The IDENTIFY study: the investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer - a multicentre observational study.

OBJECTIVE: To evaluate the contemporary prevalence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC] and renal cancer) in patients referred to secondary care with haematuria, adjusted for established patient risk markers and geographical variation. PATIENTS AND METHODS: This was an international multicentre prospective observational study. We included patients aged ≥16 years, referred to secondary care with suspected urinary tract cancer. Patients with a known or previous urological malignancy were excluded. We estimated the prevalence of bladder cancer, UTUC, renal cancer and prostate cancer; stratified by age, type of haematuria, sex, and smoking. We used a multivariable mixed-effects logistic regression to adjust cancer prevalence for age, type of haematuria, sex, smoking, hospitals, and countries. RESULTS: Of the 11 059 patients assessed for eligibility, 10 896 were included from 110 hospitals across 26 countries. The overall adjusted cancer prevalence (n = 2257) was 28.2% (95% confidence interval [CI] 22.3-34.1), bladder cancer (n = 1951) 24.7% (95% CI 19.1-30.2), UTUC (n = 128) 1.14% (95% CI 0.77-1.52), renal cancer (n = 107) 1.05% (95% CI 0.80-1.29), and prostate cancer (n = 124) 1.75% (95% CI 1.32-2.18). The odds ratios for patient risk markers in the model for all cancers were: age 1.04 (95% CI 1.03-1.05; P < 0.001), visible haematuria 3.47 (95% CI 2.90-4.15; P < 0.001), male sex 1.30 (95% CI 1.14-1.50; P < 0.001), and smoking 2.70 (95% CI 2.30-3.18; P < 0.001). CONCLUSIONS: A better understanding of cancer prevalence across an international population is required to inform clinical guidelines. We are the first to report urinary tract cancer prevalence across an international population in patients referred to secondary care, adjusted for patient risk markers and geographical variation. Bladder cancer was the most prevalent disease. Visible haematuria was the strongest predictor for urinary tract cancer.

Ejaculation-sparing versus non-ejaculation-sparing anatomic GreenLight laser enucleo-vaporization of the prostate: first comparative study.

PURPOSE: To present the step-by-step description of an ejaculation-sparing anatomic photo-selective vaporization of the prostate (PVP) technique. To report the results of a series of ejaculation-sparing versus non-ejaculation-sparing anatomic PVPs. METHODS: Sexually active, benign prostatic hyperplasia (BPH) patients undergoing an anatomic PVP between 11/2018 and 2/2020 were included. Patients were divided into group A (ejaculation-sparing surgery) and group B (control group). Baseline, peri-operative and 6-months follow-up data were evaluated. Lower urinary tract symptoms (LUTS) and sexual function were assessed through internationally validated questionnaires. Groups were matched by an inverse probability of treatment weighting (IPTW) analysis. Logistic univariable regression analysis was performed to detect predictors of antegrade ejaculation preservation. RESULTS: Overall, 76 patients were included, among which 15 in group A and 61 in group B. Median (inter-quartile range, IQR) age was 72 (66.5-77) years, median (IQR) prostate volume 63.5 (54.5-98.5) cc. No differences about peri-operative outcomes were detected, included high-grade complications. At 6-months follow-up, no differences in urinary or erectile function were detected between groups, while ejaculation-sparing patients showed better Male Sexual Health Questionnaire (MSHQ) scores [7 (1-13) vs. 1 (1-1), p < 0.001] and higher rates of antegrade ejaculation (60% vs. 13.1%, p < 0.001). The ejaculation-sparing technique was identified as a predictor of post-operative antegrade ejaculation (OR 19.3, CI 95% 7.2-51.2, p < 0.001). CONCLUSION: The ejaculation-sparing anatomic PVP showed superiority over the control group in post-operative ejaculatory function scores and antegrade ejaculation rates. Besides, preliminary results suggested similar effectiveness in LUTS relief at a short-term follow-up.

