Publications by authors named "Ofer Yossepowitch"

106 Publications

Flexible Cystoscopy in the Setting of Macroscopic Hematuria: Do the Findings Justify Its Use?

Urol Int 2021 Jul 20:1-7. Epub 2021 Jul 20.

Department of Urology, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel.

Background: Patients hospitalized due to gross hematuria frequently complete evaluation in the outpatient setting. The use of office flexible cystoscopy during hospitalization may lead to prompt diagnosis and treatment but can be limited due to low visualization and artifacts that can hamper diagnostic ability.

Objective: The objective of this study was to assess flexible cystoscopy findings and yield performed in patients hospitalized due to gross hematuria.

Methods: Medical records of patients who underwent flexible cystoscopy while hospitalized during September 2018-December 2019 were reviewed. Cystoscopic findings were categorized into (1) suspicious mass in the bladder or prostate, (2) nonsuspicious changes in the bladder, and (3) nondiagnostic exam. Descriptive statistics were used to report the clinical characteristics of the study cohort and the findings of cystoscopy. Univariate logistic regression analyses were used to identify predictors of malignant findings.

Results: The study cohort consisted of 69 patients (median age of 76 years). Initial cystoscopy findings were suspicious for malignancy in 26/69 patients (38%), nonsuspicious for malignancy in 34/69 patients (49%), and nondiagnostic in 9/69 patients (13%). The median follow-up time was 9 months (range 4-14 months). Twenty patients (29%) were diagnosed with malignancy (sensitivity of 75% and specificity of 78%). The procedure led to either diagnosis or treatment of 39 patients (57%). However, in 30 patients (43%), the initial cystoscopy did not aid in the diagnosis, led to misdiagnoses, or required a follow-up cystoscopy. On univariate analyses, none of the precystoscopy variables were predictive of bladder malignancy.

Conclusion: Flexible cystoscopy in the setting of acute hematuria requiring hospitalization did not lead to diagnosis or treatment in over 40% of cases. In this setting, consideration should be given to performing an upfront cystoscopy under anesthesia.
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http://dx.doi.org/10.1159/000517374DOI Listing
July 2021

Introducing in clinical practice a new laser suction handpiece for percutaneous nephrolithotomy.

Urologia 2021 Jul 13:3915603211031874. Epub 2021 Jul 13.

Department of Urology, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: To assess a novel combined laser suction handpiece (LSH) for performing PCNL in a clinical setting.

Methods: The study comprised 40 consecutive PCNLs performed between May 2019 and February 2020. The first 20 procedures (Group A) were performed with conventional ultrasonic or pneumatic devices and the other 20 (Group B) were performed with the use of the new LSH. All patients were treated by tubeless supine PCNL. The groups were compared for demographics, clinical data, operative time, lithotrite effectiveness, stone clearance rate (SCR), and outcome.

Results: Groups A and B were similar in age, and in stone size, complexity, and density (Hounsfield units) ( < 0.05). The average operative time was 99 and 78 min, SCR 143 and 200 mm/min, hospital stay 1.6 and 1.1 days, and stone-free rate 90% and 95%, respectively. Despite a trend toward better results with the new LSH, none of these comparisons reached statistical significance. Ineffective lithotripsy with the initial device (ultrasonic) requiring conversion to another modality (ballistic) occurred in six (30%) procedures in Group A, while all procedures were effectively accomplished with the LSH in Group B ( = 0.02). There were two complications in Group A and none in Group B ( > 0.05).

Conclusions: The LSH is as effective and safe as the traditional lithotrites for performing PCNLs. This new tool completes the capabilities of the holmium laser high-power machines, enabling them to serve as the sole platform for all endourological treatments.
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http://dx.doi.org/10.1177/03915603211031874DOI Listing
July 2021

Preoperative 68Ga-PSMA PET/CT defines a subgroup of high-risk prostate cancer patients with favorable outcomes after radical prostatectomy and lymph node dissection.

Prostate Cancer Prostatic Dis 2021 Mar 31. Epub 2021 Mar 31.

Department of Urology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel.

Background: High-risk prostate cancer is associated with adverse pathology and unfavorable outcomes after radical prostatectomy. Ga-PSMA PET/CT is more accurate than conventional imaging for preoperative staging. We aimed to evaluate whether lymph node involvement on Ga-PSMA PET/CT prior to radical prostatectomy in patients with high-risk prostate cancer is associated with worse short-term oncologic outcomes.

Methods: We retrospectively reviewed 149 patients with high-risk localized or locoregional prostate cancer who underwent Ga-PSMA PET/CT prior to radical prostatectomy between 2015 and 2020. None of the patients received neoadjuvant or adjuvant treatment. The study endpoints were PSA persistence and biochemical recurrence. Logistic regression models were used to identify preoperative predictors of PSA persistence. Kaplan-Meier analyses were used to estimate biochemical recurrence-free survival.

Results: Of 149 identified patients, 19 (13%) were found to have lymph node involvement on preoperative Ga-PSMA PET/CT. The sensitivity, specificity, and accuracy of Ga-PSMA PET/CT for identifying pathologic lymph node involvement were 68%, 95%, and 92%, respectively. PSA persistence rate was lower among patients with PET-negative lymph nodes than those with PET-positive nodes (15 vs. 84%, p < 0.001). Positive nodes on imaging (OR = 41.03, p < 0.001) and clinical T2c-T3 stage (OR = 6.96, p = 0.002) were associated with PSA persistence on multivariable analysis. Among patients with PET-negative nodes the 1- and 2-year biochemical recurrence-free survival rates were 87% and 76%, respectively.

Conclusions: Preoperative staging with Ga-PSMA PET/CT may identify a subgroup of high-risk prostate cancer patients with favorable short-term outcomes after radical prostatectomy without adjuvant treatment. Future studies will evaluate whether these results are sustained during long-term follow-up.
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http://dx.doi.org/10.1038/s41391-021-00347-yDOI Listing
March 2021

Questioning the utility of round spermatid injections in men with non-obstructive azoospermia.

Andrology 2021 Jul 13;9(4):1145-1150. Epub 2021 Apr 13.

Institute for the Study of Fertility, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Data on who among the infertile male population may benefit from round spermatid injections (ROSI) are lacking.

Objective: To determine the probability of finding round spermatids suitable for ROSI in men with non-obstructive azoospermia (NOA) in whom no spermatozoa were retrieved at testicular sperm extraction.

