Management of urolithiasis in pregnancy

Urolithiasis is the most common cause of nonobstetric abdominal pain,resulting in 1.7 admissions per 1000 deliveries.Urolithiasis most commonly occurs in the second and third trimesters,with an incidence between 1∶125 and 1∶2000.Acute urinary system obstructions are challenging to manage in obstetric patients because they contribute to physiological and anatomical changes that result in patho-logical outcomes.The restricted use of computed tomography in diagnosing and managing urolithiasis is particularly challenging.In ad-dition,a prompt diagnosis is required because the presence of renal calculi during pregnancy increases the risk of fulminating sepsis and preterm delivery.Affected pregnancies are conservatively managed;however,1 in 4 requires surgical intervention.Indications for surgi-cal interventions are complex and range from nephrostomy insertion to empirical stent placement or ureteroscopy.Therefore,a multi-disciplinary approach is required to optimize patient care.The diagnosis and management of urolithiasis in pregnancy are complex.We reviewed the role,safety,advantages and disadvantages of diagnostic tests and treatment used to manage acute urinary obstructions in pregnancy.

Single tertiary cancer center experience on the management of pT3b prostate cancer after robotic-assisted laparoscopic prostatectomy

Background:Pathological involvement of the seminal vesicle poses a treatment dilemma following robotic prostatectomy.Margin status plays an important role in deciding further management.A wide range of treatment options are available,including active monitoring,adjuvant radiotherapy,salvage radiotherapy,and occasionally androgen deprivation therapy.Patients undergoing postoperative radiotherapy tend to have higher risk of urinary and bowel morbidities.The recent RADICALS-RT concluded that adjuvant radiotherapy did not have any benefit compared with salvage radiotherapy.We aim to audit the incidence,margin status,and management of T3b cancer cases at our center.Materials and methods:A retrospective analysis was conducted of all patients diagnosed with pathological T3b(pT3b)prostate cancer following robotic-assisted laparoscopic prostatectomy from January 2012 to July 2020.Preoperative parameters analyzed included prostate-specific antigen(PSA),T stage,and age.A chi-square test and 2-tailed t test were used to determine the relationship between categorical and continuous variables,respectively.Kaplan-Meier survival curves were generated to assess overall survival in patients with pT3b prostate cancer and used to compare unadjusted progression-free survival among those who underwent adjuvant and salvage radiotherapy.Results:A total of 83(5%)of 1665 patients who underwent robotic prostatectomy were diagnosed with pT3b prostate cancer between January 2012 and July 2020.Among these,36 patients(44%)did not receive any radiotherapy during follow-up,compared with 26 patients(31%)who received adjuvant radiotherapy and 21(25%)who received salvage radiotherapy.The median age of our cohort was 64(SD,6.4)years.Mean PSA at presentation was 12.7 pg/L.Positive margins were seen in 36 patients(43%);however,there was no statistically significant difference between treatment groups(p=0.49).The median overall survival was 96%.There was no significant difference between the adjuvant and salvage groups in terms of biochemical progression-free survival(p=0.66).Five-year biochemical progression-free survival was 94%for those in the adjuvant radiotherapy group and 97%for those in the salvage radiotherapy group.Conclusions:Our audit corroborates with the recently concluded RADICALS-RT study,although we had fewer patients with positive margins.Radiotherapy can be avoided in patients with T3b prostate cancer,even if margin is positive,until there is definitive evidence of PSA recurrence.In keeping with the conclusion of RADICALS-RT,salvage radiotherapy may be preferable to adjuvant radiotherapy.

Modern methods in managing urachal adenocarcinoma

Objectives:We sought to evaluate modern diagnostic and treatment options for urachal adenocarcinoma(UAC)and to provide clarity regarding the available options and their outcomes for this poorly understood yet damaging disease.Material and methods:We conducted a systematic literature search in PubMed and Medline focusing on updated management of UAC.Results:Surgical intervention continues to be the mainstay of treatment for localized UAC.However,with the increased availability of molecular and genetic profiling,chemotherapy has consistently demonstrated promising response rates and survival outcomes,especially for a disease that commonly presents in a metastatic stage.The role of checkpoint inhibitors remains under investigation.Cross-sectional imaging is vital during postoperative surveillance.However,there may also be a role for the adoption of cystoscopy to detect bladder recurrence.Conclusions:Although the importance of surgical resection remains unchanged,improved survival outcomes with chemotherapy have been found in small retrospective studies.Randomized trial data are required to further assess the influence of systemic treatment as a primary or adjuvant therapy.Moreover,a stringent follow-up regimen incorporating evaluation for distant and local recurrence of UAC must be evaluated and adopted.

The role of imaging in immunoglobulin G4-related disease of the upper urinary tract

Background:Immunoglobulin G4-related disease remains a modern,relatively unknown field in the urological world.An increasing number of cases require urological input,often with invasive diagnostics and aggressive medical treatment first-line.Given this,we sought to evaluate modern radiological options of disease affecting the upper urinary tract,to provide clarity and reduce diagnostic burden and delay in this poorly understood yet potentially debilitating disease process.Summary:We conducted a systematic literature search including PubMed and Medline,focusing on immunoglobulin G4-related disease affecting the upper urinary tract,before reviewing articles assessing different radiological modalities in diagnosis.Consistent computed tomography findings have been demonstrated in the literature and contributed to recent breakthroughs in classification criteria,however invasive biopsy remains a mainstay in work-up,given the difficulties in comparing against malignancy.Early work in positron-emission tomography and magnetic resonance imaging has shown promise in radiologically distinguishing from other differentials,especially diffusion-weighted imaging showing high sensitivity levels,but not yet enough to formulate protocols and cause histological investigation to be redundant.Key messages:Our article has highlighted repeated findings in the literature of computed tomography appearances of lgG4-RD in the upper urinary tract,however invasive work-up remains a mainstay given the overlap with malignancy.Prospective,comparative studies into magnetic resonance imaging and positron-emission tomography are now required,given their early results,to improve consistency in reporting and reduce patient burden when investigating this benign,yet debilitating disease process.