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Purpose To evaluate whether patients with prostate cancer have worse functional urinary recovery with focal brachytherapy (FBT) at the base versus the apex of the prostate. Methods and Materials The functional outcomes of patients treated with FBT at the base of the prostate were compared with those of patients treated with FBT at the apex. Urinary symptoms, continence, and erectile dysfunction were measured using the International Prostate Symptom Score (IPSS), International Continence Score (ICS), and International Index of Erectile Function (IIEF-5) questionnaires, respectively, at baseline and at 6, 12, and 24 months after treatment. Results Twenty-eight and 13 patients were treated with FBT at the apex and the base, respectively, of the prostate. A significant difference between groups was found in the IPSS score at 6 months (mean IPSS: apex 6.4 ± 4.7, base 10.6 ± 5.7; p = 0.02), but not at baseline or at 12 and 24 months after treatment. On multivariate analysis, only FBT at the base of the prostate remained an independent predictor of worsening urinary symptoms (odds ratio, 5.8; p = 0.04). Conclusions At 6 months after FBT, significantly less urinary toxicity was found in patients who underwent FBT at the apex versus the base of the prostate. Continence and sexual side effects were minimal in all patients.

Resumen Introduccion La reaccion inflamatoria local despues de una biopsia prostatica (BP) puede influir de manera negativa en los resultados globales posprostatectomia radical. No hay evidencia suficiente en la literatura respecto al impacto del numero de punciones en los resultados posquirurgicos. Objetivos Determinar el impacto del numero de punciones de la BP en las complicaciones posquirurgicas y en el estado de los margenes operatorios. Material y metodos Se registraron prospectivamente 2.054 pacientes sometidos a prostatectomia radical asistida por robot (PRAR) en nuestra institucion. Se formaron 2 grupos de pacientes, en relacion con el numero de punciones en la BP (G1 ≤ 12 punciones; G2 > 12 punciones). Se evaluo por medio del analisis multivariable (modelos de regresion logistica) el impacto del numero de punciones en las complicaciones posquirurgicas. Resultados Se incluyeron 1.042 pacientes en el grupo 1 (≤ 12 punciones) y 1.012 pacientes en el grupo 2 (> 12 punciones). La tasa de complicaciones perioperatorias se incremento a medida que aumentaba el numero de punciones. (G1 6,4 vs. G2 8,5%; p = 0,03); no obstante, las complicaciones mayores (Clavien 3-4) fueron similares (G1 1,4 vs. G2 2,2%; p = 0,16). No hubo diferencia estadisticamente significativa respecto a los margenes quirurgicos positivos en ambos grupos (G1 11,8 vs. 9,98%; p = 0,2). El analisis multivariable (regresion logistica) demostro que el grupo 2 tenia un porcentaje un 39% mayor de experimentar complicaciones post-PRAR (OR 0,645). Conclusion El mayor numero de punciones (> 12) en la BP podria estar relacionado con mayor sangrado y complicaciones posquirurgicas despues de PRAR. Una cuidadosa evaluacion preoperatoria de los pacientes que se sometieron a biopsias o protocolos de saturacion multiple es obligatoria. La aplicacion de intervalos mas largos (> 6 semanas) entre la biopsia y la cirugia puede ser recomendable para minimizar los potenciales riesgos de complicaciones quirurgicas en los pacientes que pueden beneficiarse de PRAR. Otros estudios son todavia necesarios para confirmar estos resultados.

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with an unfavorable prognosis. Despite the poor prognosis in the majority of patients, no improvements in treatment strategies have been achieved. Therefore, the discovery of new prognostic biomarkers is of enormous interest. Sterol-O-acyl transferase 1 (SOAT1) is involved in cholesterol esterification and lipid droplet formation. Recently, it was demonstrated that SOAT1 inhibition leads to impaired steroidogenesis and cell viability in ACC. To date, no studies have addressed the impact of SOAT1 expression on ACC prognosis and clinical outcomes. We evaluated SOAT1 expression by quantitative real-time polymerase chain reaction and immunohistochemistry in a tissue microarray of 112 ACCs (Weiss score &ge, 3) from adults treated in a single tertiary center in Brazil. Two independent pathologists evaluated the immunohistochemistry results through a semiquantitative approach (0&ndash, 4). We aimed to evaluate the correlation between SOAT1 expression and clinical, biochemical and anatomopathological parameters, recurrence-free survival (RFS), progression-free survival (PFS), and overall survival (OS). SOAT1 protein expression was heterogeneous in this cohort, 37.5% of the ACCs demonstrated a strong SOAT1 protein expression (score &gt, 2), while 62.5% demonstrated a weak or absent protein expression (score &le, 2). Strong SOAT1 protein expression correlated with features of high aggressiveness in ACC, such as excessive tumor cortisol secretion (p = 0.01), an advanced disease stage [European Network for the Study of Adrenal Tumors (ENSAT) staging system 3 and 4 (p = 0.011)] and a high Ki67 index (p = 0.002). In multivariate analysis, strong SOAT1 protein expression was an independent predictor of a reduced OS (hazard ratio (HR) 2.15, confidence interval (CI) 95% 1.26&ndash, 3.66, p = 0.005) in all patients (n = 112), and a reduced RFS (HR 2.1, CI 95% 1.09&ndash, 4.06, p = 0.027) in patients with localized disease at diagnosis (n = 83). Our findings demonstrated that SOAT1 protein expression has prognostic value in ACC and reinforced the importance of investigating SOAT1 as a possible therapeutic target for patients with ACC.

