Search

Background The combination of multi-parametric MRI to locate and define suspected lesions together with their being targeted by an MRI-guided prostate biopsy has succeeded in increasing the detection rate of clinically significant disease and lowering the detection rate of non-significant prostate cancer. In this work we investigate the urologist’s learning curve of in-bore MRI-guided prostate biopsy which is considered to be a superior biopsy technique. Materials and methods Following Helsinki approval by The Chaim Sheba Medical Center ethics committee in accordance with The Sheba Medical Center institutional guidelines (5366-28-SMC) we retrospectively reviewed 110 IB-MRGpBs performed from 6/2016 to 1/2019 in a single tertiary center. All patients had a prostate multi-parametric MRI finding of at least 1 target lesion (prostate imaging reporting and data system [PI-RADS] score ≥ 3). We analyzed biopsy duration and clinically significant prostate cancer detection of targeted sampling in 2 groups of 55 patients each, once by a urologist highly trained in IB-MRGpBs and again by a urologist untrained in IB-MRGpBs. These two parameters were compared according to operating urologist and chronologic order. Results The patients’ median age was 68 years (interquartile range 62–72). The mean prostate-specific antigen level and prostate size were 8.6 ± 9.1 ng/d and 53 ± 27 cc, respectively. The mean number of target lesions was 1.47 ± 0.6. Baseline parameters did not differ significantly between the 2 urologists’ cohorts. Overall detection rates of clinically significant prostate cancer were 19%, 55%, and 69% for PI-RADS 3, 4 and 5, respectively. Clinically significant cancer detection rates did not differ significantly along the timeline or between the 2 urologists. The average duration of IB-MRGpB targeted sampling was 28 ± 15.8 min, correlating with the number of target lesions (p p Conclusions Our data suggest a very short learning curve for IB-MRGpB-targeted sampling duration, and that clinically significant cancer detection rates are not influenced by the learning curve of this technique.

Purpose We reviewed the experience with adrenal ganglioneuroma (AGN) pathologically confirmed following adrenalectomy in medium- to high-volume medical centers. Methods The medical records of all adrenalectomy cases in 4 medical centers between 2006 and 2020 were retrospectively reviewed for demographics, clinical, radiological and laboratory findings, surgical treatment, pathology results, and outcomes. Results Twenty-five out of 875 adrenalectomy cases (2.9%) were pathologically confirmed as AGN. Those patients' average age was 40.5 years (range, 4-76 years), 13 (52.0%) were males, and 18 lesions (72.0%) were right-sided. One patient had a family history of neurofibromatosis, and another had a succinate dehydrogenase gene mutation. Abdominal/back pain attributed to mass effect was the most common symptom. All 25 patients underwent abdominal computerized tomography scanning in which the average maximal tumor diameter was 6.61 cm. The mean pre- and postcontrast Hounsfield units (HU) values were 35.2 and 59, respectively; and the mean late-phase HU value was 71.1. Twenty-two patients (88.0%) underwent minimally invasive surgery. The average tumor diameter recorded in the final pathology report was 7 cm. Isolated AGN was diagnosed in 21 cases (84.0%), and the additional components reported for the remaining 4 cases included pheochromocytoma (2), ganglioneuroblastoma (1), and neurofibroma (1). The average follow-up length was 16.8 months (range, 1-136 months), during which there was no recurrence or death. Conclusion AGN is a rare, slow-growing, large benign tumor with radiological characteristics similar to those seen in malignant tumor. Final diagnosis is established by pathology after surgical resection, preferably minimally invasive, with an overall excellent prognosis.

Background: Laparoscopic (LP) and robot-assisted pyeloplasty (RAP) are minimally invasive techniques for correcting uretero-pelvic junction obstruction (UPJO). We retrospectively compared the clinical outcomes of all adults who underwent RAP (n = 41) to those who underwent LP (n = 24) for UPJO at our institution between 2003–2022. Methods: Age, sex, body mass index, surgical side, past abdominal/endoscopic surgeries, pre- and postoperative renal scans, pre- and postoperative serum creatinine levels, operative time (OT), presence of crossing vessels, estimated blood loss, postoperative complications, length of hospital stay, time to JJ stent removal, follow-up length, and postoperative hydronephrosis were analyzed. Results: The groups were demographically comparable. The mean total and skin-to-skin OTs (minutes) were significantly longer in the RAP group than in the LP group (242.4 ± 55 vs. 161.4 ± 40 p < 0.001; 163.7 ± 41.8 vs. 124.3 ± 30.3 p = 0.006, respectively). Hospital stay (days) was shorter in the RAP group (3.3 ± 2.1 vs. 7.3 ± 2.5 p < 0.001). Postoperative complication rates were identical for both groups. The LP group had a significantly longer follow-up period (85.2 ± 73 vs. 19 ± 14 months p < 0.001). The success rates for the LP and RAP groups were 87.5% and 90.6% (p = 0.708). Conclusions: RAP achieves equivalent results to LP, in adult patients. A longer OT may be expected with the robotic system since it can handle more complicated cases.

