The consequences of partial nephrectomy (PN) compared to radical nephrectomy (RN) are less documented in patients with pre-existing chronic kidney disease (CKD) or with solitary kidney (SK). We ...assessed renal outcomes, and their determinants, after PN or RN in a retrospective cohort of patients with moderate-to-severe CKD (RN-CKD and PN-CKD) or SK (PN-SK). All surgical procedures conducted between 2013 and 2018 in our institution in patients with pre-operative estimated glomerular filtration rate (eGFR)<60 mL/min/1.73m2 or with SK were included. The primary outcome was a composite criterion including CKD progression or major adverse cardio-vascular events (MACE) or death, assessed one year after surgery. Predictors of the primary outcome were determined using multivariate analyses. A total of 173 procedures were included (67 RN, and 106 PN including 27 SK patients). Patients undergoing RN were older, with larger tumors. Preoperative eGFR was not significantly different between the groups. One year after surgery, PN-CKD was associated with lower rate of the primary outcome compared to RN-CKD (43% vs 71% p = 0.007). In multivariate analysis, independent risk factors for the primary outcome were postoperative AKI (stage 1 to stage 3 ranging from OR = 8.68, 95% CI 3.23-23.33, to OR = 28.87, 95% CI 4.77-167.61), larger tumor size (OR = 1.21 per cm, 95% CI 1.02-1.45), while preoperative eGFR, age, sex, diabetes mellitus, and hypertension were not. Postoperative AKI after PN or RN was the major independent determinant of worse outcomes (CKD progression, MACE, or death) one year after surgery.
Objective To evaluate predictive radiological elements for adherent perinephric fat (APF) and the Mayo adhesive probability (MAP) score in the setting of open partial nephrectomy, and to assess their ...reproducibility. Patients and Methods We performed a retrospective case-control study involving 86 patients who had open partial nephrectomies performed by a single surgeon between January 1, 2009 and April 1, 2015. Radiological elements were assessed by 4 readers blinded to patient APF status. Univariate and multivariate analyses were performed for all radiological and clinical factors. Reproducibility was analyzed using agreement coefficients. Results On univariate analysis for radiological findings, lateral and posterior fat thickness (odds ratio OR: 1.084 1.033, 1.138, P < .001), stranding (OR: 2.179 1.431, 3.318, P < .001), −80 HU fat area, and the MAP score (OR: 1.797 1.332, 2.424, P < .001) were predictive of APF. On multivariate analysis, only age and the MAP score remained statistically significant (OR: 1.060 1.005, 1.118, P = .03; and OR: 1.560 1.137, 2.139, P = .0058, respectively). The reproducibility of the MAP score was fair (AC1 = 0.367 and kappa F = 0.353), as was that of stranding (AC1 = 0.499, kappa F = 0.376). The agreement was important if we defined a “low” (0 to 3) or “high” (4 or 5) score (AC1 = 0.706 and kappa F = 0.681). Conclusion The MAP score was the element that best predicted APF in our study, although its reproducibility among our readers was only fair. The agreement becomes important if we defined “low or high” score.
The prostate cancer 3 (PCA3) gene was discovered in 1999, on the basis of differential expression between cancer and noncancerous prostate tissue. Including the first study published in 2003, 11 ...clinical studies have evaluated its utility for the diagnosis of prostate cancer by measuring the number of PCA3 RNA copies in urine enriched with prostate cells. Although the sensitivity of the PCA3 test was less than that of serum prostate-specific antigen (PSA), its specificity appeared to be much better, particularly in patients with a previous negative biopsy. Recent studies also have suggested that this test could be used to predict cancer prognosis.
