Search

Abstract Objective The study aims to identify the optimal 4Kscore thresholds to determine the need for a prostate biopsy when multiparametric magnetic resonance imaging (MRI) (mpMRI) is negative or indeterminate. Materials and methods We analysed retrospective data from men in eight different institutions who underwent an mpMRI, 4Kscore and prostate biopsy for evaluation of prostate cancer. We selected men with a negative (PIRADS ≤2) or indeterminate (PIRADS 3) mpMRI. 4Kscore values were categorized into ranges of 1–7, 8–19, 20–32 and greater than 32. We evaluated the proportion of men with grade group 2 or higher (GG2+) cancer in groups defined by PIRADS and 4Kscore. We also evaluated the number of biopsies avoided and GG2+ cancer missed in each group reported depend on 4Kscore cutoff points. Results Among 1111 men who had an mpMRI, 4Kscore and biopsy, 625 of them had PIRADS ≤3 on mpMRI: 374 negative (PIRADS ≤2) and 251 indeterminate (PIRADS 3). In men with a negative mpMRI, we found a 4Kscore cut‐point of 33 resulted in an increased risk of GG2+ cancer on biopsy. In patients with an equivocal lesion on mpMRI, men with a 4Kscore cutoff ≥8 had a greater risk of GG2+ cancer on biopsy. Decision curve analysis supported the proposed cut‐points in each mpMRI group. Conclusions In men with negative and indeterminate mpMRI, we found the best 4Kscore threshold to determine the need for biopsy to be 33 and 8 respectively. Future prospective studies in independent populations are needed to confirm these findings.

Introduction: Renal cell carcinoma (RCC) has various histopathological tumor subtypes which have a significant implication on the oncological outcome of these patients. We aimed to evaluate the distribution of RCC subtypes presenting at a tertiary care center in the Middle East, in comparison to the distribution reported in different geographic areas worldwide. Methods: A retrospective chart review was conducted on all patients who underwent partial or radical nephrectomy for RCC at the American University of Beirut Medical Center between January 2012 and January 2018. Data on histologic subtypes were compiled and compared to representative series from different continents. Results: One hundred and seventy-nine patients with RCC were identified, of whom 122 (68.2%) were classified as clear cell, 30 (16.8%) as papillary, 17 (9.5%) as chromophobe, and 10 (5.6%) as unclassified. When compared to other regions of the world, this Middle Eastern series demonstrated a higher prevalence of the chromophobe subtype compared to Western populations (9.5% in the Middle East vs. 5.3% in the US and 3.1% in Europe) and a lower prevalence of clear cell subtype (68.2% in the Middle East vs. 78.7% in the US and 85.8% in Europe). Conversely, there was a higher prevalence of papillary RCC in the Middle East (16.8%) compared to North America (13.1%, 95% confidence interval [CI]: 12.7–13.6), Europe (11.1%, 95% CI: 10.0–12.1), and Australia (10.2%). The prevalence of chromophobe and clear cell RCC in the Middle East was similar to that reported in South America. Conclusions: The distribution of RCC subtypes in this Middle Eastern cohort was significantly different from that reported in the Western hemisphere (Europe and the US) but similar to that reported in South America and Australia. These findings may point to a possible genetic predisposition underlying the global variation in distribution.

Introduction: This is a case of a 55 year old female with an incidentally discovered right renal mass. CT scan showed a 4 cm low density lesion extending from the renal cortex into the renal vein and inferior vena cava (IVC) (level 1 thrombus) with fat content, suggestive of possible angiomyolipoma. Objective: To demonstrate the surgical steps of robotic partial nephrectomy with IVC thrombectomy. Methods: After trocar placement, the da Vinci Xi system is docked in the standard manner for right robotic partial nephrectomy. The procedure is initiated with mobilization of the colon followed by identification of the right ureter and gonadal vein. The gonadal vein is followed proximally to its insertion into the IVC. The renal vein and artery are subsequently identified and dissected. A vessel loop is passed around the renal vein to ensure proximal control of the tumor thrombus during excision of the mass. Intraoperative ultrasound is used to identify the location and depth of the mass prior to excision. Bulldog clamps are placed sequentially over the renal artery and renal vein. Traction is applied with a vessel loop and suction irrigator to ensure proximal control of the tumor thrombus. Excision of the mass is accomplished utilizing a combination of sharp and blunt dissection. An incision is made into the branch of the renal vein containing the tumor thrombus. The incision is extended circumferentially to facilitate mobilization and complete en bloc removal of the renal mass and thrombus. The renal vein defect is then closed in 2 layers with 4–0 Prolene suture. The tumor bed defect is closed in 2 layers in a continuous manner with 3–0 barbed suture. A sliding clip technique is then performed with 3–0 barbed suture in an interrupted manner to re-approximate the edges of the kidney and complete the reconstruction. Results: Estimated blood loss was 70 cc with a warm ischemia time of 45 min. The patient was discharged from the hospital on postoperative day number 1 without complications. Final pathology demonstrated a 2.1 cm angiomyolipoma with negative margins. Conclusion: Robotic partial nephrectomy with IVC thrombectomy is a feasible and safe surgical option for patients with suspected benign renal masses with extension of tumor thrombus into the IVC.