We aimed to explore whether a single-day of fasting (SDF) increase emergency room (ER) visits due to renal colic (RC). We elected to concentrate on Yom-Kippur (i.e.: SDF), the holiest day in Judaism. Food and liquid consumption is prohibited during this day for 25 h, and an estimated 50–70% fasting rate is observed. SDF always takes place between mid-September and mid-October during which the temperature in the Middle-East ranges between 19 and 30 °C. ER visits for RC between 01/2012 and 11/2019 were reviewed, and the Gregorian days on which SDF occurred were retrieved. The number of ER visits for RC was compared between SDF and the surrounding days/months as well as to another single-day "standard" holiday (SDSH) that precedes SDF in 10 days and is not associated with fasting. Of 11,717 ER visits for RC, 8775 (74.9%) were males. Male:Female ratio was 3:1. The mean daily number of ER visits for RC during the 3 days following SDF was 6.66 ± 2.49, significantly higher compared with the mean annual daily visits (4.1 ± 2.27, p p = 0.032), and the mean daily visits during September (5.06 ± 2.659, p = 0.005), and October (4.78 ± 2.23, p p = 0.207; p = 0.13, respectively). It was lower compared to SDF, however statistically insignificant (p = 0.285). A single-day fasting may increase ER visits for RC. The mechanism underlying this phenomenon is unknown.

A 75–89% expulsion rate is reported for ureteric stones ≤ 5 mm. We explored which parameters predict justified surgical intervention in cases of pain caused by p p p p = 0.007) compared to those who had no surgical intervention. The model accuracy was 0.8. Larger stone size and proximal location were the most important features in predicting the need for intervention. Altogether with pulse and ER visits, they contributed 73% of the final prediction for each patient. Although a high expulsion rate is expected for ureteral stones

Objectives: Malignant ureteral obstruction (MUO) is a devastating complication of cancer, and it is commonly treated by drainage via percutaneous nephrostomy (PCN). The objective of this study was ...

Objective To assess long-term outcome after selective arterial embolization (SAE) as first-line treatment for large or symptomatic AML. Design, Setting, and Participants Data from a prospectively maintained database on 71 patients who underwent SAE for large or symptomatic AML were reviewed. Patients with sporadic and tuberous-sclerosis-complex (TSC) were included. Outcome Measurements The main endpoints were re-embolization rates, occurrence of clinical events related to AML, size of AML, and renal function. Results Thirteen (19.1%) patients reported at least 1 major clinical event. Major complications affected 2 patients (2.9%), both ending in complete loss of renal unit function. Four renal units (5.9%) were eventually treated surgically. The re-embolization rate was 41.1%, with an average time from the initial to a repeat SAE of 2.18 years (range 0.31-10.65 years). The size of the tumor prior to SAE and after 5 and 10 years of follow-up were 8.9 cm (7-12), 6.5 cm (4-7.5), 7 cm (4-7.8), respectively [median (IQR)]. These results are translated to a size reduction of 27% in 10 years follow-up. Patients with TSC had larger tumors on long-term follow-up (77.8 vs 41.3 mm, P = .045). The long-term follow-up estimated average glomerular filtration rate was 81.97 (range 26-196). No patient needed renal replacement therapy, and disease-specific survival was 100%. Conclusions SAE is a safe treatment option for patients with symptomatic or large AML. It represents a minimally invasive intervention with good long-term outcome. SAE may be offered as first-line treatment in most cases, though, it is associated with high retreatment rates.

Background The aim of this study was to examine ureteral stricture rate after the use of UAS in an unstented ureter and compare complications of smaller vs. larger-caliber UAS. Methods We conducted a retrospective analysis of consecutive RIRS for renal stones, with the use of UAS in unstented ureters. We excluded cases with previous ureteroscopies, who carried ureteral stent or nephrostomy, had impacted stones, underwent radiation treatment, or had urinary tract malignancies. The primary outcome was formation of ureteral strictures diagnosed by hydronephrosis in ultrasound test and late secretion in dynamic renal scan. Secondary outcome was stone-free-rate (SFR) and complications. In addition, we compared safety and efficacy of smaller (9.5/11.5Fr) vs. larger-caliber (12/14Fr) UAS. Results The cohort included 165 patients with a median follow-up time of 115 days. There was no case of ureteral stricture formation after the use us UAS, despite using a larger-caliber UAS in nearly half the cases. Larger-caliber UAS was not associated with more complications compared to the smaller-caliber one (p = 0.780). SFR was non-significantly higher in the larger-caliber UAS group (p = 0.056), despite having a larger stone burden, and only stone number was associated with SFR (p = 0.003). Conclusions These data suggest that the use of UAS during RIRS in an unstented ureter is safe and does not involve ureteral stricture formation after one procedure. Furthermore, the use of wider sheaths was not found to be associated with higher complications rate.

Initial deleterious effects of the COVID-19 pandemic on urologic oncology surgeries are well described, but the possible influence of vaccination efforts and those of pandemic conditions on surgical volumes is unclear. Our aim was to examine the association between changing vaccination status and COVID-19 burden throughout the pandemic and the volume of urologic oncology surgeries in Israel. This multi-center cross-sectional study included data collected from five tertiary centers between January 2019 and December 2021. All 7327 urologic oncology surgeries were included. Epidemiological data were obtained from the Israeli Ministry of Health database. A rising trend in total urologic oncology surgery volumes was observed with ensuing COVID-19 wave peaks over time (X2 = 13.184, df = 3, p = 0.004). Total monthly surgical volumes correlated with total monthly hospitalizations due to COVID-19 (R = −0.36, p = 0.015), as well as with the monthly average Oxford Stringency Index (R = −0.31, p = 0.035). The cumulative percent of vaccinations and of new COVID-19 cases per month did not correlate with total monthly urologic surgery volumes. Our study demonstrates the gradual acclimation of the Israeli healthcare system to the COVID-19 pandemic. However, hospitalizations due to COVID-19, as well as restriction stringency, correlate with lower volumes of urologic oncological surgeries, regardless of the population’s vaccination status.