To perform a feasibility phase study of a panel of putative protein biomarkers and determine whether it can identify and predict tumor recurrence in patients with non-muscle-invasive bladder cancer (NMIBC) on follow-up.We prospectively analyzed the urine of 152 patients previously treated for NMIBC. Quantitative expression of plasminogen activator inhibitor-1 (PAI-1), DJ-1, apolipoprotein A-I (apoA-1), matrix metallopeptidase-9 (MMP-9), and interleukin-8 (IL-8) was assessed by enzyme-linked immunosorbent assay and compared amongst patients with and without bladder cancer recurrence at urine collection and during 3 years of follow-up. Tumor recurrence was confirmed by pathologic analysis. We performed a prediction analysis, excluding patients with recurrence at the start of the study, and assessed the influence of previous use of intravesical BCG on the level of biomarkers.Median follow-up time was 47 months (interquartile range 39-50 months). Sixteen patients (10.5%) were diagnosed with recurrence at the start of the study, and 21 (15.4%) were diagnosed during the study. Three biomarker proteins (apoA-1, MMP-9, and IL-8) appear to hold diagnostic potential [odds ratio (OR) = 12.9; 95% CI 3.5-47.4]; while, PAI-1 and IL-8 predict recurrence (OR = 4.1; 95% CI 1.4-11.4). Previous use of intravesical BCG did not affect biomarker levels.In the feasibility phase, the panel of urine biomarkers analyzed detected and predicted recurrence of NMIBC and provided reliable results in patients who had previously used intravesical BCG. Validation studies are required to confirm the panel clinical utility.

Objective: Germline ARMC5 mutations are considered to be the main genetic cause of primary macronodular adrenal hyperplasia (PMAH). PMAH is associated with high variability of cortisol secretion caused from subclinical hypercortisolism to overt Cushing's syndrome (CS), in general due to bilateral adrenal nodules and rarely could also be due to non-synchronic unilateral adrenal nodules. The frequency of adrenal incidentalomas (AI) associated with PMAH is unknown. This study evaluated germline allelic variants of ARMC5 in patients with bilateral and unilateral AI and in patients with overt CS associated with bilateral adrenal nodules. Methods: We performed a retrospective multicenter study involving 123 patients with AI (64 bilateral; 59 unilateral). We also analyzed 20 patients with ACTH pituitary independent overt CS associated with bilateral adrenal nodules. All patients underwent germline genotyping analysis of ARMC5; abdominal CT and were classified as normal, possible or autonomous cortisol secretion, according to the low doses of dexamethasone suppression test. Results: We identified only one pathogenic allelic variant among the patients with bilateral AI. We did not identify any pathogenic allelic variants of ARMC5 in patients with unilateral AI. Thirteen out of 20 patients (65%) with overt CS and bilateral adrenal nodules were carriers of pathogenic germline ARMC5 allelic variants, all previously described. The germline ARMC5 mutation was observed in only one patient with bilateral AI; it was associated with autonomous cortisol secretion and showed to be a familial form. Conclusion: The rarity of germline ARMC5 mutations in AI points to other molecular mechanisms involved in this common adrenal disorder and should be investigated. In contrast, patients with overt Cushing's syndrome and bilateral adrenal nodules had the presence of ARMC5 mutations that were with high prevalence and similar to the literature. Therefore, we recommend the genetic analysis of ARMC5 for patients with established Cushing's syndrome and bilateral adrenal nodules rather than patients with unilateral AI.

Purpose: To investigate risk factors for complications in patients undergoing adrenalectomy. Materials and Methods: A retrospective search of our institutional database was performed of patients who underwent adrenalectomy, between 2014 and 2018. Clinical parameters and adrenal disorder characteristics were assessed and correlated to intra and post-operative course. Complications were analyzed within 30-days after surgery. A logistic regression was performed in order to identify independent predictors of morbidity in patients after adrenalectomy. Results: The files of 154 patients were reviewed. Median age and Body Mass Index (BMI) were 52-years and 27.8kg/m2, respectively. Mean tumor size was 4.9±4cm. Median surgery duration and estimated blood loss were 140min and 50mL, respectively. There were six conversions to open surgery. Minor and major post-operative complications occurred in 17.5% and 8.4% of the patients. Intra-operative complications occurred in 26.6% of the patients. Four patients died. Mean hospitalization duration was 4-days (Interquartile Range: 3-8). Patients age (p=0.004), comorbidities (p=0.003) and pathological diagnosis (p=0.003) were independent predictors of post-operative complications. Tumor size (p

Background: Pheochromocytomas and paragangliomas (PPGLs) are neuroendocrine tumors derived from chromaffin cells. More than 30% of patients with PPGL have a hereditary predisposition. To date, at least 14 tumor susceptibility genes have been described. Mutations in the succinate dehydrogenase complex iron sulfur subunit B gene (SDHB) are more associated with paragangliomas and metastatic disease. Patients who are young, with larger tumors (>6 cm), positive genetic testing (especially SDHB) or paraganglioma have a higher risk of metastasis development. Case Report: A 14-yr-old boy was referred to investigate severe hypertension and paroxysmal headache, pallor and tachycardia. Biochemical testing for catecholamine-secreting PPGLs showed: 24h urine metanephrines 1.9 µg (normal range, 0.05 to 1.2), plasma normetanephrine 13.3 nmol/L (A (p.L180=), involving a G>A transition in the last nucleotide of SDHB exon 5. This synonymous variant results in alternative splicing of the SDHB primary transcript. This germline variant was previously reported in a 12-yr-old patient with isolated jugulotympanic paraganglioma, but it has not been associated with catecolamine-secreting paraganglioma. Neck MRI revealed no abnormalities in our patient. Conclusion: We report here a synonymous pathogenic variant in SDHB exon 5 associated with an abdominal functioning paraganglioma. Annual screening for multifocal disease (abdominal and neck PPGLs) and malignancy should be performed.