Materials And Methods: Four-hundred fifty-seven consecutive men with azoospermia underwent testicular sperm extraction. Clinical examination included age, secondary sexual characteristics, testicular size, reproductive hormone estimation, karyotyping, and Y chromosome microdeletion analyses. Histologic examination was performed, and histologic classification was determined by the most advanced spermatogenetic cell identified in the combined histologic and cytologic examination.

Results: Of the 457 azoospermic men, 342 were diagnosed with NOA, and 148 (148/342, 43%) had mixed atrophy on histopathology and retrievable spermatozoa. No spermatozoa were found in 194/342 men with NOA (57%). Histopathology diagnosed 145/194 (75%) of them with Sertoli cell only, 45/194 (23%) with spermatocyte maturation arrest, and 4/194 (2%) with spermatid maturation arrest.

Conclusions: Histopathologically identified round spermatids without spermatozoa were rare in men with NOA. Only very few of them are likely to reap the benefits of ROSI, thus presenting the need to reconsider its actual clinical value.
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http://dx.doi.org/10.1111/andr.13008DOI Listing
July 2021

Novel ultrasound-based volume estimation of prostatic benign enlargement to improve decision-making on surgical approach.

Ther Adv Urol 2021 Jan-Dec;13:1756287221993301. Epub 2021 Feb 11.

Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Aim: To assess the precision of preoperative ultrasonography (US)-determined prostate volume and to propose formulas for improving it.

Methods: This retrospective study comprised 155 consecutive men who underwent open prostatectomy for benign prostatic hyperplasia (BPH) between 2013 and 2019. Preoperative prostate volume was estimated by either abdominal US (AUS) ( = 92) or transrectal US (TRUS) ( = 63), and was compared with the weight of surgically enucleated tissue at a conversion rate of 1 ml (US) = 1 g tissue. Statistical analysis was conducted and a novel formula for prostate volume was constructed.

Results: The median prostate volumes by AUS and TRUS were 140 ml [interquartile ratio (IQR) 111-182] and 108 ml (IQR 93-120), respectively. Enucleated tissue weight was lower than the AUS assessment by a median difference of 50 g (IQR 28.7-75.7;  < 0.001), and lower than the TRUS assessment by a median difference of 27 g, IQR 10-43,  < 0.001). Using a cutoff of 80 ml, 30 (33%) AUS patients and 23 (36%) TRUS patients underwent unneeded open procedures. Mathematical calculations revealed two formulas that significantly adjusted for the actual weight: 1.082*Age + 0.523*AUS - 53.845 for AUS and 0.138*age + 2.22*prostate-specific antigen + 0.453*TRUS + 11.682 for TRUS ( < 0.001). These formulas increased the overall US prostate volume accuracy from 65% to 85%.

Conclusion: Assessment of prostate volume by US is imprecise for decision-making of whether to perform open simple prostatectomy for BPH. Our novel formulas may enhance stratification of patients with prostatic enlargement to a more optimal surgical approach. Future studies in larger cohorts are needed to substantiate our results.
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http://dx.doi.org/10.1177/1756287221993301DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887671PMC
February 2021

Radical cystectomy and perioperative chemotherapy in octogenarians with bladder cancer.

Can Urol Assoc J 2021 Feb 12. Epub 2021 Feb 12.

Department of Urology, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Introduction: We aimed to compare the treatment patterns and oncological outcomes, including postoperative morbidity and chemotherapy use, between octogenarians and patients <80 years of age who underwent radical cystectomy for bladder cancer.

Methods: We conducted a retrospective analysis of 119 patients who underwent radical cystectomy for bladder cancer at our center between January 2013 and April 2019. Comorbidities, clinical and pathological data, 30-day postoperative morbidity, and perioperative chemotherapy use were compared between octogenarians (n=31) and younger patients (n=88). Cancer-specific and overall survival rates were estimated with the Kaplan-Meier method and compared between the groups.

Results: No significant differences were found between the age groups in clinical and pathological findings, including Charlson comorbidity index, modified frailty index, albumin level, renal function, and TNM stage. The median followup for survivors was 19 months (interquartile range [IQR] 11-30). Major complications (Clavien-Dindo grade ≥3) and 30-day postoperative mortality rates did not differ between the age groups (p=0.3 and p=0.18, respectively). Despite no difference in baseline glomerular filtration rates, perioperative chemotherapy utilization rate was lower among octogenarians compared to younger patients (13% vs. 34%, p=0.03). Estimated two-year cancer-specific survival for octogenerians and younger patients were 40% and 75%, respectively. Similarly, estimated two-year overall survival rates were 30% and 69%, respectively. Both cancer-specific and overall survival rates were significantly lower in octogenarians (p=0.007 and p=0.001, respectively).

Conclusions: Radical cystectomy in octogenarians results in comparable short-term outcomes as in younger patients. However, in the elderly population, perioperative chemotherapy utilization rates are lower and survival is inferior.
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http://dx.doi.org/10.5489/cuaj.6907DOI Listing
February 2021

68Ga-PSMA-11 PET/CT Follow-Up of Patients with Prostate Cancer with Bone Metastases Who Had Reduced Bone Density after Androgen Deprivation Therapy.

Diagnostics (Basel) 2021 Feb 10;11(2). Epub 2021 Feb 10.

Department of Nuclear Medicine, Tel Aviv Sourasky Medical Center, 6 Weizmann St., Tel Aviv 6423906, Israel.

Bone metastases from prostate cancer (PCa) often show an increase in density on computed tomography (CT) after successful androgen deprivation therapy (ADT). Density may be reduced, however, as the disease progresses or, contrarily, when disease is no longer active. The current study investigated the role of 68Ga-PSMA-11 positron emission tomography/computed tomography (PET/CT) in differentiating between these two conditions.

Methods: The study cohort included 15 PCa patients with sclerotic/blastic bone metastasis in whom reduction in bone density of metastasis was noted on follow-up 68Ga-PSMA-11 PET/CT after ADT. Each patient had two PET/CT scans. Prior to the first scan, six patients were castration naïve and nine patients were already treated. All patients had ADT between the two PET/CT scans. PET parameters (SUVmax and tumor-to-background ratio), and CT parameters (HUmax) were determined and compared for each lesion on both scans. Patient's response was based on prostate-specific antigen (PSA) levels and appearance of new lesions. The Kolmogorov-Smirnov test was used to evaluate normal distribution of the continuous variables.