Introduction and Objective: Both double J-stent (DJS) and ureter catheter (UC) drainage represent routine practice following ureterorenoscopy. In select situations, a tubeless approach is possible and safe. In tubeless cases, we use a sheathless dusting technique with the Lumenis® MOSES Pulse™120 H Holmium: YAG laser. We evaluated these three drainage subgroups and compared postoperative pain, complications, and readmissions. Methods: A retrospective database of 269 consecutive patients who underwent primary ureterorenoscopy for the treatment of upper urinary tract stones between October 2018 and August 2019. The cohort was divided according to post-operative drainage as Tubeless, UC, and DJS. The decision on whether to perform post-operative drainage was by surgeon preference. Demographic and clinical parameters such as stone location, number, and burden, hydronephrosis grade, and postoperative complications (fever, acute renal failure, and the obstruction of the upper urinary tract by Stone Street) were assessed. Pain was assessed using a 0–10 Visual Analog Scale score (VAS) and the use of analgesics by dose/case in each group. Results: There were 70 (26%) tubeless, 136 (50%) UC, and 63 (24%) DJS cases. Patients drained with DJSs had a significantly higher stone burden, more severe obstruction, and prolonged operative time. Tubeless and UC-drained patients had the same stone characteristics with maximal diameters of 8.4 (6.1–12) mm and 8 (5.2–11.5) mm in comparison to the stented group, with 12 (8.6–16.6) mm, p < 0.01. The operation time was the longest in the stented group at 49 min (IQR 33–60) in comparison to the UC and tubeless groups at 32 min (23–45) and 28 min (20–40), respectively (p < 0.001). Auxiliary procedures were more prevalent in the stented group, but the overall stone-free rate was not significantly different, p = 0.285. Postoperative ER visits, readmissions, and complications were the highest in the UC-drained group, at 20% in the UC vs. 6% in the tubeless and 10% in the stented groups. Post-operative pain levels and analgesic use were significantly lower in the tubeless group with a significant reduction in opiate usage. Conclusions: A tubeless approach is safe in selected cases with fewer post-operative complications. While DJS should be considered in complex cases, UC may be omitted in straightforward cases since it does not appear to reduce immediate postoperative complications. Those fitted for tubeless procedures had improved postoperative outcomes, facilitating outpatient approach to upper urinary tract stone treatment and patient satisfaction.

Objective: The aim of this study was to assess whether there is an objective association between bladder outlet obstruction (BOO) and abnormal sensation parameters during filling cystometry in men. Methods: This was a prospective study. Consecutive patients referred for urodynamic examination were assessed for eligibility. Patients with permanent catheters, BPH related surgery, neurologic disease, or inability to complete the urodynamic study were excluded. All patients underwent full physical examination, as well as renal and bladder ultrasound including prostate size estimation, post void residual volume, and PSA, and they completed the International Prostate Symptoms Score (IPSS) questionnaire. The cohort was divided into obstructed and un-obstructed groups according to the Bladder Outlet Obstruction Index. Results: Ninety of the 115 patients recruited were obstructed (78%). Obstructed patients had significantly higher PSA, larger prostate volume, and higher IPSS. Detrusor overactivity did not differ between the two groups (45.6% vs. 48.1%, p = 0.83). First, normal, strong, and urgent desires to void were significantly lower in obstructed men: median (IQR) 118 (57–128) vs. 180 (80–200), 171 (85–257) vs. 227 (125–350), 221 (150–383) vs. 307 (180–477), and 276 (197–480) vs. 344 (280–535), respectively. First desire to void (FDV) had the highest area under the curve (AUC = 0.83, 95% CI = 0.76–0.90, p < 0.001) for predicting BOO with a Youden index of 0.78 at 140 mL. Conclusions: Our results suggest that there is a strong association between bladder oversensitivity and BOO in men. Men with FDV

Partial nephrectomy is the gold standard treatment for renal tumors less than 7 cm.To describe surgical techniques and trends of treating renal tumors less than 7 cm at our department and present the clinical outcomes of our experience with Robot-Assisted Partial Nephrectomy (RAPN).Out of an established prospective RAPN database, we retrieved demographic, clinical, surgical and pathological parameters. Operation length was defined as the time between the first surgical incision and the last suture (skin to skin). Warm ischemia time (WIT) was defined as the time between the renal artery clamping and clamp releasing. Data is presented as mean (range, standard deviation) or numeric value (%).Overall, 250 RAPN cases were recorded between the years 2013-2020. Mean tumor size was 32 mm. Mean operation length was 153 minutes. Mean warm ischemia time was 17.5 minutes. Intra-operative complication rates, including converting the surgery to an open approach or to radical nephrectomy, was low. Mean estimated blood loss was 359 cc. An increase in the utilization of the robotic approach has been recorded throughout the years, with a concurrent decrease in the open and laparoscopic approaches.RAPN is associated with lower complication rates and superior perioperative outcomes, therefore considered a good alternative to the open and laparoscopic approaches. Thus, RAPN is the gold standard treatment for renal tumors less than 7 cm at our institute.

Focal treatment for prostate cancer has been proposed as an innovative strategy that aims to achieve oncological benefit while reducing treatment-related morbidity. This treatment is suitable for patients with low and intermediate risk, organ-confined disease. Focal therapy can be categorized as follows: unifocal index lesion ablation, multifocal ablation, hemi-gland ablation or subtotal gland ablation. Different types of energies are applied in focal therapy including high intensity focal ultrasound (HIFU), cryotherapy, focal laser ablation (FLA), irreversible electroporation (IRE) and Photodynamic therapy (PDT). In this review we will briefly present a summary of leading techniques and the available data regarding their oncological outcomes and adverse events. Whole-gland therapies were excluded from this review.

