Performance of standard systematic biopsy versus MRI/TRUS fusion biopsy using the Navigo® system in contemporary cohort

INTRODUCTION

The introduction of multi parameter magnetic resonance imaging (mpMRI) of the prostate in combination with MRI/TRUS fusion and systematic biopsy resulted in improved detection of prostate cancer. The aim of the current study was to document the performance of MRI/TRUS fusion biopsy of the prostate using the Navigo™ software in a contemporary cohort of patients from nonreferral centers.

MATERIAL AND METHODS

We performed a two centers prospective data collection (2014-2020) for men with clinically suspected Pca and patients on active surveillance for low-risk Pca that were referred for TRUS biopsy after performing mpMRI of the prostate with a visible lesion. The primary outcome was detection of clinically significant cancer (csPca) defined as ISUP grade group ≥2. Patients were stratified according to biopsy technique and PI-RADS category.

RESULTS

The study group included 236 patients of whom 129 (54.9%) were diagnosed with Pca and 82 (34.7%) with csPca (GG ≥ 2) on combined biopsy. The overall detection of csPca was 31% for targeted vs. 25.4% for systematic biopsy with an absolute difference of 5.6% in favor of the fusion technique. No significant difference between the two techniques was observed for detection of benign prostate or GG1 disease. The improved performance of the targeted approach was noted only in patients with PI-RADS 4 and 5 lesions. Of the patients with csPca 10 (12%) were diagnosed only by the systematic biopsy while 20 (24%) were detected only in the fusion biopsy. Systematic biopsy of prostate lobe without MRI lesion detected only 2 cases (∼1%) with high grade disease.

CONCLUSIONS

Detection of csPca by mpMRI/TRUS fusion biopsy using the 3D Navigo™ system is feasible. The targeted approach outperforms the systematic one, however the later technique also detects high risk disease and should be included in the biopsy procedure. The overall detection rate (34.9%) of clinically significant prostate cancer by both targeted and systematic sampling is relatively low.

Morphometric analysis of nuclear symmetry in urothelial carcinoma for predicting tumor recurrence

Urothelial carcinoma is the ninth most common cancer in the world. Cytological analysis of the urine is used for screening, as well as for cases suspected for neoplasia of the urinary tract. However, the sensitivity of urine cytology examination is low. The golden standard for diagnosing bladder cancer relies upon cystoscopy followed by a biopsy, which is microscopically assessed by the pathologist. Treatment decisions are based on the histological grade and stage of the tumor. Posttreatment tumor recurrence is 50%. The purpose of this study is to predict recurrence of urothelial carcinoma using a novel morphometric method of nuclear symmetry analysis. This method may help tailor the appropriate treatment and may reduce the need of invasive surgical procedures in patients. Computerized morphometry was applied to develop multiple symmetry indices of the nuclei of the tumor cells as follows: each nucleus was physically divided along its digital axis in two segments that were separately analyzed for their shape, size, optical density, and texture. Subsequently, ratios were obtained by mathematically dividing between the morphometric values of the two nuclear segments where the denominator contained the largest value of the two. These ratios were named symmetry indices and were included as variables to predict the recurrence time of the tumors. The change in the symmetry indices (loss of symmetry) of the nuclear roundness, fractal dimension and margination were the only independent predictors of recurrence time. Computerized morphometry of nuclear symmetry indices may help to predict tumor recurrence in urothelial carcinomas.

The Use of Tissue Adhesive for Tumor Bed Closure during Partial Nephrectomy is Associated with Reduced Devascularized Functional Volume Loss

Objectives

To quantitatively compare the functional renal volume loss, following nephron sparing surgery (NSS) between patients in whom tumor bed closure was done by biological tissue adhesive and those who were managed by standard suture technique.

Methods

From our institutional NSS database we retrospectively collected patients who had two sequential quantitative single-photon emission computed tomography of ^99mTc-dimercaptosuccinic acid uptake studies, the first study immediately before surgery and the second one 3-6 months following surgery. The study group included 69 patients: 26 (37.7%) patients in the sealant group (BioGlue®) and 43 (62.3%) patients in the standard suture group.

Results

No statistically significant differences were noted in the baseline clinical and pathological characteristics of the studied groups. However, there were several statistically significant differences in operative variables: patients in the suture group had larger amount of blood loss (3-fold), longer ischemia time (26.6 vs. 21 minutes,) and slightly longer operation time. Patients in whom tumor bed was closed by sutures had nearly 3-fold higher parenchymal loss compared to patients managed by sealant (26.28 vs. 8.92 ml, p = 0.048).

Conclusions

The use of tissue sealant during tumor bed reconstruction is associated with reduced devascularized parenchymal mass loss and should be considered among modifiable surgical factors during NSS.

Antioxidant treatment ameliorates germ cell apoptosis induced by a high-dose ionizing irradiation in rats

BACKGROUND

Exposure to ionizing radiation results in cytotoxic and genotoxic effects caused mainly by the oxidative damage. In the present study, we investigated the radioprotective effect of novel antioxidant cocktail on germ cell apoptosis and spermatogenesis in rats subjected to whole body radiation (WBIR).

METHODS

Adult male rats weighing 250-270 g were divided into four groups, eight rats each. Group 1 served as untreated control, group 2 received an IP single dose of antioxidant cocktail (1 ml). Group 3 was exposed to a WBIR (6 Gy). Group 4 received antioxidant cocktail before WBIR. Rats from each group were killed after 48 h. MDA levels were measured in serum (TBARS assay). Johnsen's criteria and the number of germinal cell layers were used to categorize spermatogenesis. TUNEL assay was used to determine germ cell apoptosis. Statistical analysis was performed using one-way ANOVA test.

RESULTS

WBIR resulted in histological testicular damage (decrease in Johnsen's criteria, p < 0.05) that was accompanied by a significant increase in germ cell apoptosis, expressed as the number of apoptotic cells per 100 tubules (AI-1 apoptotic index) and the number of positive tubules per 100 tubules (AI-2 apoptotic index). Treatment with antioxidant cocktail resulted in a significant decrease in germ cell apoptosis (33% decrease in AI-1, p < 0.05 and 34% decrease in AI-2, p < 0.05) that was accompanied by an improved spermatogenesis (increase in Johnsen's criteria, p < 0.05).

CONCLUSIONS

In a rat model of WBIR, antioxidant treatment ameliorates oxidative stress-induced testicular damage, decreases germ cell apoptosis and improves spermatogenesis.

