Urology最新文献

Objective: To advocate for universal germline genetic testing (UGGT) in prostate cancer and provide practical recommendations for its implementation.

Methods: Although guidelines for germline genetic testing (GGT) in prostate cancer have progressed, usage remains limited and inconsistent due to barriers including access, cost, and variable guideline adherence. These issues prevent some patients with germline pathogenic/likely pathogenic variants from benefiting from risk assessment, precision therapies (e.g., PARP inhibitors, PD-1 inhibitors) and potential clinical trials. Despite these benefits, studies indicate that GGT use remains low, especially in prostate cancer care. The PROCLAIM trial (Shore et al., 2023) highlighted that nearly half of patients with pathogenic variants are missed under NCCN guidelines, particularly impacting non-white patients and those with incomplete family history data. Additional racial and socioeconomic disparities further hinder access and variant interpretation accuracy. Given these challenges, UGGT for all prostate cancer patients has been proposed to improve care equity and decision-making. In March 2024, prostate cancer experts convened to discuss strategies for UGGT implementation.

Results: The outcome of that meeting includes recommendations for integrating UGGT into oncology and urology practices and have been outlined in this paper.

Conclusions: To maximize the benefits while mitigating the potential risks of UGGT, it is essential to address implementation details, including careful gene panel selection, VUS reporting and management, appropriate genetics follow-up, and seamless integration of test reports into EMRs for accessibility by patients and providers.

Objective: To evaluate outcomes after flexible ureteroscopy (F-URS) for renal stone(s) using a flexible and navigable suction ureteral access sheath (FANS-UAS) comparing Thulium fiber (TFL) vs pulsed Thulium:Yttrium aluminum garnet (p-Thulium:YAG) laser.

Methods: Data from adults who had F-URS in 5 centers were prospectively collected (April 2023-January 2024). All patients had a preoperative and within 30days CT scan. Stone-free: grade A: zero fragments; grade B: single fragment ≤2mm; grade C: single fragment 2.1-4mm; grade D: single/multiple fragments >4 mm. One-to-one propensity score-matching for age, gender, prestenting, stone volume, stone location, and Hounsfield units was performed. Within 6months after surgery, an intravenous urography or CT urography scan was performed in all patients.

Results: Of 179 included patients, TFL was employed in 115 patients. After matching, 64 patients from each group with comparable baseline characteristics were included. Median lasing time was significantly longer in the TFL group (15.5 [10,23] minutes vs 13 [10,15] minutes, P=.02), while total surgical time did not differ. There was no case of blood transfusion and sepsis. Overall stone-free rate (SFR) was significantly different between the groups with a higher proportion of patients in p-Thu:YAG laser group undergoing reintervention for residual fragments (17.2% vs 3.1%). There was no case of new-onset hydronephrosis, ureteropelvic junction/ureteral stenosis, impaired urinary drainage, or altered pelvicalyceal anatomy at a median follow-up of 13weeks.

Conclusion: F-URS using FANS-UAS showed negligible serious adverse events and good SFR using both lasers. p-Thu:YAG laser showed shorter lasing time, marginal better grade A+B SFR but higher reintervention rate for residual fragments.

Objective: To investigate the microscopic and molecular structure of the urethral plate in hypospadias patients compared to normal urethral tissue, focusing on epithelial characteristics, cytokeratin expression, vascular patterns, and extracellular matrix components, including elastin fibers.

Methods: We analyzed 8 full-thickness mid urethral plate samples from pediatric hypospadias patients using immunohistochemistry to evaluate epithelial structure, cytokeratin expression (PanCK, CK7, CK10, CK13, CK14), vascular patterns (von Willebrand Factor, CD31), and extracellular matrix components (elastin). Control tissues included fetal urethras and penile urethras from gender confirmation surgery.