Background: Adrenocortical carcinoma (ACC) is a rare and, in the vast majority of cases, aggressive neoplasia. Even in cases of localized disease at the diagnosis in which complete surgical resection of the tumor is performed, rates of local and distant recurrence are very high. Aim: To retrospectively analyze the management and outcomes of cases that presented localized disease (Group 1) and metastatic disease at diagnosis (Group 2) followed in a single Institution. Results: Group 1 was formed by 23 cases and group 2 by 7 cases. In group 1, adjuvant treatment was initiated in 17 patients: 9 received adjuvant radiotherapy (ARDT) associated with mitotane and 8 patients received mitotane alone; six patients have been followed expectantly. Recurrence of the disease was observed in 70% of the cases (n=16). All had distant metastasis and 6 out of 16 also had local recurrence. Most frequent sites of metastasis were lung, liver and peritoneum, including a rare case of heart metastasis. All patients with recurrence received systemic chemotherapy. No patient who was followed without adjuvant treatment has recurred so far. The median recurrence free survival (RFS) and overall survival (OS) were 13 and 30 months, respectively. In group 2, 5 patients had only one site of metastasis at diagnosis (all of them presented lung metastases) and the remaining cases had two (lung and liver) or three sites (lung, liver and bone). In only one case neoadjuvant chemotherapy was the treatment of choice. In the remaining patients, primary tumor was resected and systemic chemotherapy and mitotane started after surgery. The number of chemotherapy regimens ranged from one to four. Median progression free survival (PFS) was 2 months (range, 0.9 to 11 months) and OS was 11 months (range, 0.9 to 30 months). Patients who had more than one metastatic site at diagnosis had a lower survival rate and the patient who underwent neoadjuvant chemotherapy presented the longest PFS (11 months). Conclusions: Group 1 cases analysis reinforces the high rate of disease recurrence in patients with localized disease despite adjuvant treatment with ARDT and mitotane. These findings support the need for multicenter clinical trials to investigate the benefit of systemic chemotherapy in an adjuvant setting in patients at high risk of recurrence. Regarding the metastatic patients at diagnosis, we emphasize the importance of a greater experience with neoadjuvant chemotherapy.

Background: PMAH is a cause of adrenal hypercortisolism and it is a genetic disease linked to ARMC5 gene in most cases. Heterogenous phenotypes due to cortisol secretion and also due to different germline mutations in the ARMC5 have been described in around the world. The diversity of the molecular second hits in adrenal nodules may be able to justify different clinical outcome in the same family. We report two sisters with the same germline mutation and different clinical outcome. Case: A 45-year-old female patient presented with clinical evidence of hypercortisolism. Metabolic syndrome has been evidenced since the age of 35. Hormonal data confirmed an autonomous cortisol secretion. Abdominal CT revealed a bilateral enlargement of adrenal glands with multiples nodules (up to 2 cm, with 10 Housfield Units). 18F-FDG-PET/CT identified a slight SUV (left SUV 3.4 and right SUV 2.7). A heterozygous germline pathogenic variant of ARMC5 was identified at exon 1: c.165_166insG, p.Ile58Asnfs*45 at BTB (POZ) domain associated with a somatic LOH of the germline mutation. In 2013, the patient underwent Adrenal Sparing Surgery (ASS). She presented an excellent control of metabolic syndrome associated with adrenal insufficiency (AI) for 12 months. After 2 years a clinical recurrence of hypercortisolism was observed and confirmed by laboratory data. A new abdominal 18F-FDG-PET/CT and CT showed an increase of SUV and enlargement of the right residual adrenal gland (SUV - 3.4). The patient was submitted to a partial right adrenalectomy. Interesting, she did not present total or partial AI after the second surgical procedure. Inversely, her sister (46 years of age), with classical Cushing´s syndrome and carrier of same germline mutation (with similar hormonal data and SUV of 18F-FDG-PET/CT), presented a long-term remission of hypercortisolism after ASS. The analysis of somatic mutation of ARMC5 revealed a new event c.2082_2088delCCCGCTC, p.Pro695Serfs*20 in heterozygous status at exon 6. Analysis of PMAH sections HE stained showed a different pattern in the proportion and distribution of clusters of compact cells (60%) relative to clear spongiocytic cells. Her sister presented 13% of compact cells, similar to the PMAH pattern. Discussion: The macronodules of PMAH are composed of clear spongiocytic cells which preferentially express 3βHSD steroidogenic enzyme, and small or compact cells, which differentially express CYP17A1 steroidogenic enzyme and are located in dispersed clusters among the clear cells. CYP17A1 has both 17α-hydroxylase activity and 17,20-lyase activity. Conclusion: The somatic events of ARMC5 should be considered and could be involved in heterogeneous cortisol secretion and clinical presentation in familial cases with different outcome. Further familial cohorts and functional studies should increase our understanding of this challenged adrenal disorder.

Background: Familial adenomatous polyposis (FAP) is an autosomal dominant condition caused by germline mutation in the tumor suppressor gene APC. FAP occurs in 1 to 10.000 individuals, and is characterized by hundreds to thousands of colonic adenomatous polyps with a high risk of developing into colorectal cancer. Extracolonic manifestations can be malignant or benign. The major causes of morbidity and mortality in patients with FAP are abdominal desmoid tumors, with incidences ranging between 7% and 17%. Adrenal incidentaloma are frequently discovered in these patients, generally as benign lesions when they undergo abdominal CT-scan in the course of surveillance. Adrenal lesions in FAP ranged from 7.4% to 16%. We described an unusual patient with FAP, associated with autonomous cortisol production due to bilateral adrenal tumors and the development of aggressive desmoid tumor after unilateral adrenalectomy. Clinical Case: A 33-years-old female FAP-patient presented with abdominal pain, weight gain (10kgs), humor instability, paroxysmal of chest pain, dizziness and tremors. The abdominal MRI showed a heterogeneous, left adrenal mass (9.0 x 7.9 x 6.7cm), suspected for malignant tumor, and right adrenal mass with 3.6 x 1.8 cm suggestive of adenoma. Abdominal CT and PETCTFDG revealed on the left adrenal lesion with 33UH and maxSUV 3.9 and a right adrenal lesion 13UH and maxSUV 3.1. Serum hormone levels were as follows: cortisol after DST (1mg-dexamethasone) 4.8 ug/Dl, ACTH 8,8pg/Ml with no other abnormal hormone secretion detected. Patient underwent left adrenalectomy. Histological analysis revealed Weiss 1, modified Weiss 2 and Ki67