Intravesical Radiofrequency-Induced Chemohyperthermia for Carcinoma in Situ of the Urinary Bladder: A Retrospective Multicentre Study

Objective:

To examine the effect of intravesical radiofrequency-induced chemohyperthermia (RF-CHT) in carcinoma in-situ (CIS) patients overall and split according to previously received therapy.

Methods:

CIS patients that underwent an induction and maintenance phase of≥6 RF-CHT instillations, and had either pathology or cystoscopy plus cytology available at 6 months of follow-up were retrospectively included. Complete response (CR), recurrences, cystectomy-free rate, overall survival (OS), and adverse events were evaluated. Analysis was performed for overall, bacillus Calmette-Guérin (BCG)-unresponsive, other BCG-treated, and treatment naïve patients.

Results:

Patients (n = 150) had a mean of 17.5, 9.2, or 0 previous BCG instillations in the BCG-unresponsive (n = 50), other BCG-treated (n = 46, missing n = 4), and treatment naïve groups (n = 47, missing n = 3), respectively. After 6 months, a CR of 46.0%, 71.7%, and 83.0% was found (p < 0.001). Subsequent 2-year recurrence rates were 17.4%, 27.3%, and 12.8%, respectively. The overall cystectomy-free rate and OS at mean follow-up (35.8 months) were 78.5% and 78.0%, respectively. These were 71.4% vs. 84.1% vs. 86.7% (cystectomy-free rate, p = 0.006) and 76.0% vs. 69.6% vs. 87.2% (OS, p = 0.06) for BCG-unresponsive vs. other BCG-treated vs. treatment naïve patients. Progression to muscle-invasive disease was seen in 13.3% of patients. Patients stopped induction or maintenance RF-CHT instillations due to adverse events in respectively 13.4% and 17.8%.

Conclusions:

Intravesical RF-CHT showed good results in both treatment naïve and BCG-treated CIS patients, avoiding the need for cystectomy in 78.5% of cases for at least 3 years with a modest risk of progression. Thus, RF-CHT proves an alternative to cystectomy in selected high-risk patients.

Preoperative neutrophil to lymphocyte ratio improves recurrence prediction of non-muscle invasive bladder cancer

Background

This study aims to prospectively evaluate the ability of Neutrophil-to-Lymphocyte ratio (NLR) to forecast recurrence in patients with non-muscle invasive bladder cancer (NMIBC). This is a continuation of our two previous retrospective studies that indicated the NLR > 2.5 criterion as a predictor of recurrence in patients with NMIBC.

Methods

Since December 2013, all patients admitted to our department for TUR-BT and agreed to participate, had a blood drawn for cell count and differential 24 h prior to surgery. Patients with pathological NMIBC were followed prospectively for disease recurrence. The end-point of the follow up was either a cancer recurrence or the termination of the study. Univariate and multivariate Cox regressions were performed to assess the NLR > 2.5 predictive capability for recurrence, versus and in conjunction to the pathologically based EORTC score, among additional statistical analyses.

Results

The study cohort included 96 men and 17 women with a median age of 72 years. Sixty-four patients (56.6%) have had a recurrence during the study occurring at the median time of 9 months (IQR 6, 13), while the median follow-up time for patients without recurrence was 18 months (IQR 10, 29). Univariate Cox regressions for recurrence demonstrated significance for NLR > 2.5 for the whole cohort (p = 0.011, HR 2.015, CI 1.175–3.454) and for the BCG sub-group (p = 0.023, HR 3.7, CI 1.2–11.9), while the EORTC score demonstrated significance for the ‘No Treatment’ subgroup (p = 0.024, HR 1.278, CI 1.03–1.58). When analyzed together as a multivariate Cox model, the NLR > 2.5 and EORTC score retained their significance for the aforementioned groups, while also improving the EORTC score significance for the whole cohort.

Conclusion

NLR > 2.5 was found to be a significant predictor of disease recurrence and demonstrated high hazard ratio and worse recurrence-free survival in patients with NMIBC, especially in those treated with BCG. Additionally, our data demonstrated statistical evidence that NLR > 2.5 might have an improving effect on the EORTC score’s prediction when analyzed together.

Method Used for Tumor Bed Closure (Suture vs. Sealant), Ischemia Time and Duration of Surgery are Independent Predictors of Post-Nephron Sparing Surgery Acute Kidney Injury

INTRODUCTION

The aim of our study was to examine the influence of tumor complexity and operative variables on the degree and rate of post-nephron sparing surgery (NSS) acute kidney injury (AKI).

METHODS

We retrospectively reviewed the records of 477 patients who underwent NSS for enhancing renal masses in our institution. AKI was determined using the latest definition by AKIN and RIFLE criteria. Serum creatinine was assessed daily starting from day 1 post-surgery and until discharge (usually on postoperative day 3). Estimated glomerular filtration was determined using the Modification of Diet in Renal Disease equation.

RESULTS

Overall, 191 patients (40%) developed postoperative AKI, and most of them (88%) were grade 1. Multivariate analysis revealed that the most significant and independent variables associated with AKI were operation time (p = 0.02), ischemia time (p = 0.02), and the use of tissue adhesive for tumor bed closure (p = 0.02). Other important factors (by univariate analysis) were the need for blood transfusion (p = 0.003) and estimated blood loss (p = 0.007).

CONCLUSIONS

Operative time, ischemia, and tumor bed closure method are independent predictors of post-NSS AKI. Efforts should be made to limit prolonged ischemia and to reduce viable parenchymal loss. Further studies concerning the functional impact of AKI in these patients will be required.

The impact of comorbidities, sex and age on the occurrence of acute kidney injury among patients undergoing nephron-sparing surgery

Background

The aim of this study was to report the impact of patients' baseline characteristics on the incidence of acute kidney injury (AKI) after nephron-sparing surgery (NSS) for localized kidney cancer.

Patients and methods

Data from our kidney cancer database were retrospectively extracted to include 402 patients who underwent NSS between March 2000 and June 2016, and had sufficient data. Definition of AKI was based on the postoperative serum creatinine levels and estimated glomerular filtration rate (eGFR) magnitude, which were measured during the 72 h after surgery.

Results

Based on RIFLE and AKIN criteria, the overall rate of postoperative AKI was 35%. The average decrease in eGFR among patients who developed AKI was 20% as compared with the non-AKI subgroup (2%). In univariate analysis, variables that were associated with AKI included right-sided tumors (p = 0.014), male sex (p = 0.01), hypertension (p = 0.003), baseline eGFR (p = 0.009) and history of nephrolithiasis (p = 0.039). However, multivariate analysis revealed that the only independent predictors of postoperative AKI were hypertension (p = 0.009) and cigarette smoking (p = 0.024).

