Predictors of prostate cancer detection in MRI PI-RADS 3 lesions - Reality of a tertiary center.

INTRODUCTION AND OBJECTIVES: The Prostate Imaging Reporting and Data System (PI-RADS) score reports the likelihood of a clinically significant prostate cancer (CsPCa) based on various multiparametric prostate magnetic resonance imaging (mpMRI) characteristics. The PI-RADS category 3 is an intermediate status, with an equivocal risk of malignancy. The PSA density (PSAD) has been proposed as a tool to facilitate biopsy decisions on PI-RADS category 3 lesions. The objective of this study is to determine the frequency of CsPCa, assess the diagnostic value of targeted biopsy and identify clinical predictors to improve the CsPCa detection rate in PI-RADS category 3 lesions. METHODS: Between 1st January 2017 and 31st December 2022, a total of 1661 men underwent a prostate biopsy at our institution. Clinical and mpMRI data of men with PI-RADS 3 lesions was reviewed. The study population was divided into two groups: target group, including those submitted to systematic plus targeted biopsy versus non-target group when only systematic or saturation biopsy were performed. Patients with PI-RADS 3 lesions were divided into three categories based on pathological biopsy results: benign, clinically insignificant disease (score Gleason = 6 or International Society of Urologic Pathologic (ISUP) 1) and clinically significant cancer (score Gleason ≥ 7 (3+4) or ISUP ≥ 2) according to target and non-target group. Univariate and multivariate analyses were performed to identify clinical predictors to improve the CsPCa detection rate in PI-RADS category 3 lesions. RESULTS: A total of 130 men with PIRADS 3 index lesions were identified. Pathologic results were benign in 77 lesions (59.2%), 19 (14.6%) were clinically insignificant (Gleason score 6) and 34 (26.2%) were clinically significant (Gleason score 7 or higher). Eighty-seven of the patients were included in the target group (66.9%) and 43 in the non-target group (33.1%). The CsPCa detection was higher in the non-target group (32.6%, n = 14 vs 23.0%, n = 20 respectively). When systematic and target biopsies were jointly performed, if the results of systematic biopsies are not considered and only the results of target biopsies are taken into account, a CsPCa diagnosis would be missed on 9 patients. The differences of insignificant cancer and CsPCa rates among the target or non-target group were not statistically significant (p = 0.50 and p = 0.24, respectively). on multivariate analysis, the abnormal DRE and lesions localized in Peripheral zone (PZ) were significantly associated with a presence of CsPCa in PI-RADS 3 lesions (oR = 3.61, 95% CI [1.22,10.72], p = 0.02 and oR = 3.31, 95% CI [1.35, 8.11], p = 0.01, respectively). A higher median PSAD significantly predisposed for CsPCa on univariate analyses (p = 0.05), however, was not significant in the multivariate analysis (p = 0.76). In our population, using 0.10 ng/ml/ml as a cut-off to perform biopsy, 41 patients would have avoided biopsy (31.5%), but 5 cases of CsPCa would not have been detected (3.4%). We could not identify any statistical significance between other clinical and imagiological variables and CsPCa detection. CONCLUSIONS: PI-RADS 3 lesions were associated with a low likelihood of CsPCa detection. A systematic biopsy associated or not with target biopsy is essential in PI-RADS 3 lesions, and targeted biopsy did not demonstrate to be superior in the detection of CsPCa. The presence of abnormal DRE and lesions localized in PZ potentially predict the presence of CsPCa in biopsied PI-RADS 3 lesions.

Management of iatrogenic urorectal fistulae in men with pelvic cancer.

