Non-muscle invasive high grade urothelial carcinoma of the bladder. Which factors can influence understaging at the time of radical cystectomy?

OBJECTIVE: To evaluate the main factors which influence understaging in patients with T1G3 non-muscle invasive bladder cancer (NMIBC). MATERIALS AND METHODS: 109 patients with T1/G3 underwent transurethral resection of bladder tumor (TURBT) and then radical cystectomy (RC) with pelvic lymph nodes dissection. A number of variables were considered when evaluating the detection of understaging. We considered the patients age and gender, as well as the size, number, location and morphology of their tumor. We also considered coexistence of bladder carcinoma in situ (CIS), microscopic vascular invasion and deep lamina propria invasion. The level of experience of the surgeon was also analyzed. RESULTS: in RC samples muscle invasion, that is understaging, was detected in 74 (67.9%) patients, while 35 (32.1%) patients were appropriately staged. In these cohort of patients with high grade tumors, understaging was associated with deep lamina propria and microscopic vascular invasion, multiple tumors, tumor size > 6 cm, tumor location (trigone and dome), presence of residual tumor; age, gender, tumor morphology, CIS associated, and experience of urological surgeon were not associated with clinical understaging. CONCLUSIONS: in our study, evaluating patients with high grade NMIBC at first TURBT, we identified some risk factors that need to be considered and that are able to increase the risk of understaging: deep lamina propria and microscopic vascular invasion, multiple tumors, tumor size > 6 cm, tumor location (trigone and dome), presence of residual tumor. When these risk factors are present, performing an early cystectomy, and not a re-TURBT, could lower the risk of worse pathological finding due to rapid disease progression of the high grade tumors, and can prolong survival.

Spontaneous recurrent hematuria and hematospermia: Unique manifestations of von Willebrand disease type I. Case report.

In this report we describe the case of a patient with unrecognized von Willebrand disease (vWD), in whom the only presenting symptoms were spontaneous and recurrent hematuria with bladder tamponade, associated with recurrent hematospermia. The diagnosis was made only after several admissions to the hospital. We suggest to include coagulopathies such as vWD as part of the evaluation in patients with unexplained genito-urinary bleeding.

Safety and efficacy of percutaneous nephrolithotomy in the Galdakao - Modified Supine Valdivia position: A prospective analysis.

OBJECTIVE: Aim of the present study was to evaluate the safety and efficacy of Percutaneous Nephrolithotomy (PCNL) in the Galdakao- Modified Supine Valdivia (GMSV) position in order to predict operative time, stone-free rate and onset of complications taking into account comorbidity, stone-related parameters and anatomic upper urinary tract abnormalities. MATERIAL AND METHODS: A prospective evaluation of patients who underwent to PCNL in GMSV position for renal stones > 2 cm, from January 2009 to February 2015 was performed. According to the technique, upper urinary tract abnormalities, stone chemical and morphological characteristics, and patients' history were matched with operative outcome, in terms of stone-free, intervention time and incidence of perioperative complications. RESULTS: Seventy-two cases were collected; mean operative time was 105 minutes (DS 41): staghorn stones and the presence of comorbidity resulted statistically significant variables. The complication-rate resulted in line with data showed in literature: hyperpyrexia and hemorrhage were the more frequently complications found. The overall stone-free was reached in 48 patients (67%), and it was influenced by patients' anatomic abnormalities. CONCLUSIONS: In the treatment of renal stones, PCNL may be a safe and effective choice; nevertheless, patients' anatomic abnormalities or staghorn-stones may influence the outcomes. Thus, a prospective study with a larger population is needed to verify our outcomes.

Sunitinib, pazopanib or sorafenib for the treatment of patients with late relapsing metastatic renal cell carcinoma.

