PI-RADS score v.2 in predicting malignancy in patients undergoing 5α-reductase inhibitor therapy.

BACKGROUND: To investigate if the PI-RADS score represents an effective tool in detecting prostate cancer in patients treated with a 5α-reductase inhibitor (dutasteride) and to identify dedicated total serum PSA and PSA density thresholds. METHODS: Between April 2015 and March 2018, 75 patients under dutasteride treatment underwent multi-parametric magnetic resonance imaging (mpMRI) scans and US/MRI fusion prostate biopsy. Lesions were classified into two groups: Group 1 included PI-RADS 4 and 5 lesions, whilst Group 2 included PI-RADS 3-4-5 lesions. Lesions in groups 1 and 2 were further divided according to the patients' history of previous prostate biopsy. RESULTS: Ninety-seven lesions were detected. In PI-RADS 4-5 group, mpMRI showed a sensitivity of 78.0% and a specificity of 78.7%. The positive predictive value (PPV) was 79.6% and the negative predictive value (NPV) 77.1%. In PI-RADS 3-4-5 group, sensitivity was 100%, specificity 21.3%, PPV 57.5%, NPV 100%. In PI-RADS 4-5 biopsy-naive group sensitivity was 71.4%, specificity 75.0%. PPV 78.9% and NPV 66.7%. In PI-RADS 4-5 non-biopsy-naive group sensitivity was 82.8%, specificity 80.6%, PPV 80%, and NPV 83.3%. PI-RADS 3-4-5 biopsy-naive group showed sensitivity 100%, specificity 31.3%, PPV 65.6%, NPV 100%. PI-RADS 3-4-5 non-biopsy-naive group showed sensitivity 100%, specificity 16.1%, PPV 52.7%, and NPV 100%. ROC curve analysis indicated a serum total PSA threshold of 6 ng/ml (AUC: 0.71-95% confidence interval: 0.60-0.81) and a PSA density >0.22 (AUC: 0.70-95% confidence interval: 0.6-0.81) as optimal cut-offs for recommending prostate biopsy. CONCLUSIONS: In our experience the PI-RADS score proved to be sufficiently accurate in predicting prostate cancer in patients under dutasteride therapy.

Uroflowmetry alterations in patients with autosomal dominant polycystic kidney disease.

OBJECTIVE: Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a heterogeneous inherited disease characterized by renal and extrarenal manifestations with progressive fluid-filled cyst development leading to end-stage renal disease. Our aim was to evaluate the prevalence of obstructive urological disease in ADPKD patients and possible associations with endothelial dysfunction, nutritional, metabolic and inflammatory markers. PATIENTS AND METHODS: The study included ADPKD patients and control group, who carried out uroflowmetry, an assessment of renal function, metabolic and nutritional parameters and an evaluation of endothelial dysfunction and atherosclerotic markers, such as Renal Resistive Index (RRI), Intima-Media Thickness (IMT) and Flow-Mediated Dilation (FMD). RESULTS: We enrolled 37 ADPKD patients (20 males with 51.0 ± 14.3 years) and 34 control group (18 males with 60.7 ± 14.4 years). We showed a significant reduction in Max Flow Rate (Qmax) (p ≤ 0.001), age (p = 0.006), FMD (p = 0.023) and Voiding Volume (p = 0.053), in addition to a significant increase in Voiding Time and Diastolic Blood Pressure (p ≤ 0.001, p = 0.049; respectively) in ADPKD patients with respect to control group. Moreover, we found a negative correlation between Qmax and creatinine (r= -0.44, p = 0.007), RRI (r= -0.49, p ≤0.001) and intact Parathyroid Hormone (r = -0.329, p = 0.046), while we found a positive correlation between Qmax and MDRD (r = 0.327, p = 0.048) and between Voiding Time and serum uric acid (r= 0.34, p = 0.039) in ADPKD patients with respect to control group. CONCLUSIONS: In our study, we showed an elevated prevalence of urological functional diseases in ADPKD patients; therefore, we suggest to include uroflowmetry in the assessment of these patients, considering the non-invasiveness, repeatability and low cost of the exam. An early intervention could slow down the progression of renal damage and an early screening of the main cardiovascular risk factors could reduce the high morbidity and mortality in ADPKD patients.