Purpose To describe the surgical treatment of a patient harboring a ureteropelvic junction obstruction (UPJO) in the lower unit of an incomplete duplicated collecting system. Methods A female patient with 32-years old presented a progressively increasing left lumbar pain for 1 year and urinary tract infections (UTI) for the past 10 years. Computed tomography demonstrated a UPJO in the lower unit of an incomplete duplicated urinary collecting system. Results The patient underwent a robot-assisted pyeloureterostomy. The surgical time was 118 minutes and there was no intraoperative complication. During surgery, anomalous vessels crossing to the lower pole of the kidney were identified. The bladder catheter and abdominal drain were removed at the first and second postoperative days. The length of the hospital stay was 2 days and the post-operative course was uneventful. The double-J stent was retrieved 4 weeks after surgery. At 18 months of follow-up, the patient had complete pain resolution and no new episodes of UTI. The control image exam revealed minimal residual hydronephrosis. Conclusion Robot-assisted pyeloureterostomy was an effective approach to the present case. Many times, the surgical strategy for patients with anatomic variants is determined intra-operatively. The surgeon must have a wide range of skills and be prepared for a timely decision.

Introdução: O seguimento de pacientes com câncer de bexiga superficial apresenta embargos financeiros e psicológicos ao paciente, devido à realização frequente de exames invasivos. Com fim de substituir ou diminuir os exames invasivos, busca-se biomarcadores urinários acurados, que permitam diagnosticar a recidiva tumoral e estratificar pacientes com maior risco de recidiva futura. O objetivo deste estudo é avaliar se expressão na urina de PAI-1, DJ-1, ApoA-1, MMP-9 e IL-8 permite identificar e antecipar a recidiva de câncer de bexiga. Método: A expressão da PAI-1, DJ-1, ApoA-1, MMP-9 e IL-8 foi mensurada por ELISA na urina de 152 pacientes tratados previamente de carcinoma urotelial superficial de bexiga e em seguimento. Os níveis das proteínas foram comparados entre pacientes com e sem recidiva de câncer de bexiga (1) no momento da coleta de urina e (2) durante o seguimento. A ocorrência de recidiva tumoral foi confirmada por análise histopatológica da biópsia de lesões suspeitas, investigadas quando havia alterações na cistoscopia, ultrassom ou citologia oncótica. Pacientes com recidiva diagnosticada no momento da coleta de urina foram excluídos da análise para avaliar o papel antecipatório das cinco proteínas. Foi avaliado se o uso prévio de BCG intra-vesical exercia influência no nível das cinco proteínas estudadas. Resultados: Entre os pacientes avaliados, 16 (10,5%) apresentaram recidiva de carcinoma urotelial no momento da coleta de urina e 21 (15,4%) apresentaram recidiva de carcinoma urotelial durante o seguimento. O seguimento mediano foi de 47 meses (interquartis de 39 e 50 meses). Um painel para o diagnóstico de recidiva tumoral incluindo três biomarcadores (ApoA-1, MMP-9 e IL-8) apresentou razão de risco de 12,9 (IC 95% =3,5-47,4) e um painel para prever pacientes que desenvolverão recidiva durante o seguimento incluindo dois biomarcadores (PAI-1 e IL-8) apresentou razão de risco de 4,1 (IC 95% =1,4-11,4). Os resultados dos painéis não foram influenciados pelo uso prévio de BCG intra-vesical. Conclusão: Os painéis apresentados permitem identificar pacientes com recidiva de carcinoma urotelial de bexiga e prever quais pacientes terão maior risco de desenvolver recidiva no futuro. O uso prévio de BCG intra-vesical não alterou a expressão dos biomarcadores Purpose: To evaluate if the urinary levels of PAI-1, DJ-1, ApoA-1, MMP-9 and IL-8 can identify and predict tumor recurrence in patients on follow-up of superficial bladder cancer. Methods: We prospectively analyzed the urine of 152 patients previously treated of superficial bladder cancer on follow-up regimen. Five biomarkers (PAI-1, DJ-1, ApoA-1, MMP-9 and IL-8) were assessed by ELISA and compared among patients with and without bladder cancer recurrence (1) in the moment of urine collection and (2) during follow-up. Tumor recurrence was evaluated with cystoscopy, ultrasound and urine oncotic cytology and confirmed by pathological analysis. Patients with recurrence at urine collection were excluded from prediction analysis. A correlation between the level of the biomarkers and previous use of intravesical BCG was investigated. Results: Median follow-up was 47 months (IQR =39-50 months). Among patients included, 16 (10,5%; N =152) and 21 (15,4%; N =136) had bladder cancer recurrence diagnosed in the moment of urine collection and during follow-up, respectively. The panel to diagnose recurrence including 3 biomarkers (ApoA-1, MMP-9 and IL-8) presented OR =12,9 (CI =3,5-47,4), while the panel to predict patients who will have a recurrence during follow-up including 2 biomarkers (PAI-1 and IL-8) presented OR =4,1 (CI =1,4- 11,4). Previous use of intra-vesical BCG didn\'t influence urine biomarkers expression. Conclusions: The 3-biomarker panel can be used to identify patients with bladder cancer recurrence. The 2-biomarker panel can be used to predict patients at greater risk of bladder cancer recurrence during follow-up. Both are reliable in patients with previous use of intravesical BCG

OBJECTIVE To estimate the conditional biochemical recurrence-free probability and to develop a predictive model according to the disease-free interval for men with clinically localized prostate cancer treated with minimally invasive radical prostatectomy. METHODS The study population consisted of 3576 consecutive patients who underwent laparoscopic radical prostatectomy and 2619 men treated with robotic radical prostatectomy in the past 15 years at Institute Mutualiste Montsouris, Paris, France. Biochemical recurrence was defined as serum prostate-specific antigen ≥0.2 ng/dL. Univariable and multivariable survival analyses were carried out to identify the prognostic factors for overall free-of-biochemical recurrence probability and conditional survival with respect to the years from surgery without recurrence. A detailed nomogram for the static and dynamic prognosis of biochemical recurrence was developed and internally validated. RESULTS The median follow-up period was 8.49 years (interquartile range 4.01-12.97), and 1148 (19%) patients experienced biochemical recurrence. Significant variables associated with biochemical recurrence in the multivariable model included preoperative prostate-specific antigen, positive surgical margins, extracapsular extension, pathological Gleason ≥4 + 3 and laparoscopic surgery (all P