INTRODUCTION: Urorectal fistula (URF) is a devastating complication of pelvic cancer treatments and a surgical challenge for the reconstructive surgeon. We report a series of male patients with URF resulting from pelvic cancer treatments, specifically prostate (PCa), bladder (BCa), and rectal cancer (RCa), and explore the differences and impact on outcomes between purely surgical and non-surgical treatment modalities. METHODS: Between October 2008 and June 2015, 15 male patients, aged 59-78 years (mean 67), with URF induced by pelvic cancer treatments were identified in our institutions. Patients with a history of diverticulitis, inflammatory bowel disease, or other benign conditions were excluded. We reviewed the patients' medical records for symptoms, diagnostic tests performed, type and etiology of the fistula, type of surgical reconstruction, followup, and outcomes. RESULTS: Fourteen patients underwent surgical reconstruction. One patient developed metastatic disease before URF repair and, therefore, was excluded from this study. Mean followup (FU) was 32.7 months (14-79). All patients received diverting colostomy and temporary urinary diversion. An exclusively transperineal approach was used in nine (64.3%) patients and a combined abdominoperineal in five (35.7%). Overall successful URF closure was achieved in 12 (85.7%) patients, nine (64.3%) of whom at the first reconstructive attempt, two (14.3%) after two attempts (in our institution), and one (7.1%) after three attempts (two of which elsewhere). An interposition flap was used in seven (50%) patients. Surgical reconstruction failed ultimately in two (14.3%) patients who still have a colostomy and do not wish any further reconstruction. CONCLUSIONS: Our study has several limitations, including its retrospective nature and the heterogeneity of our small patient cohort. Nonetheless, although surgical reconstruction of URF may be extremely difficult and complex in the non-surgical/energy ablation patients, its successful reconstruction is possible in most through a transperineal, or a more aggressive abdominoperineal, approach with tissue interposition in selected patients.

Sexual (Dys)function after Urethroplasty.

There is a paucity of published literature on the andrological consequences of urethral repair. Until recently authors have focused mainly on technical aspects and objective results. Reported outcomes of urethral reconstruction surgery have traditionally focused only on urodynamic parameters such as flow rates. Patient reported outcome measures have largely been neglected and there is a scarcity of well conducted systematic studies on the subject. For these reasons whether the different components of sexual life are more or less affected by different types of urethral reconstruction remains largely unknown. In an attempt to clarify the available scientific evidence, the authors make a critical review of available literature, systematizing it by sexual domain and study type. Brief pathophysiological correlations are discussed.

CT-based renal volume and graft function after living-donor kidney transplantation: Is there a volume threshold to avoid?

PURPOSE: Donated kidney volume influences post-transplant outcomes and graft survival. We evaluated the relationship between living-donor kidney volume and recipient graft function at 12 months post-transplantation, exploring a volume threshold for a suboptimal graft function, and compared two different formulas of volume estimation. METHODS: A retrospective analysis of 82 pairs of living-donor kidney transplants was conducted. Donor renal volumes were estimated from computerized tomography scans using the ellipsoid formula and the voxel counting technique. Linear and restricted cubic regression spline was used to analyze the association of volume with graft function. Additionally, we determined the correlation between the two volume estimation formulas and established a correction factor for the ellipsoid formula. RESULTS: Renal volume (adjusted to recipient BSA) had the strongest independent effect (B = 1.65 per 10 ml/m(2) increase, p value <0.001) on graft function at 12 months. The eGFR at 12 months was 52.5, 63.6 and 67.6 ml/min/1.73 m(2) for the low, medium and high volume ratio terciles, respectively (p value <0.001). The odds of a GFR <50 ml/min became significantly reduced with volumes above 145 cc/1.73 m(2). A strong positive correlation between the two formulas was identified (R(2) = 0.705), but the optimal correction factor for our cohort was 0.566. CONCLUSIONS: In a Caucasian population, higher donor kidney volumes estimated from preoperative CT scans are associated with higher recipient eGFRs at 12 months after live-donor transplantation. Using this criterion, transplant teams can potentially improve selection of living donors if multiple donors are available. However, the need for precise estimation of donor kidney volumes should not be overlooked.

Short-term outcomes of Altis single-incision sling procedure for stress urinary incontinence: a prospective single-center study.

