Background and objective:There is an unmet need to avoid long-term morbidity associated with standard cytotoxic treatment for low-volume metastatic seminoma. Our aim was to assess the oncological efficacy and surgical safety of retroperitoneal lymph node dissection (RPLND) as treatment in a population-based cohort of metastatic seminoma patients with limited retroperitoneal lymphadenopathy. Methods:Sixty-two seminoma patients in Norway and Sweden were included in the cohort from 2019 to 2022. Patients with lymphadenopathy ≤3 cm, having primary clinical stage (CS) IIA/B or CS I with a relapse, were operated with uni- or bilateral template RPLND, open or robot assisted. The outcome measures included surgical complications as per Clavien-Dindo, and Kaplan-Meier survival estimates for 24-mo progression-free survival (PFS) and overall survival (OS). Key findings and limitations:In the cohort, 33 (53%) had CS I with a relapse during surveillance, six (10%) CS I with a relapse following adjuvant chemotherapy, and 23 (37%) initial CS IIA/B. Metastatic seminoma was verified in 58 patients (94%) with a median largest diameter of 18 mm (interquartile range [IQR] 13-24). Robot-assisted RPLND was performed in 40 patients (65%). Clavien-Dindo III complications were observed in three patients (5%); no grade ≥IV complications occurred. Eighteen patients (29%) received adjuvant chemotherapy after surgery. The median follow-up was 23 mo (IQR 16-30), and recurrence occurred in six patients (10%) after a median of 8 mo (IQR 4-14). PFS was 90% (95% confidence interval: 0.86-1) and OS was 100% at 24 mo. Conclusions and clinical implications:RPLND as primary treatment is an option for selected low-stage seminomas with a limited burden of disease, showing low complications and low relapse rates, with the potential to reduce long-term morbidity. Patient summary:In seminoma patients with limited metastatic spread, surgery is a treatment option offering an alternative to chemotherapy or radiation. This paper covers the first 62 patients operated in Norway and Sweden.

You have accessJournal of UrologyPenile & Testicular Cancer I (MP01)1 May 2024MP01-08 MicroRNA-371a-3p (miR371a) SERUM LEVELS TO PREDICT THE PRESENCE OF METASTATIC LYMPH NODES IN MARKER NEGATIVE CLINICAL STAGE IIA/B SEMINOMA Axel Heidenreich, Anna Thor, Anders Kjellmann, Anna Grenabo Bergdahl, Mette-Pernille Myklebust, Aditya Bragodia, John Laffin, Bendu Konneh, Felix Seelemeyer, and David Pfister Axel HeidenreichAxel Heidenreich , Anna ThorAnna Thor , Anders KjellmannAnders Kjellmann , Anna Grenabo BergdahlAnna Grenabo Bergdahl , Mette-Pernille MyklebustMette-Pernille Myklebust , Aditya BragodiaAditya Bragodia , John LaffinJohn Laffin , Bendu KonnehBendu Konneh , Felix SeelemeyerFelix Seelemeyer , and David PfisterDavid Pfister View All Author Informationhttps://doi.org/10.1097/01.JU.0001008660.87408.90.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nerve sparing retroperitoneal lymph node dissection (RPLND) has emerged as a treatment alternative in marker negative CS IIA/B seminomas. However, about 10-15% of all patients harbour nonmetastatic lymph nodes at time of RPLND so that reliable biomarkers are of importance to stratify treatment. miR371a represents a new biomarker with diagnostic and predictive properties. The aim of our study was to evaluate the predictive accuracy of miR371a to identify metastatic lymph nodes. METHODS: 50 patients with marker negative CS IIA/B seminomas underwent primary RPLND with a modified template dissection. Blood specimens were drawn on the day immediately prior to surgery. For single institution measurements, cubital vein blood was placed on ice and processed within 30 minutes for extraction of miR371a. The extracted miR371a was transcribed into cDNA using cDNA Solution, Reverse Transcriptase and RNase Inhibitor. Subsequently, this cDNA was amplified. Using qPCR, the miR371a was quantified using Roche Lightcycler 480 II. The median Cp (CP=Crossing Points) of the triplicates is calculated and converted into a RQ value (RQ=Relative Frequency), which indicates whether the sample is positive or negative. RESULTS: Median age was 35.3 (21-52) years. At time of RPLND, 38 (76%) and 12 (24%) pts presented in CS IIA and CS IIB, resp. Median number of dissected lymph nodes was 27.3 (14-63), median number of positive nodes was 1.2 (1-4). A total of 4 (8%) and 46 (92%) pts had benign lymph node pathology or seminomatous metastases, resp. The median size of positive lymph nodes was 24.2 (2.5-45) mm. miR371 was negative in 4/4 (100%) pts with negative nodes and it was positive in 38/46 (82.6%) metastatic lymph nodes. Sensitivity and specificity, positive and negative predictive values varied between single and multicenter approaches (Table 1). CONCLUSIONS: miR371 has a high predictive value to identify CS IIA/B seminomas with lymph node metastases and it might be used to stratify active treatment versus active surveillance. However, negative miR371 findings are highly reliable to identify pN0 disease but false negative findings might also be due to logistic challenges. These findings have to be kept in mind when using miR371 in the decision making process for treatment strategies. Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e4 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Axel Heidenreich More articles by this author Anna Thor More articles by this author Anders Kjellmann More articles by this author Anna Grenabo Bergdahl More articles by this author Mette-Pernille Myklebust More articles by this author Aditya Bragodia More articles by this author John Laffin More articles by this author Bendu Konneh More articles by this author Felix Seelemeyer More articles by this author David Pfister More articles by this author Expand All Advertisement PDF downloadLoading ...

