The decision to proceed with radical prostatectomy has to be supported with biopsy-proven prostate cancer. However, when a patient has persistently multiple negative prostate biopsies and a high PSA, a serious diagnostic and therapeutic dilemma arises. The PIRADS score generated by the multiparametric-MRI of the prostate provides a guide for a template biopsy using MRI-ultrasound fusion technology, with the hope of minimizing a false negative result. Fluorine-18 Prostate-Specific Membrane Antigen (18F-PSMA) PET CT scan, on the other hand, is used mainly for staging prostate cancer after biochemical recurrence. The use of 18F-PSMA PET CT in the primary clinical diagnosis of prostate cancer has never been reported.The authors performed radical prostatectomy on a 66-year-old HIV-positive male with suspicious lesion on 18F-PSMA, PIRADS 5 on mp-MRI, and a persistently elevated PSA >100 despite multiple negative biopsies. The final histopathological analysis confirmed the presence of adenocarcinoma of the prostate, Gleason 7 (3+4), with negative margins. There were no intraoperative complications, and the patient was discharged in good condition. On follow-up, he had a nadir PSA of 0.058 ng/ml, has partial incontinence, and decreased erectile function and was advised phosphodiesterase inhibitors. 18F-PSMA may be utilized in the decision process for patients who are highly suspected with malignancy but have no preoperatively biopsy-proven cancer after multiple negative biopsies.

INTRODUCTION AND OBJECTIVE

The endoscopic management of staghorn calculi is very challenging owing to its complex anatomical configuration. The authors analyzed the clinical efficacy and safety of a single upper pole access PCNL (SUPA-PCNL) for Guy Stone Score (GSS) 3-4 staghorn calculi.

METHODS

Prospective data collection was done on 56 consecutive patients who with GSS 3-4 staghorn calculi. All cases were treated with a standardized technique of a single upper pole access PCNL in the prone position. The patient demographics, stone characteristics, perioperative and postoperative outcomes were analyzed.

RESULTS

The cohort exhibited diversity in age (51.7+12), gender (male to female ratio of 5.5:4.5) comorbidities, and stone burden (4.82+1.96 cm). SUPA-PCNL demonstrated a high median stonefree rate (99.5%, IQR 90-100) with minimal complications, low blood loss with a of 200cc (IQR 100-300), and median hospital stay of 3.5 days (IQR 3-5). Stone characteristics did not significantly influence outcomes. A subset required secondary treatments (12%, n=7), but overall morbidity was low (16%, n=9): (7% n=4) of which required blood transfusion, and (9% n=5) due to sepsis. The following factors were associated with increased odds of perioperative morbidity: preoperative creatinine >3 mg/dl (OR 4.19 95% Cl 0.59 – 29.71 p=0.152) and a history of endoscopic surgery (OR 7.33 95% Cl 1.20-44.96 p=0.031).

CONCLUSION

SUPA-PCNL is effective and safe for the treatment of staghorn calculi. In select patients, this approach obviates the need for a multi-tract access or an endoscopically-combined intrarenal surgery (ECIRS).

Human ; Nephrolithotomy, Percutaneous ; Morbidity ; Staghorn Calculi