Urinary Incontinence (UI) following Robot-Assisted Laparoscopic-Radical Prostatectomy (RALP) adversely affects patients' quality of life.To find parameters that predict full urinary continence (FUC) following RALP.Out of an established prospective RALP database, we retrieved and analyzed parameters that potentially predict FUC: age, Body Mass Index, American Anesthesiology Association (ASA) score, previous abdominal surgeries, pre-operative IPSS (International Prostate-Symptom Score), operative time (OT), estimated blood loss (EBL), peritoneum closure and prostate weight. FUC has been defined as 0 pads/day. Univariate analysis has been executed for comparison between patient groups, whereas multivariate analysis has been implemented for the detection of predicting factors for FUC. Data are presented as median (interquartile range) or numeric value (%).A total of 431 RALP cases were recorded between the years 2010-2019. Final analysis included 364 patients with full medical records; 81% gained FUC within 15 weeks (8-28); 96% gained FUC or used 1 pad/day within 17.5 weeks (8-36). Among those who gained FUC, smaller prostates (p=0.028) and low EBL (p=0.025) have been observed. On multivariate analysis EBL has been associated with UI (OR=0.9).Most patients gained FUC following RALP. EBL was found as risk factor for UI.

Robotic-pyeloplasty (RP) for uretero-pelvic-junction-obstruction (UPJO) has been performed in our institution since 2013.To summarize the outcomes of RP in adults over 18 years of age.Adult RP cases have been prospectively documented. Analysis included demographic data such as age, sex, American Association of Anesthesiology-ASA Score, surgical-side, pre-operative imaging. Operative time (OT), estimated blood loss (EBL), length of stay (LOS) and short-term complications were also recorded. In all cases a JJ-stent has been left in place and subsequently taken out. Complications were classified in accordance with the Clavien-Dindo classification criteria. Patients were seen periodically with repeat imaging. The renal scan was performed at least once during the post-operative follow-up. Results are given as median (inter-quartile range) or numeric values (%).A total of 32 patients aged 33.5 years (21-45.2) had RP between the years 2013-2020, among which 53% were females and 59% right sided. An ASA score of 1-2 has been observed in 87.5% of all cases. Skin-to-skin OT was 163 min (136-185), and EBL was 5 ml (0-30). Short-term post-operative complications were hematuria (3.1%), urinary leak/urinoma (12.5%), body temperature38.30C (12.5%). In 2 cases (6.2%) the JJ-stent had been re-positioned in the operating-theater (Clavien-Dindo 3b). LOS was 3 days (2-4) and JJ-stent had been taken out 39 days (31.7-45.2) post-operatively. Median length of follow-up was 19.5 months (9.5-26.7). In 92.3% of cases an improvement in hydronephrosis has been observed in post-operative imaging. The renal scan did not demonstrate renal function deterioration.Adult robotic pyeloplasty for UPJO is safe and effective. Low complication rates and over 90% success rates have been observed. These findings are in line with those found in previous studies.

Little is known about oncologic outcomes following robot-assisted-radical-prostatectomy (RALP) for clinical T3 (cT3) prostate cancer.To investigate oncologic outcomes of patients with cT3 prostate cancer treated by RALP.Medical records of patients who underwent RALP from 2010 to 2018 were retrieved. cT3 cases were reviewed. Demographic and pre/postoperative pathology data were analyzed. Patients were followed in 3-6 month intervals with repeat PSA analyses. Adjuvant/salvage treatments were monitored. Biochemical recurrence (BCR) meant PSA levels of ≥ 0.2 ng/ml.Seventy-nine patients met inclusion criteria. Median age at surgery was 64 years. Preoperative PSA level was 7.14 ng/dl, median prostate weight was 54 grams, and 23 cases (29.1%) were down-staged to pathological stage T2. Positive surgical margin rate was 42%. Five patients were lost to follow-up. Median follow-up time for the remaining 74 patients was 24 months. Postoperative relapse in PSA levels occurred in 31 patients (42%), and BCR in 28 (38%). Median time to BCR was 9 months. The overall 5-year BCR-free survival rate was 61%. Predicting factors for BCR were age (hazard-ratio [HR] 0.85, 95% confidence interval [95%CI] 0.74-0.97, P = 0.017) and prostate weight (HR 1.04, 95%CI 1.01-1.08, P = 0.021). Twenty-six patients (35%) received adjuvant/salvage treatments. Three patients died from metastatic prostate cancer 31, 52, and 78 months post-surgery. Another patient died 6 months post-surgery of unknown reasons. The 5-year cancer-specific survival rate was 92.RALP is an oncologic effective procedure for cT3 prostate cancer. Adjuvant/salvage treatment is needed to achieve optimal disease-control.