While now recognized as an aid to predict repeat prostate biopsy outcome, the urinary PCA3 (prostate cancer gene 3) test has also been recently advocated to predict initial biopsy results. The ...objective is to evaluate the performance of the PCA3 test in predicting results of initial prostate biopsies and to determine whether its incorporation into specific nomograms reinforces its diagnostic value. A prospective study included 601 consecutive patients addressed for initial prostate biopsy. The PCA3 test was performed before ≥12-core initial prostate biopsy, along with standard risk factor assessment. Diagnostic performance of the PCA3 test was evaluated. The three available nomograms (Hansen's and Chun's nomograms, as well as the updated Prostate Cancer Prevention Trial risk calculator; PCPT) were applied to the cohort, and their predictive accuracies were assessed in terms of biopsy outcome: the presence of any prostate cancer (PCa) and high-grade prostate cancer (HGPCa). The PCA3 score provided significant predictive accuracy. While the PCPT risk calculator appeared less accurate; both Chun's and Hansen's nomograms provided good calibration and high net benefit on decision curve analyses. When applying nomogram-derived PCa probability thresholds ≤30%, ≤6% of HGPCa would have been missed, while avoiding up to 48% of unnecessary biopsies. The urinary PCA3 test and PCA3-incorporating nomograms can be considered as reliable tools to aid in the initial biopsy decision.
It has been suggested that urinary PCA3 and TMPRSS2:ERG fusion tests and serum PHI correlate to cancer aggressiveness-related pathological criteria at prostatectomy. To evaluate and compare their ...ability in predicting prostate cancer aggressiveness, PHI and urinary PCA3 and TMPRSS2:ERG (T2) scores were assessed in 154 patients who underwent radical prostatectomy for biopsy-proven prostate cancer. Univariate and multivariate analyses using logistic regression and decision curve analyses were performed. All three markers were predictors of a tumor volume≥0.5 mL. Only PHI predicted Gleason score≥7. T2 score and PHI were both independent predictors of extracapsular extension(≥pT3), while multifocality was only predicted by PCA3 score. Moreover, when compared to a base model (age, digital rectal examination, serum PSA, and Gleason sum at biopsy), the addition of both PCA3 score and PHI to the base model induced a significant increase (+12%) when predicting tumor volume>0.5 mL. PHI and urinary PCA3 and T2 scores can be considered as complementary predictors of cancer aggressiveness at prostatectomy.
Renal cell carcinoma (RCC) is most often diagnosed at a localized stage, where surgery is the standard of care. Existing prognostic scores provide moderate predictive performance, leading to ...challenges in establishing follow-up recommendations after surgery and in selecting patients who could benefit from adjuvant therapy. In this study, we developed a model for individual postoperative disease-free survival (DFS) prediction using machine learning (ML) on real-world prospective data. Using the French kidney cancer research network database, UroCCR, we analyzed a cohort of surgically treated RCC patients. Participating sites were randomly assigned to either the training or testing cohort, and several ML models were trained on the training dataset. The predictive performance of the best ML model was then evaluated on the test dataset and compared with the usual risk scores. In total, 3372 patients were included, with a median follow-up of 30 months. The best results in predicting DFS were achieved using Cox PH models that included 24 variables, resulting in an iAUC of 0.81 IC95% 0.77-0.85. The ML model surpassed the predictive performance of the most commonly used risk scores while handling incomplete data in predictors. Lastly, patients were stratified into four prognostic groups with good discrimination (iAUC = 0.79 IC95% 0.74-0.83). Our study suggests that applying ML to real-world prospective data from patients undergoing surgery for localized or locally advanced RCC can provide accurate individual DFS prediction, outperforming traditional prognostic scores.
