Journal of Urology最新文献

Purpose: Our goal was to determine whether the difference between MRI-based and ultrasound (US)-based volume measurements are associated with MRI/US-targeted fusion-guided biopsy outcomes.

Materials and methods: This retrospective, single-center study involved 4177 consecutive patients biopsied between 2010 and 2023 using both MRI/US-targeted fusion and systematic biopsy. Biopsies were indicated because of elevated PSA levels or abnormal multiparametric MRI results. US volume measurements were calculated using the triplane ellipsoid formula, and MRI volumes were obtained by semiautomatic planimetric segmentation. Performance of fusion biopsy compared with systematic biopsy was analyzed with respect to the discordance between MRI and US volume measurements.

Results: In 2736 patients (66%), biopsy detected prostate cancer. In cases where both techniques yielded prostate cancers (1695/2736 [62%]), a statistically higher proportion of patients had higher Gleason scores on MRI/US-targeted fusion biopsy compared with systematic biopsy (343 patients [20.2%] vs 137 patients [8.1%], P < .001). MRI volume measurements were significantly smaller compared with US volume measurements (median [IQR] 54 mL [39-77], 56 mL [40-80], respectively, P < .001). Beyond 5 mL volume discordance, MRI/US-targeted fusion biopsy gradually showed less added diagnostic benefit compared with systematic biopsy. In the ≤ 5 mL cohort, MRI/US-targeted fusion biopsy detected more aggressive tumors in 4 times as many patients as systematic biopsy (136 vs 32 patients, P < .001).

Conclusions: Although MRI/US-targeted fusion biopsy detected more prostate cancers than systematic biopsy, the performance of MRI/US-targeted fusion biopsy declined with more discordance between volumes measured in MRI vs US. Awareness of volume discordance in MRI- and US-based volume measurements should alert the operator about the possibility of reduced performance of MRI/US-targeted fusion biopsy.

Clinical trial registration no.: NCT00102544.

Purpose: Perioperative blood transfusion (PBT) has been reported in > 50% of patients undergoing radical cystectomy (RC). Unfortunately, PBT in patients undergoing RC has been associated with poor oncological outcomes. Tranexamic acid (TXA) use has been proposed to decrease the need for PBT. Here, we seek to investigate the impact of intraoperative TXA on the risk of perioperative bleeding and venous thromboembolism (VTE) in patients undergoing RC. We also investigate its long-term impact on overall survival (OS) and cancer-specific survival (CSS) outcomes.

Materials and methods: We queried the prospectively maintained Mayo Clinic Radical Cystectomy registry and identified all RCs performed for bladder cancer between 1990 and 2021. Primary outcomes assessed include the risk of perioperative bleeding, the need for blood transfusion, and the risk of VTE. Secondary outcomes include the impact of using TXA on OS and CSS.

Results: Of 2862 patients with complete available data, 468 received TXA (TXA recipient) and were matched 1:1 for age, neoadjuvant chemotherapy, pathologic staging, and preoperative hemoglobin with a group who did not receive TXA (TXA nonrecipient). TXA recipients experienced less estimated blood loss intraoperatively (median 600 vs 650 cc) and were less likely to need PBT (31% vs 50%, P < .001) compared with TXA nonrecipients. There was no difference between groups in deep venous thrombosis and pulmonary embolism rates within 90 days of RC. In the adjusted survival model, use of TXA was not independently associated with significant impact on OS or CSS. However, perioperative blood transfusion was associated with poor OS and CSS (P < .001).

Conclusions: TXA use was associated with a significant reduction in estimated blood loss and PBT without increased risk of VTE. In univariable analyses, we observed an association between TXA use and improved OS as well as CSS. However, in multivariable analyses, TXA itself was not independently associated with improved OS or CSS; instead, PBT was. Further studies are warranted to explore strategies for minimizing PBTs and their impact on survival outcomes.

Purpose: The purpose of this study was to create and validate an anterior urethral stricture disease (aUSD) staging system based on the previously validated Length (L), Urethral Segment (S), and Etiology (E; LSE) classification system.

Materials and methods: The Trauma and Urologic Reconstructive Network of Surgeons (TURNS) prospective database was used to create and validate the staging system. A novel Urethroplasty Triad Score was created to aid in ranking the stagings into stricture severity based on (1) functional outcomes, (2) location of urethral meatus (eg, orthotopic, perineal), and (3) number of surgeries required for repair. Staging was secondarily validated in a non-TURNS dataset and then compared with 2 previously described aUSD severity scores-the U-score and the LSE score.

Results: Five aUSD stages, with 10 total substages, were ultimately created: stage I-short bulbar, stage II-long bulbar, stage III-penile/fossa of favorable etiology, stage IV-penile/fossa of adverse pathology, and stage V-pan-urethral (3-segment). Mean Urethroplasty Triad Score decreased (increasing severity) with each substage, with the linear trend being validated in both the separate validation cohort and within the individual TURNS. LSE staging was superior to the LSE score and U-score in predicting the need for multiple stages or a nonorthotopic meatus and was similar in predicting surgical outcomes.

Conclusions: Each stage and substage of this novel LSE staging system was shown to provide unique information on stricture characteristics, repairs, and surgical outcomes. The LSE staging system will improve communication of stricture complexity/severity with our patients and organize aUSD for multi-institutional outcomes studies and clinical trial recruitment purposes.

Purpose: Endoscopic management (EM) is an increasingly accepted option for upper tract urothelial carcinoma (UTUC). Feasibility can be dependent on a variety of variables. The objective of this study was to identify anatomic and phenotypic tumor characteristics that affect EM, using structured expert forecasting, develop and obtain consensus on an assessment score, and perform initial validation of the score in a retrospective database.

Materials and methods: We used a modified Delphi method to elicit expert opinions, develop a scale, and gain consensus. Two survey rounds identified 5 consensus categories from which the Upper anatomic Tract, tumor Radius, tumor Architecture, tumor Count, tumor locaTion (TRACT) Endometry Score was created. An institutional UTUC database was used for initial validation. Patients with low-grade or high-grade UTUC undergoing EM were included. The Upper TRACT Endometry Score was calculated based on variables present at initial ureteroscopy. The primary outcome was extent of procedures received defined as a categorical, ordinal scale. The association of the Upper TRACT Endometry Score with outcomes was evaluated using multivariable ordinal logistic regression and exact tests.

Results: Thirty international endourologic and urologic oncology experts participated in the surveys. One hundred ten renal units (102 patients) were identified for validation. Multivariable ordinal logistic regression demonstrated that as the Upper TRACT Endometry Score increases, the likelihood of requiring a more intensive intervention increases. The Fisher exact test suggested a significant relationship between the Upper TRACT Endometry Score and procedures received (P = .004).

Conclusions: The Upper TRACT Endometry Score is a straightforward tool that with additional validation could be used to help counsel patients and to standardize reporting of variables that may affect EM of UTUC.