Objective: Several risk factors for end-stage renal disease (ESRD), in patients undergoing surgical treatment for renal cell carcinoma (RCC), have been suggested by others. This study aimed to investigate such risk factors and disclose the effect of developing ESRD, postoperatively, on overall survival. The risk of developing ESRD after RCC diagnosis was also evaluated. Material and methods: The data of 16,220 patients with RCC and 162,199 controls were extracted from the Renal Cell Cancer Database Sweden, with linkages across multiple national registers between 2005 and 2020. Cox proportional hazards regression, Kaplan–Meier curves and cumulative incidence were used for statistical analysis. Results: The 5-year cumulative incidence of ESRD following RCC diagnosis was 2.4% (95% confidence interval [CI] 2.1–2.6) and 0.4% (95% CI 0.3–0.4) for the patients with RCC and controls, respectively. Age, chronic kidney disease, higher T-stage and radical nephrectomy (RN) were significant risk factors for ESRD within 1-year of surgery. A total of 104 and 12,152 patients with and without ESRD, respectively, survived 1-year postoperatively. The 5-year overall survival rates of patients with ESRD and those with RCC only were 50% (95% CI 0.40–0.60) and 80% (95% CI 0.80–0.81), respectively. Conclusions: Patients who developed ESRD following renal cancer surgery had significantly poorer survival outcomes. Advanced age, comorbidities, higher-stage tumours and RN were identified as risk factors for developing ESRD. Surgical decisions are crucial. Efforts to spare renal function, including nephron-sparing surgery and active surveillance in appropriate cases, are highly relevant to reduce the development of severe kidney dysfunction.

Objectives To assess whether extended surveillance with repeated computed tomography (CT) scans for patients with clinical stage IIA (CS IIA; <2 cm abdominal node involvement) and negative markers (Mk−) non‐seminomatous germ cell tumours (NSGCTs) can identify those with true CS I. To assess the rate of benign lymph nodes, teratoma, and viable cancer in retroperitoneal lymph node dissection (RPLND) histopathology for patients with CS IIA Mk− NSGCT. Patients and methods Observational prospective population‐based study of patients diagnosed 2008–2019 with CS IIA Mk− NSGCT in the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) registry. Patients were managed with surveillance, with CT scans, and tumour markers every sixth week for a maximum of 18 weeks. Patients with radiological regression were treated as CS I, if progression with chemotherapy, and remaining CS IIA Mk− disease with RPLND. The end‐point was the number and percentage of patients down‐staged to CS I on surveillance and rate of RPLND histopathology presented as benign, teratoma, or viable cancer. Results Overall, 126 patients with CS IIA Mk− NSGCT were included but 41 received therapy upfront. After surveillance for a median (range) of 6 (6–18) weeks, 23/85 (27%) patients were in true CS I and four (5%) progressed. Of the remaining 58 patients with lasting CS IIA Mk− NSGCT, 16 received chemotherapy and 42 underwent RPLND. The RPLND histopathology revealed benign lymph nodes in 11 (26%), teratoma in two (6%), and viable cancer in 29 (70%) patients. Conclusions Surveillance with repeated CT scans can identify patients in true CS I, thus avoiding overtreatment. The RPLND histopathology in patients with CS IIA Mk− NSGCT had a high rate of cancer and a low rate of teratoma.

