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Background The optimal number of systematic biopsy cores in the era of multi-parametric MRI targeted biopsy remains unclear, especially on its impact of focal therapy planning. Our objective is to investigate the impact of reducing the number of systematic cores on prostate cancer detection in the era of MRI-US fusion targeted biopsy and as well as its relevance in template planning for focal therapy. Materials and methods A retrospective analysis of 398 consecutive men who underwent both systematic saturation (~24 cores) and MRI-US fusion targeted biopsy was performed. Four reduced-core systematic biopsy strategies (two-thirds, half, one-third and one-quarter systematic cores) were modelled and the detection rates of clinically-significant prostate cancer (csPCa defined as grade group ≥2) were compared to that of a full systematic biopsy using McNemar’s test. Focal therapy treatment plans were made based on positive cores on combined (targeted and systematic) biopsy and the various reduced-cores strategies to compare the proportion who had a change in treatment plan. Results csPCa was detected in 42% (168/398) of this patient cohort. Non-targeted systematic saturation biopsy had a 21% (83/398) csPCa detection rate. Our four strategies reduced the mean number of non-targeted systematic cores from 21.8 to 14.5, 10.9, 7.3 and 5.4 cores and their csPCa detection rates were significantly decreased to 16%, 13%, 9% and 8% respectively (all p p = 0.0434). Conclusions Reducing the number of systematic biopsies when performing an MRI-targeted biopsy leads to reduced detection of csPCa and alter the treatment plans for focal therapy, possibly limiting its oncological efficacy.

Childhood priapism is a rare entity and there is currently no consensus regarding its contemporary management. The use of perioperative anticoagulation and open distal corpora-glandular shunt procedure in the management of childhood priapism has not been reported in the literature. We present a stuttering case of a 13-year-old boy who presented with idiopathic ischaemic priapism lasting 13 h in duration, which recurred despite corporal aspiration and alpha-adrenergic agonist injections, percutaneous distal shunt surgery, and revision of percutaneous distal shunt surgery. He was eventually successfully managed with perioperative subcutaneous enoxaparin, oral aspirin and clopidogrel in conjunction with an Al-Ghorab shunt, which led to sustained detumescence but with spontaneous morning erections. In paediatric patients with sustained childhood priaprism failing stepwise treatments, an Al-Ghorab shunt with perioperative anticoagulation is a viable option.

OBJECTIVE To compare the detection rates of prostate cancer between systematic biopsy and targeted biopsy using a stereotactic robot-assisted transperineal prostate platform. MATERIALS AND METHODS We identified consecutive patients with suspicious lesion(s) on multiparametric magnetic resonance imaging (mpMRI), who underwent both systematic and MRI-transrectal ultrasonography (US) fusion targeted biopsy using our proprietary transperineal robot-assisted prostate biopsy platform between January 2015 and January 2019 at our institution, for retrospective analysis. Comparative analysis was performed between systematic and targeted biopsy using McNemar's test, and the cohort was further stratified by prior biopsy status and Prostate Imaging Reporting and Data System (PI-RADS) v2.0 score. International Society of Urological Pathology (ISUP) grade group (GG) ≥2 cancers (previously known as Gleason grade ≥7) were considered to be clinically significant. RESULTS A total of 500 patients were included in our final analysis, of whom 67 (13%) were patients with low-risk cancer on active surveillance. Of the 433 patients without prior diagnosis of cancer, 288 (67%) were biopsy-naive. A total of 248 (57%) were diagnosed with prostate cancer, with 199 (46%) having clinically significant prostate cancer (ISUP GG ≥2). There were no statistically significant differences in the overall prostate cancer and clinically significant prostate cancer detection rate between systematic and targeted biopsy (51% vs 49% and 40% vs 38% respectively; P = 0.306 and P = 0.609). Of the 248 prostate cancers detected, 75% (187/248) were detected on both systematic and targeted biopsy, 14% (35/248) were detected on systematic biopsy alone and 11% (26/248) were detected on targeted biopsy alone. Of the 199 clinically significant cancers detected, 69% (138/199) were detected on both systematic and targeted biopsy, 17% (33/199) on systematic biopsy alone and 14% (28/199) on targeted biopsy alone. There were no statistically significant differences in the detection rate between systematic and targeted biopsy for both overall and clinically significant prostate cancer, even when the cohort was stratified by prior biopsy status and PI-RADS score. Targeted biopsy has greater sampling efficiency compared to systematic biopsy for both overall and clinically significant prostate cancer (23.2% vs 9.8%, P < 0.001 and 14.8% vs 5.6%, P < 0.001). CONCLUSIONS Using our robot-assisted transperineal prostate platform, combined MRI-US targeted biopsy with concurrent systematic prostate systematic biopsy probably represents the optimal method for the detection of clinically significant prostate cancer.