Results: Post-ADT reduction in bone density was identified in 37 lesions. The mean HUmax was 883.9 ± 175.1 on the first scan and 395.6 ± 157.1 on the second scan ( < 0.001). Twenty-one of the 37 lesions showed no increased tracer uptake on the second PET/CT scan raising the likelihood of a response. The other 16 lesions were associated with increased uptake suggestive of an active resistant disease. Bone density was not different in lesions that no longer showed an increased uptake as compared with those that did. Seven of the study patients responded to therapy, and none of the 16 lesions found in these patients showed increased 68Ga-PSMA-11 uptake. In eight patients with progressive disease, all 12 lesions in five of them showed increased 68Ga-PSMA-11 uptake, there was mixed response in two patients (having two lesions with increased uptake and one without) and although all three lesions no longer showed an increased uptake, new lesions were detected in the eighth patient.

Conclusion: A decrease in density of bone lesions may reflect clinical progression, or contrarily, a response to therapy in patients with PCa and skeletal involvement treated with ADT. Uptake of 68Ga-PSMA-11 may separate between these two vastly opposing conditions.
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http://dx.doi.org/10.3390/diagnostics11020277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916801PMC
February 2021

The significance of equivocal bone findings in staging PSMA imaging in the preoperative setting: validation of the PSMA-RADS version 1.0.

EJNMMI Res 2021 Jan 6;11(1). Epub 2021 Jan 6.

Departments of Nuclear Medicine, Tel-Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel-Aviv, Israel.

Background: Assessing the extent of disease in newly diagnosed prostate cancer (PC) patients is crucial for tailoring an appropriate treatment approach. Prostate-specific membrane antigen (PSMA)-targeted positron emission tomography/computed tomography (PET/CT) reportedly has greater accuracy than conventional imaging for staging PC. As with any imaging modality, pitfalls and nonspecific findings do occur. The PSMA reporting and data system (PSMA-RADS) version 1.0 offers structured interpretation of PSMA-targeted studies and classifies lesions by likelihood of clinical significance. The aim of this retrospective study was to evaluate the clinical significance of equivocal bone findings on staging PSMA-targeted imaging, as defined by PSMA-RADS version 1.0, in the preoperative setting. Fifteen of 406 consecutive patients staged by PET/CT prior to radical prostatectomy had equivocal bone lesions. The scans were retrospectively scored with the PSMA-RADS version 1.0 system, blinded to disease course and follow-up data. Postoperative persistence of prostate-specific antigen levels supported by imaging and histological findings was used as the reference standard for the true significance of equivocal imaging findings.

Results: Thirteen of the 15 patients had an overall PSMA-RADS score of 3B, of whom only two had true metastatic disease. The remaining patients had scores of 4 (n = 1) or 5 (n = 1), all confirmed as true positive prostate-related malignant lesions. A per-lesion analysis identified 29 bone lesions, of which 27 were scored PSMA-RADS 3B, and only three of them were true metastases. Thus, debatable lesions proved to have no clinical significance in 84.6% of cases, and only 11% of equivocal PSMA-RADS 3B bone lesions were true positive.

Conclusions: In intermediate and high-risk patients staged prior to radical prostatectomy, the majority of PSMA-RADS 3B lesions are of no clinical relevance. Bone lesions judged as being highly suspicious for metastases (PSMA-RADS 4/5) were all validated as true positives.
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http://dx.doi.org/10.1186/s13550-020-00745-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7788112PMC
January 2021

The effect of delaying transperineal fusion biopsy of the prostate for patients with suspicious MRI findings-Implications for the COVID-19 era.

Urol Oncol 2021 01 7;39(1):73.e1-73.e8. Epub 2020 Aug 7.

Department of Urology, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel. Electronic address:

Objective: Image guided biopsies are an integral part of prostate cancer evaluation. The effect of delaying biopsies of suspicious prostate mpMRI lesions is uncertain and clinically relevant during the COVID-19 crisis. We evaluated the association between biopsy delay time and pathologic findings on subsequent prostate biopsy.

Materials And Methods: After obtaining IRB approval we reviewed the medical records of 214 patients who underwent image-guided transperineal fusion biopsy of the prostate biopsy between 2017 and 2019. Study outcomes included clinically significant (ISUP grade group ≥2) and any prostate cancer on biopsy. Logistic regression was used to evaluate the association between biopsy delay time and outcomes while adjusting for known predictors of cancer on biopsy.

Results: The study cohort included 195 men with a median age of 68. Median delay between mpMRI and biopsy was 5 months, and 90% of patients had a ≤8 months delay. A significant association was found between PI-RADS 5 lesions and no previous biopsies and shorter delay time. Delay time was not associated with clinically significant or any cancer on biopsy. A higher risk of significant cancer was associated with older age (P = 0.008), higher PSA (0.003), smaller prostate volume (<0.001), no previous biopsy (0.012) and PI-RADS 5 lesions (0.015).

Conclusions: Our findings suggest that under current practice, where men with PI-RADS 5 lesions and no previous biopsies undergo earlier evaluation, a delay of up to 8 months between imaging and biopsy does not affect biopsy findings. In the current COVID-19 crisis, selectively delaying image-guided prostate biopsies is unlikely to result in a higher rate of significant cancer.
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http://dx.doi.org/10.1016/j.urolonc.2020.07.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413128PMC
January 2021

Long-Term Follow-Up of Yearly Replaced Double Internal Stents for Extrinsic Malignant Ureteral Obstruction.

J Endourol 2021 01 1;35(1):71-76. Epub 2020 Sep 1.

