7% were performed with CDA and 83.8% with MAA. Overall rates of infectious complication (1.5%) and infectious hospitalization (0.6-0.7%) were not significantly different between patients undergoing TR PB with MAA compared to TR PB with CDA. There was no difference in rates of infectious complication and infectious hospitalization between practices that regularly vs. selectively used CDA. Among practices that selectively used CDA, rates of infectious hospitalization were significantly lower (p[0.046) with CDA (0.4%) compared to MAA (0.8%). Rates of infectious complication were significantly lower with TP PB (n[1209, 1.8% of PB) compared to both CDA and MAA pathway transrectal PB (0.3% vs 1.5%) but there was no significant difference in infectious hospitalization rates.CONCLUSIONS: Utilization of rectal swabs to permit CDA with PB has been sparse across MUSIC practices. Our evidence indicates that both CDA and MAA are safe, with lower infectious hospitalization rates in the patients that selectively received CDA. TP PB appears to be a good alterative that can be performed with comparable overall complication rates to TR PB, and without antibiotics. Source of Funding: Funding from the Blue Cross Blue Shield of Michigan. The corresponding author would like to thank the Betz Family Endowment for Cancer Research for their continued support. Funding was provided to BRL in part by the Spectrum Health Foundation (RG0813-1036). The authors would like to acknowledge the support provided by the Value Partnerships program at Blue Cross Blue Shield of Michigan.
INTRODUCTION AND OBJECTIVE: Focal therapy of prostate cancer (PCa) is of increasing interest, but a convenient metric to determine success is lacking. We evaluated the role of PSA and MRI in determining tissue resolution of PCa after partial gland ablation (PGA).METHODS: 138 men with unilateral, clinically significant PCa (csPCa) underwent a prospective PGA trial employing cryotherapy (CRYO, N[91) or high intensity focused ultrasound (HIFU, N[47) between 2/2016 and 8/2020. PSA determinations were performed prior to PGA and at 3, 6, 12 and 18 months after treatment. MRI and MRIguided biopsy (MRGB) were performed at baseline, 6 and 18 mos. The analysis was powered to test if !80% reduction in PSA from baseline predicts absence of ! GG2 in the ablation zone at 6 mos in 90% of men. This metric was chosen because it appears to predict long-term 'failure free survival' (Stabile, 2020). Primary outcomes were presence of ! GG2 on MRGB at 6 mo. and adverse event profile. Secondary outcomes were effects on MRI and absence of !GG2 at 18 months All biopsy sessions included systematic, targeted, and tracked biopsy. 6-mo biopsy was ipsilateral to treatment; 18-mo biopsy was bilateral (Fig. 1).RESULTS: All 138 men underwent PGA successfully, 131 completing 6-mo and 70 completing 18-mo MRGB (total 339 biopsy sessions). At 6-mo biopsy, 75% of patients (99/131) were free of csPCa. An 80% decline in PSA from baseline to nadir correctly ruled out csPCa in 85% of patients (NPV 85%). However PPV was only 29% and AUC only 0.58. PSA decline was similar among CRYO and HIFU cohorts and was independent of treatment outcome (Fig. 2). Disappearance of MRI lesions, seen in 72% (93/130), was also unrelated to outcome. PSA density was more predictive of outcomes than other permutations of PSA. At 18 months, using the biopsy criterion, 60% of patients (42/70) were free of csPCa. No serious adverse events were encountered.CONCLUSIONS: Following PGA, tissue resolution of csPCA (75% at 6 months, 60% at 18 months) was not completely ascertained by PSA or MRI. MR-guided biopsy should be used to determine success or failure of PGA during continued surveillance.
The first two patients had nephrostomy tube before surgery, while the third patient has double J ureteral stent to avoid obstructive urophaty. The preoperative work-up was performed with a computed tomography scan, renal scintigraphy and diagnostic ureteroscopy with retrograde pyelography to confirm the position and the length of the stricture. In these cases a combined endoscopic and robot-assisted approach was used. The patients were positioned in the standard flank position. Four robotic trocars were placed in line along the pararectal line. One additional 12 mm assistance trocar and Air Seal trocar were placed. After mobilisation of colon the urether was identified and isolated. The stricture was located in the lower and distal part of the lumbar urether, in the first and second case respectively and in the right pelvic urether in third case. The flexible uretheroscope was backloaded and the distal end of the stricture was easily identified by a transillumination technique. To identify the proximal end of the stricture, Indocianine Green was administrated to the patient. The stricture appeared as a devascularized portion of the ureter and was precisely marked and sectioned with monopolar scissors. A flexibile ureteroscopy was also perfomed up to exclude presence of further strictures. Distal and proximal ureteral ends were spatulated and a termino-terminal tension-free anastomosis was perfomed using two 4-0 Vycril running sutures. Antegrade ureteral stenting was performed before the anastomosis was completed in the first two cases. In the third case a decision was made to perform a uretero-vesical reimplantation with psoas hitch, due to the position and length of the stricture. In this case a double J stent was placed and a Lich-Gregoir anastomosis was performed with double running suture with 4-0 Vicryl RESULTS: Mean operative time and console time were 186 (SD 11) minutes and 156 (SD 20) minutes, respectively. Mean hospitalization time was 4 days. Uretheral stent was removed after a mean of 4 weeks after surgery. No perioperative complications were reported. 3 month after surgery the CT scan showed a regression of the hydronephrosis and good functional results at renal scintigrapy in all cases CONCLUSIONS: The management of ureteral strictures is challenging. This technique is safe and feasible for short strictures up to 2 cm and assure good early functional results
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