What is the role of contrast-enhanced ultrasound in the evaluation of the endoleak of aortic endoprostheses? A comparison between CEUS and CT on a widespread scale.

OBJECTIVE: To evaluate the accuracy of contrast-enhanced ultrasound (CEUS) in comparison to CT angiography (CTA) to identify and classify endoleaks following abdominal aortic aneurism repair with endoprosthesis. MATERIALS AND METHODS: A retrospective analysis of 181 patients treated with EVAR, from September 2009 to September 2014, was performed. Patients were evaluated with CEUS, CTA and angiography in the cases requiring treatment. Sac diameter, sac integrity, identification and classification of endoleaks were taken into consideration. Sensitivity, specificity, accuracy and negative predictive values were considered for each modality of endoleak identification. RESULTS: Forty-two endoleaks (23.2%; type II: 39 cases, type III: 3 cases) were documented. Sensitivity and specificity of CEUS and CT were, respectively, 97.6 and 90.5, 100 and 100%. In two cases, CEUS was able to better classify endoleaks compared to CT. CONCLUSIONS: CEUS accuracy to identify endoleaks following EVAR is similar to CT. CEUS should be considered as an effective modality for the long-term surveillance of EVAR because of its capability to correctly classify endoleaks with no ionizing radiation exposure.

Detection of small testicular masses in monorchid patients using US, CPDUS, CEUS and US-guided biopsy.

PURPOSE: Testis sparing surgery (TSS) is a well-known technique in the treatment of small testicular masses. Grayscale ultrasound (US), color/power Doppler US (CPDUS) and contrast-enhanced ultrasound (CEUS) are considered the best diagnostic imaging tools in those patients. Aim of this study was to assess the role of US imaging in the detection of small testicular masses in monorchid patients after orchiectomy for malignant neoplasm, and in guiding surgery to reach the target and also to differentiate lesions which presented vascular activity within the mass. METHODS: From January 2011 to October 2014, 18 patients were enrolled in this study. They had previously undergone orchiectomy and were investigated for suspected contralateral disease. During routine follow-up, all patients underwent grayscale US. If findings were positive, CPDUS and CEUS were performed and eventually all patients underwent surgery. After exteriorization of the testis, the small mass was identified by intraoperative US, and a needle was placed under US guidance. After excision of the mass, frozen section examination was performed. When malignancy was found, radical orchiectomy was performed; if histological outcome was negative, the healthy testis was conserved. RESULTS: All patients underwent grayscale US examination, which showed small hypoechoic masses. Each mass identified at US imaging was confirmed at surgery. All patients underwent CPDUS; 12/19 lesions showed blood flow while 7/19 showed absence of blood flow. At CEUS, 16/19 lesions showed enhancement and subsequent histological examination revealed that 8 were seminomas and 3 were Leydig cell tumors. In 5/19 cases CEUS showed the presence of lesions (focal inflammatory lesions) and in 3/19 cases CEUS was negative. CONCLUSIONS: TSS in monorchid patients may be a safe procedure leading to excellent results. We therefore consider it a valid alternative to radical orchiectomy, and US imaging is essential to guide the resection of non-palpable neoplasms and to exclude concomitant lesions.

Role of magnetic resonance spectroscopic imaging ([¹H]MRSI) and dynamic contrast-enhanced MRI (DCE-MRI) in identifying prostate cancer foci in patients with negative biopsy and high levels of prostate-specific antigen (PSA).

PURPOSE: The purpose of this study was to evaluate the role of magnetic resonance spectroscopic imaging (MRSI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in detecting tumour foci in patients with elevated prostate-specific antigen (PSA) and negative transrectal ultrasonography (TRUS)-guided biopsy. MATERIALS AND METHODS: This prospective randomised trial was conducted on 150 patients who underwent [¹H]MRSI and DCE-MRI and targeted biopsies of suspicious areas on MRI associated with random biopsies. RESULTS: After the second biopsy, the diagnosis of prostate adenocarcinoma was made in 64/150 cases. On a per-patient basis, MRSI had 82.8% sensitivity, 91.8% specificity, 88.3% positive predictive value (PPV), 87.8% negative predictive value (NPV) and 85.7% diagnostic accuracy. The sensitivity, specificity, PPV, NPV and accuracy for DCE-MRI was 76.5%, 89.5%, 84.5%, 83.7% and 82%, respectively. The combination of MRSI and DCE-MRI yielded 93.7% sensitivity, 90.7% specificity, 88.2% PPV, 95.1% NPV and 90.9% accuracy in detecting prostate carcinoma. CONCLUSIONS: The combined study with [¹H]MRSI and DCE-MRI showed promising results in guiding the biopsy of cancer foci in patients with an initial negative TRUS-guided biopsy.