Results: The hypospadias urethral plate exhibited a multi-layered epithelium, contrasting with the single-layered normal urethral epithelium. Cytokeratin expression differed significantly: CK7 was predominantly negative in hypospadias samples but strongly positive in controls; CK10 showed variable expression; CK13 and CK14 were consistently positive in hypospadias samples, with CK14 exhibiting strong expression in the basal layer. Vascular analysis revealed fewer sub-epithelial capillaries and smaller vascular spaces in hypospadias tissue. Elastin expression was positive in hypospadias samples, while fetal urethra showed lower expression and adult urethra displayed distinct elastin fiber bundles. Minimal smooth muscle tissue was observed in hypospadias and fetal samples compared to adult controls.

Conclusion: The urethral plate in hypospadias patients demonstrates significant structural and molecular differences from normal urethral tissue, suggesting a developmental delay or arrest. These differences may contribute to surgical challenges and post-operative complications. Understanding these unique tissue characteristics could inform the development of novel surgical techniques or tissue engineering approaches to improve hypospadias repair outcomes.

Objective: To evaluate characteristics, hospital course, and outcomes of pediatric high-grade renal trauma (HGRT) using the Traumatic Renal Injury Collaborative in Kids (TRICK) consortium METHODS: This was a retrospective cohort study of a large, multi-center registry of HGRT. Patients < 18 years of age with HGRT (grades III, IV, and V) from 2007-2020 were included. Patient demographics, presenting characteristics, hospital courses, outcomes, and follow-ups were extracted and compared.

Results: Out of the 315 patients included, most were male (69.5%) with blunt renal trauma (96.2%). 61% of patients were transferred to a level 1 trauma center. Those with higher injury grade had higher injury severity score (ISS) (ISS 14 vs 17 vs 25; p=0.003), greater need for surgical procedures (0.7% vs 8.3% vs 21.2%; p=<0.001), and higher complication rates (14.6% vs 20.7% vs 33.3%; p=0.043). Demographics and practice patterns differed between institutions including ISS severity, use of delayed imaging, IR intervention, and urology consult, and repeat imaging.

Conclusion: Pediatric HGRT has overall low morbidity and mortality. Most injuries occurred in males following blunt renal trauma secondary to motor vehicle collision. Hospital course and outcomes were dependent on renal grade, with practice patterns and follow-up differing between institutions. The current registry provides updated information on pediatric HGRT in the clinical setting for counseling and guide decision making. The differences noted in site specific management also allow for comparison across sites, identify areas of need, and to implement future improvements.

Objectives: To describe the ureteropelvic junction (UPJ) anatomy in children undergoing robotic-assisted pyeloplasty through analysis of high-resolution video.

Materials and methods: Pediatric pyeloplasty recordings were examined, measuring pre- and post-spatulation ureteral diameters. Data on patient demographics, symptoms, hydronephrosis grade, renal function, and UPJ pathology were gathered to compare differences amongst UPJ obstruction etiology.

Results: Fifty consecutive robotic pyeloplasties by a single surgeon from over a three-year period were reviewed, 45 (7 females, 38 males, mean age 5.5 years) were included, excluding two revisions and three poorly recorded cases. 67% had left-sided UPJ obstruction (UPJO). Thirty-one (69%) showed intrinsic UPJ narrowing with significant diameter reduction by an average of 1.1 mm, compared to the proximal ureter, both in vivo and after ureteral spatulation (p<0.0001), with mean UPJ-to-normal ureter distance of 4.2 mm. Nine (20%) had crossing vessels, with 63% within 3 mm of the UPJ. Two (4%) had high inserting ureters, and three (7%) had ureteral polyps. Those aged 0-2 years (42%) universally had intrinsic narrowing of the UPJ. In older patients, 50% presented with abdominal/flank pain; among them, 56% with crossing vessels, 33% with ureteral narrowing, and 100% with high insertion. Patients with crossing vessels and polyps exhibited lower average split renal function (34.5% and 26%, respectively) compared to intrinsic narrowing and high insertion groups (both 47%).

Conclusions: Robotic pyeloplasty review details UPJ anatomy, emphasizing >1 mm of intrinsic UPJO narrowing, distance to normal caliber ureter (<8 mm, mean 4.2 mm), crossing vessel proximity (within 1.8 cm of UPJ), and normal ureteral caliber in polyps and high insertions. Analyzing UPJ anatomy offers surgical insights related to etiology, patient age, and presentation.