Department of Urology, Tel-Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

To assess long-term outcomes of double internal stents (DIS) for the relief of external malignant ureteral obstruction (MUO). DIS (7F each; 12-month indwelling time) were inserted under general anesthesia in 62 consecutive patients (75 renal units) with MUO during 2007-2018. Surveillance was performed every 3 months, and stents were exchanged routinely every year. The need for permanent stent retrieval was considered stent failure. Maintenance of stent patency and disease-specific survival (DSS) were estimated (Kaplan-Meier). Risk factors were also assessed (univariate and multivariable Cox regression analyses). The median follow-up was 27 months (interquartile range [IQR] 20-27). The most frequent tumors causing obstruction were colorectal and ovarian cancers. Six patients (10%) had stent failure caused by sepsis, creatinine elevation, or hematuria. The average time to failure was 15 months (range 1-27). A history of radiation and an estimated glomerular filtration rate (eGFR) ≤45 mL/(min/1.73 m) were associated with stent failure ( = 0.038 and  = 0.001, respectively). Thirty-nine patients died with a median DSS of 21 months (IQR 8.6-not reached). Multivariate analysis identified eGFR ≤60 mL/(min/1.73 m) (hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.1-4.2,  = 0.02) and need for balloon dilation (HR 2.1, 95% CI 1.1-4.1,  = 0.02) as independent predictors for disease-related mortality. Twenty-six patients (42%) had stent-related complications, for example, irritative symptoms, hematuria, and infections, of whom only two failed. One-year indwelling DIS provide effective long-term relief of MUO and represent a simple and effective alternative to other methods of urinary diversion. They avoid the need for external tubes and contribute to improved patient satisfaction.
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http://dx.doi.org/10.1089/end.2020.0469DOI Listing
January 2021

Surgical Approach to Abdominal Tumors Involving the Inferior Vena Cava.

Isr Med Assoc J 2020 Jun;22(6):364-368

Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Background: Abdominal tumors invading the inferior vena cava (IVC) present significant challenges to surgeons and oncologists.

Objectives: To describe a surgical approach and patient outcomes.

Methods: The authors conducted a retrospective analysis of surgically resected tumors with IVC involvement by direct tumor encasement or intravascular tumor growth. Patients were classified according to level of IVC involvement, presence of intravascular tumor thrombus, and presence of hepatic parenchymal involvement.

Results: Study patients presented with leiomyosarcomas (n=5), renal cell carcinoma (n=7), hepatocellular carcinoma (n=1), cholangiocarcinoma (n=2), Wilms tumor (n=1), neuroblastoma (n=1), endometrial leiomyomatosis (n=1), adrenocortical carcinoma (n=1), and paraganglioma (n=1). The surgeries were conducted between 2010 and 2019. Extension of tumor thrombus above the hepatic veins required a venovenous bypass (n=3) or a full cardiac bypass (n=1). Hepatic parenchymal involvement required total hepatic vascular isolation with in situ hepatic perfusion and cooling (n=3). Circular resection of IVC was performed in five cases. Six patients had early postoperative complications, and the 90-day mortality rate was 10%. Twelve patients were alive, and six were disease-free after a mean follow-up of 1.6 years.

Conclusions: Surgical resection of abdominal tumors with IVC involvement can be performed in selected patients with acceptable morbidity and mortality. Careful patient selection, and multidisciplinary involvement in preoperative planning are key for optimal outcome.
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June 2020

Extracorporeal ureter handling during laparoscopic pyeloplasty: tips and tricks for beginners.

Cent European J Urol 2019 6;72(4):413-417. Epub 2019 Dec 6.

Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.

Introduction: Laparoscopic preparation of the ureter is a challenging part of upper urinary tract reconstruction, due to limited depth perception provided by the camera and lack of wristed motion of most laparoscopic instruments needed for adequate spatulation and scar tissue removal. One solution has been to perform the more difficult portions of the surgery in an extracorporeal manner. A hybrid intracorporeal-extracorporeal approach to upper tract ureteral reconstruction facilitates ureteral preparation at the stage of mastering the technique.

Material And Methods: This retrospective study included 100 patients with primary ureteropelvic junction obstruction, who underwent laparoscopic pyeloplasty from 2014 to 2017. The patients were stratified into 2 groups: those who underwent conventional laparoscopic surgery and those who were managed with the hybrid approach. For the hybrid approach, externalizing the ureter to skin level required additional mobilization of the upper urinary tract.

Results: A total of 47 patients underwent conventional laparoscopic pyeloplasty and 53 - hybrid surgery. The maximum body mass index was 32. The hybrid approach was 8.5 minutes shorter compared to the conventional approach (p <0.001). No complications higher than Clavien-Dindo IIIb (n = 2) were observed (in both groups). Complete success (the resolution of pain and/or hydronephrosis) was observed in 92.5% in the hybrid group and in 95.7% in the conventional treatment group.

Conclusions: Hybrid pyeloplasty may be considered safe and effective. It has the advantage of making the surgery less challenging and time-consuming while offering improved precision. The advantages of the technique are particularly apparent during training. This technique can be recommended in the learning process of the surgeon.
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http://dx.doi.org/10.5173/ceju.2019.0022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6979559PMC
December 2019

Editorial Comment.

J Urol 2020 04 26;203(4):765-766. Epub 2019 Dec 26.

Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

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http://dx.doi.org/10.1097/JU.0000000000000579.01DOI Listing
April 2020

Head-to-Head Comparison of Ga-PSMA-11 with F-PSMA-1007 PET/CT in Staging Prostate Cancer Using Histopathology and Immunohistochemical Analysis as a Reference Standard.

J Nucl Med 2020 04 27;61(4):527-532. Epub 2019 Sep 27.

Department of Nuclear Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

F-PSMA-1007 is a novel prostate-specific membrane antigen (PSMA)-based radiopharmaceutical for imaging prostate cancer (PCa). The aim of this study was to compare the diagnostic accuracy of F-PSMA-1007 with Ga-PSMA-11 PET/CT in the same patients presenting with newly diagnosed intermediate- or high-risk PCa. Sixteen patients with intermediate- or high-risk PCa underwent F-PSMA-1007 and Ga-PSMA-11 PET/CT within 15 d. PET findings were compared between the 2 radiotracers and with reference-standard pathologic specimens obtained from radical prostatectomy. The Cohen κ-coefficient was used to assess the concordance between F-PSMA-1007 and Ga-PSMA-11 for detection of intraprostatic lesions. The McNemar test was used to assess agreement between intraprostatic PET/CT findings and histopathologic findings. Sensitivity, specificity, positive predictive value, and negative predictive value were reported for each radiotracer. SUV was measured for all lesions, and tumor-to-background activity was calculated. Areas under receiver-operating-characteristic curves were calculated for discriminating diseased from nondiseased prostate segments, and optimal SUV cutoffs were calculated using the Youden index for each radiotracer. PSMA-avid lesions in the prostate were identified in all 16 patients with an almost perfect concordance between the 2 tracers (κ ranged from 0.871 to 1). Aside from the dominant intraprostatic lesion, similarly detected by both radiotracers, a second less intense positive focus was detected in 4 patients only with F-PSMA-1007. Three of these secondary foci were confirmed as Gleason grade 3 lesions, whereas the fourth was shown on pathologic examination to represent chronic prostatitis. This pilot study showed that both F-PSMA-1007 and Ga-PSMA-11 identify all dominant prostatic lesions in patients with intermediate- or high-risk PCa at staging. F-PSMA-1007, however, may detect additional low-grade lesions of limited clinical relevance.
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http://dx.doi.org/10.2967/jnumed.119.234187DOI Listing
April 2020

[Ga]Ga-PSMA-11 PET/CT for monitoring response to treatment in metastatic prostate cancer: is there any added value over standard follow-up?