Objectives Our objective was to evaluate the effect of the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), lymphocyte/monocyte ratio (LMR), and red blood cell distribution width (RDW) on the survival outcomes of nonmetastatic clear cell renal cell carcinoma (ccRCC). Materials and Methods We accessed our single-center, urologic-oncologic registry to extract the data for patients who had undergone nephrectomy for nonmetastatic ccRCC. The optimal cutoff for these markers was determined using X-tile software, and survival analyses using Cox regression were performed. Results A total of 687 patients had undergone nephrectomy. The optimal cutoffs for NLR, PLR, LMR, and RDW were 3.3, 210, 2.4, and 14.3%, respectively. The NLR, PLR, LMR, and RDW were significantly associated with a larger pathologic tumor size, and stage, more aggressive Fuhrman grade, and the presence of tumor necrosis. After adjusting for age, baseline Eastern Cooperative Oncology Group, pathologic tumor and nodal stage, and Fuhrman grade, only PLR remained an independent prognostic marker for both cancer-specific survival (hazard ratio, 2.69; 95% confidence interval, 1.36-5.33; P = .004) and overall survival (hazard ratio, 2.19; 95% confidence interval, 1.36-3.50; P = .001). When the PLR was included with the Leibovich score and University of California, Los Angeles, integrated staging system, the Harrell’s c-index increased from 0.854 to 0.876 and 0.751 to 0.810, respectively, for cancer-specific survival at 5 years after nephrectomy. When risk stratified by the Leibovich risk group and UCLA integrated staging system, PLR was a significant prognostic factor only within the intermediate- to high-risk groups. Conclusions PLR is a robust prognostic marker in nonmetastatic ccRCC that clearly outperforms other inflammatory indexes in those who had undergone nephrectomy. However, its prognostic effect was limited in the low-risk category of ccRCC.

Uroflowmetry remains an important tool for the assessment of patients with lower urinary tract symptoms (LUTS), but accuracy can be limited by within-subject variation of urinary flow rates. Voiding acoustics appear to correlate well with conventional uroflowmetry and show promise as a convenient home-based alternative for the monitoring of urinary flows.To evaluate the ability of a sound-based deep learning algorithm (Audioflow) to predict uroflowmetry parameters and identify abnormal urinary flow patterns.In this prospective open-label study, 534 male participants recruited at Singapore General Hospital between December 1, 2017 and July 1, 2019 voided into a uroflowmetry machine, and voiding acoustics were recorded using a smartphone in close proximity. The Audioflow algorithm consisted of two models-the first model for the prediction of flow parameters including maximum flow rate (QLin's correlation coefficient was used to evaluate the agreement between Audioflow predictions and conventional uroflowmetry for QA total of 331 patients were included for analysis. Agreement between Audioflow and conventional uroflowmetry for QThe results of this study suggest that a deep learning algorithm can predict uroflowmetry parameters and identify abnormal urinary voids based on voiding sounds, and shows promise as a simple home-based alternative to uroflowmetry in the management of patients with LUTS.In this study, we trained a deep learning-based algorithm to measure urinary flow rates and identify abnormal flow patterns based on voiding sounds. This may provide a convenient, home-based alternative to conventional uroflowmetry for the assessment and monitoring of patients with lower urinary tract symptoms.