Abstract Background Limited data on patterns of recurrence (local or metastatic) after salvage radical prostatectomy (SP) is available. Objective To examine biochemical, local and metastatic patterns ...of recurrence in patients undergoing SP for radiation-recurrent prostate cancer. Design, setting, and participants 146 patients with biopsy-proven local recurrence of prostate cancer after radiation therapy treated with SP were evaluated in a retrospective study at a single institution. Intervention All patients underwent SP by mainly two surgeons. Measurements Biochemical recurrence (BCR) after SP was defined as a serum prostate-specific antigen (PSA) level of ≥0.2 ng/ml or was defined by the initiation of androgen deprivation therapy. All predictors analyzed were determined after radiotherapy, before SP, and included PSA level, clinical stage, biopsy Gleason score, age at SP, and time interval from radiotherapy to SP. Results and limitations Of the 146 patients treated with SP, 65 developed BCR. The median follow-up period for recurrence-free patients was 3.8 yr; 43 patients (29%) were followed for >5 yr. Overall, the 5-yr recurrence-free probability was 54% (95% CI, 44–63%). Clinical local recurrence occurred in only one patient who also had bone metastases. Overall, there were 16 prostate cancer–specific deaths and 19 deaths from other causes. The 5-yr cumulative incidence of death from prostate cancer was 4% (95% CI, 2–11%). Pre-SP serum PSA level and biopsy Gleason score were significantly associated with death due to prostate cancer ( p < 0.0005 and p = 0.002, respectively). This study is retrospective and included carefully selected patients treated over a long period by, mainly, two experienced surgeons. Conclusions SP provides excellent local cancer control; only one patient in our series experienced a clinical local recurrence. Earlier identification of patients with persistent, viable local cancer despite radiation therapy will appropriately select patients for SP.
Study Type – Therapy (case series)
Level of Evidence 4
OBJECTIVE
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To assess, in a risk/benefit analysis, the additional risk for complications and benefits of extending the indications and ...anatomical limits of pelvic lymph node dissection (PLND).
PATIENTS AND METHODS
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In total, 971 consecutive patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy from 2003–2007.
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Before 1 February 2005, patients with a nomogram probability of lymph node invasion (LNI) <2% did not undergo PLND (No PLND group), whereas those with a LNI ≥2% had a PLND limited to the external iliac nodal group (limited PLND group).
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After 1 February 2005, all patients underwent a standard PLND including the external iliac, hypogastric and obturator fossa nodal groups (standard PLND group).
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The risk parameters were PLND‐related complications and operating time. Complications were graded using a modified Clavien classification. The benefit was the detection of nodal metastases.
RESULTS
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In the subgroup of patients with a LNI ≥2%, standard PLND was a superior operation than the limited PLND in detecting nodal metastases (14.3% vs 4.5%, respectively; P = 0.003).
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The risk/benefit of standard vs limited PLND would be one additional grade 3 complication per 20 additional patients with nodal metastases. In the subgroup of patients with LNI <2%, three patients (1.0%) had positive nodes after a standard PLND.
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The risk/benefit of standard PLND vs no PLND would be one additional grade 3 complication per three or four additional patients with nodal metastasis. The no PLND group was associated with the lowest risk of grade 1, 2 and 3 complications compared to either the limited or standard PLND groups (P < 0.001).
CONCLUSIONS
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In patients with LNI ≥2%, standard PLND detects more nodal metastasis. PLND is associated with higher but non‐prohibitive complications rate.
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The present study found no evidence that the incidence of complications would be reduced by a limited PLND.
The ZSI 475FtM is a new prosthesis that has recently been specifically designed for phalloplasty. It has several functions that have been conceived to answer the challenges of implantation after ...phalloplasty: a large base for pubic bone fixation, realistically shaped hard glans, and a pump shaped like a testicle.
To assess the safety, feasibility, and patient satisfaction of the ZSI 475 FtM.
Surgical outcomes were analyzed after implantation of the prosthesis between June 2016 and September 2017 (single institution, single surgeon). Patients were then asked to answer a satisfaction questionnaire that included the International Index of Erectile Function-5, Erectile Dysfunction Inventory of Treatment Satisfaction, and Self-Esteem and Relationship, as well as other non-validated questions.
Complication rates and the scores of the different questionnaires were reviewed.