Dietary modifications and patient-tailored medical management are significant in controlling renal stone disease. Nevertheless, the literature regarding effectiveness is sparse.To explore the impact of dietary modifications and medical management on 24-hour urinary metabolic profiles (UMP) and renal stone status in recurrent kidney stone formers.We reviewed our prospective registry database of patients treated for nephrolithiasis. Data included age, sex, 24-hour UMP, and stone burden before treatment. Under individual treatment, patients were followed at 6-8 month intervals with repeat 24-hour UMP and radiographic images. Nephrolithiasis-related events (e.g., surgery, renal colic) were also recorded. We included patients with established long-term follow-up prior to the initiation of designated treatment, comparing individual nephrolithiasis status before and after treatment initiation.Inclusion criteria were met by 44 patients. Median age at treatment start was 60.5 (50.2-70.2) years. Male:Female ratio was 3.9:1. Median follow-up was 10 (6-25) years and 5 (3-6) years before and after initiation of medical and dietary treatment, respectively. Metabolic abnormalities detected included: hypocitraturia (95.5%), low urine volume (56.8%), hypercalciuria (45.5%), hyperoxaluria (40.9%), and hyperuricosuria (13.6%). Repeat 24-hour UMP under appropriate diet and medical treatment revealed a progressive increase in citrate levels compared to baseline and significantly decreased calcium levels (P = 0.001 and 0.03, respectively). A significant decrease was observed in stone burden (P = 0.001) and overall nephrolithiasis-related events.Dietary modifications and medical management significantly aid in correcting urinary metabolic abnormalities. Consequently, reduced nehprolithiasis-related events and better stone burden control is expected.

We reviewed the oncologic and surgical outcomes of endoscopic treatments for low grade upper tract urothelial carcinoma, and assessed the prognostic significance of tumor size, location and multifocality.We retrospectively reviewed all patients who underwent endoscopic treatment for low grade upper tract urothelial carcinoma at our institution between 2014 and 2019. Tumors were treated with a dual laser generator, which alternately produces holmium and neodymium lasers. A stringent ureteroscopic followup protocol was conducted. We looked for an association between outcome and tumor size, location or multifocality, and for predictive factors for time to local recurrence and progression.The cohort included 59 patients (62 renal units), 27% of tumors were multifocal and 40% were2 cm. The median followup time was 22 months (IQR 11-41), and the median number of ureteroscopies was 5.5 (4-9). Local recurrence was observed in 46 renal units (74.1%) at a median of 6.5 months after initial surgery. Four patients (6.4%) developed disease progression and were referred for radical surgery: 2 had pathological progression and 2 had a rapid and high volume local recurrence, and 1 later developed metastatic disease. The progression-free rate was 93.2%. Tumor location in kidney (p=0.03, HR 1.95) and multifocality (p=0.005, HR 3.25) significantly predicted time to local recurrence. No factor predicted time to progression.Ureteroscopic treatment of large, multifocal, low grade upper tract urothelial carcinoma is feasible, does not involve significant complications and has good short-term oncologic outcomes, with a 93.2% progression-free survival rate. Tumors located in the kidney and multifocality yielded shorter time to local recurrence but not progression.

Ureteroscopic methods have been rapidly evolving in the last several decades. With advances in flexible devices, optics and laser technologies, the endourologic surgeon has now the tools to treat high-volume tumors, in difficult locations, with good oncologic outcome. This makes radical nephroureterectomy unnecessary in some cases. Endoscopy in the setting of UTUC will surely continue to evolve and become applicable to a wider selection of patients. In this review we describe the surgical technique and provide tips and tricks which we use in our practice of endoscopic retrograde treatment of upper-tract urothelial carcinoma.

Purpose Prostate multiparametric magnetic resonance imaging (mpMRI) improves diagnosis of clinically significant cancer and reduces over-detection of nonsignificant cancer. Disagreement in the interpretation of mpMRI readings is well-known, with a reported discrepancy rate of 10% to 42%. We report the clinical repercussions of this variability on prostate biopsy candidates. Materials and Methods Medical records of patients referred from 11 medical centers for MR-guided prostate biopsy (MRGpB) between October, 2017 and January, 2019 were retrospectively analyzed. Patients with at least one prostate imaging reporting and data system (PI-RADS) 3 or greater prostate lesion were selected, and the mpMRI studies (all read by others) were reviewed by our prostate mpMRI reader. Outcomes included changes in PI-RADS score and the subsequent effect on total needle samples and indication for biopsy. Results Eighty-two patients with 128 lesions were suitable for analysis (mean age 66.5 ± 7.1 years, mean PSA 6.8 ± 8.5 ng/ml). Nine (11%) patients had suspicious rectal exams (T2a). Following our prostate mpMRI reader's imaging revisions, the PI-RADS score was downgraded in 66 (52%) lesions, upgraded in 15 (12%), and unchanged in 47 (37%), leaving a total of 84 suspected lesions (kappa = 0.17). Biopsy was deferred in 22 (27%) patients, and an estimated 136.4 (34.4%) samples were avoided (P = 0.0001 for both). There was a trend toward prostate size to correlate with imaging revision and abortion of biopsy (P = 0.06) while enrollment in active surveillance correlated with proof from such outcome (P = 0.007). Conclusion These data suggest that high interobserver disagreement in prostate mpMRIs from diverse institutes significantly affects prostate biopsy practice. The clinical consequences of this discord are significant.

The association between perioperative blood transfusion (PBT) with adverse oncological outcomes have been previously reported in multiple malignancies including RCC. Nevertheless, the importance of transfusion timing is still unclear. The primary purpose of this study is to appraise whether the receipt of intraoperative blood transfusion (BT) differ from postoperative BT in regards to cancer outcomes in renal cell carcinoma (RCC) patients treated with nephrectomy. Data on 1168 patients with RCC, who underwent radical or partial nephrectomy as primary therapy between 1988–2013 were analyzed. PBT was defined as transfusion of allogeneic red blood cells (RBC) during surgery or the postsurgical period. Survival was analyzed and compared using the Kaplan–Meier method with the log-rank test. Of 1168 patients, 198 patients (16.9%) received a PBT. Including 117 intraoperative BT and 81 postoperative BT. Only 21 (10.6%) patients required both intraoperative and postoperative BT. On multivariate analyses, receipt of PBT was associated with significantly worse local disease recurrence (HR: 2.4; P = 0.017), metastatic progression (HR: 2.7; P = 0.005), cancer-specific mortality (HR: 3.5; P = 0.002) and all-cause mortality (HR: 2.1; P = 0.005). Nevertheless, postoperative BT was not independently associated with increased risk of local recurrence (p = 0.1), metastatic progression (P = 0.16) or kidney cancer death (P = 0.63), yet did significantly increase the risk of overall mortality (HR: 2.6; P = 0.004). In the current study, intraoperative transfusion of allogeneic RBC is associated with increased risks of cancer recurrence and mortality following nephrectomy.