64-detector row CT cystography with virtual cystoscopy in the detection of bladder carcinoma: preliminary experience in selected patients.

PURPOSE: This study was conducted to evaluate the role of computed tomography cystography (CTC) and virtual cystoscopy (VC) with 64-slice CT in diagnosing bladder lesions using flexible cystoscopy as the reference standard. MATERIALS AND METHODS: Twenty-eight patients with suspected bladder cancer and ten patients who had undergone transurethral resection of the bladder were studied by CTC and VC in both the supine and prone positions after distending the bladder with air. The patient population was divided into three groups based on lesion size at flexible cystoscopy. Results of the CT study were compared with those of flexible cystoscopy. RESULTS: Flexible cystoscopy depicted 88 bladder lesions in the 38 patients examined. Sensitivity and specificity values of CTC and VC alone were constantly lower than those of the combined-approach (group 1: 93.10% and 92.31%; group 2: 100% and 100%; group 3: 100% and 100%, respectively). Receiver operating characteristic (ROC) curve analysis showed that the combined approach decreases the lower dimensional threshold for lesion detection (1.4 mm). CONCLUSIONS: VC and CTC with 64-slice CT are promising diagnostic techniques for bladder cancers measuring 1-5 mm. Further studies on larger patient populations are required to validate our results.

Prostate cancer detection rate of transrectal ultrasonography, digital rectal examination, and prostate-specific antigen: results of a five-year study of 6- versus 12-core transperineal prostate biopsy.

AIM: The purpose of the present comparative work was the processing and assessment of data collected in a five-year period of urological practice with more than 1.500 transperineal, ultrasound-guided, prostatic biopsies performed. Our aim was to identify advantages and limitations of 6 and 12-core protocols, by extending the evaluation not only to cancer detection rate but also to the other histological findings. METHODS: A total of 1.151 patients were included in the study. Two subgroups were identified: 836 patients who had undergone a 6-core biopsy from 2001 to 2004, and 315 patients who had undergone a 12-core biopsy from 2005 to 2006. RESULTS: Cancer detection rate was 291/836 (34.8%) in group 1 (6-core biopsy), and 148/315 (47%) in group 2 (12-core biopsy) (P<0.0001). The total number of histological diagnoses other than cancer was 162/836 in group 1 (19.4%) and 103/315 (32.7%) in group 2 (P<0.0001). CONCLUSION: In prostate biopsy, a higher number of cores seems to definitely improve its diagnostic value by dramatically decreasing the number of negative findings. The 12-core technique is particularly effective in case of prostate-specific antigen (PSA) values ranging between 4.1 and 10 ng/mL combined with a free-to-total PSA ratio below 16%, in case of negative digital rectal examination and when serum prostate-specific antigen levels are lower than 4 ng/mL. On the other hand, in the case of abnormal digital rectal examination, especially when combined with high prostate-specific antigen levels and/or changes detected at transrectal ultrasound, the 6-core technique can be considered a reasonable strategy.

Percutaneous sclerotization of simple renal cysts with 95% ethanol followed by 24-48 h drainage with nephrostomy tube.