EJNMMI Res 2019 Aug 29;9(1):84. Epub 2019 Aug 29.

Department of Nuclear Medicine, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, 6 Weizmann St, 6423906, Tel-Aviv, Israel.

Background: The aim of the current study was to assess whether and to what extent monitoring response to treatment using prostate-specific membrane antigen (PSMA)-based positron-emitting tomography/computerized tomography (PET/CT) studies contribute clinically relevant data to routine clinical follow-up during treatment of patients with metastatic prostate cancer (PCa).

Results: Fifty-two patients with metastatic PCa who underwent [Ga]Ga-PSMA-11 PET/CT imaging and serum prostate-specific antigen (PSA) level measurements before and during treatment were investigated. Response was categorized by serum PSA dynamics according to improvement, stable disease, and disease progression and compared to change in imaging findings on pre- and post-treatment PET/CTs. McNemar's test was used to assess agreement between PET/CT- and PSA-based responses to treatment. Thirty-four patients (65.4%) had compatible biochemical- and imaging-based response to treatment. However, the imaging and biochemical responses were discrepant in 18/52 patients (34.6%). PET/CT showed progressive disease in 5/52 patients (9.6%) and improvement/stable disease in 13/52 (25%) compared to biochemical assessment results. Discrepancy between imaging and biochemical response was most prominent in biochemically stable patients (90.9%), followed by patients with biochemical progression (33.3%), and in only few (8.7%) patients with biochemical improvement. The imaging-based response was suitable for choosing subsequent treatment in 22 of 30 patients (73.3%) with longer follow-up (median time of 10.3 months (IQR 6.3-18.2)). The relevance of the imaging methodology was reflected by its ability to assess individual lesions in cases of heterogeneous lesion responses, reveal the appearance of new lesions, and identify lesions that required specific consideration, such as targeted radiotherapy.

Conclusions: Results of this retrospective analysis showed that biochemical responses to treatment and [Ga]Ga-PSMA-11 PET/CT-based responses to treatment differ in one third of metastatic PCa patients. The latter additionally enabled lesion-based and not solely patient-based analysis. Monitoring response during treatment by [Ga]Ga-PSMA-11 PET/CT is suitable for decision-making in patient management and choice of treatment in the majority of patients.
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http://dx.doi.org/10.1186/s13550-019-0554-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715755PMC
August 2019

68Ga-PSMA PET/CT: Does it predict adverse pathology findings at radical prostatectomy?

Urol Oncol 2019 09 14;37(9):574.e19-574.e24. Epub 2019 Jun 14.

Department of Urology, Tel-Aviv Sourasky Medical Center, Sackler School Of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel.

Introduction: Data on the accuracy of 68Ga-PSMA positron emission tomography/computed tomography (PET/CT) in patients with intermediate/high-risk prostate cancer are being accumulated. Its role in assessing the extent of local disease has not been fully elaborated.

Aim: To determine the performance characteristics of 68Ga-PSMA PET/CT in identifying local disease extension in patients with intermediate/high risk prostate cancer.

Methods: 68Ga-PSMA PET/CT studies of 61 consecutive patients with intermediate/high-risk prostate cancer who underwent radical prostatectomy were reviewed by nuclear medicine specialists. Tumor location, extraprostatic extension (EPE), seminal vesicle invasion (SVI), and lymph nodes involvement (LNI) were compared to pathological findings. The incremental value of 68Ga-PSMA PET/CT to established nomograms was determined.

Results: Two patients without pathologic uptake of 68Ga-PSMA were excluded. Seventeen patients were diagnosed with EPE (29%), 12(20%) had SVI and 3(5%) LNI. The concordance between tumor location and 68Ga-PSMA PET/CT findings was 48%, and EPE was not indicated by PET in any of the patients. The sensitivity, specificity, positive, and negative predictive value for SVI were 58%, 96%, 78%, 90%, respectively (area under the receiver operating characteristic curve = 0.77) and for LNI 67%, 98%, 67%, 98%, respectively (area under the receiver operating characteristic curve = 0.82). Incorporating imaging findings into the MSKCC-SVI nomogram enhanced the diagnostic accuracy from 0.84 to 0.95 (Integrated Discrimination Increment 0.24, P = 0.004).

Conclusion: In patients with intermediate/high-risk prostate cancer, 68Ga-PSMA PET/CT provides information regarding intraprostatic tumor location, SVI and LNI but has no role in assessment for EPE. This information might be useful for pretreatment counseling, decision-making and possibly preoperative planning.
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http://dx.doi.org/10.1016/j.urolonc.2019.05.015DOI Listing
September 2019

Radical prostatectomy performed via robotic, transperitoneal and extraperitoneoscopic approaches: functional and early oncological outcomes.

Cent European J Urol 2018 30;71(4):378-385. Epub 2018 Oct 30.

Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.

Introduction: Oncological remission along with high postoperative functionality [continence and erectile function (EF)] are the main aspects of prostate cancer (PCa) treatment. The aim of this study was to compare functional and oncological treatment results achieved after a nerve-sparing radical prostatectomy (RP) via transperitoneal (TPRP), extraperitoneal (EPRP) and robot-assisted (RARP) approach.

Material And Methods: From March 2015 to March 2016, 507 RP were performed at the Institute for Urology and Reproductive Health (Moscow, Russia). A total of 264 patients with localized (cТ1а-2с) prostate cancer [prostate-specific antigen (PSA) <20 ng/ml, Gleason score ≤7], intact prostate capsule (according to MRI), International Index of Erectile Function (IIEF-5) ≥19 and a life expectancy >10 years were included into the retrospective study. All the surgeries were performed by a single surgeon. The outcomes were evaluated after urethral catheter removal and 3-6-12 months after RP.