Pancreatic injuries during nephrectomy are rare, despite the relatively close anatomic relation between the kidneys and the pancreas. The data regarding the incidence and outcome of pancreatic injuries are scarce.To assess the frequency and the clinical significance of pancreatic injuries during nephrectomy.A retrospective analysis was conducted of all patients who underwent nephrectomy over a period of 30 years (1987-2016) in a large tertiary medical center. Demographic, clinical, and surgical data were collected and analyzed.A total of 1674 patients underwent nephrectomy during the study period. Of those, 553 (33%) and 294 patients (17.5%) underwent left nephrectomy and radical left nephrectomy, respectively. Among those, four patients (0.2% of the total group, 0.7% of the left nephrectomy group, and 1.36% of the radical left nephrectomy) experienced iatrogenic injuries to the pancreas. None of the injuries were recognized intraoperatively. All patients were treated with drains in an attempt to control the pancreatic leak and one patient required additional surgical interventions. Average length of stay was 65 days (range 15-190 days). Mean follow-up was 23.3 months (range 7.7-115 months).Pancreatic injuries during nephrectomy are rare and carry a significant risk for postoperative morbidity.

INTRODUCTION AND OBJECTIVE:The clinical significance of a positive surgical margin (PSM) following partial nephrectomy (PN) remains controversial. The purpose of the current study was to examine th...

Background Ataxia telangiectasia (AT) is a neurodegenerative cerebellar disorder, caused by mutations in the ATM gene, involved in DNA repair. Radiosensitivity, progressive ataxia, immune deficiency and malignancies, are well known symptoms, but urological manifestations are scarcely described. Objective To characterize urologic manifestations in a large cohort of AT patients. Methods Retrospective cross-sectional chart study comprising 52 AT patients followed at a National AT Center. Results 25% of the cohort (13 patients/8 males) had urologic symptoms, which presented at 11 ± 4.3 years. The most common symptom was secondary enuresis affecting 15% of the patients (8 children/4 males). Incontinence appeared at 8 ± 6.2 years of age, and resolved spontaneously within 15 ± 8.3 months in 6 patients. It preceded loss of ambulatory capacity by 1–2 years in 7 patients. Lumbosacral MRI were normal (4 children) and urine cultures (all) were negative. Urodynamic evaluation that was performed in only one patient revealed overactive bladder. Additional manifestations were macroscopic hematuria due to bladder telangiectasia in a 12-year-old, and renal cell carcinoma in a 22-year-old. Other manifestations unrelated to AT were neprolithiasis, vesico-ureteral reflux and scrotal pain, each in 1 patient. Discussion Transient secondary enuresis is a frequent finding in AT patients, heralding loss of ambulatory capacity, tough it's pathophysiological mechanism is largely no understood.

Background: The contemporary surgical approach to Wilms' tumors follows that used in adults with renal cell carcinomas, namely, early occlusion of the renal vessels and then removal of the kidney as an intact mass. For years, the surgical approach at our institution has been different, starting with blunt separation of the kidney from the surrounding tissues, followed by its delivery outside the abdominal cavity while it is only attached to the major blood vessels which are subsequently ligated. We aimed to present this “tumor delivery technique” and evaluate its outcomes. Materials and Methods: We retrospectively reviewed medical records of children who underwent nephrectomy for Wilms' tumor using “tumor delivery technique.” All procedures were performed by the same team, according to the same surgical principles. Results: Between 2000 and 2015, 36 children were operated. Median age was 31 months (interquartile range [IQR]: 6–45 mo), and median maximal tumor diameter was 10 cm (IQR: 8–13.9 cm). Tumors were located to the right side in 47%, left side in 42%, and bilateral in 11%. Twelve children have received preoperative neoadjuvant chemotherapy. Capsular disruption and tumor spillage were documented in 4 cases (11%). Conclusions: “Tumor delivery technique” is an easy and safe approach which might reduce the overall complication rates and the incidence of intraoperative tumor spillage.

Until recently, radical nephroureterectomy was considered the gold standard treatment for upper tract urothelial carcinoma (UTUC). Post-operative complications, long-term adverse effects of nephrectomy as well as the risk of contralateral recurrence have led to the development of nephron-sparing techniques.To evaluate the safety, complication rate, and oncologic outcomes of ureteroscopic nephron-sparing treatment for low-grade UTUC utilizing a hybrid laser system that incorporates two types of lasers: Nd:YAG and Ho:YAG.We reviewed the files of patients who underwent ureteroscopic treatment for UTUC with the hybrid laser system between the years 2014-2018. Only cases of low-grade UTUC and follow-up time of at least 6 months were included in the present study. The following were analyzed: demographic data, tumor histologic characteristics, peri-operative complications, histologic upgrade, oncologic outcomes (i.e: local recurrence, local spread, metastatic progression).A total of 38 patients, who underwent 74 ureteroscopies, met inclusion criteria. Mean tumor size was 16.2 mm. No intra-operative complications were recorded. Two post-operative complications were recorded in one patient - hematuria and retroperitoneal bleeding - both had been treated conservatively. Mean follow-up time was 21.8 months. Local recurrence rate was 73%. Histologic upgrade has been observed in two patients. Four patients (10.5%) were referred to radical nephroureterectomy. There were no cases of local spread, distant metastases or death during the follow-up period.Endoscopic dual-laser treatment for low-grade UTUC is safe, surgically feasible and associated with good short-term oncologic outcome. Patient selection and strict follow-up are mandatory.