Purpose:The SWENOTECA-MIR prospective multicenter study aims to assess the clinical value of miR-371a-3p as a novel marker in metastatic germ cell tumor patients undergoing retroperitoneal lymph node dissection (RPLND), to predict the presence of viable residual tumor.Materials and Methods:A total of 114 patients (86 nonseminomas, 28 seminomas) who underwent surgery for presumed metastatic disease pre chemotherapy (primary RPLND) and post chemotherapy RPLND were included. The expression of miR-371a-3p was evaluated using reverse transcription-digital droplet polymerase chain reaction before and after RPLND. Pre- and postoperative miR-371a-3p levels were statistically compared, and optimism-corrected performance calculations compared with conventional serum tumor markers. Associations were evaluated by logistic regression. Patients who underwent primary RPLND were categorized into seminoma and nonseminoma groups.Results:Among the seminoma patients (n = 24) undergoing primary RPLND, all had normal conventional markers. Six patients received adjuvant treatment before surgery. miR-371a-3p exhibited a sensitivity of 74%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 21% for viable tumor. The levels of miR-371a-3p significantly decreased after surgery. In the nonseminoma group (n = 18) treated with primary RPLND, 22% had elevated conventional markers and 3 had received prior adjuvant treatment. miR-371a-3p showed a sensitivity of 34%, specificity of 88%, positive predictive value of 67%, and negative predictive value of 62% for the primary nonseminoma patients. No association was observed between stage or prior adjuvant treatment and the outcome of the miR test. In the postchemotherapy group (n = 72), the miR-371a-3p sensitivity was 9%, reducing to 0 when excluding patients with seminoma (n = 4). Teratomas and benign histology were essentially negative.Conclusions:Our study highlights miR-371a-3p as a fairly sensitive and highly specific marker for prechemotherapy seminomas, outperforming conventional markers. However, in prechemotherapy nonseminomas as well as in postchemotherapy patients, we observed low sensitivity and no significant differences in miR-371a-3p levels before and after surgery, suggesting limited utility for miR-371a-3p in this context.

Objective To validate Vergouwe's prediction model using the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) RETROP database and to define its clinical utility. Materials and methods Vergouwe's prediction model for benign histopathology in post‐chemotherapy retroperitoneal lymph node dissection (PC‐RPLND) uses the following variables: presence of teratoma in orchiectomy specimen; pre‐chemotherapy level of alpha‐fetoprotein; β‐Human chorionic gonadotropin and lactate dehydrogenase; and lymph node size pre‐ and post‐chemotherapy. Our validation cohort consisted of patients included in RETROP, a prospective population‐based database of patients in Sweden and Norway with metastatic nonseminoma, who underwent PC‐RPLND in the period 2007–2014. Discrimination and calibration analyses were used to validate Vergouwe's prediction model results. Calibration plots were created and a Hosmer–Lemeshow test was calculated. Clinical utility, expressed as opt‐out net benefit (NB opt‐out ), was analysed using decision curve analysis. Results Overall, 284 patients were included in the analysis, of whom 130 (46%) had benign histology after PC‐RPLND. Discrimination analysis showed good reproducibility, with an area under the receiver‐operating characteristic curve (AUC) of 0.82 (95% confidence interval 0.77–0.87) compared to Vergouwe's prediction model (AUC between 0.77 and 0.84). Calibration was acceptable with no recalibration. Using a prediction threshold of 70% for benign histopathology, NB opt‐out was 0.098. Using the model and this threshold, 61 patients would have been spared surgery. However, only 51 of 61 were correctly classified as benign. Conclusions The model was externally validated with good reproducibility. In a clinical setting, the model may identify patients with a high chance of benign histopathology, thereby sparing patients of surgery. However, meticulous follow‐up is required.

Objective: Nationwide register data provide unique opportunities for real-world assessment of complications from different surgical methods. This study aimed to assess incidence of, and predictors for, post-operative complications and to evaluate 90-day mortality following different surgical procedures and thermal ablation for renal cell carcinoma (RCC).Material and methods: All patients undergoing surgical treatment and thermal ablation for RCC in Sweden during 2015–2019 were identified from the National Swedish Kidney Cancer Register. Frequencies and types of post-operative complications were analysed. Logistic regression models were used to identify predictors for 90-day major (Clavien-Dindo grades III–V) complications, including death.Results: The overall complication rate was 24% (1295/5505), of which 495 (8.7%) were major complications. Most complications occurred following open surgery, of which bleeding and infection were the most common. Twice as many complications were observed in patients undergoing open surgery compared to minimally invasive surgery (20% vs. 10%, P < 0.001). Statistically significant predictors for major complications irrespective of surgical category and technique were American society of anesthiologists (ASA) score, tumour diameter and serum creatinine. Separating radical and partial nephrectomy, surgical technique remained a significant risk factor for major complications. Most complications occurred within the first 20 days. The overall 90-day readmission rate was 6.2%, and 30- and 90-day mortality rates were 0.47% and 1.5%, respectively.Conclusions: In conclusion, bleeding and infection were the most common major complications after RCC surgery. Twice as many patients undergoing open surgery suffer a major post-operative complication as compared to patients subjected to minimally invasive surgery. General predictors for major complications were ASA score, tumour size, kidney function and surgical technique.