Purpose Several multiparametric magnetic resonance imaging (mpMRI)-based models have been developed with significant improvements in diagnostic accuracy for clinically significant prostate cancer (csCaP), but lack proper external validation. We therefore sought to externally validate and compare all published mpMRI-based csCaP risk prediction models in an independent Asian population. Patients and Methods A total of 449 men undergoing combined transperineal fusion-targeted/systematic prostate biopsy at our specialist center between 2015 to 2019 were retrospectively analyzed. csCaP was defined as lesions with ISUP (International Society of Urological Pathology) grade group ≥2. The performance of 6 mpMRI-based risk models (MRI-ERSPC-3/4, Distler, Radtke, Mehralivand, van Leeuwen and He) were evaluated in terms of discrimination, calibration and clinical utility, using area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analyses. Results A total of 202 (45%) subjects were diagnosed with csCaP. All models demonstrated excellent accuracy with AUCs ranging from 0.75 to 0.86, and most significantly outperformed mpMRI PIRADSv2.0 (Prostate Imaging Reporting and Data System version 2.0) alone. The models by Mehralivand and He showed good calibration to our validation population, with respective intercepts of -0.08 and -0.84. All models were nevertheless recalibrated to the csCaP prevalence in our population for analysis. Decision curve analysis showed that above a threshold probability of 10%, all mpMRI-based models demonstrated superior net benefit compared to mpMRI PIRADSv2.0 or a biopsy-all-men strategy. The van Leeuwen model had the greatest net benefit, avoiding 39% of unnecessary biopsies while missing only 4% of csCaP, at a threshold probability of 15%. Conclusions The mpMRI-based risk models demonstrate excellent discrimination and clinical utility and are easy to apply in practice, suggesting that individualized risk-based approaches can be considered over mpMRI alone to avoid unnecessary biopsies.

To evaluate the clinically-significant prostate cancer (csCaP) detection rate of systematic (SBx) vs. targeted biopsy (TBx), after accounting for the overlapping systematic cores within the MRI regions of interest.We identified 398 consecutive men who underwent both transperineal systematic and targeted biopsy between January 2015 to January 2019. We reclassified overlapping systematic cores in the MRI regions of interest as target cores. The detection rates of SBx and TBx were compared using McNemar's test.Detection rate of csCaP (grade group ≥2) was 42% (168/398). Median number of systematic and targeted cores were 23 (IQR 19-29) and 9 (IQR 6-12) respectively. A median of 3 (IQR 2-4) overlapping systematic cores were reclassified as targeted cores. After accounting for overlap, csPC detection rate on SBx decreased from 37% and 21% while the csCaP detection rate of TBx increased from 34% to 39% (both P0.001), with TBx having a better detection rate (39% vs. 21%, P0.001). A previous negative biopsy was associated with a lower risk of having csCaP on non-targeted SBx (OR 0.27, 95% CI: 0.12 - 0.58, P = 0.001). Only 5% (13/243) of those who had no cancer detected on TBx had csCaP on non-targeted SBx compared to 45% (70/155) of those who had csCaP on TBx (P0.001).The utility of SBx in detecting csCaP decreases after accounting for overlap into the MRI region of interest, especially in men with a prior negative biopsy. Overlapping systematic cores improve the csCaP detection rate on TBx.

To compare the detection rates of prostate cancer between systematic biopsy and targeted biopsy using a stereotactic robot-assisted transperineal prostate platform.We identified consecutive patients with suspicious lesion(s) on multiparametric magnetic resonance imaging (mpMRI), who underwent both systematic and MRI-transrectal ultrasonography (US) fusion targeted biopsy using our proprietary transperineal robot-assisted prostate biopsy platform between January 2015 and January 2019 at our institution, for retrospective analysis. Comparative analysis was performed between systematic and targeted biopsy using McNemar's test, and the cohort was further stratified by prior biopsy status and Prostate Imaging Reporting and Data System (PI-RADS) v2.0 score. International Society of Urological Pathology (ISUP) grade group (GG) ≥2 cancers (previously known as Gleason grade ≥7) were considered to be clinically significant.A total of 500 patients were included in our final analysis, of whom 67 (13%) were patients with low-risk cancer on active surveillance. Of the 433 patients without prior diagnosis of cancer, 288 (67%) were biopsy-naïve. A total of 248 (57%) were diagnosed with prostate cancer, with 199 (46%) having clinically significant prostate cancer (ISUP GG ≥2). There were no statistically significant differences in the overall prostate cancer and clinically significant prostate cancer detection rate between systematic and targeted biopsy (51% vs 49% and 40% vs 38% respectively; P = 0.306 and P = 0.609). Of the 248 prostate cancers detected, 75% (187/248) were detected on both systematic and targeted biopsy, 14% (35/248) were detected on systematic biopsy alone and 11% (26/248) were detected on targeted biopsy alone. Of the 199 clinically significant cancers detected, 69% (138/199) were detected on both systematic and targeted biopsy, 17% (33/199) on systematic biopsy alone and 14% (28/199) on targeted biopsy alone. There were no statistically significant differences in the detection rate between systematic and targeted biopsy for both overall and clinically significant prostate cancer, even when the cohort was stratified by prior biopsy status and PI-RADS score. Targeted biopsy has greater sampling efficiency compared to systematic biopsy for both overall and clinically significant prostate cancer (23.2% vs 9.8%, P0.001 and 14.8% vs 5.6%, P0.001).Using our robot-assisted transperineal prostate platform, combined MRI-US targeted biopsy with concurrent systematic prostate systematic biopsy probably represents the optimal method for the detection of clinically significant prostate cancer.