Results: Nerve preservation (NP) was performed for 153 patients without significant distinctions in time (р = 0.064) and blood loss (р = 0.073). The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-SF) score was lower for NP: 9.23 ±6.59 and 3.86 ±5.38 after 3 and 12 months respectively compared with continence after RP without nerve preservation (NP): 14.27 ±5.1 vs. 6.15 ±4.76 (р <0.001). Continent was 52.2% vs. 83.3% vs. 81.8% in TPRP, RARP and EPRP groups; р <0.001. IIEF-5 scores were 14.67 ±9.4, 4.2 ±4.26 and 4.0 ±2.07 after RARP, TPRP and EPRP respectively (р = 0.002). After 12 months the PSA: TPRP = 0.11 ±0.19, RARP = 0.03 ±0.05 and EPRP = 0.53 ±1.87 ng/ml (р <0.001). Outcomes depend on surgical approach and was better in the RARP-group (AUC = 0.768 ±0.034 (CI 95% 0,701-0.834; р <0.001).

Conclusions: We suggest RARP with NP as a method of choice for treatment of prostate cancer in patients interested in preservation of EF and quality of life in general.
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http://dx.doi.org/10.5173/ceju.2018.1739DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6338822PMC
October 2018

Heat shock proteins 60 and 70 are associated with long-term outcome of T1-stage high-grade urothelial tumors of the bladder treated with intravesical Bacillus Calmette-Guérin immunotherapy.

Urol Oncol 2018 12 15;36(12):531.e9-531.e17. Epub 2018 Oct 15.

Department of Urology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objectives: High-grade nonmuscle-invasive urothelial tumors of the bladder that fail intravesical Bacillus Calmette-Guérin (BCG) immunotherapy are at the highest risk of progression. Initial evidence links heat shock protein expression levels and outcome of bladder cancer after BCG treatment. We aimed to determine the association between HSP60, 70, and 90 expression levels and long-term outcomes of T1 high-grade (T1HG) urothelial bladder tumors treated with BCG immunotherapy.

Materials And Methods: Data of 54 consecutive patients with primary T1HG bladder tumors who underwent transurethral resection between 2002 and 2008 and received at least an induction course of BCG were reviewed. Immunohistochemical staining for heat shock protein (HSP)60, 70, and 90 were performed on resected specimens. Study outcomes included disease recurrence and progression. The association between HSP expression levels and outcomes were evaluated with univariable and multivariable Cox proportional hazards models.

Results: During a median follow-up of 9.6 years, 25 patients had a disease recurrence and 14 patients a disease progression. Estimated 5-year recurrence and progression-free survival were 59% and 81%, respectively. On multivariable analyses, HSP60 staining >65% was associated with a higher risk for progression (hazard ratio [HR] = 3.96, 95% confidence interval [CI] 1.35-11.58, P = 0.012), and HSP70 staining >5% was associated with a decreased risk for progression (HR = 0.33, 95% CI 0.11-0.98, P = 0.045), and recurrence (HR = 0.29, 95% CI 0.13-0.65, P = 0.003). HSP90 expression was not associated with disease recurrence or progression. Five patients had both a HSP60 staining >65% and a HSP70 staining ≤5% all of whom recurred at a median time of 6 months (interquartile range 3, 16) and 80% of whom progressed at a median time of 26 months (interquartile range 5, 60).

Conclusions: HSP60 and 70 cellular expression levels are associated with long-term outcome following BCG treatment of T1HG urothelial bladder tumors. These findings, if further validated, may be used to better stratify the risk of disease recurrence and progression in this group of patients.
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http://dx.doi.org/10.1016/j.urolonc.2018.09.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6289697PMC
December 2018

Predictors of surgical site infection after radical cystectomy: should we enhance surgical antibiotic prophylaxis?

World J Urol 2019 Jun 15;37(6):1137-1143. Epub 2018 Sep 15.

Department of Urology, Beilinson Hospital, Rabin Medical Center and Tel Aviv University Sackler School of Medicine, Petah Tikva, Israel.

Purpose: To compare surgical site infections (SSI) rate after radical cystectomy (RC) over time and ascertain whether antibiotic prophylaxis should be enhanced.

Methods: All medical records of RC patients in a single tertiary uro-oncology center between 2007 and 2017 were analyzed. SSI was defined using the criteria of the US Centers for Disease Control and Prevention. All bacterial culture results and antimicrobial resistance rates were recorded. Lastly, multivariable logistic regression analysis was performed to ascertain SSI predictors.

Results: RC was performed in 405 patients, of which 96 (23.7%) developed SSI. No differences were demonstrated in the mean age, gender, NIDDM prevalence, neoadjuvant chemotherapy, positive preoperative urine culture, bowel preparation, and surgery time between both groups. However, statistically significant higher median BMI, age-adjusted Charlson Comorbidity score, usage of ceftriaxone preoperatively, and intensive care unit (ICU) hospitalization were noted in SSI patients. Overall, 62/96 (63.5%) SSI patients had a positive wound culture, with only 16.7% of the pathogens being sensitive to their perioperative antibiotics. Lastly, on multivariable analysis rising BMI, preoperative ceftriaxone and ICU hospitalization were associated with a higher SSI rate.

Conclusions: Preoperative BMI reduction, and maximal preoperative medical optimization in an attempt to lower ICU admittance rates, should be part of the ideal strategy for lowering SSI rates. Additionally, preoperative antibiotics should be enhanced to harbor-wide spectrum coverage, based on local resistance rates.
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http://dx.doi.org/10.1007/s00345-018-2482-5DOI Listing
June 2019

Author Reply.

Urology 2018 08 6;118:112-113. Epub 2018 Jun 6.

Division of Urology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

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http://dx.doi.org/10.1016/j.urology.2018.04.042DOI Listing
August 2018

Patient Compliance With Maintenance Intravesical Therapy for Nonmuscle Invasive Bladder Cancer.

Urology 2018 08 21;118:107-113. Epub 2018 May 21.

Division of Urology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: To assess patient adherence to intravesical instillation therapy for nonmuscle invasive urothelial carcinoma outside of clinical trials.

Materials And Methods: We reviewed the records of patients from 2000 to 2013 who received intravesical therapy for nonmuscle invasive urothelial carcinoma. Patients with evidence of tumor recurrence or progression were excluded. We performed univariable and multivariable regression analyses to predict adherence to intravesical therapy.