The SARS-CoV-2 virus is currently causing a global pandemic. Infection may result in a systemic disease called COVID-19, affecting primarily the respiratory tract. Often the gastrointestinal tract and kidneys also become involved. Angiotensin converting enzyme 2 (ACE2) serves as the receptor for SARS-CoV-2. The membrane proteins, Transmembrane serine protease 2 (TMPRSS2) and Neuropilin 1 (NRP1) are accessory proteins facilitating the virus entry. In this study we show that the human proximal kidney tubules, express these factors. We hypothesized that cancers derived from proximal tubules as clear cell (CCRCC) and papillary renal cell carcinoma (PRCC), retain the expression of the SARS-CoV-2 entry factors making these cancers susceptible to SARS-CoV-2 infection. We used bioinformatics, western blotting, and assessment of tissue micro arrays (TMA) including 263 cases of CCRCC, 139 cases of PRCC and 18 cases of chromophobe RCC to demonstrate that the majority of CCRCC and PRCC cases retained the RNA and protein expression of the entry factors for SARS-CoV-2. We furthermore show that SARS-CoV-2 virus propagated robustly in primary cultures of CCRCC and PRCC cells with a visible virus cytopathogenic effect correlating with viral RNA expression levels. We also noted that the delta-variant of SARS-CoV-2 causes cancer cells to form syncytia in-vitro. This phenomenon was also identified histologically in CCRCC tissue from a patient that had been hospitalized for COVID-19, twelve months prior to nephrectomy. Our data provide insights into SARS-CoV-2 infectivity in renal cell carcinoma and that the virus causes a distinct cytopathogenic effect.

You have accessJournal of UrologyCME1 Apr 2023MP33-04 THE EARLY RESULTS OF THE SWENOTECA (SWEDISH NORWEGIAN TESTICULAR CANCER GROUP) INTRODUCTION OF PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION (RPLND) IN SEMINOMA STAGE IIA-IIB ≤ 3cm Anna Thor, Axel Gerdtsson, Bjarte Almas, Dag Halvorsen, Gabriella Cohn Cedermark, Helene Neegaard, Ingrid Glimelius, Hege Sagstuen Haugnes, Asa Karlsdottir, Olof Stahl, Signe Melsen Larsen, Anna Grenabo Bergdahl, Torgrim Tandstad, and Anders Kjellman Anna ThorAnna Thor More articles by this author , Axel GerdtssonAxel Gerdtsson More articles by this author , Bjarte AlmasBjarte Almas More articles by this author , Dag HalvorsenDag Halvorsen More articles by this author , Gabriella Cohn CedermarkGabriella Cohn Cedermark More articles by this author , Helene NeegaardHelene Neegaard More articles by this author , Ingrid GlimeliusIngrid Glimelius More articles by this author , Hege Sagstuen HaugnesHege Sagstuen Haugnes More articles by this author , Asa KarlsdottirAsa Karlsdottir More articles by this author , Olof StahlOlof Stahl More articles by this author , Signe Melsen LarsenSigne Melsen Larsen More articles by this author , Anna Grenabo BergdahlAnna Grenabo Bergdahl More articles by this author , Torgrim TandstadTorgrim Tandstad More articles by this author , and Anders KjellmanAnders Kjellman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003266.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Chemotherapy or radiotherapy have been the standard treatment for stage II seminomas with excellent results for survival but associated with significant long-term treatment-related toxicities. Several prospective trials have shown primary retroperitoneal lymph node dissection (RPLND) to be effective and safe as an alternative treatment. These results made us change the guidelines in the latest update of the SWENOTECA treatment program making surgery with RPLND the primary treatment modality in seminoma stage IIA to IIB ≤ 3 cm with 1-2 metastatic nodes. We have done an update of the result of the patients treated by the new management program. METHODS: The RPLND surgery in Sweden and Norway are centralised to 5 hospitals all participating in this study. In the study we included both patients with recurrence after initial stage I disease and patients with stage IIA and B at diagnosis. The patients were operated between 2019 and 2022. We collected information on operation time, bleeding, peri- and postoperative complications. We also analysed the histology and if adjuvant chemotherapy was given. We followed the patients for any recurrence of disease. RESULTS: We have included 61 patients operated from January 2019 to September 2022. The number of operations per site varied from 4 to 22. The mean age of patients at time of RPLND was 42.6 years (range 25-79). 38 patients had stage I disease at diagnosis and a recurrence. 23 patients had stage IIA or IIB disease at diagnosis. At time of RPLND 46 patients had IIA-disease and 14 stage IIB-disease (one missing data). The histology from RPLND showed seminoma in 56 patients, necrosis in two patients, teratoma in one patient (two missing data). 24 patients were operated with robotic laparoscopic technique. Seven patients out of 61 had a Clavien-Dindo postoperative complication > 2. The patients have been followed for a median of 17 months (range 2-45). Five patients have had recurrences, three in operated template and two outside templates. CONCLUSIONS: Our early results of primary RPLND of seminomas IIA-IIB ≤ 3 cm, show promising results. Longer follow-up is required to fully ensure that this is a safe treatment option. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e451 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anna Thor More articles by this author Axel Gerdtsson More articles by this author Bjarte Almas More articles by this author Dag Halvorsen More articles by this author Gabriella Cohn Cedermark More articles by this author Helene Neegaard More articles by this author Ingrid Glimelius More articles by this author Hege Sagstuen Haugnes More articles by this author Asa Karlsdottir More articles by this author Olof Stahl More articles by this author Signe Melsen Larsen More articles by this author Anna Grenabo Bergdahl More articles by this author Torgrim Tandstad More articles by this author Anders Kjellman More articles by this author Expand All Advertisement PDF downloadLoading ...