Conclusion

AKI is a common complication of NSS affecting about one-third of the patients. The most important risk factors are hypertension and smoking.

Heparanase 2 expression inversely correlates with bladder carcinoma grade and stage

While the pro-tumorigenic function of heparanase is well taken, the role of its close homolog, heparanase 2 (Hpa2) in cancer is by far less investigated. Utilizing immunohistochemical analysis we found that Hpa2 is expressed by normal bladder transitional epithelium and its levels are decreased substantially in bladder cancer. Notably, tumors that retain high levels of Hpa2 were diagnosed as low grade (p=0.001) and low stage (p=0.002), suggesting that Hpa2 is required to preserve cell differentiation and halt cell motility. Indeed, migration of 5637 bladder carcinoma cells was attenuated significantly by exogenous addition of purified Hpa2, and over expression of Hpa2 in 5637 cells resulted in smaller tumors that were diagnosed as low grade. We also noted that tumors produced by Hpa2 over expressing cells are abundantly decorated with stromal cells and collagen deposition evident by Masson's/Trichrome staining, correlating with a marked increase in lysyl oxidase (LOX) staining. The association between Hpa2 and LOX was further confirmed clinically, because of the 16 cases that exhibited strong staining of Hpa2, 14 (87.5%) were also stained strongly for LOX (p=0.05). Collectively, our results suggest that Hpa2 functions as a tumor suppressor in bladder cancer, maintaining cellular differentiation and decreasing cell motility in a manner that appears to be independent of regulating heparanase activity.

Oncologic Outcomes of Partial Nephrectomy for Stage T3a Renal Cell Cancer

BACKGROUND

Partial nephrectomy (PN) for clinical stage T3 tumors is controversial. Radical nephrectomy (RN) has been associated with a greater rate of chronic kidney disease, an increased risk of cardiovascular disease, and increased mortality compared with PN. We present our long-term 2-center experience with PN for stage pT3a tumors and compare the oncologic outcomes with those of similar patients treated with RN.

MATERIALS AND METHODS

We reviewed the data from all patients who had undergone nephrectomy for renal cell carcinoma from 1987 to 2015 in 2 medical centers. The study included 134 patients with pathologic stage T3a tumors, of whom 48 and 86 underwent PN and RN, respectively. We compared the 2 groups (PN and RN) using univariate and multivariate analyses.

RESULTS

The tumors of all patients with pathologic stage T3a who had undergone PN had been pathologically upstaged from clinical stage T1 or T2. Univariate and multivariate analyses revealed tumor size was significantly different statistically between the study groups (median, 7.0 cm in RN group vs. 4.0 cm in PN group; P < .001). Surgery type was not a predictor of local recurrence (P = .978), metastatic progression (P = .972), death from renal cancer (P = .626), or death from all causes (P = .974) at the 5-year follow-up point.

CONCLUSION

The results of the present study have shown similar oncologic outcomes between 48 patients with stage pT3a renal cancer who underwent PN and 86 patients who underwent RN. Although PN was not performed on clinical T3a tumors, our findings suggest that PN can also be considered for these tumors and, thus, avoid the long-term complications of RN. However, strict follow-up protocols are mandatory.

Allium Stents: A Novel Solution for the Management of Upper and Lower Urinary Tract Strictures

Stents are widely use in endoscopic urological procedures. One of the most important indications is the treatment of urinary tract strictures. Allium™ Medical has introduced several types of stents for the treatment of different types of urinary tract strictures, based on anatomic location. All the stents are made of nitinol and coated with a co-polymer that reduces encrustations. These stents are self-expandable and have a large caliber and a high radial force. They have different shapes, designed especially for the treatment of each type of stricture. One of the most important features of Allium-manufactured stents is the ease of removal, due to their special unraveling feature. The company has introduced the Bulbar Urethral Stent (BUS) for treatment of bulbar urethral strictures; a rounded stent available in different lengths. Initial data on 64 patients with bulbar urethral stricture treated with the BUS showed a significant improvement in symptoms, with minimal complications and few adverse events. For treatment of prostate obstruction in patients unfit for surgery or unwilling to undergo a classical prostatic surgery, the Triangular Prostatic Stent (TPS) was introduced, which has a triangular shape that fits in the prostatic urethra. Its body has a high radial force attached to an anchor (which prevents migration) through a trans-sphincteric wire (which reduces incontinence rate). Initial data on 51 patients showed significant improvement in symptoms and in urinary peak flow rate, with a relatively small number of complications. The Round Posterior Stent (RPS) was designed for treatment of post radical prostatectomy bladder neck contracture. This short, round stent has an anchor, which is placed in the bladder neck. This stent being relatively new, the clinical data are still limited. Ureteral strictures can be treated with the Ureteral Stent (URS), which is round-shaped, available in different lengths, and has an anchor option (for very distal or very proximal strictures). We have previously published data on 107 URSs inserted in patients with ureteral stricture due to several etiologies, including patients who failed previous treatment. All patients were asymptomatic for a long period of follow-up after stent removal, with only one case of re-stenosis. In this paper, we review the urological "covered" stents produced by Allium Medical with the relevant clinical data available at the present time.

The use of bovine serum albumin-glutaraldehyde tissue adhesive (BioGlue®) for tumor bed closure following open partial nephrectomy

OBJECTIVES

To report the results of the use of Bovine Serum Albumin-Glutaraldehyde tissue adhesive (BioGlue®) for tumor bed closure in open nephron-sparing surgery (NSS).

MATERIALS AND METHODS

The cohort included 255 patients with enhancing renal mass who underwent open NSS. We used open flank approach, with in-situ hypothermia and enucleation of the tumor. For tumor bed closure, we used the BioGlue^® sealant for tumor bed filling, without suturing the edges.

RESULTS

Mean patients' age was 65.4 years. 5.1% of patients had pre-operative chronic renal failure. Mean renal mass diameter was 4.2±1.6cm and mean R.E.N.A.L nephrometry score was 8.0±1.6. Mean ischemia time was 21.8±7.6. Mean estimated blood loss was 42±82ml and only two patients required blood transfusion. Urine leak and pseudo-aneurysm were recorded in two and one patient, respectively. None of the operations were converted to radical nephrectomy. The average change between post-operative and pre-operative eGFR (Δ=-1.7ml/min) was insignificant in a mean follow-up of 30.1±29.6 months. The 10-year recurrence-free survival rate was 99% and the 10-year overall survival rate was 85%.

CONCLUSIONS

The use of BioGlue^® alone for hemostasis after NSS is a feasible and safe alternative to classical suturing. Its use enables satisfactory functional outcome and could potentially reduce ischemia time.

