10, respectively, were included. Forty-eight percent of cases were downgraded to a final GS of 7 at RP, including 54% of BGS 8, and 32% of BGS 9-10 group. Overall, 31% had pT2 disease at RP. Multiple biopsy features, including the GS, the number of positive cores, the number of cores with high-GS cancer, and the maximum volume of high-grade cancer per core (MVPC) consistently predicted final GS and RP tumor stage. Multivariate analysis showed that biopsy GS and MVPC were independent predictors of final GS, while MVPC was also an independent predictor for final pT stage. Patients with high BGS are not a homogeneous group in terms of local tumor characteristics. In addition to BGS (9-10 being worse than 8), other biopsy findings, especially the number of involved cores, number of cores with high-BGS cancer, and MVPC are important predictors of findings at RP that should be incorporated in the decision treatment planning. Most patients with only one core BGS 8 cancer harbor GS 7 cancer.

To the Editor: We read with interest the original contribution by Zoppini et al.(1), because of the great number of subjects involved and the use of death certificates as a reliable source of information. Nevertheless, they claim some limitation, such as the follow-up duration (maximum 7 years) and the lack of data on diabetes type, treatment, and complications. We carried out a similar study, a prospective cohort record-linked study, analyzing data of 969 morbidly obese (BMI >35 kg/m2) outpatients first visited in the period 1995–2001 (221 patients with diabetes mellitus type 2, 101 men and 120 women; 748 patients without diabetes, 222 men and 526 women); we collected clinical and pharmacological story, anthropometric data, and we completed a full panel of blood exams at baseline. Then, we evaluated the development of complications after a mean 15-year follow-up and, where applicable, mortality data. All these data were retrieved through the Lombardy Region Administrative Database, which lists death causes and exemptions; as described by Zoppini et al.(1), in Italy subjects with chronic diseases are entitled to free disease-specific care, and these patients are listed in a regional electronic database (2). In particular, we analyzed data regarding exemption for chronic liver disease (CLD) and for diabetes mellitus (DM). The same method was used to collect mortality data, according to ICD 10 classification. Our data showed at baseline that diabetic obese patients had hypertransaminasemia in a higher percentage of cases compared with nondiabetic obese patients (17.9% vs. 4.06%, P=0.0001 for aspartate aminotransferase and 55.5% vs. 34.1%, P=0.0001 for alanine aminotransferase); moreover, after a 15-year follow-up, diabetic subjects were more prone to develop an exemption for CLD than nondiabetic subjects (4.52% vs. 1.47%), regardless of aspartate aminotransferase and alanine aminotransferase levels at baseline. Mortality data were similar to those collected by Zoppini et al., with a higher mortality rate among diabetic patients, especially for neoplasia (11.3% vs. 2.6% P=0.001), followed by cardiovascular diseases (6.7% vs. 2.1%, P=0.0001), liver disease (2.7% vs. 0% P=0.0001), and renal (0.9% vs. 0%, P=0.05) and lung diseases (0.9% vs. 0.1%, P=NS). Although minding some limitations, our study’s strengths are the long follow-up period and the collection of patients’ complete information at baseline, which helps define patients at increased risk of comorbidities and mortality on the basis of anthropometric and blood examinations. Limitations are represented by the fact that in the exemption category for CLD, diseases different from NAFLD are also accounted for, and by the fact that we only examined obese patients.