OBJECTIVE:To evaluate the long-term efficacy of selective arterial embolisation in renal angiomyolipoma (AML), with emphasis on tumour shrinkage, potential regrowth and the necessity of supplementary procedures.  Material and methods: A retrospective review of all 58 consecutive embolisations at two institutions, between 1999 and 2018, was performed. Clinical notes, laboratory data and imaging were reviewed.RESULTS:The overall complication rate was 6.8%, with no Clavien-Dindo grades III-V complications. Kidney function was unaffected by embolisation as measured by creatinine. Median radiological follow-up was 4.8 years (interquartile range [IQR]: 2.8-7.8), and median clinical follow-up was 7.5 years (IQR: 4.7-14.0). Decreasing AML size was observed in 96% of procedures. Maximal shrinkage (30% median diameter decrease; IQR: 15-44) was reached after median 2.2 years (IQR: 0.6-4.8). During follow-up, regrowth occurred in 38% of patients, and four bleeding episodes occurred in three patients with tuberous sclerosis. Growing size and/or rebleeding prompted a redo embolisation in 9% of spontaneous AML and 50% of tuberous sclerosis-associated AML.CONCLUSIONS:Being a well-tolerated treatment with few complications, selective arterial embolisation renders a pronounced size-reduction in most patients with AML, and kidney function is preserved. Regrowth is common, and a radiological follow-up is necessary. Tuberous sclerosis is a risk factor for the need of reintervention.

Background: Chemotherapy or radiotherapy have been standard treatment for stage II seminomas with excellent survival but are associated with significant long-term treatment-related toxicities. Several prospective trials have shown primary retroperitoneal lymph node dissection (RPLND) to be an effective and safe alternative. The current SWENOTECA treatment program recommends primary RPLND in seminoma stage IIA to IIB ≤ 3 cm with 1-2 metastatic nodes as the standard treatment modality. We present preliminary results combined with data from Cologne. Methods: Within SWENOTECA, RPLND is centralized to 5 hospitals and Cologne is a tertiary centre for patients recruited from different parts of Germany. Both patients with recurrence after initial stage I disease and patients with primary stage IIA and IIB at diagnosis were included. We collected information on operation time, bleeding, peri- and postoperative complications. We also analyzed histologic outcome and whether adjuvant chemotherapy was given. We followed the patients for any recurrence of disease. Results: We have included 94 patients operated from May 2018 to November 2022. The number of operations per site varied from 4 to 28. The mean age of patients at time of RPLND was 41.8 years (range 21-79). Overall, 54 patients had recurrence after initial stage I disease and 40 patients had primary stage IIA/IIB disease at diagnosis (one missing data). At time of RPLND 62 patients had IIA-disease and 31 stage IIB-disease (one missing data). The histology from RPLND showed seminoma in 83 patients, benign/necrosis in eight patients, vital non-seminomatous GCT in one patient, teratoma only in one patient and lymphoma in one patient. Mean number of resected nodes was 19, and mean number of positive nodes were 1.5. Twenty-six patients (28%) were operated with robotic laparoscopic technique. Ten patients (10.6%) had a Clavien-Dindo postoperative complication > 2. Twenty-three of the patients were given adjuvant oncological treatment after RPLND, most of them one course of BEP. The patients have been followed for in median 18 months (range 2-59). Nine patients (9.6 %) have had recurrences, all but one in the first year after RPLND. Conclusions: Our early results of primary RPLND of seminomas IIA-IIB ≤ 3 cm are promising. Longer follow-up is required to ensure this as a safe treatment option.