Unraveling Antimicrobial Susceptibility of Bacterial Networks on Micropillar Architectures Using Intrinsic Phase-Shift Spectroscopy

With global antimicrobial resistance becoming increasingly detrimental to society, improving current clinical antimicrobial susceptibility testing (AST) is crucial to allow physicians to initiate appropriate antibiotic treatment as early as possible, reducing not only mortality rates but also the emergence of resistant pathogens. In this work, we tackle the main bottlenecks in clinical AST by designing biofunctionalized silicon micropillar arrays to provide both a preferable solid-liquid interface for bacteria networking and a simultaneous transducing element that monitors the response of bacteria when exposed to chosen antibiotics in real time. We harness the intrinsic ability of the micropillar architectures to relay optical phase-shift reflectometric interference spectroscopic measurements (referred to as PRISM) and employ it as a platform for culture-free, label-free phenotypic AST. The responses of E. coli to various concentrations of five clinically relevant antibiotics are optically tracked by PRISM, allowing for the minimum inhibitory concentration (MIC) values to be determined and compared to both standard broth microdilution testing and clinic-based automated AST system readouts. Capture of bacteria within these microtopologies, followed by incubation of the cells with the appropriate antibiotic solution, yields rapid determinations of antibiotic susceptibility. This platform not only provides accurate MIC determinations in a rapid manner (total assay time of 2-3 h versus 8 h with automated AST systems) but can also be employed as an advantageous method to differentiate bacteriostatic and bactericidal antibiotics.

Thermo reversible hydrogel based delivery of mitomycin C for treatment of upper tract urothelial carcinoma (UTUC)

e16089

Background: There is a large unmet need for novel drug delivery systems and effective therapy for UTUC, especially for patients with CKD and anatomic solitary kidneys. A temperature sensitive water-soluble gel formulation of Mitomycin C (MMC) demonstrated increased drug delivery time (4 to 6 hrs) and safety in the pelvicalyceal system of swine and human bladders. We report the efficacy and safety of gel+MMC as primary treatment (tx) of UTUC on a compassionate use basis. Methods: Compassionate use approval was obtained on an individual patient basis from the respective regulatory authorities and IRBs. 22 patients were approved for tx to date from 14 institutions in 4 countries. Tx included 6 weekly instillations instilled via ureteral catheter or percutaneous nephrostomy. Gel volume ranged from 5-20cc and MMC concentration was 2-6 mg/cc. Adverse events were recorded throughout treatment. Ureteroscopy was performed 2-6 weeks following tx completion for response determination. Results: Median age of the cohort was 75 yrs, with 15 males. 18 patients (pts) had low-grade (LG) tumor, 2 high-grade (HG), and 2 indeterminate grade. 16 (73%) completed treatment - 9 pts had a complete response, CR (41%; 59% of those who completed tx), 5 pts had a partial response, PR (23%; 31%), and 2 pts had no response, NR (9.1%, 12.5%). 4 patients could not complete tx due to adverse events (pyelonephritis, acute renal failure, pancytopenia, and unstable cardiac condition), 1 patient was diagnosed with a non-urothelial cancer during treatment, and 1 patient died prior to the third instillation due to suspected pulmonary embolus, determined to be unrelated to treatment with MitoGel. A total of 77 adverse events were recorded with 6 events related to MitoGel and serious (requiring intervention), and 21 events related to treatment and not serious. CR (9) and PR (5) were observed in 14 of 15 evaluable patients completing treatment for LG tumors. Conclusions: This compassionate use program of a thermosensitive gel+MMC for chemoablation of UTUC demonstrates proof of concept for treatment of low-grade tumors. A single arm Phase III multi-center registration trial to treat patients with low-grade renal pelvis tumors has been activated.

Bovine serum albumin-glutaraldehyde (BioGlue®) tissue adhesive versus standard renorrhaphy following renal mass enucleation: a retrospective comparison

BACKGROUND

To present the operative and post-operative comparison between patients who underwent tumor-bed closure with sutures compared with bovine serum albumin-glutaraldehyde (BioGlue^®) tissue sealant only.

METHODS

We retrospectively analyzed data from our ongoing database of 507 eligible patients who underwent open NSS nephron-sparing surgery in our department between January 1995 and May 2014. Patients had tumor-bed closure with sealant adhesive (255 patients) or standard suture technique (252 patients). Demographic, clinical and perioperative data were compared between the two groups, by Chi-square test or by Fisher-Irwin exact test for categorical variables, and by t test for differences in means or by Wilcoxon rank sum test for continuous variables. A multivariate analysis was also done.

RESULTS

Patients' baseline characteristics showed similar distribution of the analyzed parameters among both groups, with few differences: younger age in the sealant group (65.4 versus 68.4 years, p = 0.01) and slightly larger mass size in the suture group (4.0 versus 3.9 cm, p = 0.03). Ischemia time was significantly shorter in the sealant group (21.8 versus 27.0 minutes, p = 0001). Blood loss and transfusion rate (0.8% versus 11.9%, p = 0.0001) were significantly less in the sealant group. A multivariate analysis showed date of surgery and blood loss as the major parameters affecting transfusion rate.

CONCLUSIONS

Closing the tumor bed with BioGlue^® tissue adhesive is feasible, safe, can shorten ischemia time and potentially reduce transfusion rate.

Diagnosis and Classification of 17 Diseases from 1404 Subjects via Pattern Analysis of Exhaled Molecules

We report on an artificially intelligent nanoarray based on molecularly modified gold nanoparticles and a random network of single-walled carbon nanotubes for noninvasive diagnosis and classification of a number of diseases from exhaled breath. The performance of this artificially intelligent nanoarray was clinically assessed on breath samples collected from 1404 subjects having one of 17 different disease conditions included in the study or having no evidence of any disease (healthy controls). Blind experiments showed that 86% accuracy could be achieved with the artificially intelligent nanoarray, allowing both detection and discrimination between the different disease conditions examined. Analysis of the artificially intelligent nanoarray also showed that each disease has its own unique breathprint, and that the presence of one disease would not screen out others. Cluster analysis showed a reasonable classification power of diseases from the same categories. The effect of confounding clinical and environmental factors on the performance of the nanoarray did not significantly alter the obtained results. The diagnosis and classification power of the nanoarray was also validated by an independent analytical technique, i.e., gas chromatography linked with mass spectrometry. This analysis found that 13 exhaled chemical species, called volatile organic compounds, are associated with certain diseases, and the composition of this assembly of volatile organic compounds differs from one disease to another. Overall, these findings could contribute to one of the most important criteria for successful health intervention in the modern era, viz. easy-to-use, inexpensive (affordable), and miniaturized tools that could also be used for personalized screening, diagnosis, and follow-up of a number of diseases, which can clearly be extended by further development.