68Ga-PSMA-11 PET/CT in recurrent hormone-sensitive prostate cancer (HSPC): a prospective single-centre study in patients eligible for salvage therapy.

OBJECTIVES: The primary objective is to assess the efficacy of 68Ga-PSMA-11-PET/CT to detect recurrent location(s) in hormone-sensitive prostate cancer (PCa). Secondary objectives are (1) to evaluate changes in clinical management; (2) to determine which covariates independently predict positive scan; (3) to assess 68Ga-PSMA-11-PET/CT performance in different settings of PSA relapse. MATERIALS AND METHODS: Inclusion criteria include (1) histologically diagnosed PCa; (2) previous radical therapy; (3) proven biochemical recurrence (BCR) or biochemical persistence (BCP); (4) hormone-sensitive PCa (HSPC); (5) androgen deprivation therapy (ADT)-free for at least 6 months; (6) PSA < 1.5 ng/mL or any PSA in case of negative choline-PET/CT (n = 38). Changes in clinical management were defined by multidisciplinary tumour-board. Clinical settings were BCP (group-1, n = 25); first-time BCR (group-2, n = 121); BCR after salvage therapy (group-3, n = 77). RESULTS: Two hundred twenty-three (223) consecutive patients were enrolled: median PSA = 0.65 ng/mL (0.2-8.9) and median PSAdt = 9.3 months (0.4-144.6). 96.9% received RP as primary therapy. 68Ga-PSMA-11-PET/CT positivity rate was 39.9% (CI95% 33.5-46.7%). Disease confined to pelvis was detected in 23.3% of cases. At least one distant lesion was observed in 16.6% of cases. Secondary objectives are as follows: (1) changes in clinical management were observed in 34.5% of patients; (2) PSA, PSAdt and T stage > 3a were independent predictors (all p < 0.03); (3) 68Ga-PSMA-11-PET/CT positivity rate was 56% (in group 1, 36.3% in group 2, 40.3% in group 3. CONCLUSION: This study attested the overall good performance of 68Ga-PSMA-11-PET/CT to detect PCa locations in HSPC patients eligible for salvage therapy, influencing the therapy management in 35.4% of cases. Furthermore, patient characteristics are influencing factors of 68Ga-PSMA-11-PET/CT positivity rate and should be considered to reduce false negative scan.

Inferior vena cava prosthetic replacement in a patient with horseshoe kidney and metastatic testicular tumor: technical considerations and review of the literature.

BACKGROUND: Seminomatous and non-seminomatous Germ Cell Tumors (GCT) of the testis are a rare cancer, with an estimated incidence of 56.3 per million white males and 10 per million black males in the United States.The association between non-seminomatous GCT and horseshoe kidney is a rare event and is seen in about 1.3% of patients requiring retroperitoneal lymph node dissection. To our knowledge, no cases have been reported in which replacement of the IVC was also necessary. CASE PRESENTATION: We report the case of a 22-year-old man with horseshoe kidney and metastatic non-seminomatous germ cell tumor involving the wall of the inferior vena cava.Following post-chemotherapy retroperitonal lymph node dissection, the inferior vena cava was replaced with an expanded polytetrafluoroethylene graft.At 2-years follow-up, the patient was in good health and the graft was patent. No clinical or diagnostic signs of renal impairment or recurrence of neoplastic disease were noted. CONCLUSION: Radical surgery is warranted in patients with non-seminomatous germ cell tumor metastasizing to the retroperitoneal lymph nodes. When vena cava replacement is required, and the situation is further complicated by horseshoe kidney, as in this case, surgical technique will rely on multidisciplinary surgical treatment planning by a team composed of urologists, vascular surgeons and oncologists.

Sarcopenia Predicts Disease Progression in Patients with T1 High-grade Non-muscle-invasive Bladder Cancer Treated with Adjuvant Intravesical Bacillus Calmette-Guérin: Implications for Decision-making?