Abstract Objectives We aim to determine if robot‐assisted retroperitoneal lymph node dissection (R‐RPLND) can be performed as a safe option to open RPLND in selected patients with metastatic germ cell cancer. Patients and methods This population‐based prospective study was performed at a one of two national referral centres for RPLND in Sweden. All patients referred during January 2017–March 2021 were screened for possible inclusion. R‐RPLND was performed using the Da Vinci Xi surgical system. Perioperative parameters, postoperative complications (Clavien–Dindo), final pathology, preservation of antegrade ejaculation and relapse rates were evaluated. Classifiers for selecting patients to open versus robotic RPLND were analysed by logistic regression modelling. The median follow‐up was 23 months. Results Of 87 patients referred, 29 were selected for R‐RPLND, 19 in a post‐chemotherapy setting. In median, retroperitoneal tumour diameter was 18 mm, BMI 24 kg/m2, operative time 433 min, estimated blood loss 50 ml and length of stay 3 days. One patient underwent open conversion due to failure to progress. Four patients had Clavien–Dindo grade 3 complications, of which three were chylous‐related. No in‐field recurrences occurred during follow‐up. Conclusion This population‐based study suggests that R‐RPLND can be safely performed in at least one third of patients referred for an RPLND. A relatively high rate of lymph‐leakage may represent a potential drawback. Tumour size may be the most important discriminator when deciding on robotic versus open RPLND. Further studies with longer follow‐up are needed to validate the results.

You have accessJournal of UrologyCME1 May 2022PD51-07 PREDICTING THE HISTOPATHOLOGY RESULT OF POST-CHEMO RETROPERITONEAL LYMPH NODE DISSECTION (PC-RPLND) Axel Gerdtsson, Anna Thor, Anna Grenabo Bergdahl, Helene Negaard, Bjarte Almås, Ingrid Glimelius, Åsa Karlsdottir, Dag Halvorsen, Kristine Engen Andreassen, Signe Melsen Larsen, Rolf Wahlqvist, Hege Saagstuen Haugnes, Torgrim Tandstad, Göran Holmberg, Gabriella Cohn Cedermark, Olof Ståhl, Gustav Thorison, and Anders Kjellman Axel GerdtssonAxel Gerdtsson More articles by this author , Anna ThorAnna Thor More articles by this author , Anna Grenabo BergdahlAnna Grenabo Bergdahl More articles by this author , Helene NegaardHelene Negaard More articles by this author , Bjarte AlmåsBjarte Almås More articles by this author , Ingrid GlimeliusIngrid Glimelius More articles by this author , Åsa KarlsdottirÅsa Karlsdottir More articles by this author , Dag HalvorsenDag Halvorsen More articles by this author , Kristine Engen AndreassenKristine Engen Andreassen More articles by this author , Signe Melsen LarsenSigne Melsen Larsen More articles by this author , Rolf WahlqvistRolf Wahlqvist More articles by this author , Hege Saagstuen HaugnesHege Saagstuen Haugnes More articles by this author , Torgrim TandstadTorgrim Tandstad More articles by this author , Göran HolmbergGöran Holmberg More articles by this author , Gabriella Cohn CedermarkGabriella Cohn Cedermark More articles by this author , Olof StåhlOlof Ståhl More articles by this author , Gustav ThorisonGustav Thorison More articles by this author , and Anders KjellmanAnders Kjellman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002622.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: PC-RPLND for metastatic non-seminoma is a challenging procedure. In up to 50% of patients undergoing PC-RPLND, the histopathology results reveal necrosis/fibrosis, and the surgery was hence not necessary. Several different prediction models have been introduced with the aim of selecting the right patients for surgery. The aim of this study was to try to improve the most used model (by Vergouwe) by adding new variables and to test it on our Swedish Norwegian Testicular Cancer Group (SWENOTECA) RETROP data. RETROP is a population-based dataset of patients with non-seminoma that underwent PC-RPLND between 2007 and 2014. METHODS: Patients with Non-Seminoma Germ Cell Tumour (NSGCT) in Sweden and Norway that underwent PC-RPLND between 1st September 2007 and 1st September 2014 were included. Information for the study regarding teratoma in orchiectomy specimen, lymph node size pre and post chemotherapy, AFP, HCG and LDH levels before chemotherapy, chemotherapy given, Royal Marsden clinical stage, prognostic group according to the IGCCCG and histopathology results from PC-RPLND were obtained at time of surgery, from SWENOTECA register and chart review.Statistical analysisDiscrimination and calibration analyses were used to validate Vergouwes results. Calibration plots were created and Hosmer–Lemeshow test was calculated. Clinical utility expressed as Net benefit were analyzed using Decision curve analysis.The original algoritm was trained with Random Forest, a machine learning program. Additional data such as IGCCCG prognostic group, Royal Marsden clinical stage, number of chemotherapy courses, AFP, HCG and lymph node shrinkage as continuous variables with non-linear restricted cubic spines were added. RESULTS: In total 284 patients met the criteria to be included in this study.Discrimination analysis showed good reproducibility with AUC of 0.819 (95% CI 0.765 – 0.863) compared to Vergouwes original study in 2007 with AUC between 0.77 and 0.84. The calibration plot, as well as Hosmer-Lemeshow test (p = 0.44) showed good calibration.For patients with post-chemo lymph nodes between 10-19 mm, 14 % would be classified as false negatives using the model with a 70% prediction level.Machine learning did not improve the model. CONCLUSIONS: The model was validated in this material with good reproducibility. For clinical use the model needs further development with new variables. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e845 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Axel Gerdtsson More articles by this author Anna Thor More articles by this author Anna Grenabo Bergdahl More articles by this author Helene Negaard More articles by this author Bjarte Almås More articles by this author Ingrid Glimelius More articles by this author Åsa Karlsdottir More articles by this author Dag Halvorsen More articles by this author Kristine Engen Andreassen More articles by this author Signe Melsen Larsen More articles by this author Rolf Wahlqvist More articles by this author Hege Saagstuen Haugnes More articles by this author Torgrim Tandstad More articles by this author Göran Holmberg More articles by this author Gabriella Cohn Cedermark More articles by this author Olof Ståhl More articles by this author Gustav Thorison More articles by this author Anders Kjellman More articles by this author Expand All Advertisement PDF downloadLoading ...