Update in urethral stents

Urethral stents were first introduced in 1988, and since then, they have undergone significant improvements. However, they did not gain a wide popularity and their use is limited to a small number of centers around the world. Urethral stents can be used in the entire urethra and for various and diverse indications. In the anterior urethra, it can be used to treat urethral strictures. In the prostatic urethra, they can be used for the treatment of prostatic obstruction, including benign, malignant and iatrogenic prostatic obstruction. Moreover, although not widely used, it can be also applied for the treatment of posterior urethral stricture and bladder neck contracture, usually resulting in urinary incontinence and the need for subsequent procedures. Our main experience are with Allium urethral stents, and as such, we provide the latest updates in urethral stents with special emphasis on the various types of Allium urethral stents: bulbar, prostatic and bladder neck stents.

[KIDNEY DISEASES IN NORTH ISRAEL ACCORDING TO KIDNEY BIOPSIES - BNAI-ZION MEDICAL CENTER 14 YEARS' EXPERIENCE]

INTRODUCTION

Little is known about the prevalence of kidney diseases according to renal biopsy in Israel. Since updated literature worldwide emphasizes changing etiologies of chronic kidney disease, it is crucial to research and define the epidemiology and pathology of kidney disease in Israel. Hereby, we introduce an original review of the prevalence of kidney diseases in our study population, which we believe reflects the prevalence of kidney diseases in the population of Israel.

AIMS

To investigate the prevalence of kidney diseases diagnosed by renal biopsy, according to age, gender, race and clinical symptoms.

METHODS

A total of 155 kidney biopsies were conducted in the years 2000-2014 in Bnai-Zion Medical Center in Haifa, according to formal accepted indications. Most of the biopsies (65%) were needle aspirations in a retroperitoneal approach, in which 90% were ultrasound guided and the rest computed tomography guided, while the other 35% of biopsies involved laparoscopic approaches.

RESULTS

The most common indications for kidney biopsy were nephrotic syndrome, nephritic syndrome and proteinuria (37.4%, 25.8% and 24.5%, respectively). Average glomeruli number per biopsy was 17.5 vs. 82.2 for needle aspiration and laparoscopic approach, respectively (statistically significant). The most common diagnosis was focal segmental glomerulosclerosis (FSGS), followed by chronic glomerulonephritis, IgA nephropathy, lupus nephritis, minimal change disease (MCD), membranous nephropathy and tubulointerstitial disease (20%, 11.5%, 11.5%, 10.1%, 9.5%, 8.1% and 6.1%, respectively).

CONCLUSIONS

FSGS was the most common diagnosis in patients presented with nephrotic syndrome or proteinuria, men, and patients above 60 years of age. Patients below 30 years of age were mainly diagnosed with IgA nephropathy.

DISCUSSION

In recent years, FSGS is becoming more prevalent compared with other chronic kidney disease especially in the older population. IgA nephropathy is still the most common diagnosis in young patients and in patients presented with hematuria. To the best of our knowledge, no data exists on the prevalence of kidney diseases in Israel, and our study is an important contribution to the epidemiological and clinical knowledge on the subject.

Successful Endovascular Control of Renal Artery in a Transplant Kidney During Nephron Sparing Surgery (NSS) for Large Centrally Located Tumor

Renal cell carcinoma in a transplant kidney is a rare condition. Nephron Sparing Surgery (NSS) is the treatment of choice. One of the main technical challenges is obtaining adequate vascular control. We present a rare case of large centrally located hillar tumor in a kidney 18 years after transplantation treated with NSS. Vascular control was achieved by using a novel approach. Post-operative course was uneventful with minimal decrease in renal function. We believe that this unique choice of treatment can be used in cases of NSS where the access to the renal pedicle is limited.

Nephron Sparing Surgery for Renal Mass: Is There Any Difference between Oncocytoma and Malignant Lesions

INTRODUCTION

A relatively high proportion of patients who undergo partial or radical nephrectomy for enhancing renal mass actually have oncocytoma, a benign renal tumor. Several parameters have been shown to be typical for oncocytoma, but only a small number of patients present with these parameters. The aim of our study was to report the clinical, operative and postoperative characteristics of patients who underwent nephron-sparing surgery in our center with a histopathological diagnosis of oncocytoma compared to patients with malignant renal tumor.

PATIENTS AND METHODS

Sixty-three out of 530 patients who underwent nephron-sparing surgery for enhancing renal mass were diagnosed with oncocytoma. Clinical and radiological features and operational data of these patients were compared with patients who had malignant renal tumors.

RESULTS

Mean age of patients with histologically proven non-malignant oncocytoma was significantly higher than that in patients with malignant renal cell carcinoma (66.7 vs. 61.4 years). All other analyzed variables showed no significant difference between the 2 groups.

CONCLUSIONS

No reliable clinical, operative or radiological parameters can differentiate preoperatively between oncocytoma and malignant renal neoplasms.

[INTERMEDIATE-TERM FOLLOW-UP OF PATIENTS UNDERGOING ACTIVE SURVEILLANCE FOR SMALL RENAL MASS: INDICATIONS FOR SURGICAL INTERVENTION]

INTRODUCTION

The increase in the use of imaging studies led to an increase in the diagnosis of small renal masses. However, most of the small renal masses are asymptomatic, grow slowly, and will not metastasize due to their relative benign biology. We still cannot differentiate malignant from benign masses using imaging studies, hence there is a dilemma between excision and follow-up.

OBJECTIVE

To report our intermediate-term results of active surveillance in patients with small renal masses in our urology department at the Bnai-Zion Medical Center.

PATIENTS AND METHODS

Retrospective analysis of 70 patients diagnosed at our department with renal mass < 4cm in its maximal diameter between 2003 and 2012. The maximal diameter of the masses at diagnosis was measured using computed tomography and diameter was recorded during follow-up.

RESULTS

Seventy patients with 78 small renal masses met the inclusion criteria. Mean age at diagnosis was 68 years. The mean folow-up period was 34 months; 54 of 78 masses grew in size, of them 8 were excised. All patients who had surgery had a nephron-sparing procedure. The growth rate and the size at diagnosis were both higher in the group of patients who underwent surgery.

CONCLUSION

Most of the small renal masses can be managed safely by active surveillance.

DISCUSSION

Only 4% of the masses were upstaged, and none to stage > 2. None of the patients developed metastasis or died from renal cancer during the follow-up period.