A 19-year-old female patient presented refractory disabling loin pain associated with mild kidney atrophy (split renal function of 33%). Investigation revealed elevated serum renin level; a therapeutic test with oral renin inhibitor was tried, obtaining important pain control. Aiming to resolve the symptom while preserving the patient kidney and attributing the pain mechanism to be associated with the abnormal renin production, a laparoscopic kidney denervation was performed with no complications and complete pain resolution.

The participation of aberrant receptors and intra-adrenal ACTH in hyperplastic tissue are considered mechanisms that regulate hypercortisolism in PMAH. Additionally, germline ARMC5 mutations have been described as the most frequent genetic abnormality found in patients diagnosed with PMAH. Previous functional studies analyzed ARMC5 role using H295R cells. Therefore, we investigated the role of ARMC5 in cell cultures obtained from PMAH nodules containing steroidogenic cells, aberrant receptors and intra-adrenal ACTH. ARMC5 silencing in non-mutated PMAH cell cultures decreased steroidogenesis-related genes and increased CCNE1 mRNA expression and proliferative capacity without affecting cell viability. Additionally, ARMC5 overexpression induced cell death in PMAH mutated cell cultures, thereby decreasing cell viability. We confirmed the role of ARMC5 as an important pro-apoptotic protein involved in PMAH-related steroidogenesis. We also report for the first time the involvement of ARMC5 in controlling proliferation and regulating cell cycle in PMAH cell cultures; these effects need to be explored further.

Purpose: To evaluate the role of ARDT after surgical resection of ACC. Materials and Methods: Records of patients from our institutional ACC database were retrospectively assessed. A paired comparison analysis was used to evaluate the oncological outcomes between patients treated with surgery followed by ARDT or surgery only (control). The endpoints were LRFS, RFS, and OS. A systematic review of the literature and meta-analysis was also performed to evaluate local recurrence of ACC when ARDT was used. Results: Ten patients were included in each Group. The median follow-up times were 32 months and 35 months for the ARDT and control Groups, respectively. The results for LRFS (p=0.11), RFS (p=0.92), and OS (p=0.47) were similar among subsets. The mean time to present with local recurrence was significantly longer in the ARDT group compared with the control Group (419±206 days vs. 181±86 days, respectively; p=0.03). ARDT was well tolerated by the patients; there were no reports of late toxicity. The meta-analysis, which included four retrospective series, revealed that ARDT had a protective effect on LRFS (HR=0.4; CI=0.17-0.94). Conclusions: ARDT may reduce the chance and prolong the time to ACC local recurrence. However, there were no benefits for disease recurrence control or overall survival for patients who underwent this complementary therapy.

To evaluate predictive factors associated with detectable prostate-specific antigen (PSA) and describe clinical recurrence (CR) and cancer-specific mortality (CSM) after robot-assisted radical prostatectomy (RARP). The study included 2500 patients who were treated with RARP at a single institution between 2000 and 2016. All patients had clinically localized PCa. Patients were divided into two groups according to PSA value at 6 weeks after surgery: undetectable (n = 2271; PSA

Robot-assisted radical prostatectomy (RARP) has been embraced by urologists and has become a treatment standard in many countries already. Learning how to perform a RARP is challenging and has not yet been standardized. The current review summarizes the latest concepts regarding the most effective way of training for RARP.The strategy to learn RARP should comprise didactic activities, skills lab training, participating in surgeries and mentorship. Skills lab and virtual simulators are valuable tools to develop manual abilities and to overcome the initial technical learning curve. Participating in surgeries is crucial for familiarization with the robot installation, steps of the surgical procedure and is essential for troubleshooting. Mentorship improves learning and is the safest way to initiate real practice. Innate and individual background variances were suggested to influence the learning process; however, there is paucity of robust evidence correlating previous surgical experience and, for example videogame playing with faster learning of RARP. Structured curricula were proposed to orient the training for robotic surgery; currently, only one is focused exclusively on urology.Systematic training is the most effective way to learn and surpass the possibly intense learning curve of RARP. Training activities should focus on developing cognitive and manual abilities. The existing curricula for robotic surgery training still require constant refinement; however, they offer good and structured guidance to train for RARP.

A young patient from central Africa presented acute renal insufficiency due to extrinsic compression of the distal ureters by a pelvic mass. After initial medical management, a biopsy revealed poorly differentiated bladder cancer and Schistosoma haematobium eggs embedded in the bladder wall. The initial workup showed evidence of locoregional disease. Radical cystectomy with an incontinent urinary diversion was performed with no complications. Carcinosarcoma of the bladder was diagnosed by pathological analysis of the surgical specimen. After a short follow-up, the patient was readmitted presenting with lung and bone metastases. At 60 days after diagnosis, he died of respiratory insufficiency caused by pulmonary metastatic disease.

Objective To determine the feasibility and safety of performing robotic-assisted laparoscopic urological surgery (RALS) in infants and young children, highlighting technical challenges posed by the smaller body size and their potential solutions. Patients and methods We retrospectively reviewed perioperative records of all patients less than 3 years of age who underwent RALS at our institution between January 2006 and October 2012. Intraoperative data included difficulties with the robotic instruments or surgical procedure. Post-operative data included length of hospital stay and any complications. Results A total of 65 children less than 3 years underwent RALS. The average patient age was 1.6 years ± 0.7, with 14 patients under 1 year of age. Median patient weight was 11.6 kg ± 2.5 kg. Mean operative time was 153.3 ± 57 min. No conversions to open technique or intra-operative complications were reported. A total of 12 post-operative complications were identified after a mean follow-up of 13.6 months: 7 early complications and 5 late complications. Smaller children did not have more complications than larger children. Conclusion There are inherent challenges with performing RALS in infants and young children. However, they may be overcome with specific technical maneuvers and through understanding of the limitations of the robotic system.