Background: The distribution of retroperitoneal lymph node metastases for patients with nonseminoma and a residual tumour of 10-49 mm in a population-based setting is unknown. This information is needed to justify selection of patients for a unilateral template resection. Objective: To describe the location of retroperitoneal metastases and recurrences in patients with nonseminoma germ cell tumour (NSGCT) with a residual tumour of 10-49 mm. Design, setting, and participants: RETROP is a population-based prospective observational mapping study of 213 patients in Sweden and Norway with a retroperitoneal residual tumour of 10-49 mm who underwent postchemotherapy retroperitoneal lymph node dissection for metastatic NSGCT during 2007-2014 with median follow-up of 100 mo. Patients were classified according to the testis primary tumour and the distribution of unilateral or bilateral lymph node metastases (with reference to the aorta) present on pre- and/or postchemotherapy computed tomography (CT) scans. Outcome measurements and statistical analysis: The distribution and rate of teratoma or cancer in unilateral or bilateral retroperitoneal fields and the location and rate of retroperitoneal recurrence were measured. Results and limitations: In total, 65% of the patients had unilateral retroperitoneal lymph node metastases (RLNMs) on CT scans. Patients with unilateral RLNMs had a low risk of contralateral teratoma or cancer (1.6% for right- and 2.6% for left-sided NSGCT) or retroperitoneal recurrence (0% for right- and 4% for left-sided NSGCT). A weakness of the study is that the pathology specimen could not be fully designated to one specific area for some of the patients. Conclusions: Men with postchemotherapy residual disease of 10-49 mm and unilateral metastases on pre- and postchemotherapy CT scans have a low risk of contralateral disease and should be considered for a unilateral template resection. Patient summary: The surgeon can use computed tomography (CT) scans in deciding on the extent of lymph node dissection in patients with testicular cancer. (c) 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.

OBJECTIVE:This study examined whether previously reported results, indicating that prostate-specific antigen (PSA) screening can reduce prostate cancer (PC) mortality regardless of sociodemographic inequality, could be corroborated in an 18 year follow-up. MATERIALS AND METHODS:In 1994, 20,000 men aged 50-64 years were randomized from the Göteborg population register to PSA screening or control (1:1) (study ID: ISRCTN54449243). Men in the screening group (n = 9950) were invited for biennial PSA testing up to the median age of 69 years. Prostate biopsy was recommended for men with PSA ≥2.5 ng/ml. Last follow-up was on 31 December 2012. RESULTS:In the screening group, 77% (7647/9950) attended at least once. After 18 years, 1396 men in the screening group and 962 controls had been diagnosed with PC [hazard ratio 1.51, 95% confidence interval (CI) 1.39-1.64]. Cumulative PC mortality was 0.98% (95% CI 0.78-1.22%) in the screening group versus 1.50% (95% CI 1.26-1.79%) in controls, an absolute reduction of 0.52% (95% CI 0.17-0.87%). The rate ratio (RR) for PC death was 0.65 (95% CI 0.49-0.87). To prevent one death from PC, the number needed to invite was 231 and the number needed to diagnose was 10. Systematic PSA screening demonstrated greater benefit in PC mortality for men who started screening at age 55-59 years (RR 0.47, 95% CI 0.29-0.78) and men with low education (RR 0.49, 95% CI 0.31-0.78). CONCLUSIONS:These data corroborate previous findings that systematic PSA screening reduces PC mortality and suggest that systematic screening may reduce sociodemographic inequality in PC mortality.