PURPOSE: Late recurrence of renal cell carcinoma is not a rare event. In this retrospective study we investigate the clinicopathological features and the outcome of patients treated with sorafenib, sunitinib and pazopanib for late relapsing renal cell carcinoma. MATERIALS AND METHODS: Data were collected from 21 Italian centers involved in the treatment of metastatic renal cell carcinoma. Late relapse was defined as more than 5 years after initial radical nephrectomy. RESULTS: A total of 2,490 patients were screened and 269 (11%) were included in the study. First line therapy was sunitinib in 190 patients (71%), sorafenib in 58 (21%) and pazopanib in 21 (8%). Median progression-free survival was 20.0 months for sunitinib (95% CI 17.0-25.1), and 14.1 months for sorafenib (95% CI 11.0-29.0) and pazopanib (95% CI 11.2-not reported). On multivariate analysis MSKCC score and metastases to lymph nodes, liver and brain were associated with worst overall survival, while pancreatic metastases were associated with longer survival. Furthermore, age, MSKCC score and brain metastases were associated with worst progression-free survival. CONCLUSIONS: Patients with late relapsing renal cell carcinoma seem to present a characteristic pattern of metastatic spread without showing significant differences in terms of progression-free survival among sorafenib, sunitinib and pazopanib.

Recent aspects of sunitinib therapy in patients with metastatic clear-cell renal cell carcinoma: a systematic review of the literature.

Sunitinib is an orally available inhibitor of multiple tyrosine-kinase receptors approved for the treatment of advanced clear-cell renal cell carcinoma (ccRCC), a disease which has habitually had a very poor patient survival rate. Although it has become the most widely used drug for this disease, it remains not completely clear the best treatment strategy with these agent. The aim of this review is to highlight the most recent and interesting aspects of the research on treatment of advanced ccRCC with sunitinib and eventually determine alternative treatment schedule to reduce the incidence of side effects; we also wanted to review recent biomarkers able to predict response to therapy and also to point out the mechanism of acquired resistance to this drug.

α1-Blockers for the treatment of recurrent urinary tract infections in women with dysfunctional voiding: a prospective randomized study.

OBJECTIVES: To evaluate the therapeutic effects of tamsulosin on recurrent urinary tract infections in women with dysfunctional voiding. METHODS: A total of 155 women with recurrent urinary tract infections and dysfunctional voiding were included and randomly assigned to the following groups: uroflowmetry biofeedback (group 1), α1-adrenoceptor antagonists (group 2), uroflowmetry biofeedback combined with α1-adrenoceptor antagonists (group 3) and no treatment (group 4). Patients were evaluated by the American Urological Association Symptom Index at 3, 6 and 12 months. Urodynamics was carried out in patients of groups 1, 2, and 3 at 3, 6 and 12 months, whereas urodynamics was only carried out at 12 months in group 4. All patients were followed up for 1 year with monthly urine cultures. RESULTS: The incidence of storage and emptying symptoms decreased significantly at 3, 6 and 12 months. Mean flow rate, flow time and voiding volume increased significantly (with a better outcome in patients of group 3), whereas post-void residual urine decreased. Mean opening detrusor pressure and detrusor pressure at maximum flow decreased significantly (with a better outcome in patients of group 3). Mean urethral closure pressure and maximum urethral closure pressure decreased significantly with a more significant decrease for patients in group 3. The prevalence of urinary tract infection decreased significantly in all groups after treatment, and this decrease remained stable during the follow up. CONCLUSIONS: In women with dysfunctional voiding and recurrent urinary tract infection, tamsulosin associated with uroflowmetry biofeedback might be an effective and safe treatment option for improving urinary symptoms and quality of life.

Is it possible to predict the need of inguinal lymphadenectomy in patients with squamous cell carcinoma of the penis? A clinical and a pathological study.