SUMMARY

Active surveillance is a safe and reliable option for some patients with small renal mass.

[MULTICENTER EXPERIENCE WITH ALLIUM URETERAL STENT FOR THE TREATMENT OF URETERAL STRICTURE AND FISTULA]

INTRODUCTION

Chronic ureteral stricture and ureteral fistula are treated with urinary diversion using percutaneous nephrostomy or double pigtail stent. Both of these techniques require replacement of the tube every few months in order to prevent encrustations and obstruction.

OBJECTIVES

To report the long-term efficacy of the new Allium Ureteral Stent (URS) in the treatment of ureteral stricture and fistula.

METHODS

The Allium URS is a newly-developed ureteral stent made of nickel-titanium (Nitinol), which is inserted in a small diameter and spontaneously expands into and preserves a large-caliber. The stent is coated with a biochemical co-polymer which prevents tissue ingrowth and incrustations. The stent is inserted antegradely or retrogradely with intraoperative x-ray guidance after dilation of the stricture. The Allium URS stent was inserted into 107 ureters of 92 patients in 5 different centers worldwide; 69 patients carried a percutaneous nephrostomy before the procedure and 38 patients had a ureteral stent. The etiologies underlying the strictures were: gynecological cancer (with or without irradiation), bladder cancer, iatrogenic stricture, ureteroileal stenosis, stricture following uretero-pelvic junction obstruction repair and iatrogenic ureteral fistula.

RESULTS

During a mean follow-up of 27 months, only one stent was obstructed after eleven-indwelling months; 21 patients died of their primary disease carrying the stent. Stent migration was seen in 11 patients within 8 months after its insertion, and these stents were removed. In 4 patients with early stent migration, the stents were replaced. In 18 patients the stents were removed as planned after one year of indwelling time, and these patients were asymptomatic in a follow-up period of up to 59 months.

CONCLUSION

The results of our study show that the use of Allium URS for the treatment of ureteral strictures is feasible, safe and effective. The relative ease of its insertion could encourage its use in a wide range of other indications.

DISCUSSION

Due to its unique structure, the Allium URS is superior to the regular pigtail stents in the treatment of ureteral strictures. Stent migration was seen in only 10.7% of the patients, mainly in patients with stricture of the mid-ureter.

SUMMARY

The use of the Allium URS stent in the treatment of proximal and distaL ureteral strictures is safe and effective.

The role of hyperthermia as a treatment for non-muscle invasive bladder cancer

Non-muscle invasive bladder cancer (NMIBC) has a high tendency for recurrence and progression. Currently, all known intravesical agents are associated with adverse effects (AEs) and limited efficacy. The combination of hyperthermia (HT) with intravesical Mitomycin C (MMC) chemotherapy has been shown to improve outcomes. The added efficacy of HT to MMC was first shown in preclinical studies. The reports on patients with NMIBC have indicated that the treatment is safe and well tolerated. Several clinical studies reported the efficacy of radiofrequency-induced chemotherapy effect (RITE) in the treatment of patients with NMIBC. This modality was shown to be superior to MMC alone. RITE was effective also in patients with high-risk NMIBC, including those who failed Bacillus Calmette-Guérin (BCG). This study provides an updated review of literature regarding the use of RITE in patients with NMIBC.

Allium™ TPS--A New Prostatic Stent for the Treatment of Patients with Benign Prostatic Obstruction: The First Report

INTRODUCTION

Several prostatic stents were developed in the last three decades, none of which were able to provide a real alternative in patients unfit or unwilling to undergo classical prostatic surgeries. In this study, we report the results of the use of a newly developed prostatic stent--the Allium™ Triangular Prostatic Stent (TPS).

PATIENTS AND METHODS

The Allium TPS is a highly flexible, nitinol-built polymer-covered stent, which prevents tissue ingrowth and reduces encrustations. Between 2008 and 2014, at two centers (Israel and Turkey), the stent was inserted under local or regional anesthesia in 51 patients with benign prostatic obstruction (BPO) who are unwilling or unfit for surgery. Patients were followed for 12 months from surgery. The primary outcome was symptom improvement as measured by the international prostate symptom score (IPSS) and improvement in peak urinary flow.

RESULTS

Stent insertion was successful in all patients. The mean IPSS decreased from 26.4 to 7.7 on the last follow-up. The mean peak flow increased from 5.5 mL/second before stent insertion to 16.0 mL/second 1 year thereafter. The main adverse effect was transient pain in nine patients. No stent migration or obstruction was seen. Patients reported satisfaction and improvement in quality of life.

CONCLUSION

Our short-term results show that Allium TPS is safe and effective for the treatment of patients with BPO.

Endothelial Function Assessment in Patients with Erectile Dysfunction

BACKGROUND

Erectile dysfunction (ED), a common problem in males of all ages, can be of organic, psychogenic or combined etiology. Organic ED is mainly caused by vascular and neurological disorders. One of the available tests for differentiating organic from inorganic ED is measuring penile tumescence and rigidity during the REM phase of sleep. However, this test lacks the ability to differentiate between a vascular and non-vascular cause of organic ED.

OBJECTIVES

To compare the results of the EndoPAT test and the nocturnal penile tumescence (NPT) test in patients with erectile dysfunction.

METHODS

Twenty patients with ED were recruited for the study. Each participant was evaluated by the SHIM score, RigiScan during polysomnography, and two EndoPAT tests (at the beginning and end of the study).

RESULTS

Seventeen patients had a SHIM score 21; 4 of them had organic ED with a mean EndoPAT score of 1.49, significantly lower than the 1.93 mean EndoPAT score of the 11 patients in the psychogenic ED group (P = 0.047). Two participants had a neurological impairment (spinal trauma and herniated disk). The average SHIM score in the vascular organic group was 6.25 points as compared to 11.69 for the psychogenic group (P = 0.027). The positive predictive value was 43% and the negative predictive value 90%.

CONCLUSIONS

EndoPAT could be helpful in excluding organic ED.

A new self-expanding, large-caliber ureteral stent: results of a multicenter experience

BACKGROUND AND PURPOSE

Ureteral strictures (US) can be a recurrent chronic illness that leads to severe side effects and poor quality of life. Several options to treat US exist, including repeated dilations, stents, minimally invasive reconstructive surgeries, and urinary diversion or nephrectomy. Placement of an ureteral stent is a good minimally invasive option but has major limitations, such as stent migration, mucosal in-growth, incrustations, and stent obstruction. Our study aim was to evaluate the safety and the efficacy of a new self-expanding, large caliber ureteral stent (Allium(®)).