Accessory spleen is not a common finding, usually located nearby the normal anatomic location of the spleen, oftentimes in the splenic hilum, the great omentum and the pancreas. Pelvic accessory spleen is a very rare finding, mostly asymptomatic and incidentally radiologically detected. Herein, we present an 18 years old male who underwent an investigation for daytime urinary frequency and suspicious small right pelvic mass was demonstrated by both ultrasound and MRI scans. In view of being a potentially malignant tumor, a robotic-assisted removal was uneventfully performed and the final pathology was surprisingly compatible with an accessory spleen.

UROCIT-K is a potassium-citrate regimen prescribed for the prevention of kidney stone formation. In 2013, K-CITEK was introduced to the local market as a new potassium-citrate regimen that reduces kidney stone formation in a declared rate of 93.We sought to explore the efficacy of K-CITEK versus UROCIT-K.A prospective database of patients treated with potassium-citrate regimens for nephrolithiasis has been reviewed. Patients were divided into two groups: those who were treated with UROCIT-K only (Group 1) and those who were treated with K-CITEK only (Group 2). The two groups were compared as regards to demographics, length of follow-up, urinary citrate level and stone burden changes, as well as the number of stone events (i.e: colic, surgery) throughout the follow-up period. In a separate analysis another group (Group 3) was checked. This group consisted of patients who were initially treated with UROCIT-K and later on were switched to K-CITEK.The study group consisted of 104 patients: 54 patients in Group 1, 38 in group 2 and 12 in group 3. The latter was omitted from analysis due to the small size. Groups 1 and 2 resembled in their demographic data and medical comorbidities. No statistically significant differences were found in terms of change in urinary citrate levels, stone burden or recurrent stone events.K-CITEK for the treatment of kidney stone prevention was found to be as equally effective as UROCIT-K in terms of increasing urinary citrate levels, reducing stone burden and maintaining the intervals between kidney stone events.

INTRODUCTION AND OBJECTIVES:Radical Nephroureterectomy (RNU) is considered the gold standard treatment for upper tract urothelial carcinoma (UTUC) larger than 2cm. The purpose of this study was to ...

An experienced surgical team, in general, and the surgeon assistant in particular are believed to play a critical role in the operation’s safety and success. We sought to explore whether the assistant’s seniority influences perioperative course following robot assisted laparoscopic radical prostatectomy (RALP). We reviewed our prospective registry database of RALP cases performed by a single surgeon who during the study period was beyond his learning curve. The following parameters were documented and analyzed: patient’s age, body mass index (BMI), associated comorbidities, previous abdominal surgeries, assistant’s identity, total and skin-to-skin operative time (tOT, ssOT, respectively), estimated blood loss (EBL), immediate post-operative complications, length of stay (LOS), and prostate weight per final pathology report. Univariate analysis and Spearman’s correlation test were used to evaluate whether the assistant’s seniority influenced perioperative course. Between the years 2011–2015, 106 consecutive cases were retrieved and analyzed. Prostate weight was found to be associated with longer tOT (Spearman’s ρ = 0.34, p

Background The use of ureteral access sheath (UAS) during ureteroscopy is controversial. We aimed to explore practice patterns of UAS during ureteroscopy for nephrolithiasis among endourologists worldwide. Methods A 15-question survey was designed using the SurveyMonkey® platform. The questions covered the background and professional experience of the potential respondents, indications for UAS insertion, UAS caliber and possible complications associated with its use. The questions were anonymously tabulated in order to determine practice patterns of UAS during ureteroscopy for nephrolithiasis among endourologists. The survey was then distributed via e-mail to all the Endourological Society members. Results 216 members responded. 99.53% of the respondents practice as endourologists, 63.4% are fellowship trained and 74.4% are at least 6 years post-fellow. 73.2% practice in an academic facility. 77.3% perform at least 100 ureteroscopies annually. 46 and 76% routinely use UAS for the treatment of ureteral and kidney stones, respectively. In both cases, the 12/14 access sheath is the most common. 42% use UAS in primary ureteroscopy. 90.3% believe that a double J stent insertion is not mandatory prior to UAS insertion. 79.1% think the use of UAS does not increase postoperative complications rate, and if the latter does encounter, then most likely it is either a ureteral stricture (93.2%) or pain (48%). Conclusions UAS is commonly used by highly skilled endourologists during ureteroscopy. 12/14 UAS is mostly used. Ureteral stricture and post-operative pain are proposed as possible complications following UAS introduction, however pre-stenting is not mandatory as overall low complication rate is expected.