Background: Skeletal muscle loss (sarcopenia) has been linked to cancer cachexia and can predict survival in several tumors, including advanced genitourinary malignancies. Objective: To investigate the predictive and prognostic role of sarcopenia in patients with T1 high grade (HG) non-muscle invasive bladder cancer (NMIBC) treated with adjuvant intravesical Bacillus Calmette-Guerin (BCG). Design setting and participants: Oncological outcomes were evaluated for 185 patients with T1 HG NMIBC treated with BCG at two European referral centers. Sarcopenia, identified from computed tomography scans performed within 2 mo after surgery, was defined as a skeletal muscle index of <39 cm2/m2 for women and <55 cm2/m2 for men. Outcome measurements and statistical analysis: The main endpoint was the association between sarcopenia and disease recurrence and progression. Kaplan-Meier curves and multivariable Cox models were built, and the clinical value of any association was assessed using Harrell's C index and decision curve analysis (DCA). Results and limitations: Sarcopenia was present in 130 patients (70%). On multivariable Cox regression analyses that accounted for the effect of standard clinicopathological prognosticators, sarcopenia was independently associated with disease progression (hazard ratio 3.41; p = 0.02). Addition of sarcopenia to a standard model for prediction of disease progression improved the discrimination of the model from 62% to 70%. DCA revealed superior net benefits for the proposed model in comparison to the strategies of treating all or no patients with radical cystectomy, and in comparison to the existing predictive model. Limitations are inherent to the retrospective design. Conclusions: We demonstrated the prognostic role of sarcopenia in T1 HG NMIBC. Pending external validation, this tool could be easily incorporated into existing nomograms for prediction of disease progression to improve clinical decision-making and patient counseling. Patient summary: We looked at the role of loss of skeletal muscle (sarcopenia) as a factor in predicting prognosis for stage T1 high-grade non-muscle-invasive bladder cancer. We found that sarcopenia is a ready-to-use, cost-free marker that could be used to guide treatment and follow-up in this disease, although the results need to be confirmed in other studies.

Evaluating the Protective Effect of Intravesical Bacillus Calmette-Guerin against SARS-CoV-2 in Non-Muscle Invasive Bladder Cancer Patients: A Multicenter Observational Trial.

We aim to evaluate the potential protective role of intravesical Bacillus Calmette-Guerin (BCG) against SARS-CoV-2 in patients with non-muscle invasive bladder cancer (NMIBC). Patients treated with intravesical adjuvant therapy for NMIBC between January 2018 and December 2019 at two Italian referral centers were divided into two groups based on the received intravesical treatment regimen (BCG vs. chemotherapy). The study's primary endpoint was evaluating SARS-CoV-2 disease incidence and severity among patients treated with intravesical BCG compared to the control group. The study's secondary endpoint was the evaluation of SARS-CoV-2 infection (estimated with serology testing) in the study groups. Overall, 340 patients treated with BCG and 166 treated with intravesical chemotherapy were included in the study. Among patients treated with BCG, 165 (49%) experienced BCG-related adverse events, and serious adverse events occurred in 33 (10%) patients. Receiving BCG or experiencing systemic BCG-related adverse events were not associated with symptomatic proven SARS-CoV-2 infection (p = 0.9) nor with a positive serology test (p = 0.5). The main limitations are related to the retrospective nature of the study. In this multicenter observational trial, a protective role of intravesical BCG against SARS-CoV-2 could not be demonstrated. These results may be used for decision-making regarding ongoing and future trials.

The association of Boswellia resin extract and propolis derived polyphenols can improve quality of life in patients affected by prostatitis-like symptoms.