OBJECTIVE: to investigate the role of CD- 44 immunohistochemical expression within tumoural and non-tumoural tissue, aiming to understand if it can help us to predict the need of performing inguinal lymph nodes dissection to complete surgery of the penis. MATERIALS AND METHODS: CD44 immunohistochemical expression was investigated in tissue specimens from 39 patients with squamous cell carcinoma of the penis who underwent partial or total penectomy between 1987 and 2008. Patient age, tumour size, and grade; CD44 intensity score, cytological expression, topographic and distribution pattern were evaluated by immunohistochemistry on archived material and correlated with disease-specific survival. RESULTS: mean patients age was 67.7 years; mean followup was 130.44 months. Bilateral inguinal lymphadenectomy was performed in 14 patients; there were 8 N+ patients (23.5%). pTis-pT1 vs. > pT1 and the EAU classification of risk group resulted to be predictive of lymph nodal metastases at univariate analysis (respectively p = 0.006 and p = 0.045), but not the grading. The intensity score, cytological expression, topographic and distribution pattern of CD44 staining did not correlate with stage, grade and lymph nodes metastases. All disease related deaths occurred only in patients showing an high CD44 intratumoral expression, but this correlation is not statistically significant. Multivariate analysis showed that only lymph node metastasis was an independent prognostic factor predictive of lymph nodes metastases. CONCLUSIONS: CD44 expression in patients with squamous cell carcinoma of the penis is not able to predict the need of performing inguinal lymphadenectomy; staging and the EAU classification of risk group resulted to be predictive of lymph nodal metastases.

A conservative approach to perineal Fournier's gangrene.

Fournier's gangrene (FG) is a disease involving necrosis of perineum and external genitalia; in 95% of cases it is possible to diagnose the Fournier's gangrene just by physical examination. The clinical presentation of FG varies from an initial localized infection to large areas with necrotizing infection. The disease typically affect elderly men (6°-7° decade) with important systemic comorbidities; women are less frequently affected. Despite improvements in diagnosis and management, the mortality rate nowadays is between 20% and 43%. The severity and mortality of the disease is dependent upon the general condition of the patient at presentation and upon the rate of spread of the infection. Treatment involves a multidisciplinary approach: intensive systematic management, broad-spectrum antibiotic therapy, early surgical debridement (wide abscission of necrotic tissues and surgical drainage of peritoneum, scrotum, penis, and inguinal areas), hyperbaric oxygen therapy; surgery can eventually be repeated if necessary; reconstructive surgery has an important role in the final treatment of the disease. The technical difficulties frequently encountered and the inability to make a complete removal of the necrotizing tissues at the time of surgery in some cases has led to the application of combined techniques, in view of the enhancement effect of specific advanced medications, targeted antibiotic therapy and hyperbaric medicine. We have considered 6 patients affected by Fournier's gangrene treated at our institution; all the patients received treatment with the help of plastic surgeons of the same institution. After debridement, all the patients were treated with advanced specific dressings consisting of plates and strips made of calcium alginate, hydrogels and polyurethane and twodimensional cavity foams. Reconstructive surgery was necessary in one case. Hyperbaric oxygen therapy (HBO) has been performed in all cases. The multidisciplinary approach, the combined use of HBO therapy and the adoption of advanced specific dressings, have made possible the complete healing of the lesions in a shorter period, avoiding further surgery in 5 out of 6 patients.

Risk of gastrointestinal events with sorafenib, sunitinib and pazopanib in patients with solid tumors: a systematic review and meta-analysis of clinical trials.