Objective We sought to explore the yield of transrectal ultrasound (TRUS) in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Materials and methods The records of all patients, who were referred for TRUS caused by CP/CPPS, were retrospectively reviewed. Digital rectal examination (DRE) was performed before TRUS. The following parameters were recorded: prostatic length; width; height; volume; external border; peripheral zone (PZ); transitional zone (TZ); TZ/PZ border; seminal vesicles appearance (SV); presence of median lobe; dilation of vas deferens (VD) or ejaculatory duct (ED); and presence of significant postvoid residual (PVR). Unique sonographic findings, if present, were recorded as well. Data were compared to those of an age-matched control group that had undergone the same imaging for other reasons. Results Two hundred and sixteen patients with suspected CP/CPPS underwent DRE and TRUS. Per DRE, their prostates appeared smaller and homogeneous compared with the control group. Differences seen in TRUS between the study and the control groups, respectively, were as follows: fewer irregularities, fewer hypoechoic areas in PZ; fewer cystic spaces, fewer enlarged median lobes in TZ; less ED dilation; more calcifications; more VD dilation; and more periurethral vascularity. No differences were seen in SV parameters and in PVR. None of the patients has been given different diagnosis or treatment following TRUS. Conclusion The findings of TRUS studies in patients with suspected CP/CPPS are not pathognomonic for this entity, and TRUS is therefore considered as having very little yield in this setting.

Objective Multicystic dysplastic kidney (MCDK) is a developmental anomaly believed to be a consequence of either early in utero urinary tract obstruction or failure of union between the ureteric bud and the metanephric blastema. Concomitant finding of MCDK and ipsilateral obstructive ureterocele may further support the obstructive theory. We aimed to explore the possible linkage between MCDK and ipsilateral obstructive ureterocele. Materials and Methods Ultrasonographic imaging and voiding cystourethrography (VCUG) of children diagnosed with MCDK were retrospectively reviewed. Results A total of 28 children with MCDK were included, all of whom underwent ultrasonography and 16 underwent VCUG. Ten of the 16 children (62%) who underwent VCUG had vesicoureteral reflux, none of which was to the MCDK. Twenty of 28 children (71%) had MCDK replacing the entire kidney, among whom seven (35%) had an ipsilateral ureterocele on bladder imaging. Eight of 28 children (29%) had segmental disease, all involving the upper pole of a duplex kidney (right, 4; left, 4). All four left-sided kidneys with segmental MCDKs had an associated ipsilateral ureterocele. Conclusion Our data highlight the fact that MCDK is frequently identified with a concomitant finding of an ipsilateral ureterocele, which should be carefully sought whenever MCDK is identified. The reported association strongly supports the theory of MCDK development as a result of an in utero urinary tract obstruction.

A 24-h urine metabolic profile (24-UMP) is an integral part of nephrolithiasis work-up. We aimed to explore whether it can be waived under certain circumstances. We reviewed our prospective registry database of patients seen at our outpatient clinic for nephrolithiasis between the years 2010 and 2017. Data included: gender, age at first stone, body mass index (BMI), self-reported comorbidities and family history of nephrolithiasis. A 24-UMP was obtained from each patient under random diet. The following were recorded: urine volume, urinary levels of sodium, calcium, uric acid, oxalate and citrate. Presence of at least one comorbidity (i.e., hypertension/diabetes/hyperlipidemia) was defined as “associated comorbidities” (AC). Their absence was defined as “no comorbidities” (NC). Subjects were divided into two subgroups: first-time and recurrent stone formers, which were further divided into two subgroups: 1st + AC; 1st + NC; recurrent + AC; recurrent + NC. 24-UMPs have been compared between the four groups. Four hundred and fifty-seven patients were included in the study. In the AC groups, patients demonstrated higher BMI levels (p = 0.001), and were statistically significantly obese (BMI > 30, p = 0.001) and older at first stone event (p = 0.001). First formers, either with AC or NC were more likely to have low urine volume (LUV) compared with recurrent formers (72.5 vs. 59.5%, p = 0.005). In the remaining metabolic abnormalities, no such differences were observed. First-time stone formers, either with or without AC are likely to demonstrate LUV as their primary metabolic abnormality in 24-UMP. Therefore, 24-UMP may be postponed until recurrent stone event.

The prevalence and etiology of nephrolithiasis vary, depending on geography, gender and ethnicity.To analyze the demographic data of return nephrolithiasis patients in a tertiary care center.We retrospectively reviewed our prospective registry database of return patients seen at our outpatient clinic for nephrolithiasis. Data included gender, age at first visit, age at first stone event, body mass index (BMI), self-reported hypertension, diabetes mellitus (DM), and hyperlipidemia. All patients were seen at least twice and had undergone a metabolic workup.A total of 260 return patients were seen during the period 2010-2015. The male:female ratio was 3.1:1. Mean age at the first stone event was 44.1 years. Median time elapsed since the first stone event to medical evaluation was 5 years (interquartile range 1-12 years). Hypertension was reported by 33.1% of the patients, DM by 23.5% and hyperlipidemia by 30.4%. All three diseases were reported by 11.5% of patients. The metabolic abnormalities detected were hypocitraturia (60%), low urine volume (LUV) (60%), hypercalciuria (40.8%), hyperoxaluria (24.2%), hyperuricosuria (16.5%) and hyperuricemia (13.5%). Stone compositions from most to least frequent were calcium-oxalate (81%), calcium-phosphate (11.9%) and uric acid (7.1%). We also found that 24.6% were obese (BMI ≥ 30 kg/m2) and showed higher rates of hypertension, DM, hyperlipidemia, hyperuricemia and hyperuricosuria compared with non-obese patients. Significantly higher rates of obesity and LUV were detected in females compared with males. Patients over age 45 had lower rates of hyperuricemia compared with patients ≥ 45 years old (P = 0.038).Factors related to nephrolithiasis can potentially differ among populations and countries. Our findings emphasize the significance of individualized national health programs to address local issues.