Introduction: Radical cystectomy (RC) is a very complex urologic procedure. Despite improvements in practice, technique and process of care, it is still associated with significant complications, including death, with reported postoperative mortality rates ranging from 0.8% to 8%. We examine the quality of surgical care indicators and document the mortality rates at 30, 60 and 90 days after RC across Quebec.Methods: Within the Régie de l’assurance maladie du Québec (RAMQ) administrative database (this database provides prospectively collected universal data on all medical services) and the Institut de la statistique du Québec (ISQ) database (this provides vital status data), we used procedure codes to identify patients who underwent RC for bladder cancer in Quebec over 10 years (between 2000 and 2009), as well as RC outcomes and dates of death. Data obtained were retrospectively analyzed in relation to multiple parameters, including patient characteristics and healthcare providers’ volumes. The outcomes analyzed included postoperative complications and mortality rates at 30, 60 and 90 days.Results: A total of 2778 RC were performed in 48 hospitals by 122 urologists across Quebec. Among them, 851 (30.6%) patients had at least one postoperative complication and 350 (12.6%) patients had more than one complication. The overall mortality rates at 30, 60 and 90 days were 2.8%, 5.3% and 7.5%, respectively, with significantly elevated 90-day mortality rates in some centres. In the multivariate analysis, increased age was associated with increased risk of post-RC complications and mortality. For example, patients over 75 had more chance of having at least one postoperative complication (odds ratio [OR] 1.66, 95% confidence interval [CI]:1.31-2.11) and mortality at 90 days (OR 3.28, 95% CI: 2.05-5.26). Provider volume effect on outcomes was statistically significant, with large hospitals having decreased risk of 30-day mortality (OR 0.29, 95% CI: 0.12-0.70), 60-day mortality (OR 0.41, 95% CI:0.26-0.82) and 90-day mortality (OR 0.52, 95% CI: 0.29-0.93) when compared to smaller hospitals. Surgeon volume showed weak, but not statistically significant, evidence of reduced odds of mortality for the high-volume surgeon. Limitations of our study include reliance on administrative data, which lack some relevant clinical information (such as patient functional status and tumour pathological characteristics) to perform risk adjustment analysis.Conclusion: Our study demonstrates that postoperative outcomes after RC in Quebec varies based on several parameters. In addition, 30-day postoperative mortality after RC in Quebec appears acceptable. However, 90-day postoperative mortality rates remain significantly elevated in some centres, particularly in the elderly. This requires further research.

Introduction: According to the Royal College objectives of training in urology, urologic surgical procedures are divided as category A, B and C. We wanted to determine the level of proficiency required and achieved by urology training faculty for Royal College accreditation.Methods: We conducted a survey that was sent electronically to all Canadian urology training faculty. Questions focused on demographics (i.e., years of practice, geographic location, subspecialty, access to robotic surgery), operating room contact with residents, opinion on the level of proficiency required from a list of 54 surgical procedures, and whether their most recent graduates attained category A proficiency in these procedures.Results: The response rate was 43.7% (95/217). Among respondents, 92.6% were full timers, 21.1% practiced urology for less than 5 years and 3.2% for more than 30 years. Responses from Quebec and Ontario formed 69.4% (34.7% each). Of the respondents, 37.9% were uro-oncologists and 75.7% reported having access to robotic surgery. Sixty percent of faculty members operate with R5 residents between 2 to 5 days per month. When respondents were asked which categories should be listed as category A, only 8 procedures received 100% agreement. Also, results varied significantly when analyzed by sub-specialty. For example, almost 50% or more of uro-oncologists believed that radical cystectomy, anterior pelvic exenteration and extended pelvic lymphadenectomy should not be category A. The following procedures had significant disagreement suggesting the need for re-classification: glanular hypospadias repair, boari flap, entero-vesical and vesico-vaginal fistulae repair. Overall, more than 80% of faculty reported that their recent graduating residents had achieved category A proficiency, in a subset of procedures. However, more than 50% of all faculty either disagreed or were ambivalent that all of their graduating residents were Category A proficient in several procedures.Conclusions: There is sufficient disagreement among Canadian urology faculty to suggest another revision of the current Royal College list of category A procedures.

Background Bladder cancer (BC) has the highest lifetime treatment costs per patient of all cancers. The objective of this study was to characterize the use of health-care services and costs associated with BC among patients who underwent radical cystectomy (RC) in the province of Quebec. Methods We conducted a descriptive study in a retrospective cohort of patients who underwent RC for BC between 2000 and 2009. Data was obtained from two health administrative databases (RAMQ and ISQ). We calculated average costs per patient and total costs in 2014 Canadian dollars for the following components of costs: 1) Pre-surgery costs (pre and post-urologist consultations, urologist consultations, cystoscopies, TURBTs, imaging procedures); 2) Costs of radical cystectomy and 3) Post-surgery costs (urologist consultations, post-operative consultations, medical oncologist consultations, imaging procedures and post-operative complication management). ARIMA models were used to evaluate trends in average costs per patient over the study period. Results Among 2759 patients included in the study (75 % men), average pre-surgery costs, RC costs, and post-surgery costs were estimated at 3762$, 18979$ and 4770$, respectively. RC cost was responsible for 69 % of total costs, followed by post-operative consultations (7.8 %), post-operative complications and TURBTs (6 % of total costs, each). Academic hospitals performed RC at a lower average cost, compared to community hospitals (difference of $1000, p