Results: A total of 729 patients started 861 induction cycles, 63% with bacillus Calmette-Guèrin (BCG) and 37% with mitomycin C (MMC). The rate of completion of 6 weeks induction therapy with BCG and MMC was similar (86% and 87%, respectively). Within the BCG cohort, 161 (35%) patients commenced the Southwest Oncology Group (SWOG) maintenance protocol after induction and 16 (10%) completed all 21 treatments. A monthly protocol for BCG was started by 87 patients (19%) and 48 (55%) completed all 9 treatments. MMC therapy was started in 270 patients, 97 of whom (36%) commenced monthly maintenance treatment, and 46 (47%) completed treatments. Median number of instillations was 7 for patients undergoing monthly maintenance therapy (MMC or BCG) and 9 for patients allocated to 3 years BCG. On multivariable analysis, recurrence after prior treatment of urothelial carcinoma was predictive of patients' adherence to treatment.

Conclusion: Compliance with intravesical therapy is low in clinical practice, notably for longer treatment schedules.
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http://dx.doi.org/10.1016/j.urology.2018.04.039DOI Listing
August 2018

Toward Respiratory-Gated Retrograde Intrarenal Surgery: A Prospective Controlled Randomized Study.

J Endourol 2018 09 21;32(9):812-817. Epub 2018 Jun 21.

1 Endourology Unit, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv, Israel .

Introduction: We set out to investigate whether general anesthesia with low ventilation (LV, respiratory rate ≤8/minute and tidal volume <500 mL) could reduce renal mobility and thereby facilitate improved retrograde intrarenal surgery (RIRS) compared with general anesthesia with standard ventilation (SV).

Materials And Methods: All 60 consecutive patients who presented for RIRS in our department from September 1, 2017 to December 31, 2017 were prospectively randomized 1:1 into one group that was selected to receive SV and another that received LV. Significant factors influencing the study endpoints considered fragmentation rate (FR), removal rate (RR), processing rate (PR), and operating rate (OR), were statistically analyzed for the whole group as well as for comparison by level of surgeon expertise.

Results: Univariate analysis revealed that LV was a significant factor in improving all endpoints. Some endpoints were also affected by the stone's volume, number, and density as well as the surgeon expertise. LV remained the single independent factor for FR, RR, and PR in the multivariate analysis. LV significantly improved all four of the fellows' endpoints (p < 0.05 for each) and positively influenced the expert's RR (p = 0.04), PR (p = 0.02) and OR (p = 0.04). The performance gap between the fellows and the experts narrowed under LV. The end-tidal CO was significantly higher in the LV group (50 vs 36 mm Hg; p < 0.0001), however, without any clinical significance. The overall stone-free rate (97%) and complication rate (5%) were not significantly different between the two groups. The patient's anesthesia-related safety was not affected by the mode of ventilation as evidenced by no need to convert from LV to SV during the procedures.

Conclusions: LV during RIRS has a significant positive impact on the overall improvement of surgical performance and effectiveness. It does not negatively affect the patient's anesthesia-related safety and may contribute to considerably improving the performance of in-training endourologists.
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http://dx.doi.org/10.1089/end.2018.0231DOI Listing
September 2018

Urinary Tract Infections After Urinary Diversion-Different Occurrence Patterns in Patients With Ileal Conduit and Orthotopic Neobladder.

Urology 2018 Jun 4;116:87-92. Epub 2018 Apr 4.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Objective: To compare the incidence rate of urinary tract infections (UTIs) and associated pathogens between patients with ileal conduit and patients with orthotopic neobladder urinary diversion.

Patients And Methods: The medical records of 179 patients treated with radical cystectomy between 2006 and 2011 were reviewed and data pertaining to postoperative UTI were collected. UTI incidence was reported at 3 months' intervals and compared by diversion type. Preoperative predictors of UTI were evaluated with Cox regression analyses.

Results: The study cohort included 130 patients with ileal conduit and 49 patients with orthotopic neobladder. Patients with a neobladder were younger (P <.001). Median follow-up was 38 months (IQR [interquartile range], 11-63). Median time from surgery to first infection was 1.5 months (IQR, 1-12.5) for patients with a neobladder and 11 months (IQR, 2.5-27) for patients with a conduit (P = .04). During the first 3 months after surgery, 29% of the patients with a neobladder and 8% of the patients with ileal conduit had a UTI episode (P = .001). Rates of UTI did not differ during subsequent follow-up. Diversion type was not associated with UTI on multivariable analysis. Escherichia coli was the most common pathogen in patients with a conduit (58%), and Klebsiella spp. in patients with a neobladder (29%).

Conclusion: The risk of UTI is significantly higher in patients with a neobladder during the first 3 months after surgery and comparable to patients with ileal conduit during subsequent follow-up. These findings may facilitate preoperative counseling regarding the expected risk of UTI after urinary diversion.
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http://dx.doi.org/10.1016/j.urology.2018.03.042DOI Listing
June 2018

How Prevalent is Hydronephrosis Secondary to Acute Appendicitis: A Cross-Sectional Study.

Isr Med Assoc J 2018 Mar;20(3):141-144

Division of Surgery, Rabin Medical Center (Beilinson Campus), Petah Tikva, associated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Right hydronephrosis secondary to acute appendicitis is an under-reported phenomenon with only several case reports published.

Objectives: To assess the incidence of this phenomenon in our database of patients diagnosed with acute appendicitis.

Methods: Data were collected on 1092 patients who underwent surgery due to acute appendicitis between 2003 and 2007 in our tertiary medical center. The data entailed demographic, surgical, and hospitalization parameters including ultrasound or computed tomography examinations and presence of right hydronephrosis prior to surgery.

Results: Out of 1092 patients, appendicitis was eventually diagnosed in 87.4% of the patients. Only 594 (54%) had preoperative imaging performed prior to surgery (ultrasound or computed tomography). Out of these 594 patients, 21 (3.5%) had a new right hydronephrosis diagnosed and all had appendicitis with 15/21 (71%) having a retrocecal appendix. Of those with retrocecal appendix, 10 were pregnant women (48%). Erythrocyturia was present in 15/21 patients (71%) and in 10/11 of patients (91%) after excluding those who were pregnant. No significant differences were seen in patients with hydronephrosis regarding age, hospitalization, and surgery time. In all patients, an ultrasound was performed 2 weeks after surgery demonstrating the disappearance of hydronephrosis. Median follow-up time was 41.7 months (range 14.8-118.4 months).