AIM OF THE STUDY: We propose some technique devices for treating simple renal cysts with percutaneous puncture (PCN) to reduce recurrences. MATERIALS AND METHODS: Between January 1995 and December 1998, a series of 42 patients, 13 females and 29 males, ranging in age between 49 and 73 were treated for symptomatic kidney cystic disease. The cysts varied between 7.4 and 13.6 cm in diameter and from 100 to 570 cm(3) in volume. This technique consists of echo-guided emptying of the cyst, and slowly inserting a quantity of pure 95% ethanol, equivalent to about 1/3 of the cyst volume, into the cavity. This acts as a sclerosant agent on the cyst walls. The protocol of this technique also includes positioning a curled drainage catheter, for 24-48 h, in suction, to ensure a correct collapse of the cyst walls and to avoid cyst recurrence. RESULTS: Of the 42 patients treated, only 4 did not complete the protocol. In 3 cases, the patients were not able to stand the procedure because of intense pain during cyst filling with alcohol. The other patient had intracystic hemorrhage. The results were evaluated by ultrasonography at 7 days post-operatively and then at 1, 3, 6, 9 and 12 months later. There was a further follow-up lasting from 12 to 36 months. Of 38 patients treated, 29 (76%) did not have any recurrence. 8 patients (21%) developed a small liquid layer of 3-4 cm, which did not enlarge in subsequent check-ups. We observed a recurrence, which spontaneously reduced in volume, only in 1 patient. CONCLUSIONS: This procedure was simple to apply in an out-patient setting and used low-cost materials which are easily obtained. Moreover, the results appear to confirm the validity of this technique.

Plasma levels of coenzyme Q(10), vitamin E and lipids in uremic patients on conservative therapy and hemodialysis treatment: some possible biochemical and clinical implications.

Coenzyme Q(10) (CoQ(10)), vitamin E, total cholesterol, HDL-cholesterol (HDLC) and triglycerides were measured in the plasma of 62 patients with kidney failure, 46 under hemodialysis treatment and 16 under conservative therapy, and 95 controls. The sum of LDL-cholesterol (LDL-C) and VLDL-cholesterol (VLDL-C) was also calculated for each patient. The ratio CoQ(10)/LDL-C+VLDL-C in both conservative therapy and hemodialysis populations was significantly lower (P<0.001) compared with normal controls and remained unchanged after the dialysis treatment. On the contrary the ratio vitamin E/LDL-C+VLDL-C was normal but decreased significantly (P<0.02) after each dialysis. Since coenzyme Q is the main inhibitor of the prooxidant action of vitamin E, it was hypothesized that its decrease in both the populations examined could make the lipoproteins of these patients more vulnerable to a peroxidative attack.

[Does the neurologic assessment have a decisive role in the early diagnosis of urinary disorders of uncertain etiology? A case of spinal chordoma]. / La valutazione neurourologica ha un ruolo decisivo nella diagnosi precoce delle disfunzioni minzionali a patogenesi incerta? Un caso di cordoma spinale.

The Authors report a rare case of detrusor areflexia due to a sacral column chordoma characterized as initial symptomatology, by dysuria and recurrent urinary tract infections. The patient was treated for a long time in a symptomatic way by her physicians. The Authors while discussing the case, underline the importance of an accurate differential diagnostical framing in patients with voiding and/or anorectal dysfunctions of uncertain nature. This framing must exclude those voiding pathologies of neurological origin which are frequently evinced merely by an aspecific voiding symptomatology of dysuric or irritative nature.

[Diverticula of the female urethra. Comparison of imaging techniques]. / Diverticoli dell'uretra femminile. Tecniche di imaging a confronto.

BACKGROUND AND AIMS: Urethral diverticula is a rare pathology with an incidence varying between 0.3 and 6%. It is difficult to diagnose owing to the aspecificity of its clinical symptoms. The aim of this study was to evaluate the imaging techniques now available for its diagnosis. METHODS: The sample consisted of 19 female patients aged between 20 and 53 years old undergoing diverticolectomy owing to urethral diverticula between 1980 and 1996 at the 4th Division of the Department of Urology at "La Sapienza" University of Rome. All patients underwent preoperative X-ray examinations (micturitional cystourethrography and P positive urethrography). A retrospective study was performed in order to evaluate the accuracy of the individual methods. RESULTS: Micturitional urethrocystography showed a sensitivity equivalent to 77% of cases. P positive urethrography showed a 85.7% accuracy rate. Lastly, transvaginal ultrasonography, which always showed the diverticular sac in all patients in which it was used, also highlighting multiple and divided diverticuli which were not visible using traditional radiology. The latter method is easy to use and well tolerated by patients; moreover, it shows the spatial relations of the diverticulum and allows the characteristics of periurethral tissues to be evaluated. CONCLUSIONS: The authors affirm that transvaginal ultrasonography is the first method of choice for the diagnosis of urethral diverticula.