Gastrointestinal (GI) events have been described with sorafenib, sunitinib and pazopanib in cancer patients. We performed an up-to-date meta-analysis to determine the incidence and relative risk (RR) in patients with cancer treated with these agents. PubMed databases were searched for articles published till May 2013. Eligible studies were selected according to PRISMA statement. Summary incidence, RR, and 95% CIs were calculated using random-effects or fixed-effects models based on the heterogeneity of selected studies. A total of 6,447 patients were available for the meta-analysis; 2,260 had renal cell carcinoma (RCC) and 4,187, 1,691 non-small cell lung cancers, 599 hepatocellular cancers, 1,066 breast cancers, 165 neuroendocrine tumors, 304 gastrointestinal stromal tumors and 362 soft tissue sarcomas. Diarrhea was the most common GI event. When stratified by tumor type (RCC vs. non-RCC), the difference among the incidences of GI events was significant for diarrhea (p < 0.001) and vomiting (p = 0.006), that resulted higher in RCC patients. In RCC patients, sorafenib registered the lower incidence and RR of all grades GI events. The difference was statistically significant for sorafenib versus sunitinib-related all and high-grade events (p < 0.001) and for sorafenib versus pazopanib all grades GI events (p < 0.001) and high-grade anorexia (p < 0.001). Treatment with VEGFR TKIs sorafenib, sunitinib and pazopanib is associated with a significant increase in the risk of GI events in patients with cancer, and frequent clinical monitoring should be emphasized when managing these three and newer VEGFR TKIs.

Testicular microlithiasis and dyspermia: is there any correlation?

BACKGROUND: Testicular microlithiasis (MT) is an uncommon sonographic finding (prevalence in the literature: 0.7 to 6%). Several studies have highlighted its possible correlation with an increased risk of testicular cancer, but few studies have investigated its possible link with dyspermia. OBJECTIVES: The aim of our study was to investigate in our series the number of patients with microlithiasis, diagnosed by ultrasound, and compare the quality of their sperm with that of patients in a control group with normal testicular ultrasound exam. MATERIALS AND METHODS: We performed 277 consecutive testicular ultrasound examinations from January 2012 to July 2012. Among all these, we selected 86 patients that showed no pathological elements at echography and 11 patients affected by MT, to one or both testicles. Each patient was also submitted to a short-term semen analysis using the WHO2010 parameters for sperm evaluation. RESULTS: Among 11 patients with MT, 7 (63.63%) were dyspermic and 4 (36.36%) were normospermic. Among the 86 patients with normal testicular ultrasound 51 (59.3%) were dyspermic, 4 (4.65%) were azoospermic, while the remaining 31 (36.05%) were normospermic. Comparing the results of the two groups we obtained an odds ratio of 0.99 (95% CI: 0.27 to 3.64, p: 0.98). CONCLUSIONS: This study, although preliminary, with a low number of participants, shows that sperm quality is not affected by the presence of testicular microlithiasis, because the results of spermiograms are almost comparable between the two groups.

Improvement of lower urinary tract symptoms and sexual activity after open simple prostatectomy: prospective analysis of 50 cases.

OBJECTIVES: To evaluate the improvement of Lower Urinary Tract Symptoms (LUTS) and Erectile Function (EF) evaluated before and after Open Simple Prostatectomy, focusing on which patients this procedure allows better outcomes in term of sexual activity. MATERIAL AND METHODS: 50 men with large size benign prostatic hyperplasia (BHP) greater than 80 gr were prospectively evaluated before and 6 months after Open Simple Prostatectomy (Freyer procedure) between October 2012 to September 2013. Patients had a pre-operative transrectal ultrasound (TRUS) for volume evaluation and filled pre and post operative questionnaires for International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) score. RESULTS: Mean patients age was 71 years (D.S. 3,5), mean prostate volume results 103 ml (D.S. 23,7); regarding LUTS and EF, mean improvement of IPSS score was 15,3 (D.S. 4) and mean increase of IIEF-5 score was 3,4 (D.S.3). This study highlights a correlation between patients' age and increase of IIEF-5 score; no correlation with prostate size was found. CONCLUSION: According to the EAU Guidelines 2014, large size BPH (over 80-100 mL) with LUTS refractory to medical management continue to have open prostatectomy as the treatment of choice. In our experience we found not only an reduction of LUTS after the procedure but also an improvement of erectile function; this improvement was related with patient's age.

The impact of repeated prostate biopsies on sexual function and urinary symptoms in patients with diagnosis of Atypical Small Acinar Proliferation (ASAP): can ecoDoppler reduce side effects?

