Indian Journal of Urology
EDITORIAL
Year
: 2022  |  Volume : 38  |  Issue : 4  |  Page : 249--251

Round up


Swarnendu Mandal 
 Department of Urology, AIIMS, Bhubaneshwar, Odisha, India

Correspondence Address:
Swarnendu Mandal
Department of Urology, AIIMS, Bhubaneshwar, Odisha
India




How to cite this article:
Mandal S. Round up.Indian J Urol 2022;38:249-251


How to cite this URL:
Mandal S. Round up. Indian J Urol [serial online] 2022 [cited 2022 Nov 29 ];38:249-251
Available from: https://www.indianjurol.com/text.asp?2022/38/4/249/357736


Full Text



 Prediction of Biochemical Recurrence Based on Molecular Detection of Lymph Node Metastasis After Radical Prostatectomy



Over 20% of lymph node (LN)-negative (pN0) patients develop tumor recurrence.[1] Conventional HPE may miss micrometastases (mMs) which could be detected by analyzing the mRNA expression of epithelial markers in prostate cancer (PC) patients.[2]

This study[2] evaluated the appropriate marker panel as a surrogate for LN mM and its predictive value for biochemical recurrence-free survival (bRFS). Patients with localized PC undergoing radical prostatectomy with extended LND were examined for mM by routine HPE and molecular analyses. Of the 2108 LNs from 60 PC patients screened with routine HPE, 63 LNs from 12 patients (20%) showed mM. A total of 1023 LNs from the same 60 patients were screened for mRNA expression of prostate epithelial markers (PSA, PSCA, EpCAM, prostate-specific membrane antigen [PSMA], and NKX3-1).

Prostate epithelial markers were identified as the panel of markers best suited for molecular detection of LN mM including molecular markers of stemness, epithelial-to-mesenchymal transition, or reactive stroma. The median bRFS was 5.7 years (95% confidence interval CI [1.1–11.9]) and 11.8 years (95% CI [6.2–not reached]) in pN1 and pN0 patients, respectively. The positive and negative predictive values of the LN mM markers for biochemical recurrence (BCR) were 66.7% and 62.5%, respectively. Thus, the prostate epithelial cell markers increase with the number of positive LNs and predict BCR after surgery.

 Functional Recoverability After Pyeloplasty in Children with <20% Differential Function



The decision to perform pyeloplasty or nephrectomy for adult UPJO with split function <20% is still debatable. A recent systematic review[3] including 731 patients concluded with a low level of evidence, that pyeloplasty may relieve symptoms, and stabilize kidney function. The study by Sarhan et al.[4] addresses the debate on pediatric patients.

The retrospective study evaluated 21 children with primary unilateral UPJO with differential renal function (DRF) of <20% on diuretic renography. The median age was 1.5 years (IQR: 3 m–5 years), and the median follow-up period was 2.5 years (IQR: 1–6 years). Preoperative DRF ranged from 8% to 20% and postoperative values obtained at a median 7 months interval (7–9 months), ranged from 14% to 36%. Diuretic renography showed an improved DRF by ≥5 in 15 patients (71.5%), 8 of them (38%) having a 10%–15% improvement, while the remaining showed similar DRF with a nonobstructive pattern. Renal ultrasound showed improved hydronephrosis (HDN) in 16 patients (4 patients had complete resolution) and stable in the remaining 5. Most of the improvement was noted in the first postoperative ultrasonography 16/21 (76%).

None of these preoperative variables were significant predictors for the improvement of DFR and HDN. Children with unilateral UPJO and <20% DRF had favorable outcomes after pyeloplasty. Improvement of HDN in the first postoperative renal ultrasound was a good indicator of success.

 Stereotactic Ablative Radiation For Systemic Therapy–NaïVe Oligometastatic Renal Cell Carcinoma (RCC)



Postcytoreductive nephrectomy done for oligometastatic renal cell carcinoma (RCC), stereotactic ablative radiotherapy (SABR) may control the disease at metastatic sites with lower toxicity than systemic therapy.[5] This single-arm phase II trial included 23 systemic therapy-naïve RCC patients (22 postnephrectomy) with three or fewer extracranial metastatic lesions and received SABR to cover more than 95% of the target volume.[5] A total of 57 target lesions were treated among which 33 lesions received upfront therapy subsequently, followed by 24 target lesions. The lungs (47%), abdominal LNs (11%), and bones (7% each for spine and nonspine) were the most common sites that received SABR. The median follow-up was 21.7 months.

At 1 year, the freedom from systemic therapy (primary endpoint) was 91.3% (95% CI: 69.5–97.8), exceeding the prespecified 60% benchmark. The 1-year PFS was 82.6% (95% CI: 60.1–93.1). Local control was 100% with no grade 3 or 4 toxicities and unaffected quality of life (QoL). One-year OS was 95.7% (95% CI: 72.9, 99.4) and CSS was 100%.

SABR could safely and effectively control the postnephrectomy oligometastatic RCC disease burden without compromising the QoL.

 Temperature Profiles During Ureteroscopy with Laser Activation in a Model Ureter



Laser-induced fluid heating may cause ureteral thermal injury and lead to ureteral stricture and renal failure.[6] More than 90% of the energy released during laser activation (LA) is absorbed by the fluid that mixes in response to fluid irrigation and LA raising its temperature.[7] The risk of thermal tissue injury is dependent upon temperature increase and duration of exposure.[8]

This study evaluated the volume of fluid that mixes during LA at different irrigation rates (IRs) and characterized the temperature distribution (measured by thermocouples) in a model ureter (plastic tube).[9] With LA, the volume of total fluid mixing was small, even at an IR of up to 40 ml/min. For IRs ≤12 ml/min, the calculated thermal dose within the model ureter exceeded the threshold of tissue injury. The ureteroscope thermocouple accurately measured the intraluminal temperatures. The study findings reinforce that until temperature sensors are incorporated into ureteroscopic systems, laser power settings should be judiciously selected to minimize the risk of ureteral thermal injury.