Background: The aim of our study was to evaluate the outcome of active surveillance (AS) for prostate cancer for a cohort of patients at our institution. Methods: A total of 43 patients with low risk prostate cancer were enrolled in an active surveillance pilot program at our institution between 2008 and 2018. Follow up protocols included: periodic prostate specific antigen (PSA), digital rectal examination (DRE), multiparametric MRI, and prostate biopsy at one year. Pertinent parameters were collected, and descriptive statistics were reported along with a subset analysis of patients that dropped out of the protocol to receive active treatment for disease progression. Results: Out of 43 eligible patients, 46.5% had a significant rise in follow up PSA. DRE was initially suspicious in 27.9% of patients, and none had any change in DRE on follow up. Initially, prostate MRIs showed PIRADS 3, 4, and 5 in 14%, 37.2%, and 11.6% respectively, while 23.2% had a negative initial MRI. 14% did not have an MRI. Upon follow up, 18.6% of patients had progression on MRI. Initial biopsies revealed that 86% were classified as WHO group 1, while 14% as WHO group 2. With regards to the follow up biopsies, 11.6% were upgraded. 20.9% of our patients had active treatment; 44.4% due to upgraded biopsy results, 22.2% due to PSA progression, 22.2% due to strong patient preference, and 11.1% due to radiologic progression. Conclusions: For selected men with low risk prostate cancer, AS is a reasonable alternative. The decision for active treatment should be tailored upon changes in PSA, DRE, MRI, and biopsy results.

Objective: Pelvic lymphadenectomy (PLN) during Retzius-Sparing Robotic-Assisted Radical Prostatectomy (RS-RARP) may be challenging because the medial umbilical ligaments are not released, and the anterior structures are preserved. The incidence of symptomatic lymphoceles following PLN during RS-RARP has been reported to be higher than standard approaches (anterior technique) for RARP. We describe the anatomic scalene triangle as a useful landmark to facilitate PLN during RS-RARP and compare outcomes of PLN using this technique versus PLN for standard RARP. Patients and Surgical Procedure: This is a single center, institutional review board approved, retrospective case-control study of 200 consecutive patients undergoing RS-RARP or standard RARP. We compared perioperative factors such as age, BMI, PSA, grade group, tumor stage, lymph node yield, and incidence of symptomatic lymphoceles using t-test for continuous variables and Fisher's exact test for categorical variables. A P-value of < 0.05 was considered statistically significant. In the RS-RARP, group the anatomic scalene triangle was used as a landmark for PLN. The scalene triangle is formed superiorly by the vas deferens, medially by the medial umbilical ligament, and laterally by the external iliac vein. The peritoneum overlying the triangle is incised and an avascular plane in this space is developed. Retraction of the vas deferens and medial umbilical ligament facilitates exposure of the lymph node packet and obturator nerve. Once the lymph node packet is isolated, surgical clips are applied and mobilization of the lymph nodes is performed cranially. Once the proximal extent of the dissection has been reached, the lymph node packet is divided and removed. Results: There were no statistically significant differences between RS-RARP and standard RARP with respect to age, BMI, PSA, grade group, tumor stage, lymph node yield, or incidence of symptomatic lymphoceles. There were 4 symptomatic lymphoceles in the RS-RARP group and 1 symptomatic lymphocele in the standard RARP group. These were all treated with percutaneous drainage by interventional radiology. Conclusions: The anatomic scalene triangle is a useful landmark to facilitate a safe, reproducible, and efficient PLN during RS-RARP. We observed a 4% incidence of symptomatic lymphoceles compared to prior, smaller series which have demonstrated 8–16% incidence of symptomatic lymphoceles with PLN during RS-RARP. Although there was a higher incidence of symptomatic lymphoceles in the RS-RARP group compared to standard RARP, this was not statistically significant.

Prostate cancer (PCa) is the second most common cancer in men. Common treatments include active surveillance, surgery, or radiation. Androgen deprivation therapy and chemotherapy are usually reserved for advanced disease or biochemical recurrence, such as castration-resistant prostate cancer (CRPC), but they are not considered curative because PCa cells eventually develop drug resistance. The latter is achieved through various cellular mechanisms that ultimately circumvent the pharmaceutical’s mode of action. The need for novel therapeutic approaches is necessary under these circumstances. An alternative way to treat PCa is by repurposing of existing drugs that were initially intended for other conditions. By extrapolating the effects of previously approved drugs to the intracellular processes of PCa, treatment options will expand. In addition, drug repurposing is cost-effective and efficient because it utilizes drugs that have already demonstrated safety and efficacy. This review catalogues the drugs that can be repurposed for PCa in preclinical studies as well as clinical trials.

Introduction: Voiding cystourethrogram (VCUG) is a very popular test performed to evaluate genitourinary tract anomalies. Nevertheless, this test can be overused and can lead to unnecessary patient discomfort, radiation exposure, and cost. We sought to study the practice patterns in ordering a VCUG in a Middle Eastern tertiary care center. Methods: Over a period of 3 years, a retrospective analysis of all VCUG images done for pediatric patients in a single center was made. Further clinical details were extracted from the electronic health records. The specialty of an ordering physician and the reported indication for the procedure were noted. Indications for VCUG were recorded based on the AAP 2011 guidelines, NICE guidelines 2007, and ACR 2011 guidelines. Based on these criteria, patients were analyzed. Results: A total of 92 VCUGs were evaluated. Of all VCUGs done, pediatricians ordered the most VCUGs (50/92), followed by pediatric infectious disease (16/92), pediatric nephrology (9/92), pediatric urology (7/92), adult urology (5/92), pediatric surgery (3/92), obstetrician-gynecologist (1/92), and emergency medicine (1/92). Properly indicated VCUGs were 50% by general pediatrics, 55% by pediatric infectious disease, 45% by pediatric nephrology, 40% by adult urology, 33% by pediatric surgery, and 100% by pediatric urology. Conclusion: VCUG is utilized differently by different specialties. In some centers, adult specialties may order a pediatric VCUG. General pediatricians order VCUG the most with a tendency for misuse in up to 50%. Pediatric urology is not the most ordering specialty of VCUG; however, it utilizes it most appropriately. The noted practice patterns may be improved with awareness of the indications and limitations of the study and with proper referral.