Conclusions: Our study shows that 3.5% of our cohort had right hydronephrosis secondary to acute appendicitis. Although this presentation is very rare, physicians should be aware of this phenomenon and the risk for delayed diagnosis and treatment of acute appendicitis.
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March 2018

Diagnostic Needle Biopsies in Renal Masses: Patient and Physician Perspectives.

Eur Urol Focus 2018 09 23;4(5):749-753. Epub 2016 Nov 23.

Institute of Urology, Rabin Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: The utility of renal mass biopsies (RMB) in the diagnosis of kidney tumors remains debatable.

Objective: To assess patient and urologist preferences regarding the utilization of RMB.

Design, Setting, And Participants: Seventy-three patients diagnosed with renal tumors and 59 board-certified urologists were asked to participate in an interview-based study.

Outcome Measurements And Statistical Analysis: Using the standard gamble method we determined the minimal accepted accuracy at which RMB would be favored as part of the diagnostic process. Clinical and demographic data with potential to affect participants' preferences were analyzed.

Results And Limitations: At the time of the study interview, 56 patients (77%) were referred for kidney surgery and 17 (23%) opted for surveillance. Overall, 59% of the patients accepted some level of inaccuracy (1-20%), whereas 27% refuted a biopsy. Anxiety associated with the possibility of missing cancer was the primary determinant (82%) for declining RMB among patients referred for surgery, while fear of complications was the primary reason (58%) among those undergoing surveillance. Having an academic degree was associated with a lower accuracy threshold (p=0.03). Of the 59 participating urologists, 39% were reluctant to recommend RMB, primarily because of its inexorable nondiagnostic rate.

Conclusions: Most patients and urologists would favor RMB to facilitate their definitive treatment decision. Diagnostic accuracy of 95% was acceptable by the majority of study participants. The utility of RMB as part of the diagnostic algorithm for renal tumors should be discussed with patients, emphasizing its potential benefits and limitations.

Patient Summary: Although needle biopsy seems to be an effective tool to differentiate benign from malignant kidney lesions, it is not commonly used. Our study shows that most patients would opt for a biopsy before definitive treatment decision despite its imperfect accuracy. Hence, the option of undergoing renal biopsy should be discussed with all patients diagnosed with small renal tumors.
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http://dx.doi.org/10.1016/j.euf.2016.11.003DOI Listing
September 2018

Nitric oxide charged catheters as a potential strategy for prevention of hospital acquired infections.

PLoS One 2017 14;12(4):e0174443. Epub 2017 Apr 14.

ENOX Ltd., Habarzel 38, Tel-Aviv, Israel.

Background: Catheter-Associated Hospital-Acquired Infections (HAI's) are caused by biofilm-forming bacteria. Using a novel approach, we generated anti-infective barrier on catheters by charging them with Nitric Oxide (NO), a naturally-produced gas molecule. NO is slowly released from the catheter upon contact with physiological fluids, and prevents bacterial colonization and biofilm formation onto catheter surfaces.

Aims And Methods: The aim of the study was to assess the anti-infective properties of NO-charged catheters exposed to low concentration (up to 103 CFU/ml) of microbial cells in-vitro. We assessed NO-charged tracheal tubes using Pseudomonas aeruginosa, dialysis and biliary catheters using Escherichia coli, and urinary catheters using E. coli, Candida albicans or Enterococcus faecalis. Safety and tolerability of NO-charged urinary catheters were evaluated in a phase 1 clinical study in 12 patients. Six patients were catheterized with NO-charged catheters (NO-group), followed by 6 patients catheterized with regular control catheters (CT-group). Comparison of safety parameters between the study groups was performed.

Results: NO-charged tracheal, dialysis biliary and urinary catheters prevented P. aeruginosa, E. coli and C. albicans attachment and colonization onto their surfaces and eradicated corresponding planktonic microbial cells in the surrounding media after 24-48 hours, while E. faecalis colonization onto urinary catheters was reduced by 1 log compared to controls. All patients catheterized with an NO-charged urinary catheter successfully completed the study without experiencing NO-related AE's or serious AE's (SAE's).

Conclusion: These data highlight the potential of NO-based technology as potential platform for preventing catheter-associated HAI's.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0174443PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5391919PMC
April 2017

Re: Effectiveness of Adjuvant Chemotherapy for Locally Advanced Bladder Cancer.

Eur Urol 2016 07 18;70(1):204. Epub 2016 Apr 18.

Department of Urology, Rabin Medical Center, Petah Tikva, Israel. Electronic address:

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http://dx.doi.org/10.1016/j.eururo.2016.03.058DOI Listing
July 2016

Update of the ICUD-SIU consultation on upper tract urothelial carcinoma 2016: treatment of low-risk upper tract urothelial carcinoma.

World J Urol 2017 Mar 27;35(3):355-365. Epub 2016 May 27.

Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1373, Houston, TX, 77030, USA.

Introduction: The conservative management of upper tract urothelial carcinoma (UTUC) has historically been offered to patients with imperative indications. The recent International Consultation on Urologic Diseases (ICUD) publication on UTUC stratified treatment allocations based on high- and low-risk groups. This report updates the conservative management of the low-risk group.

Methods: The ICUD for low-risk UTUC working group performed a thorough review of the literature with an assessment of the level of evidence and grade of recommendation for a variety of published studies in this disease space. We update these publications and provide a summary of that original report.

Results: There are no prospective randomized controlled studies to support surgical management guidelines. A risk-stratified approach based on clinical, endoscopic, and biopsy assessment allows selection of patients who could benefit from kidney-preserving procedures with oncological outcomes potentially similar to radical nephroureterectomy with bladder cuff excision, with the added benefit of renal function preservation. These treatments are aided by the development of high-definition flexible digital URS, multi-biopsies with the aid of access sheaths and other tools, and promising developments in the use of adjuvant topical therapy.

Conclusions: Recent developments in imaging, minimally invasive techniques, multimodality approaches, and adjuvant topical regimens and bladder cancer prevention raise the hope for improved risk stratification and may greatly improve the endoscopic treatment for low-risk UTUC.
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http://dx.doi.org/10.1007/s00345-016-1859-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5554604PMC
March 2017

Curing Lymph Node Metastasis in Prostate Cancer: The Ongoing Battle Between Improving Surgical Quality and Tumor Biology.

Eur Urol Focus 2017 04 12;3(2-3):256-257. Epub 2016 May 12.

Department of Urology, Rabin Medical Center, Petach-Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address:

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http://dx.doi.org/10.1016/j.euf.2016.04.004DOI Listing
April 2017
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