OBJECTIVES: Chronic prostatitis syndrome is a bothering and poorly understood condition. Many patients report genitourinary pain and Lower Urinary Tract Symptoms as a main complaint. Many different pharmacological or behavioural therapies are prescribed in daily clinical practice, but efficacy data are still lacking. The aim of our study was to test the efficacy and safety of a transrectal delivered association of Boswellia resin extract and propolis derived polyphenols for the relief of prostatitis - like symptoms. MATERIALS AND METHODS: Patients affected by chronic/recurrent prostatitis - like symptoms were prospectively enrolled in our study from December, 2016 to December, 2018. Patients were screened at baseline through clinical examination and validated questionnaires administration: Chronic Prostatitis Symptom Index (CPSI), International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF). Inclusion criteria were: age ≥ 18; prostatitis symptoms persisting for at least 3 of the last 6 months; CPSI pain domain score ≥ 5; previous negative Meares-Stamey test. Treatment consisted on the administration of 1 suppository containing Boswellia resin extract and propolis derived polyphenols, once a day for 20 days. The primary endpoint of the study was the improvement of quality of life after treatment, defined by a reduction of ≥ 2 points, or ≥ 25%, of mean CPSI pain domain score, compared to baseline. Secondary endpoints were the improvement of post-treatment CPSI total score and the analysis of treatment - related adverse events. All patients were re-evaluated 1 month after treatment. RESULTS: 40 patients were enrolled in our study. Median age (Inter - Quartile Range IQR) was 51.5 (41.5-63.2) years. Mean baseline CPSI scores were: 22.15 (total score), 9.67 (pain domain), 5.15 (micturition domain) and 7.35 (quality of life domain), respectively. No significant adverse events were reported. At 1 month follow-up, CPSI scores appeared modified as follows: 16.40 (total score, p = 0.001); 6.92 (pain domain; p = 0.001; 4.02 (micturition domain, p = 0.09); 5.45 (quality of life domain, p = 0.002). Mean CPSI pain domain score reduction was -2.75 points (-28.5%). Mean CPSI total score reduction was -5.75 points (-26%). CONCLUSIONS: The association of Boswellia resin extract and propolis derived polyphenols can reduce genitourinary pain and then improve quality of life of men affected by bothersome prostatitis - like symptoms.

Asymptomatic chronic urachal abscess mimicking a bladder tumor.

A 72-year-old man was admitted with a lower abdominal mass, occasionally detected during a previous laparoscopy. The cystoscopy revealed a bulging mass 5 cm in diameter at the vesical dome. The computed tomography (CT) scan showed an extravescical extension in close relationship with the posterior abdominal wall. Two consecutive endoscopic biopsies and a CT-guided percutaneous biopsy were not helpful. At surgery, a mass about 10 cm in diameter was found at the vesical dome and removed "en-block". The microscopic examination showed a chronic urachal abscess. To our knowledge, this is the second case of asymptomatic urachal abcess mimicking a bladder neoplasm. The reasons of a surgical approach are discussed.

Immunological stress in kidney cancer patients undergoing either open nephrectomy or nephron-sparing surgery: an immunophenotypic study of lymphocyte subpopulations and circulating dendritic cells.

Immunosuppression is a characteristic hallmark of renal cell carcinoma (RCC), with several complex immune defects, almost solely at the level of cell-mediated immune function, well evident even in patients at first diagnosis. The main circulating lymphocyte subsets and the total number of circulating dendritic cells were quantified in 47 RCC patients at diagnosis (T0), 12 h (T1), 24 h (T2) and 8 days following either radical nephrectomy or nephron-sparing surgery using flow cytometry. RCC patients presented, at baseline, (T0) a profound state of immunosuppression involving naïve T-cells, memory T-cells, CD16+ NK and total circulating dendritic cells, that worsened after 12 (T1) and 24 h (T2) from surgery, involving the majority of the analysed subsets; after 8 days (T3) from surgical removal of tumor, however, there was a return of all the analyzed parameters to the basal state. In conclusion, surgery causes transient but relevant immune suppression in RCC patients; even though, by day +8, this tends to return to baseline, immunostimulatory therapies could be considered in the peri-operative setting with the aim of reducing immunosuppression and, hopefully, also disease recurrence.