Primary ADT (pADT) monotherapy is used significantly for patients with clinically localised disease in Asia and is acceptable even by guidelines, especially in intermediate- and high-risk disease. This occurs despite controversy in the West and data suggesting association with adverse effects, notably cardiovascular events. We therefore sought to assess the impact of pADT on all-cause mortality and prostate cancer-specific mortality (PCSM) in Asian men with high-risk and unfavourable intermediate-risk PCa. With cancer registry data, men from a single centre in Singapore with clinically localised high-risk/unfavourable intermediate-risk PCa diagnosed between 2004 and 2014 and either treated conservatively with no therapy or started on pADT within 1 year of diagnosis were followed up through January 2017. Patients with non-localised PCa (clinical stage T4, regional/distant lymph node involvement, metastases), or receipt of local therapy (radical prostatectomy/radiotherapy) were excluded. The primary outcomes of all-cause mortality and PCSM were analysed with Cox proportional hazards regression models. Three hundred and forty Asian men were analysed, and 177 (52.1%) were started on pADT, with mean age of 77 (49–98) years. There were 119 deaths in the cohort, and 68 (38.4%) occurred in patients treated with pADT (median follow-up, 4.4 years). After adjusting for comorbidities and clinical characteristics, pADT did not provide benefit to all-cause mortality, PCSM or cardiovascular mortality. For clinically localised unfavourable intermediate-risk and high-risk PCa, starting pADT within 12 months of diagnosis is not associated with improved 5-year all-cause mortality or PCSM compared to patients treated conservatively with no therapy and should be discouraged due to lack of mortality benefit.

Hematuria is not uncommonly seen among children. We describe the case of a 13-year-old boy who was diagnosed with urothelial carcinoma after presenting with persistent gross hematuria for 2 weeks. We highlight the importance of adequate workup for gross hematuria as it is often associated with an underlying pathology that could lead to significant morbidity if left undiagnosed.

Objective: Despite high-grade intravesical prostatic protrusion (IPP) being closely related to bladder outlet obstruction (BOO), up to 21% of patients with low IPP remain obstructed. This study evaluates the characteristics and urodynamic findings of men with small prostates and low IPP. Methods: One hundred and fourteen men aged >50 years old with lower urinary tract symptoms (LUTS) were assessed with symptoms, uroflowmetry, serum prostate-specific antigen (PSA), transabdominal ultrasound measurement of prostate volume (PV), IPP and post-void residual urine (PVRU). All patients underwent pressure flow studies. Patients with PV

The treatment of choice for diabetic foot osteomyelitis is surgical debridement and targeted antibiotics with or without revascularization, depending on vascular status. In our society, debridement is done by either a vascular or orthopedic surgeon, and the common teaching is that generous amputation of bone with the accompanying soft tissue envelope is essential for adequate source control and to prevent recurrence (which remains as high as 30% even with this approach). Most of our patients undergo formal ray amputation through the metatarsal neck, while a few get digital amputations through the interphalangeal joints. Many of the resultant wounds cannot be closed and are left to heal by secondary intention. These amputations invariably alter the biomechanics of the foot and leave large and slow-healing open wounds, which have associated adverse psychosocial impacts. We describe 2 cases of patients who had osteomyelitis in the region of the forefoot who underwent complete bony resections of the osteomyelitis but with sparing of the soft tissue envelopes with good outcomes, and we challenge the dogma that maximal debridement of soft tissue must accompany debridement of necrotic and infected bone.