OBJECTIVES: To establish whether repeated trans-rectal ultrasound-guided Prostate Needle Biopsies (PNBx) performed in men with diagnosis of Small Acinar Atypical Proliferation (ASAP) predispose these subjects to Erectile Dysfunction (ED) and to evaluate if EcoColorDoppler (ECD) can help to reduce this side effect. MATERIALS AND METHODS: We performed a retrospective study regarding 190 men with diagnosis of ASAP detected between January 2001 and December 2011, who underwent to repeated prostate needle biopsies (PNBx). These patients were investigated about Erectile Function (EF) and Lower Urinary tract Symptoms (LUTS) using International Index of Erectile Function (IIEF-5) and International Prostate Symptom Score (IPSS) questionnaires before the first PNBx and 3 months after each other one. In particular, among the 89 men without ED before first PNBx, we compared IIEF-5 score between 64 patients who underwent to standard PNBx and 25 patients submitted to a PNBx done with in addition ECD ultrasound imaging. RESULTS: Mean patient age was 65 years (SD 7.7); mean follow-up was 3.2 years (SD 1.8) and the mean number of re-biopsies completed was 2 (SD 1.5). Among the 143 men considered, only 89 resulted with a normal EF (IIEF-5 score > 21): in this group incidence of ED (IIEF-5 score < 21) among patients who underwent to standard PNBx was 4/64 (6.25%) while in patients submitted to a PNBx with ECD was 1/25 (4%). A greater decrease of EF was observed in patients undergone to 3 or more biopsies; no relationship between IPSS score and re-PNBx was identified. CONCLUSION: Repeated PNBx done in patients with diagnosis of ASAP appear to get worse EF; number of biopsies seems to increase the risk of ED. Use of ECD in transrectal ultrasound- guided PNBx may have a role to avoid neurovascular bundles (NVBs) and preserve EF; anyway further studies are highly recommended to validate this hypothesis.

Perivascular epithelioid cell tumor (PEC-ome) of the prostate: ultrasound feature in case report.

INTRODUCTION: We describe a rare tumor arising from the prostate gland: Perivascular Epithelioid Cells tumor (PEC-ome). A 54-years old was treated for acute urinary retention with alpha-blockers at presentation due to benign prostate enlargement (65 cc) with asymmetric middle lobe and regular PSA (0.92 ng/ml). After 5 months, patient developed a second acute urinary retention episode and nodules in the left lung; he was treated with transurethral resection of the prostate and left lobectomy. RESULTS: Histological examination of prostate and lung tissue gave the same diagnosis: leiomyosarcoma with atypical morphological features and patient was observed for 4 months. Considering the uncommon diagnosis, pathological review by the uro-pathologist at our Hospital was done. Additional immunohistochemistry was done and both tumors showed similar and typical features of metastatic PEC-ome (T1b N0 M1). Therefore a new staging showed local and distant progression with prostatic mass and small lung metastasis. Three cycles of Gemcitabine and Pazopanib were administered, but 2 months later a new urinary retention occurred, despite chemotherapy. Patient referred to our Hospital for salvage pelvic surgery with lymph node dissection. Final pathological diagnosis was PEC-ome of the prostate stage pT4 pN0 R0 M1. CONCLUSIONS: PEC-ome is a rare but rapidly invasive mesothelial tumor with early metastatic potential. When this tumors originates from the fibromuscular stroma of the prostate it mimics benign prostatic enlargement and causes LUTS. Expert pathology aided by immunoisthochemistry is the cornerstone of diagnosis. There are no pathognomonic imaging on ultrasound or symptoms suggesting the presence of PEC-ome in early stage. A multidisciplinary approach is necessary and radical surgery should be done to treat this aggressive cancer.

Primary B-cell lymphoblastic lymphoma of the testis.