Renal cell carcinoma-induced immunosuppression: an immunophenotypic study of lymphocyte subpopulations and circulating dendritic cells.

BACKGROUND: Renal cell carcinoma (RCC)-induced immune dysfunction in patients at first diagnosis was investigated. PATIENTS AND METHODS: The main circulating lymphocyte subsets, the total number of circulating and intratumor dendritic cells and the titers of circulating VEGF were quantified in 47 RCC patients, using flow cytometric, immunohistochemical and ELISA assays. RESULTS: Despite a significant activation of CD3/HLA-DR+ lymphocytes and of the CD56+ NK subset, RCC patients presented a marked immunosuppression of CD4/CD45RA naïve T-cells, CD4/CD45RO memory T-cells, CD16+ NK-cells, and total circulating dendritic cells, as well as a significant increase of lymphocytes co-expressing the CD4 and CD8 antigens. Finally, CD16+/CD56+ NK and DCs were poorly represented in tumor specimens. CONCLUSION: The complex immunological dysfunctions demonstrated involve different levels of immunocompetence and indicate a pattern of major disturbance of the immune system.

Subcapsular Hematoma Causing Anuria After Renal Graft Trauma.

A 67-year-old man presented to the emergency department 22 hours after a trauma to his kidney graft. He was asymptomatic during the first 10 hours, then he became anuric. His serum creatinine level was 2.73 mg/dL (baseline, 0.7 mg/dL), and his hemoglobin concentration was 13.1 g/dL. Computer tomography showed a 4-cm subcapsular hematoma without active bleeding. He underwent urgent decompression of the hematoma, and we did not find any active bleeding or parenchymal laceration. Urinary output had already recovered by the end of surgery without early or late complications. In conclusion, subcapsular hematoma, complicating a traumatic event on a kidney graft, can lead to a progressive parenchymal compression resulting in anuria. So, although in the absence of anemia, such events require urgent surgical decompression. Symptoms cannot be immediate, so all the graft trauma should be investigated with early ultrasound. Little is known in the case of major renal trauma but mildly symptomatic. Probably surgical exploration is better than observation to prevent possible early and late complications such as organ rejection or a Page kidney.

Surgical implantation of artificial urinary device and penile prosthesis through trans-scrotal incision for postprostatectomy urinary incontinence and erectile dysfunction: synchronous or delayed procedure?

OBJECTIVE: To compare simultaneous and 2-stage surgical implantation of an artificial urinary sphincter (AUS) and penile prosthesis (PP) for patients with severe urinary incontinence and erectile dysfunction after prostatectomy. METHODS: The data from 23 patients were reviewed, 15 (group 1) underwent simultaneous implantation and 8 (group 2) underwent 2-stage surgery. The operative time, complications, postoperative pain, incidence of pre- and postoperative urinary incontinence, erectile dysfunction rating (International Consultation on Incontinence questionnaire, Incontinence Quality of Life, International Index of Erectile Function, and Erectile Dysfunction Inventory of Treatment Satisfaction), and patient satisfaction were evaluated. RESULTS: The mean operative time was 140 minutes for the simultaneous procedure (group 1) and 105 minutes for AUS placement and 65 minutes for PP placement (group 2). No major postoperative complications were recorded. The average postoperative hospital stay was 2.5 days after the double-implant procedure and 2.4 days after AUS and 1.2 days after PP placement. The visual analog scale score at 6 and 24 hours after surgery was 5 and 3 in group 1, and 4 and 3 after AUS and 3 and 2 after PP (group 2; P > .05). At 1 year, all patients were socially continent, with an average International Consultation on Incontinence score of 2 in group 1 and 2 in group 2. Of the patients in groups 1 and 2, 65% and 68% were completely dry, respectively (P > .05). The Incontinence Quality of Life score increased from 37 to 84 in group 1 and from 41 to 82 in group 2. The Patient Global Impression of Improvement revealed that 92% of group 1 and 95% of group 2 experienced "great improvement" (P > .05). The International Index of Erectile Function and Erectile Dysfunction Inventory of Treatment Satisfaction score was 70 of 75 and 87 of 100 in group 1 and 72 of 75 and 86 of 100 in group 2, respectively (P > .05). Group 1 patients were completely satisfied, and all group 2 patients stated they would have preferred synchronous surgery. CONCLUSION: AUS and PP synchronous placement is feasible and safe and as effective as the 2-stage procedure, with better acceptance by patients.