20 patients who had gender dysphoria and underwent operation for a female-to-male procedure were included. The mean age was 37.9 years. Complications after 21 implantations included 2 (9.5%) infections that were medically treated (Clavien II), 1 (4.7%) infection treated by explantation (Clavien IIIb), 2 (9.5%) mechanical failures (Clavien IIIb), and 1 (4.7%) malpositioning (Clavien IIIb). The mean follow-up was 8.9 months (SD 4.0), with 50% of the implanted patients having >12 months of follow-up. 14 patients (70%) answered the satisfaction questionnaire. 12 patients (85.7%) had regular penetrative sexual intercourse. The mean International Index of Erectile Function-5 score was 20.2 of 25 (standard deviation SD 7.9), the mean Self-Esteem and Relationship score was 84.5 of 100 (SD 9.9), and the mean Erectile Dysfunction Inventory of Treatment Satisfaction score was 82 of 100 (SD 17.5). 13 patients (92.8%) were satisfied or very satisfied with the prosthesis.
This new innovative prosthesis could better answer the challenges faced by the implantation of an erectile device by phalloplasty.
Our study is the first to report data on this new prosthesis. The main limitation is the small number of patients and the short follow-up.
Preliminary results for the ZSI 475 FtM are encouraging. Safety seems to be satisfactory, and patient satisfaction is high. Long-term studies are needed for further analysis. Neuville P, Morel-Journel N, Cabelguenne D, et al. First Outcomes of the ZSI 475 FtM, a Specific Prosthesis Designed for Phalloplasty. J Sex Med 2019;16:316-322.
Abstract
BACKGROUND AND AIMS
Partial nephrectomy (PN) has progressively replaced radical nephrectomy (RN) whenever feasible for renal tumors. However, its effects on renal outcomes are less known in ...patients with pre-existing chronic kidney disease (CKD) or with solitary kidney (SK). We aimed to assess renal and major clinical outcomes after PN or RN in patients with moderate to severe CKD or SK.
METHOD
We included all surgical procedures conducted between 2013 and 2018 in the Hospices Civils de Lyon, in patients with last pre-operative estimated glomerular filtration rate (eGFR) <60mL/min/1.73m², or with SK. Exclusion criteria were eGFR < 15mL/min/1.73m² or dialysis, RN on SK, ablative therapy. Demographic, tumors and surgeries characteristics were collected, as well as eGFR 1 month and 1 year after surgery. Main outcome was a composite criterion including CKD progression or major cardio-vascular events or death, assessed 1 year after surgery. Predictors of the main outcome were determined using multivariate analyses.
RESULTS
We included 173 procedures (67 RN and 79 PN on CKD patients, 27 PN on SK patients). Patients undergoing RN were older, had bigger tumors and higher T stages on TNM classification. Preoperative estimated glomerular filtration rate (eGFR) and CKD stages were not different between the groups. One year after surgery, PN was associated with less occurrence of the main composite outcome compared to RN (42.9% versus 70.7%, P < 0.01). On multivariate analysis, independent risk factors for the main outcome were postoperative AKI (no AKI as reference; AKI stage 1 odds ratio (OR) = 8.68, 95% confidence interval (CI) 3.23–23.33; AKI stage 2 OR = 23.50, 95% CI 2.33–236.51; AKI stage 3 OR = 28.87, 95% CI 4.77–167.61) and bigger tumor size (OR = 1.21/cm, 95% CI 1.02–1.45), while preoperative eGFR was not (Table 1). Compared to pre-operative values, eGFR significantly decreased both after RN or PN 1 month after surgery (eGFR loss -12mL/min 1.73m² after RN P < 0.001, −3mL/min/1.73m² after PN, P < 0.05) and this decrease remained stable 1 year after surgery (eGFR loss -11mL/min/1.73m² after RN, P < 0.001, −3mL/min/1.73m² after PN, P < 0.05), but renal function was better preserved after PN than after RN at 1 month (P < 0.05) or 1 year (P < 0.01) (Figure 1).
CONCLUSION
In moderate to severe CKD patients, PN was associated with less risk of CKD progression or major cardio-vascular event or death 1 year after surgery, compared to RN. Postoperative AKI was the major determinant of clinical and renal outcomes.
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