We present a rare case of primary lymphoblastic B-cell lymphoma of the testis focusing on ultrasonographic and pathological features and clinical implications. Pathological examination revealed primary testicular lymphoblastic B-cell lymphoma which was treated with adjuvant chemotherapy, including rachicentesis with administration of chemotherapy and with radiotherapy of contralateral testis. Primary testicular lymphoblastic B cell lymphoma is an aggressive disease and it is necessary a multimodal therapy (surgery, chemotherapy and radiotherapy) to prevent metastasis.

Biopsy follow-up in patients with isolated atypical small acinar proliferation (ASAP) in prostate biopsy.

The incidence of prostate cancer (PCA) was evaluated in 155 patients with isolated Atypical Small Acinar Proliferation (ASAP) found on initial prostate biopsy, after a medium-term follow-up (40 months) with at least one re-biopsy. Clinical and histological data were analysed. Cancer was detected in 81 of 155 (52.3%). The cancer detection rate was 71.6%, 91.3%, 97.5%, 100% at the 1st re-biopsy, 2nd, 3rd, and 4th rebiopsy respectively. At the uni- and multivariate analyses, prostate volume (≤ 30 cc), transition zone volume (≤ 10 cc), small core length at the initial biopsy (≤ 10 mm) and few number of cores at initial biopsy (≤ 8) are predictive of cancer. Furthermore, tumour characteristics on the whole surgical specimens was assessed in 30 men: 13 of 30 (43 %) had clinically relevant cancer (volume > 0.5 ml or/and Gleason score ≥ 7, or pT3). Most of relevant cancers were detected in the distal apex, anterior gland and midline. These anatomical sites could be under-sampled at the initial biopsy using the transrectal approach. Our data suggest that follow-up biopsy is recommended in all cases of isolated ASAP detected after biopsy using endfire transrectal probe. The re-biopsy strategy should increase the number of cores (or a saturation biopsy), focusing on area of ASAP in the initial biopsy, but also including the under-sampled areas (anterior gland, distal apex and midline) to detect clinically relevant cancers.

Prostatic fiducial markers implantation by transrectal ultrasound for adaptive image guided radiotherapy in localized cancer: 7-years experience.

OBJECTIVE: we present our 7-years' experience with fiducial gold markers inserted before Image-Guided Radiotherapy (IGRT) focusing on our echo-guided technique reporting early and late complications. MATERIAL AND METHODS: 78 prostate cancer (PCA) patients who underwent fiducial markers placement for adaptive IGRT (period 2007-2014) were selected. Mean patient age was 75 years (range 60-81), mean PSA 7.8 ng/ml (range 3.1-10), clinical stage < T3, mean Gleason Score 6.4 (range 6-7). We recorded early and late complications. Maximum distance between the Clinical Target Volume (CTV) and Planning Target Volume (PTV) was assessed for each direction and the mean PTV reduction was estimated. RESULTS: we describe in details our echo-guided technique of intraprostatic gold fiducial markers insertion prior to adaptative IGRT. We report rare early toxicity (5-7% grade 1-2), a mean PTV reduction of 37% and a very low late toxicity (only 3.4% bladder G3 and 8% rectal G2 side effects). CONCLUSION: Our technique of fiducial gold markers implantation for adaptative IGRT is safe and well-tolerated and it resulted helpful to reduce CTV-PTV margin in all cases; the effects on clinical practice seem significant in terms of late toxicity but further investigations are needed with longer follow-up.

HtrA1 in human urothelial bladder cancer: a secreted protein and a potential novel biomarker.