PATIENTS AND METHODS

During 2005 to 2011, 49 stents were inserted in 49 renal units (40 patients) for a mean indwelling time of 17 months (range 1-63 mos).

RESULTS

Migration was observed in seven (14.2%) patients, mandating stent removal. Only one stent was occluded. In eight renal units, the stents were removed as scheduled, and no reobstruction was detected during follow-up. Twenty-eight patients currently have a patent stent.

CONCLUSIONS

The Allium stent provides an attractive solution for long-term internal ureteral drainage. Its design allows good anchoring, prevents intraluminal ingrowth, and has the ability of rapid disintegration for extremely easy removal.

Predicting progression of bladder urothelial carcinoma using microRNA expression

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Recurrence and progression prediction in urothelial cancer is currently based on clinical and pathological factors: tumour grade, tumour stage, number of lesions, tumour size, previous recurrence rate, and presence of concomitant carcinoma in situ. These factors are not specific enough to predict progression and ∼50% of patients diagnosed as high risk in fact do not progress within 3 years. Patient follow-up is both expensive and unpleasant (frequent invasive cystoscopies). Molecular biomarkers, including microRNAs have been studied to provide additional prognostic information for these patients, but to date no molecular biomarker has become the 'gold standard' for patient diagnosis and follow-up. We used Rosetta Genomics' highly specific microRNA expression profiling platforms to study the prognostic role of microRNAs in bladder cancer. Using microdissection we chose specific tumour microRNAs to study in order to avoid background contamination. Tumour progression was associated with altered levels of microRNAs. In particular, high expression levels of miR-29c* were associated with a good prognosis. The study found that the use of microRNAs for determining progression and invasiveness for patients with urothelial cancer could potentially have a substantial impact on the treatment and follow-up individual patients.

OBJECTIVE

To identify microRNAs that could be useful as prognostic markers for non-muscle-invasive (NMI) bladder carcinoma.

PATIENTS AND METHODS

Formalin-fixed, paraffin-embedded samples of 108 NMI bladder carcinomas, and 29 carcinomas invading bladder muscle were collected, and microRNA expression levels were measured using microarrays. For 19 samples, microdissection was performed to compare microRNA expression between the tumour and surrounding tissue. MicroRNAs that were found to be unrelated to the tumour itself were excluded as potential prognostic markers.

RESULTS

Expression profiles identified microRNAs that were differentially expressed in NMI tumours from patients who later progressed to carcinoma invading bladder muscle compared with NMI tumours from patients that did not progress. The microRNA profile of tumours invading the bladder muscle was more similar to that of NMI tumours from patients who later progressed, than to that of the same-stage NMI tumours from patients who did not later progress. The expression level of one microRNA, miR-29c*, was significantly under-expressed in tumours that progressed and could be used to stratify patients with T1 disease into risk groups.

CONCLUSIONS

MicroRNAs can be useful biomarkers for prognosis in patients with urothelial carcinoma. In our study, expression levels of several microRNAs, including miR-29c* identified high- and low-risk groups. These biomarkers show promise for the stratification of patients with bladder cancer.

Methotrexate induces germ cell apoptosis and impairs spermatogenesis in a rat

PURPOSE

The primary toxic effects of methotrexate (MTX) are myelosuppression and/or intestinal mucositis. The objective of the present study is to investigate the effect of MTX on germ cell apoptosis and spermatogenesis in a rat.

METHODS

Male Sprague-Dawley rats were divided into three experimental groups: control rats treated with vehicle; MTX-2 rats treated with one dose (20 μg/kg) of MTX given IP and killed on the second day; and MTX rats treated with IP MTX (20 μg/kg) and killed on day 4. Johnsen's criteria and the number of germinal cell layers in the testes were used to categorize the spermatogenesis. TUNEL assay was used to determine germ cell apoptosis. Western blotting was used to determine Bax and Bcl-2 protein levels. Statistical analysis was performed using the non-parametric Kruskal-Wallis ANOVA test, with p less than 0.05 considered statistically significant.

RESULTS

On day 2, MTX-treated animals demonstrated minimal changes in the histological parameters of spermatogenesis, but germ cell apoptosis increased significantly (threefold increase, p = 0.002) compared to control rats. On day 4, MTX-treated rats demonstrated a trend toward a decrease in germ cell apoptosis, compared to day 2, and showed histological signs of impaired spermatogenesis (decreased number of germ cell layers and Johnsen's criteria). A significant increase in cell apoptosis in MTX-treated rats was correlated with higher Bax/Bcl-2 protein levels.

CONCLUSIONS

MTX induced germ cell apoptosis and impaired spermatogenesis in rat testes.

Phosphodiesterase-5 inhibition attenuates early renal ischemia-reperfusion-induced acute kidney injury: assessment by quantitative measurement of urinary NGAL and KIM-1

Acute kidney injury (AKI) is a common clinical problem that still lacks effective treatment. Phosphodiesterase-5 (PDE5) inhibitors possess anti-apoptotic and anti-oxidant properties, making it a promising therapy for ischemia-reperfusion (I/R) injury of various organs. The present study evaluated the early nephroprotective effects of Tadalafil, a PDE5 inhibitor, in an experimental model of renal I/R. Sprague-Dawley rats were divided into two groups: vehicle-treated I/R (n = 10), and Tadalafil (10 mg/kg po)-treated I/R group (n = 11). After removal of the right kidney and collection of two baseline urine samples, the left renal artery was clamped for 45 min followed by reperfusion for 60, 120, 180, and 240 min. Functional and histological parameters of the kidneys from the various groups were determined. In the vehicle-treated I/R group, glomerular filtration rate was significantly reduced compared with that in normal kidneys. In addition, the ischemic kidney showed remarkable cast formation, necrosis, and congestion, a consistent pattern of acute tubular necrosis. Furthermore, urinary excretion of NGAL and KIM-1, two novel biomarkers of kidney injury, substantially increased following I/R insult. In contrast, Tadalafil treatment resulted in a significant improvement in kidney function and amelioration of the adverse histological alterations of the ischemic kidney. Noteworthy, the urinary excretion of NGAL and KIM-1 markedly decreased in the Tadalafil-treated I/R group. These findings demonstrate that Tadalafil possesses early nephroprotective effects in rat kidneys subjected to I/R insult. This approach may suggest a prophylactic therapy for patients with ischemic AKI.

Safety and hemostatic efficacy of fibrin pad in partial nephrectomy: results of an open-label phase I and a randomized, standard-of-care-controlled phase I/II study

Background

Bleeding severity, anatomic location, tissue characteristics, and visibility are common challenges encountered while managing intraoperative bleeding, and conventional hemostatic measures (suture, ligature, and cautery) may sometimes be ineffective or impractical. While topical absorbable hemostats (TAH) are useful hemostatic adjuvants, each TAH has associated disadvantages.