The objective of this study is to evaluate the diagnostic properties of urinary biomarkers in adults with ureteropelvic junction obstruction: KIM-1, NGAL, CA19-9, and β2-microglobulin. We also assessed urinary biomarker concentrations following pyeloplasty.We prospectively studied adults from December 2013 to February 2015. We included 47 patients with a mean age of 38.6 ± 12.7 years. Each patient provided four samples of voided urine for biomarker measurement, one at pre-operative consultation and the others at 1, 3, and 6 months of post-operative follow-up. The control group consisted of 40 healthy individuals with no hydronephrosis on ultrasound evaluation.KIM-1 had an area under the curve of 0.79 (95% CI 0.70-0.89), NGAL 0.71 (95% CI 0.61-0.83), CA19-9 0.70 (95% CI 0.60-0.81), and β2-microgloblin 0.61 (95% CI 0.50-0.73). KIM-1 was the most sensitive marker with a cut-off of 170.4 pg/mg creatinine (sensitivity 91.4%, specificity 59.1%), whereas CA19-9 was the most specific with a cut-off of 51.3 U/mg creatinine (sensitivity 48.9%, specificity 88.0%). Urinary concentrations of biomarkers decreased after pyeloplasty.The evaluation of urinary biomarkers is useful in adults undergoing pyeloplasty. KIM-1, NGAL, and CA19-9 were elevated and significantly decreased after surgery.

Prostate cancer (PCa) is stratified into different risk categories based on the patient's prognosis. High-risk disease was formerly characterized by an increased risk of metastasis and lethality, requiring complex treatments. Surgery was recently highlighted to have a pivotal role for the treatment of such cases, even as monotherapy. In the past, open radical prostatectomy was performed for most patients with high-risk PCa; however, robot-assisted radical prostatectomy (RARP) emerged as a reasonable option because it provided optimal outcomes for low- and intermediate-risk PCa. Robust studies are lacking to properly assess the role of RARP for high-risk PCa. We summarize this knowledge and present a literature review on the perioperative recovery and functional and oncologic outcomes of RARP for the treatment of patients with high-risk PCa.

To perform a meta-analysis comparing the rates of positive surgical margins (PSM) and biochemical recurrence (BCR) between open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP) in patients with high-risk prostate cancer. A systematic review was performed on Pubmed, Embase and Scopus databases in August 2016, according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. References retrieved were evaluated using the Newcastle–Ottawa scale and the Black and Down’s tool for quality assessment. Nine retrospective cohorts comparing ORP and RARP were selected and included in the meta-analysis. All studies reported the PSMs. Patients treated with RARP presented less risk of PSMs (risk difference −0.04, p 0.02) than those treated with ORP. Five articles reported hazard ratios for BCR-free survival. Patients treated with RARP had less risk of BCR (HR 0.72, 95% CI 0.58–0.89) than those treated with ORP. Reports for PSM assessment were considered of adequate quality, while the studies retrieved for BCR assessment were considered limited because of the heterogeneity of their results. Patients with high-risk prostate cancer treated with RARP have less risk of having PSM and BCR when compared to those treated with ORP. A strong conclusion is precluded due to the observational nature of the studies retrieved for our analysis.

INTRODUCTION AND OBJECTIVES: Laparoscopic pyeloplasty has been considered the gold-standard treatment for adults with ureteropelvic junction obstruction (UPJO). Likewise, it is well established in adults that a symptomatic non-functioning renal unit should be removed. This study aimed to evaluate safety, kidney function recovery and symptoms improvement after laparoscopic pyeloplasty in adults with poorly functioning kidneys due to UPJO. METHODS: Retrospective data analysis from August 2008 to November 2015, from a prospectively maintained database, was performed. Patients with poorly functioning kidney who underwent Anderson-Hynes dismembered laparoscopic pyeloplasty were included. In one patient, the retroperitoneal approach was preferred due to multiple previous abdominal surgeries. Poor function was defined as a split renal function of 15% in renal scintigraphy with Tc-99m DMSA. Pre and postoperative data were compared regarding differential renal function (DRF) and symptoms. Success was defined as split renal function stabilization (absolute variation of less than 5% in renal scintigraphy) and symptoms improvement. Outcome (renal function stabilization, intra and pos-op complications and symptoms) was further compared to a similar group of patients who underwent Anderson-Hynes dismembered laparoscopic pyeloplasty in normal functioning renal units. RESULTS: We identified 167 patients who underwent laparoscopic pyeloplasty in our service. From those, 14 patients had poor renal function, with a mean age of 37 years (23 60 years). No major intra or post-operative complications were seen. At a mean follow up of 21.2 months (4-53 m) all patients reported symptoms improvement, no cases of recurrent pyelonephritis or stone formation was seen. Until this date, no patient needed further surgical treatment as re-pyeloplasty, endoscopic treatment or nephrectomy. Complete symptom resolution was seen in 10 patients (71%). One patient, despite showing complete symptom resolution, had decreased postoperative DRF in renal scintigraphy. Overall success rate was 92.8% (13/14). Split renal function remained stable in 11 patients (78,6%), considerably decreased in 1 (7.1%) and considerably increased in 2 (14.3%) patients. Renal function stabilization, intra and post-operative complications were statically similar (p>0.05) when compared to patients with normal functioning renal units who underwent the same procedure. No patient with normal functions renal units showed improvement in DRF measured with Tc99m DMSA. CONCLUSIONS: Laparoscopic pyeloplasty is an alternative to nephrectomy in adults with poorly functioning kidneys due to UPJO, enabling good symptom control with possible considerable improvement in renal function. In this study, laparoscopic pyeloplasty in this of patients showed similar outcomes and success rates to those presented by patients with normal functioning renal units.