Our aim was to analyze the expression of the serine protease HtrA1 in human bladder tissue and urine in order to point out its possible association with the presence of urothelial bladder cancer. Bladder tissue and urine specimens from cancer patients with different tumor grades and stages (n = 68) and from individuals with cystitis (n = 16) were collected along with biopsy specimens and urine from healthy individuals (n = 68). For the first time, we demonstrated by immunohistochemistry that HtrA1 protein is produced by bladder urothelium in both physiological and inflammatory conditions, whereas it is not detectable in urothelial cancer cells regardless of tumor grade and stage. A different HtrA1 expression between normal-looking and neoplastic bladder tissue, despite similar HtrA1 mRNA levels, was also found by western blotting, which disclosed the presence of two forms of HtrA1, a native form of ∼50 kDa and an autocatalytic form of ∼38 kDa. Our investigations documented the presence of the two forms of HtrA1 also in urine. The ∼38 kDa form was significantly down-regulated in neoplastic tissue, whereas significantly higher amounts of both HtrA1 forms were found in urine from cancer patients compared with both healthy subjects and patients with cystitis. Our findings suggest that HtrA1 is a downexpressed molecule since an early stage of bladder urothelial carcinoma development and that urinary HtrA1 protein may be considered, if successfully validated, as an early and highly sensitive and specific biomarker for this neoplasia (the sensitivity and specificity of HtrA1 are 92.65% and 95.59%, respectively).

Comparison of tamsulosin vs tamsulosin/sildenafil effectiveness in the treatment of erectile dysfunction in patients affected by type III chronic prostatitis.

AIM: We evaluated the effectiveness of tamsulosin monotherapy versus tamsulosin plus sildenafil combination therapy on erectile dysfunction (ED) in young patients with type III chronic prostatitis and ED by using symptom score scales. MATERIALS AND METHODS: 44 male patients were divided into 2 groups: the first group (20 patients) was treated with tamsulosin 0,4 mg monotherapy and the second one 24 patients) was treated with tamsulosin 0,4 mg plus sildenafil 50 mg combination therapy. "International Prostate Symptom Score, "National Institute of Health Chronic Prostatitis Symptom Index" (NIH-CPSI) and "International Index of Erectile Function" (IIEF-5) were investigated in each group of patients, and scores calculated during the first medical examination. Both groups were treated with tamsulosin once daily for 60 days, while sildenafil 50 mg was given on demand (at least 2 times per week) for 60 days. During the second medical examination IPSS, NIH-CPSI and IIEF-5 scores were analyzed once more. Afterwards, the alterations of scores among medical examinations in each group and between both groups were statistically compared. RESULTS: The age average of the 44 cases included was 32.04 3.15 years. Both groups present a statistically significant decrease, between the first and the second medical examination, in IPSS, NIH-CPSI scores and statistically significant increase in IIEF-5 score. In addition, there is no statistically significant difference, in all scores, between mono and combination therapy. CONCLUSIONS: tamsulosin monotherapy, as well as a combination therapy (tamsulosin plus sildenafil) has an improving effect on symptoms and on ED in patients with type III prostatitis. In the near future alpha-blockers monotherapy could be used in the treatment of chronic prostatitis and ED cases instead of phosphodiesterase type 5 (PDE-5) inhibitors combination therapy.

Comparison between WHO (World Health Organization) 2010 and WHO 1999 parameters for semen analysis - interpretation of 529 consecutive samples.

OBJECTIVE: To quantify how many men with normal semen according to WHO (WHO - World Health Organization) 1999 criteria, should be considered with abnormal semen according to 2010 criteria and vice versa; to study which parameter of volume, concentration, motility and morphology is the most responsible of this change. MATERIALS AND METHODS: We studied, using WHO 1999 parameters, 529 consecutive semen samples from 427 men, collected in our Department from January 2008 to December 2009, then we re-evaluated those results using WHO 2010 parameters; we also studied each parameter to understand how changed the classification from normal (defined normal by all parameters) to abnormal (defined abnormal by at least one parameter) using the two WHO criteria. RESULTS: 3 men (0.56%) were azoospermic. Among the remaining 526 samples, 199 (37.83%) were considered normal and 246 (46.76%) abnormal both according to WHO 1999 and WHO 2010 criteria; we found that none of the samples classified normal according to the previous criteria was classified abnormal according the more recent criteria, while 82 (15.58%) evaluated as abnormal according 1999 criteria changed to normal according 2010 criteria. The concordance between 1999 and 2010 evaluation was 84.44%. CONCLUSIONS: In this study we noted that the changes from WHO 1999 to WHO 2010 criteria did not modify the interpretation of semen quality, because comparing the two classifications we demonstrated that there is a substantial agreement, considering the three parameters (count, motility and morphology) all together, and also considering each single parameter. Anyhow, almost 16% of the patients considered infertile according to the old criteria, should be evaluated normal by the new classification and they should not need any treatment for infertility.