Methods

We evaluated the safety and hemostatic efficacy of a new advanced biologic combination product―fibrin pad―to potentially address some gaps associated with TAHs. Fibrin pad was assessed as adjunctive hemostat in open partial nephrectomy in single-center, open-label, Phase I study (N = 10), and as primary hemostat in multicenter, single-blind, randomized, standard-of-care (SOC)-controlled Phase I/II study (N = 7) in Israel. It was used to control mild-to-moderate bleeding in Phase I and also spurting arterial bleeding in Phase I/II study. Phase I study assessed safety and Phase I/II study, proportion of successes at 10 min following randomization, analyzed by Fisher exact tests at 5% significance level.

Results

Phase I (N = 10): All patients completed the study. Hemostasis was achieved within 3–4 min (average = 3.1 min) of a single application in all patients. Fibrin pad was found to be safe for human use, with no product-related adverse events reported. Phase I/II (N = 7): Hemostatic success at 10 min (primary endpoint) was achieved in 3/4 patients treated with fibrin pad versus 0/3 patients treated with SOC. No clinically significant change in laboratory or coagulation parameters was recorded, except a case of post-procedural hemorrhage with fibrin pad, which was considered serious and related to the fibrin pad treatment, and required re-operation. Although Data Safety Monitoring Board authorized trial continuation, the sponsor decided against proceeding toward an indication for primary treatment of severe arterial hemorrhage as a replacement for sutures. The study was suspended after 7/30 planned subjects were enrolled.

Conclusions

The first-in-man trial of fibrin pad demonstrated its safety and efficacy as an adjunctive hemostatic technique for mild-to-moderate bleeding in partial nephrectomy. The study also suggested that the product should not replace sutures or meticulous surgical techniques for the treatment of severe arterial hemorrhage.

Trial registration

Phase I/II trial, NCT00598130

Detection of prostate cancer by radio-frequency near-field spectroscopy in radical prostatectomy ex vivo specimens

BACKGROUND

The aim of radical prostatectomy (RP) is the complete removal of the prostate gland with negative surgical margins. The presence of cancer at the surgical margin is associated with higher probability of disease progression. Current methods of intraoperative margin assessment are inaccurate or time-consuming.The study goal was to evaluate the ability of a novel device (Dune Medical Devices) to differentiate between cancer and BPH.

METHODS

A total of 49 patients undergoing RP in four medical centers between November 2007 and May 2008 were enrolled in this study.The device was applied to numerous intra- and extra-capsular sites of freshly excised RP specimens. Measurement sites were accurately marked and analyzed histologically. The ability of the device to differentiate between malignant and nonmalignant sites was assessed.

RESULTS

A total of 15,156 measurements from 45 patients were analyzed. Differentiation of the intra-capsular malignant sites from extra-capsular nonmalignant sites (bladder neck and apex regions) depends on the cancer feature size. Differentiation was achieved with sensitivity and specificity of 93.6 (95% confidence interval (CI): 88-98) and 94.1 (95% CI: 93-95), respectively, at feature sizes at or >0.8 mm in diameter. The device was able to discriminate between all intra-capsular malignant (with feature sizes down to a few cells) and nonmalignant measurement sites, with sensitivity and specificity of 80.8 (95% CI: 73-87) and 68.4 (95% CI: 67-69), respectively.

CONCLUSIONS

First results from a radio-frequency near-field spectroscopy sensor look promising for differentiation between cancer and benign prostate tissue. The sensor's dimensions (radius of ~ 1 mm) and design enable use in open, laparoscopic and robotic RP to evaluate the surgical margins intraoperatively.

10-year single-center experience of combined intravesical chemohyperthermia for nonmuscle invasive bladder cancer

Aim: Owing to the limited efficacy and significant toxicity of most topical intravesical agents for the management of nonmuscle invasive bladder cancer (NMIBC), a search for new therapeutic modalities continues. This study evaluates the safety and efficacy of a relatively new modality, combined intravesical chemotherapy and hyperthermia, using the intravesical chemohyperthermia system. Methods: The data summarize our 10 years of experience in the Department of Urology at Bnai Zion Medical Center, Israel. Ninety two patients with NMIBC (88 evaluable) were treated according to the adjuvant (66 patients) and the neoadjuvant (26 patients) protocols, with up to 7 years follow-up. Results: Over the follow-up period, 56 out of 64 patients (72%) treated according to the adjuvant protocol remained free from recurrences. The progression rate was 4.7% (three out of 64 patients). An initial complete response was documented in 19 out of 24 patients (79%) treated according to the neoadjuvant protocol. During the follow-up period, 16 out of these 19 patients (84%) remained free from recurrences. All of the recurrences in this group had stage Ta grade 1 tumors. Conclusion: Microwave-induced chemohyperthermia is a safe and effective treatment option for patients with NMIBC, both in the adjuvant and neoadjuvant settings. The use of this treatment modality did not expose the patients to an increased risk of progression.

Predictors and mechanisms of oncological failure following nephron-sparing surgery for renal cancer

BACKGROUND

One of the major concerns in performing nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) is the risk of tumor recurrence.

OBJECTIVES

To assess the rate, predictors and mechanisms of oncological failure in patients after NSS for renal cancer.

METHODS

Between 1993 and 2008 NSS was performed in 229 patients via flank incision. Only patients without metastases at diagnosis and minimal 12 months follow-up were included in the outcome analysis.

RESULTS

During a mean follow-up of 45 +/- 34 months (range 6-168 months) tumor recurrence was observed in 13 patients (5.6%). Mean follow-up time for detection of oncological failure was 51 months (range 6-132 months). All patients with oncological failure were males, with a mean age of 61 years (median 58, range 51-74 years). The average size of the enucleated lesion was 5 cm (range 4-7 cm). Intraoperative frozen sections as well as postoperative final pathological examination of the surgical margins were negative in all recurrent cases. Mechanisms of recurrence were distant metastases (n=4), surgical scar implantation (n=2), perirenal fat recurrence (n=2), local renal recurrence at the surgical site (n=1), and new renal lesions (n=4). Predictors of oncological failure included warm ischemia time (P = 0.058), tumor size (P = 0.001), tumor location (central versus peripheral) (P = 0.015), and multifocality (P = 0.001).

CONCLUSIONS

Distant dissemination, seeding during surgery, residual disease and new growth are the mechanisms responsible for cancer relapse. Large central lesions, long warm ischemia time and multifocality were significant predictors of oncological failure.