 Comparison of Perioperative Outcomes Following Transperitoneal Versus Retroperitoneal Robot-Assisted Partial Nephrectomy



The evidence for retroperitoneal versus transperitoneal surgical access for robotic-assisted partial nephrectomy (RAPN) is lacking.[10] Posterior tumors are deemed suitable for the retroperitoneal (RPRAPN) and anterior ones for the transperitoneal (TPRAPN) approach.[11]

The multicenter study included 3801 patients from the Vattikuti Collective Quality Initiative database who underwent RAPN. The two surgical groups (n = 309 in each group) were matched for age, sex, tumor size and location, renal nephrometry score, preoperative creatinine, and eGFR. Trifecta was defined as the absence of complications, negative surgical margins, and warm ischemia time (WIT) <20 min or zero ischemia.

The RPRAPN group tumors were more likely to be posteriorly located (75.2% vs. 38.8%, P = 0.000). Operative time and WIT were significantly shorter with RPRAPN, with lower intraoperative blood loss and transfusion rate. Intraoperative complications were significantly higher with RPRAPN, but postoperative complication rates were similar. Trifecta outcomes were significantly better with RPRAPN (70.2% vs. 53%, P = 0.000). RPRAPN may be the preferred approach for posterior tumors at experienced centers.

 Number of Dissected Lymph Nodes and Prognosis in Muscle-Invasive Bladder Cancer (MIBC) in the ERA of Neoadjuvant Chemotherapy (NAC)



A larger number of dissected lymph nodes (DLNs) improves the prognosis of muscle-invasive bladder cancer (MIBC), but most patients in the prior studies did not include patients who received NAC, and this study evaluated the benefit of a larger number of DLNs in post-NAC patients.[12] The study included 477 patients who underwent platinum-based combination NAC, followed by radical cystectomy for MIBC. The mean number of DLN was 14 (range: 0–49), and the cohort was divided into two groups of <15 and ≥15 DLNs.

The group with ≥15 DLNs had significantly better 5-year OS (68.1% vs. 57.2%, P = 0.01), and the extent of lymphadenectomy correlated significantly with prognosis (HR 0.72, 95% CI 0.52–0.99, P = 0.04. On subset analysis for OS in the non-NAC group, patients who had ≥15 DLNs had significantly better 5-year OS (70.3% vs. 46.9%, P < 0.01), but a similar analysis in the NAC group revealed no benefit (66.5% vs. 71.1%, P = 0.43). A greater number of DLNs was not associated with better OS in NAC patients (HR 1.34, 95% CI 0.8–2.24, P = 0.25), and the evidence points against performing extended LND in such patients.

 Prostate-Specific Membrane Antigen Radio-Guided Surgery To Detect Nodal Metastases in Primary Prostate Cancer Patients Undergoing Robot-Assisted Radical Prostatectomy (RARP) and Extended Pelvic Lymph Node Dissection



PSMA-based radio-guided surgery (PSMA-RGS) has proven efficacy in detecting lymph-nodal invasion (LNI) in patients undergoing salvage LN dissection, but evidence in a primary setting is scarce.[13],[14] This prospective phase II trial reports the safety and feasibility of robotic-assisted PSMA-RGS after completing the first 10 of 100 cases. The trial is currently enrolling cN0cM0 primary prostate cancer patients as per conventional imaging who are candidates for RARP with extended pelvic lymph node dissection.[14]

The 68Ga-PSMA positron emission tomography/magnetic resonance imaging (PET/MRI) done 1 week before surgery identified 11 positive lymph node spots but missed 3 nodal regions positive at final pathology. 99 mTc-PSMA was administered 20 h before surgery, and single-photon emission computed tomography/computed tomography imaging was performed 270 min after the administration, which identified 2 (17%) patients with positive spots but missed 1 of the 11 regions (9%) identified at 68Ga-PSMA PET/MRI. An intraoperative drop-in gamma probe was used to identify nodal metastasis, which was repeated to confirm the removal of the radioactive lesion. The drop-in probe did not detect activity at 91 locations, of which 87 contained no cancer and 4 harbored LNI. The sensitivity, specificity, PPV, and NPV were 50%, 99%, 80%, and 96%, respectively. The specificity of this technique can be used to confirm the removal of suspicious nodes at preoperative PSMA PET.

 First Successful Xenotransplant: Porcine Heart into Adult Human with End-Stage Heart Disease



A patient with nonischemic cardiomyopathy who was ineligible for conventional allograft underwent cardiac transplantation from a geneticall

y-altered pig with ten distinct gene edits.[15] The basis for immunosuppression was CD40 blockage. The xenograft operated normally once the patient was weaned off of ECMO. On the 49th day following the transplantation, there was a sudden xenograft failure along with diastolic thickening, and on day 60, life support was withdrawn. The autopsy revealed an edematous heart with the loss of integrity and necrosis of myocytes. Compliment staining was not noted, and typical xenotransplant rejection features were not seen.[16] Further evaluation of the mechanism of this xenograft failure is ongoing.

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.

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