Anna Grenabo Bergdahl *, Ulrica Wilderang , Gunnar Aus , Sigrid Carlsson , Jan-Erik Damber , Maria Franlund , Kjell Geterud , Ali Khatami , Andreas Socratous , Johan Stranne , Mikael Hellstrom , Jonas Hugosson a Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden; Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Urology, Carlanderska Hospital, Gothenburg, Sweden; Department of Surgery (Urology Service), Memorial SloanKettering Cancer Centre, NY, USA; Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden

Background: Magnetic resonance imaging (MRI) and targeted biopsies (TB) have shown potential to more accurately detect significant prostate cancer compared with prostatespecific antigen (PSA) and systematic biopsies (SB). Objective: To compare sequential screening (PSA + MRI) with conventional PSA screening.Design, setting, and participants: Of 384 attendees in the 10th screening round of theGoteborg randomised screening trial, 124 men, median age 69.5 yr, had a PSA of >= 1.8 ng/ml and underwent a prebiopsy MRI. Men with suspicious lesions on MRI and/or PSA > 3.0 ng/ml were referred for biopsy. SB was performed blinded to MRI results and TB was performed in menwith tumour-suspicious findings on MRI. Three screening strategies were compared (PSA >= 3.0 + SB; PSA >= 3.0 + MRI + TB and PSA >= 1.8 + MRI + TB).Outcome measurements and statistical analysis: Cancer detection rates, sensitivity, and specificity were calculated per screening strategy and compared using McNemar's test.Results and limitations: In total, 28 cases of prostate cancer were detected, of which 20 were diagnosed in biopsy-naive men. Both PSA >= 3.0 + MRI and PSA >= 1.8 + MRI significantly increased specificity compared with PSA >= 3.0 + SB (0.92 and 0.79 vs 0.52; p < 0.002 for both), while sensitivity was significantly higher for PSA >= 1.8 + MRI compared with PSA >= 3.0 + MRI (0.73 vs 0.46, p = 0.008). The detection rate of significant cancer was higher with PSA >= 1.8 + MRI compared with PSA >= 3.0 + SB (5.9% vs 4.0%), while the detection rate of insignificant cancer was lowered by PSA >= 3.0 + MRI (0.3% vs 1.2%). The primary limitation of this study is the small sample of men.Conclusion: A screening strategy with a lowered PSAcut-off followed by TB in MRI-positive men seems to increase the detection of significant cancers while improving specificity. If replicated, these results may contribute to a paradigm shift in future screening.Patient summary: Major concerns in prostate-specific antigen screening are overdiagnosis and underdiagnosis. We evaluated whether prostate magnetic resonance imaging could improve the balance of benefits to harm in prostate cancer screening screening, and we found a promising potential of using magnetic resonance imaging in addition to prostate-specific antigen. (C) 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Although prostate-specific antigen (PSA)-based screening has been shown to reduce prostate cancer (PC)-specific mortality with large variations in mortality reduction with different screening algorithms, the optimal screening strategy has not yet been established. This thesis aims at exploring aspects of underdiagnosis in PC screening, focusing on the impact of screening failures on screening effectiveness. All of its papers are based on the Goteborg randomized PC screening trial except for Paper I, which also includes data from the Dutch center of the European Randomized Study of Screening for Prostate Cancer (ERSPC). Paper I analyzes the frequency of interval cancers (IC) between a 2and a 4-year screening interval, as high IC rates are recognized as a limitation for screening effectiveness in screening for other cancers. Extremely few IC cases were detected and no difference was found in cumulative incidences of IC with a 2and 4-year interval. In Paper II, the risk of PC death is compared between attendees and nonattendees in screening. A large proportion of PC deaths occurred in nonattendees, and the majority of attendees dying from PC were men aged !60 years when detected at their first (prevalence) screen. Paper III analyzes the PC incidence after screening cessation (due to upper age limit). Compared to the control arm, the incidence of potentially aggressive PC was reduced in the screening arm up to 9 years post-screening but thereafter approached the incidence of the control group. In Paper IV, multiparametric magnetic resonance imaging (mpMRI) was evaluated as a screening tool. A lowered PSA cut-off (1.8 ng/ml) + mpMRI followed by targeted biopsy yielded a higher detection rate of clinically significant PC compared with “conventional” screening (PSA, cut-off !3 ng/ml followed by systematic biopsy), requiring a decreased number of biopsies. In conclusion, better screening strategies are needed to improve on screening failures. One option may be to lower the PSA cut-off and introduce sequential testing with mpMRI to decide which men to refer for biopsy. Age at screening start and cessation greatly impacts efficiency; starting at age 60 is probably too late, and stopping at age 70 for all men is probably too early.