[Surgical resection of a massive residual retroperineal mass after chemotherapy in non-seminomatous germ cell tumor of the testis: a borderline case]. / Chirurgia su voluminosa massa residua retroperitoneale dopo chemioterapia per tumore non seminomatoso del testicolo: un caso limite.

BACKGROUND: According to the last EAU Guidelines about testicular cancer, surgical resection of residual masses after chemotherapy in NSGCT is indicated in the case of visible residual masses and when serum levels of tumor markers are normal or normalizing. If markers are not normalized and when several chemotherapeutic regimens have failed to cure metastatic disease, resection of residual tumors (so called "desperation surgery") should be offered to these patients. METHODS: We are going to present the case of a 30-year-old patient, affected by metastatic NSGCT. According to the prognostic-based staging system for metastatic germ cell cancer, our patient was in the poor prognosis group. The retroperitoneal mass involved all major vascular structures and still caused a bilateral obstruction of the upper urinary tract. Histological examination after radical orchiectomy revealed embryonal carcinoma and immature teratoma. The patient underwent a four-cycle VIP chemotherapy and then salvage chemotherapy with four cycles of TIP. After chemotherapy, the patient still presented large multiple metastatic localizations. Tumor markers were reduced but not normalized. The patient was then proposed for the resection of residual tumor. The residual mass could not be dissected from the left renal pedicle, so the left nephrectomy was unavoidable. The mass was hardly detached from vena cava and aorta. A bilateral iliac and retroperitoneal lymphadenectomy was performed. At the end of the procedure, the retroperitoneal space was completely free. RESULTS: Post-operative hospital stay was regular. A CT scan performed 3 months after the procedure did not show any residual lesion in the retroperitoneum. Three and six months later, the patient underwent the residual tumor resection of the right mediastinum and then of the left mediastinum and supraclavear metastases. Afterwards the patient underwent an EP consolidation chemotherapy. The patient is alive, 12 months after the retroperitoneal surgery. CONCLUSIONS: Our experience confirms that resection of residual tumors is safe and feasible also in cases of very large abdominal disease.

Robotic-assisted laparoscopic prostatectomy in Italy: perioperative data on the first 150 patients.

BACKGROUND: In 2004 we performed the first robot-assisted laparoscopic prostatectomy (RALP) at Aosta, Italy. METHODS: Data about our first 150 RALPs are presented. RESULTS: Mean patient age was 65.2 (range 51-75) years; mean preoperative PSA level 7.9 (range 1.8-25.0) ng/ml. Nerve sparing was performed in 109 cases (72.7%) with lymph nodes dissection in 27 (18.0%). Operative time: patients 1-50, mean 213.3 (range 185-290) min; patients 51-100, 207.3 (range 185-335) min; patients 101-150, 171.7 (range 123-270) min. Two procedures were converted to open. Mean blood loss was 235 (range 20-1000) ml with two blood transfusions. One patient was reoperated for anastomotic leakage. Four patients were treated by colostomy and rectal suture for rectal injury (n = 3) or recto-urethral fistula (n = 1). The overall complication incidence was 13.3% (20 events), while mortality was nil. CONCLUSIONS: The incidence of complications is slightly higher than in major pilot centres but it is comparable, hence RALP also appears feasible in our italian peripheral centre.