Erectile rehabilitation with intracavernous alprostadil after radical prostatectomy: refusal and dropout rates.

UNLABELLED: Study Type--Therapy (outcomes) Level of Evidence 2a. What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a well known implication of radical prostatectomy (RP). Despite the search for technical improvement in the surgical procedure (e.g. nerve-sparing surgery, robot-assisted RP), many patients still suffer from an inability to achieve a satisfactory erection after surgery. In the last 20 years a great effort has been made to re-establish good sexual function in these patients. Many different approaches have been used, such as intracavernous prostaglandin E1 (PGE1), phosphodiesterase-5 inhibitors, vacuum devices and penile prostheses. Although many studies have addressed the main questions about efficacy of different approaches to ED, there is a lack of data about adherence to therapy and the main reasons why patients drop out of these treatment programmes. In the present study, a cohort of men treated with RP underwent a postoperative rehabilitation protocol with PGE1 intracavernous injections. During the follow-up period, we were able to assess a real-life practice pattern of adherence and dropout, evaluating the main causes of therapy discontinuation. This could be of help in the counselling of these patients during the path towards erection recovery. OBJECTIVES: • To assess the rate of compliance in the first 6 months of a rehabilitation protocol that includes intracavernous alprostadil administration in patients undergoing radical retropubic prostatectomy. • To determine the reasons for and timings of dropout from the protocol by the patients and their subsequent outcomes. PATIENTS AND METHODS: • All patients undergoing radical prostatectomy (RP) at our institution between 1 January 2007 and 31 December 2009 were considered for a protocol of postoperative intracavernous sexual rehabilitation and were administered entry questionnaires to evaluate their preoperative sexual activity. • Four weeks after surgery, the patients were invited to return for a first visit, where the aim of the protocol and possible risks and benefits were explained. For those who agreed to attend, subsequent visits to include assisted self-administration of increasing doses of intracavernous alprostadil and a period of autonomous homely self-administration were planned. • Patients were followed up at 3-month intervals, where data on functional outcomes, patient satisfaction, and the number of patients who dropped out and their reasons, were recorded by means of appropriate questionnaires. • Statistical analysis was performed using Student's t-test or a chi-squared test, where appropriate. RESULTS: • Of 430 patients, 157 (36.5%) refused to undergo the protocol of rehabilitation and 18.6% of the patients who began the protocol dropped out over the first 6 months. • Reasons for refusal were: patient's lack of sexual interest (51.6%); lack of interest by the partner (30.2%); and presence of transitory incontinence (26.7%). • Reasons for dropout were: disappointment with treatment efficacy (64.7%); injection pain (45%); and difficulties with or fear of performing the injection by themselves or by the partner (35.2%). No patient claimed the cost of the drug to be a cause for dropout. CONCLUSIONS: • The protocol we used, involving intracavernous alprostadil injection, proved to be a safe and efficient way of achieving sexual rehabilitation in patients who have undergone RP. Nevertheless, high patient motivation and adherence to the protocol were required. • Factors influencing patients refusal and early-to-medium time dropout were both patient- and partner-related. Appropriate information, counselling and support of the couple before the beginning and at all stages of the rehabilitation play a fundamental role in reducing the dropout rate. • The situation regarding those patients who still need adjuvant therapy after surgery is less clear and further research on this is required.