Background The use of an endovascular approach for treatment of abdominal aortic aneurysms has gained traction over the past 2 decades. One of the major drawbacks of the endovascular approach is the increased rates of reintervention, with the majority arising from endoleaks that occur up to 20% of the time. Although type II endoleak is the most common subtype (25–45% of all endoleaks), it is associated with the greatest dilemma and debate with regard to indications and modalities of treatment. The open surgical approach to management of type II endoleak has gained interest and popularity over the years because of issues associated with the endovascular approach. Methods We present a case of a patient with type II endoleak undergoing transperitoneal sacotomy, endoaneurysmorrhaphy, and stent-graft preservation, after having failed endovascular intervention. In addition, we describe the difficulties associated with posteriorly located backbleeding lumbar arteries and a unique case of iatrogenically created type III endoleak intraoperatively. Results A literature review was performed with regard to the risk factors, indications for intervention, and modalities of treatment for type II endoleaks. In addition, suggestions are provided for future improvements in surgical technique. Conclusions Type II endoleak is a common complication of endovascular aortic repair. In spite of this, management strategies are poorly standardized with no definitive gold standard. More collective data and pooled experience will be needed to further refine the open surgical technique and objectively assess its benefits and shortcomings vis-a-vis other alternatives.

Purpose The Leibovich model was updated to prognosticate oncological outcomes in postnephrectomy nonmetastatic renal cell carcinoma (RCC) for each major histological subtype including clear cell (ccRCC), papillary (papRCC), and chromophobe RCC. We evaluated its performance in an independent population of predominantly Asian patients from Singapore. Materials and Methods Nine hundred and forty two binephric patients with nonmetastatic unilateral RCC treated with radical/partial nephrectomy from 1990 to 2015 from Singapore were retrospectively reviewed. Based on the Leibovich model, ccRCC patients were scored from 0 to 25 and papRCC patients divided into 3 risk groups. Primary outcomes of progression-free survival (PFS) and cancer-specific survival (CSS) were assessed with the Kaplan–Meier method. Receiver operating characteristic curves and calibration plots were obtained to determine discrimination and calibration respectively. Results Eight hundred and twenty nine patients (88%) had ccRCC where 16.2% experienced disease progression while 11.9% died of RCC over a median follow-up of 76 (42–117) months. There was good discrimination (c-index 0.81 for PFS, 0.83 for CSS) and calibration (PFS calibration-in-the-large 0.002 and calibration slope 0.99, CSS calibration-in-the-large 0.005 and calibration slope 0.96). One hundred and thirteen patients (12%) had papRCC, where 18.6% progressed while 14.2% died from RCC over a median follow-up of 69.5 (36.0–112.0) months. Discrimination was slightly weaker (c-index 0.72 for PFS, 0.74 for CSS), and the model was only calibrated for CSS (calibration-in-the-large 0.002, calibration slope 0.98), not for PFS (calibration-in-the-large 0.09, calibration slope 1.93). Conclusions The updated Leibovich score is applicable for prognostication of progression and death in both ccRCC and papRCC, even when applied to an independent population of Asian patients. Further validation is required to ensure accuracy in prognosticating PFS for papRCC.

Objective Men with benign prostate hyperplasia (BPH) with good urinary flow may still have bladder outlet obstruction (BOO). Intravesical prostatic protrusion (IPP) has been shown to be able to predict BOO. We aim to investigate the use of IPP to predict BOO in men with good urinary flow. Methods One hundred and fourteen consecutive men (>50 years old) presenting with lower urinary tract symptoms suggestive of BPH were recruited in 2001 and 2002. They were evaluated with serum prostate specific antigen (PSA), uroflowmetry and transabdominal ultrasound measurement of IPP and prostate volume (PV). Pressure-flow urodynamic studies were performed on all men and BOO was defined by BOO index > 40. Men with Q max ≥ 12.0 mL/s were considered to have good flow. Results Among the 114 men, 61 patients had good urinary flow. Their median age, PV and Q max were 66 years, 32.9 mm 3 and 14.5 mL/s respectively. 14/61 (23.0%) patients had BOO and their distribution of IPP were as follows: Grade 1 – 0/20 (0%) obstructed, Grade 2 – 6/22 (27.3%) and Grade 3 – 8/19 (42.1%). Sensitivity of Grade 2/3 IPP for BOO was 100% while specificity of Grade 3 IPP was 76.6%. The area-under-curve (AUC) for IPP was greater than that for PV (0.757 vs. 0.696). Conclusion Even in men with good flow, high grades of IPP were more likely to have BOO and hence, may be a useful adjunct to predict BOO.