Concomitant ceco-appendicular and urinary tuberculosis. Description of two rare cases: physiopathological and diagnostic remarks.

Two cases of specific tubercular processes in the ceco-appendicular zone and the urinary system in men aged 25 and 30 years are described. Both patients reported abdominal pain and persistent fever that did not respond to treatment. Surgery revealed ulcerated appendix, intraperitoneal serous exudate, ascitic liquid, peritoneal ulcerocaseous nodules, and fibrous adhesions. Histological sections revealed a tubercular puchet in the ceco-appendicular zone. Subsequent x-ray test in response to reports of frequent painful urination showed specific lesions in the papillae and renal ureteral ampullae, and urine cultures were positive for Koch's bacillus. Treatment with streptomycin, followed by isoniazid, rifampicin, ethambutol, and morinamid for 2 years, was effective.

[Variations of plasma renin in hemodialysis]. / Variazioni della renina plasmatica in corso di emodialisi.

We evaluated the variations of serum renin concentrations during hemodialysis in 17 patients (5 hypertensive and 12 normotensive). In addition we have studied the relationships between serum renin levels, right heart atrium diameters, arterial pressure, and body weight. At the end of the hemodialytic process we observed in both groups of patients an increase in the serum renin concentrations, as well as changes in the above parameters.

As regards to the immunosuppressive treatment in kidney transplant. Possibilities and limits.

The Authors deal with the immunosuppressive drugs administered to kidney-transplant receiving. The point out the complexity of the utilized pharmacological schemes, underlining the metabolic and immunologic iatrogenic effects brought about by this therapeutic iter, which should not neglect the clinical conditions of the patient.

[Physiopathological and nutritional changes in hemodialysis patients and in those who have undergone renal transplantation]. / Le alterazioni fisiopatologiche e nutrizionali nei soggetti emodializzati ed in quelli sottoposti a trapianto renale.

The paper examines the complex metabolic behaviour of patients undergoing hemodialysis and renal transplantation. It underlines the importance of the metabolic and nutritional status of these patients since inadequate nutritional therapy may result in the failure of hemodialysis and/or surgery. Given the complexity of the metabolic syndrome and its bronchopulmonary, cardiovascular and septic complications, it is necessary to monitor the various chemical and clinical parameters in these patients in order to guarantee an optimal recovery and satisfactory survival rate. Fortunately today, by replacing the use of Azathioprine, Cyclosporin--irrespective of its collateral and/or secondary effects--has replaced the use of corticosteroids whose immunodepressive action made it obligatory to start simultaneous prophylactic antibiotic treatment and/or chemotherapy in order to avoid the development of other chance disease. The paper also reports the findings of a retrospective study (1976-1986) which evaluated various physiopathological and metabolic parameters and compared them to data reported in the literature.

[The current physiopathological, diagnostic, clinical and therapeutic considerations of peptic ulcer. A comparison between traditional and modern therapeutic methods]. / Attuali considerazioni fisiopatologiche, diagnostiche, cliniche e terapeutiche sull'ulcera peptica. Raffronto tra metodiche terapeutiche tradizionali e moderne.

The authors, keeping in mind their clinical, diagnostic and therapeutic experience on ulcerous gastric and duodenal pathology, underline the effectiveness of the traditional antacids as well as that of the modern up-to-date antisecretory and cytoprotective agents. After having put into evidence the causes that can provoke peptic ulcer not excluding that of iatrogenic and their probable aetiopathogenetic mechanism and having hinted at another pathology that uses the same therapeutic remedies, the gastro-oesophagus reflux, they discuss in detail the active principles used in the gastric or duodenal pathology, the possible side and/or secondary effects that in the long run are determined when using only the modern therapy with the usual antacids. Therefore, they hope that these therapies are used after carefully considering the general clinical and anatomicopathologic situation of the lesion that must be created.