INTRODUCTION AND HYPOTHESIS: Data on Altis® (Coloplast), a new adjustable single-incision sling (SIS) procedure for the treatment of female stress urinary incontinence (SUI), are scarce. Our aim was to evaluate the efficacy and complication rates of this procedure. METHODS: In this prospective observational study, a total of 52 women with SUI were implanted with an Altis sling in an ambulatory setting. Before and after intervention (3, 6, and 12 months), women completed the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF). In addition, patients underwent a cough stress test at each evaluation and a post-voiding residual urine volume estimation at 3 months. The main outcomes measured were subjective cure (ICIQ-SF = 0), subjective improvement (ICIQ-SF >0 and < preoperative ICIQ-SF), and objective cure (negative cough stress test and no pad usage) rates. De novo overactive bladder (OAB) symptoms, changes in voiding habits and adverse events were also analyzed. RESULTS: The subjective cure rate at 12 months was 84.0%, with an additional improvement rate of 8.0%. The objective cure rate was 90.2%. Later postoperative complications included 1 case of vaginal extrusion (requiring surgical removal of the eroded mesh segment), 3 cases of vaginal exposure of the adjustment thread (managed conservatively), de novo urgency in 3 patients, and mild dyspareunia in 2 patients. CONCLUSIONS: The Altis sling is a safe and effective SIS procedure for the treatment of SUI with a short-term follow-up.

[Penoscrotal aggressive angiomyxoma]. / Angiomixoma agresivo penoescrotal.

Aggressive angiomyxoma denotes an extremely infrequent mesenchymal tumour. In virtually every case it involves genital, pelvic or perineal female structures. Cases involving male patients are extremely rare. It is a distinctive tumour with a characteristic clinical course and specific and well characterized microscopic features. The authors report an additional clinical case in a young male patient with massive scrotal and penile involvement, necessitating exeresis followed by complex reconstructive procedure implying flap and graft use. A review of the available literature concerning etiopathogenic, clinical, imagiologic, histological and differential diagnosis, therapeutic and prognostic aspects is also presented.

[Primary mucinous adenocarcinoma of the renal pelvis--adicional case report]. / Adenocarcinoma mucinoso primário de pélvis renal--caso adicional.

Mucinous adenocarcinoma of the renal pelvis may be classified as among the rarest neoplasms of the genitourinary tract. Until the present moment just a few dozen cases have been reported previously. Despite the known association with chronic inflammatory conditions of the upper urinary tract, the exact pathogenesis remains unknown. The authors report an adicional clinical case with particular aspects in what concerns differential diagnosis. A review of the available literature concerning clinical, imagiologic, therapeutic and prognostic aspects is also presented.

Atualização acerca do papiloma do urotélio / Update on urotelial papiloma

Inverted papilomas are rare urotelial neoformations, which account for 2.2% to 4.5% of urotelial neoplasms (benign or malignant). Most of them have vesical location, namely on the trigonal area, although there are cases which have been described along the whole of the urinary excretory system. In spite of the well defined histological criteria, their origin is not entirely understood. Considered as benign tumors in the past, multiple evidence points out to the possibility of recurrence and to association with urotelial carcinomas, synchronic or metachronic, thus causing problems with the patient's followup. The distinction between inverted papilomas and urotelial carcinomas also poses problems, especially when located in the high excretory system, very often leading to aggressive, unnecessary surgical procedures with loss of kidney units. The authors present a critical review of the available literature on the etiology, clinical presentation, diagnostic criteria, treatment and prognostic aspects of this condition

Os papilomas invertidos são neoformações uroteliais raras, constituindo entre 2.2% e 4.5% das neoplasias uroteliais (benignas ou malignas). Apresentam maioritariamente localização vesical, nomeadamente (principalmente) a nível da região trigonal, embora haja (aunque hay) casos descritos ao longo de todo o aparelho (aparato) excretor urinário. Apesar dos critérios histológicos estarem bem definidos, a sua génese é incompletamente compreendida. Considerados no passado tumores benignos, múltiplas evidências apontam para a possibilidade de recorrência e associação com carcinomas uroteliais, de forma síncrona ou metacrónica, impondo (imponiendo) problemas no que toca ao seguimento dos doentes (enfermos). Colocam problemas ao nível de diagnóstico diferencial com os carcinomas uroteliais, designadamente quando localizados no aparelho excretor alto, motivando muitas vezes atitudes cirúrgicas agressivas desnecessárias, condicionando perda (pérdida) de unidades renais. Os autores realizam uma revisão crítica da literatura disponível acerca da etiologia, clínica, critérios e meios de diagnóstico, tratamento e aspectos de prognóstico desta afecção