PURPOSE: Socioeconomic status (SES) may influence cancer characteristics and behavior in several aspects. We analyzed PCa characteristics and behavior among low income uninsured men, and compare them to high income patients with health insurance in a developing country. MATERIALS AND METHODS: A retrospective case-control study was performed on 934 patients with clinically localized PCa who underwent radical prostatectomy between March, 1999 and July, 2009. Patients were divided in two groups, according to their SES. In group 1 (n=380), all had low income, low educational levels and couldn't afford medical insurance. In group 2 (n=554), all had higher income, higher education and had medical insurance. RESULTS: Patients from group 1 were older, had higher Gleason scores, higher rates of seminal vesicle and bladder neck involvement. The Kaplan Meier disease-free survival curve demonstrated that after a follow-up of four years, about 50% of uninsured patients had biochemical recurrence, versus 21% of insured patients (Log rank test: p < 0.001). A multivariate Cox regression analysis for the risk of disease recurrence demonstrated that only PSA levels, Gleason score, seminal vesicle involvement and SES were statistically significant variables. Patients with a low SES presented 1.8 times the risk of recurrence as compared to patients with a high SES. CONCLUSIONS: Patients with low SES were older, presented more aggressive PCa characteristics and a high rate of disease recurrence. A low SES constituted an independent predictor for disease recurrence.

OBJECTIVES: To establish a formula that estimates tumor volume in localized prostate cancer based on serum prostate specific antigen levels. One of the main prognostic variables in localized prostate cancer is tumor volume, which can be precisely defined only after prostate extirpation. The present study defines a simple method that allows for estimation of tumor volume before treatment, which can help to establish a better therapeutic strategy for each patient. METHODS: From 1997 to 2002, 735 patients with prostate cancer of stagesT1c-T2c without any previous treatment were submitted to radical prostatectomy. Surgical specimens were evaluated by the same pathologist and the total tumor volume (in cc) and the relative tumor volume (as the percent of the total prostate volume) were determined using the grid morphometric method. Pretreatment serum prostate specific antigen was correlated with tumor volume in each patient using a linear regression model. RESULTS: There were positive correlations between the serum levels of prostate specific antigen and the total tumor volume in cc (p

Introduction The local inflammatory process after prostate biopsies can have a negative impact on functional outcomes of radical prostatectomy. There is no evidence in literature demonstrating its impact on radical prostatectomy. Objectives To evaluate the impact of the number of TRUS core biopsies in the surgical morbidity and rate of positive margin on robot assisted radical prostatectomy (RARP). Material and methods A prospectively maintained database of 2054 RARPs in a single institution. Patients were further grouped into 2 groups based on the number of TRUS biopsy cores (G1 ≤ 12 cores; G2 > 12 cores). Multivariable logistic regression model was applied to analyze the impact of number of cores on complications. Results A total number of 1042 patients in the group 1 (≤12 cores) and 1012 patients in the group 2 (>12 cores) were included. The rate of perioperative complications increased with higher number of biopsies (G1 6.4 vs. G2 8.5%; p = 0.03), but high grade complication (Clavien 3–4) were similar (G1 1.4 vs. G2 2.2%; p = 0.16). Positive surgical margin rates were similar in both groups (G1 11.8 vs. 9.98%; p = 0.2). At the multivariable logistic regression analysis shown that G2 had a 39% (OR 0.645) higher rate to experience perioperative complications during RARP. Conclusion Higher number of TRUS biopsy cores (>12) is associated to higher blood loss and perioperative complications during RARP. Careful preoperative evaluation for those patients underwent multiple biopsies or saturation protocols is mandatory. Application of longer intervals (>6 weeks) between biopsy and surgery may be advisable to minimize potential risks of surgical complications in patients may benefit from RARP. Further studies are still necessary to confirm these results.

To evaluate the outcomes of ureteral strictures treatment after endoureterotomy using the holmium laser or open/laparoscopic surgery.From a database of 1101 patients that underwent semi-rigid holmium laser ureterolithotripsy from 2003 to 2013, we performed a search for patients treated for ureteral stricture. Parameters analyzed included patient demographic, stone burden, and ureteral stricture characteristics. Treatment included holmium laser endoureterotomy for stenosis ≤ 1 cm and open/laparoscopic repair for stenosis1 cm or for failed endoscopic treatment. Outcomes and complications were assessed. Success was defined as symptom improvement and radiographic obstruction resolution.Of all the patients, 32 (2.8%) evolved with ureteral stenosis and all had impacted calculi at the time of surgery. Twenty-two patients with complete follow up were studied. After a mean follow up of 18.5 months (range 3-70), the success rates for endoureterotomy and open/laparoscopic stricture repair group were 50% and 82%, respectively. The hospitalization period was significantly shorter for patients who had undergone endoureterotomy (2.7 +/- 1.4 days versus 4.8 +/- 1.4 days; p = 0.003). Only minor complications occurred in both groups.The rate of ureteral stricture after holmium laser ureterolithotripsy for impacted calculi is higher than reported for non-impacted stones. Holmium laser endoureterotomy for stenosis shorter than 1 cm treated half of the cases. Open/laparoscopic repair had good outcomes in cases of longer stenosis.

To avoid hormonal replacement after partial adrenalectomy (PA), establishing the precise limit of an adrenal gland resection is essential. Herein, we evaluated the use of three-dimensional (3D) adrenal gland printing and volumetry measurement before PA to improve the determination of the remnant gland volume.Concomitant total adrenalectomy and a contralateral PA were performed in a patient with primary macronodular adrenal hyperplasia that exhibited mild hypercortisolism, arterial hypertension, and diabetes. Before surgery, a 3D replica of the adrenal gland to be partially resected was printed and given to the surgeon. The volumetry of the gland was measured by computed tomography 3D image reconstruction.No postoperative complications were noted. Immediately after the surgery, the patient initiated corticosteroid replacement, which was interrupted 52 days later. At the 6-month follow-up, the patient stopped using medications for diabetes and reduced the number of antihypertensive medications from 5 to 1. The pre- and postoperative serum cortisol levels were, respectively, 28 and 8.7 mcg/dl (n 5-25 mcg/dl). The pre- and postoperative adrenocorticotropic hormone levels were, respectively,5 and 88 pg/ml (n 7.2-63 pg/ml). The postoperative adrenal volume was 12% of the total preoperative adrenal volume.The use of 3D printing associated with adrenal volumetry might be a useful tool for the surgeon when performing PA, enabling an estimation of the remnant gland volume.

_______________________________________________________________________________________ 177 RADIOLOGY PAGE A 43 years-old man presented to our stone clinic complaining of back pain for the last 3 months. He had sig-nificant past medical history for nephrolithiasis: he had undergone unsuccessful SWL for left renal calculi five years ago and also presented with several episodes of pyelonephritis in the last months, requiring hospitalization for intravenous antibiotics. Initial laboratory work-up revealed normal serum creatinine (0.92 mg/dL) and hemoglobin levels (15.3 g/dL); urine culture was negative. Abdominal computed tomography (CT) revealed a 140 mm² stone in the left renal pelvis with 1500 Hounsfield Units (Figure-1a); thickening of the urothelium surrounding the stone was suspected after contrast infusion (Figure-1b) and confirmed in the excretory phase (Figure-1c). Nonenhanced CT is the gold standard for detecting urinary calculi in the acute setting with reported sensitivity of 96% and specificity of 98% (1). Nearly all stones are visible on CT and secondary signs of obstruction are easily identified. Contrast-enhanced CT may be indicated if there are findings that suggest renal or other pathology which requires further evaluation (2). Our patient presented with significant edema surrounding the renal stone, fact correctly pointed-out by the radiologist reading the image exam. The patient underwent a percutaneous nephrolithotripsy (PCNL) in the complete supine position as previously described (3). A single puncture in the middle calyx provided access to the collecting system. Tract dilatation was performed

55 Background: To estimate the conditional biochemical recurrence-free survival (BCR) rates and cancer-specific mortality (CSM) for men with clinically localized prostate cancer (PCa) treated with radical prostatectomy (RP) at our institution. Methods: A total of 3576 patients underwent laparoscopic radical prostatectomy (LARP) and 2619 men were treated with robotic radical prostatectomy (RARP) in the last 15 years. BCR of primary treatment was defined as PSA > 0.2 ng/dl. PCa death was defined as patients who died with metastasis in an androgen independent setting. Kaplan-Meier and Cox regression methods were used to estimate the conditional survival probabilities and CSM. Results: The median follow-up was 8.49 years (IQR 4.01-12.97). A total of 92 (1.48%) patients (80 LARP and 12 RARP) died of disease. Positive surgical margins (PSM) were identified in 1202 patients (19.4%); of these, 664 (55.24%) had organ confined disease and 523 (43.51%) had extraprostatic extension (EPE). BCR-free survival rate was found significantly higher with RARP (83% vs 77% for LARP at 10 years; p < 0.001). For patients with PSA < 10 ng/dl BCR-free survival at 10 years was 80% vs 64% for PSA 10-20 ng/dl, and 59% for PSA > 20ng/dl; p > 0.001. Conditional probability of BCR after surgery 1st year was 6.7%. Those who reach the 2nd year of surgery without recurrence had a relapse probability of 4%, (cumulative probability 9.8%) That probability falls to 3.5% after the 3rd year (cumulative probability 13%), 2% after the 4th year (cumulative probability 15%) and is 2.1% after the 5th year (cumulative probability 17%). After 10 years of follow-up without recurrence, the possibility of relapse was 0.8%, (cumulative probability 21%). Men without BCR had a clinical trend of higher CSM at 10 years (7% vs 2% no BCR; p 0.06). Within the patients who develop BCR, those with BCR in the first three years of follow-up had higher CSM (9% vs 4% for BCR after 3 years; p 0.04). Conclusions: BRC free survival outcomes are affected by risk factors associated with type of surgery and prognosis in PCa. The period elapsed from RP is associated with BCR-free survival and the risk of recurrence decrease with increasing survival.

113 Background: Follow up after radical prostatectomy should be tailored to clinical and pathologic characteristics. To determine predictive factors for early, intermediate and late biochemical recurrence (BCR) after minimally invasive radical prostatectomy (MIRP: lap and robot) in patients with localized prostate cancer (PCa). Methods: Prospective clinical, pathologic, and outcome data were collected for 6195 patients with cT1-3N0M0 PCa treated with MIRP at our institution from 2000 to 2016. None of them received neoadjuvant therapy. BCR was defined as PSA level greater than 0.2 ng/ml. Time to BCR was divided in terciles to identify variables associated with early ( < 12 months), intermediate (12-36 months) and late BCR ( > 36 months). Comparisons among groups were performed using ANOVA or Chi square test. Logistic regression models were built to determine risk factors associated with BCR at each time interval. Results: We identified 1148 (19%) patients with BCR. Median time to BCR was 24 months. Statistically significant differences were found between the groups concerning PSA preoperative, D’Amico risk, type of surgery, pT stage, pathological Gleason, positive margins and extracapsular extension. Multivariable logistic regression analysis showed preoperative PSA, positive nodes, positive surgical margins and laparoscopic surgery were associated with early BCR. Laparoscopic surgery was the only risk factor associated with intermediate term BCR. Significant predictors of late BCR included Gleason ≥ 7, ≥ pT3, positive surgical margins, lymph node dissection performance and laparoscopic surgery. Conclusions: Patients with high risk features like Gleason ≥ 7, ≥ pT3 and or positive surgical margins may develop late recurrence and deserve long term follow up. Identify patients with higher PSA and lymph node invasion has an important predictive role due to the risk of BCR within the first year. The association between laparoscopic technique and late BCR deserves further evaluation.