Could 68Ga-PSMA PET/CT Evaluation Reduce the Number of Scheduled Prostate Biopsies in Men Enrolled in Active Surveillance Protocols?

Background: To evaluate the accuracy of 68Ga-prostate specific membrane antigen (PSMA) PET/CT in the diagnosis of clinically significant prostate cancer (csPCa) (Grade Group > 2) in men enrolled in Active Surveillance (AS) protocol. Methods: From May 2013 to May 2021, 173 men with very low-risk PCa were enrolled in an AS protocol study. During the follow-up, 38/173 (22%) men were upgraded and 8/173 (4.6%) decided to leave the AS protocol. After four years from confirmatory biopsy (range: 48−52 months), 30/127 (23.6%) consecutive patients were submitted to mpMRI and 68Ga-PSMA PET/CT scan before scheduled repeated biopsy. All the mpMRI (PI-RADS > 3) and 68Ga-PET/TC standardised uptake value (SUVmax) > 5 g/mL index lesions underwent targeted cores (mpMRI-TPBx and PSMA-TPBx) combined with transperineal saturation prostate biopsy (SPBx: median 20 cores). Results: mpMRI and 68Ga-PSMA PET/CT showed 14/30 (46.6%) and 6/30 (20%) lesions suspicious for PCa. In 2/30 (6.6%) men, a csPCa was found; 68Ga-PSMA-TPBx vs. mpMRI-TPBx vs. SPBx diagnosed 1/2 (50%) vs. 1/2 (50%) vs. 2/2 (100%) csPCa, respectively. In detail, mpMRI and 68Ga-PSMA PET/TC demonstrated 13/30 (43.3%) vs. 5/30 (16.7%) false positive and 1 (50%) vs. 1 (50%) false negative results. Conclusion: 68Ga-PSMA PET/CT did not improve the detection for csPCa of SPBx but would have spared 24/30 (80%) scheduled biopsies showing a lower false positive rate in comparison with mpMRI (20% vs. 43.3%) and a negative predictive value of 85.7% vs. 57.1%, respectively.

mpMRI PI-RADS score 3 lesions diagnosed by reference vs affiliated radiological centers: Our experience in 950 cases.

INTRODUCTION: The detection rate for clinically significant prostate cancer (csPCa) in men with mpMRI PI-RADS score 3 diagnosed by affiliated radiology centers vs radiological reference center was evaluated. MATERIALS AND METHODS: From January 2017 to December 2020, 950 men (median age 64 years) underwent mpMRI for abnormal PSA values (median 6.3 ng/ml). Among the 950 patients who underwent mpMRI 500 were evaluated by a reference center and 450 by outpatient radiological affiliated centers. All the mpMRI index lesions characterized by a PI-RADS 3 underwent targeted cores combined with extended prostate biopsy. Two radiologists of the radiological reference center revised all the mpMRI lesions 3. RESULTS: Overall, 361/950 (38%) patients had a mpMRI lesion PI-RADS score 3: 120/500 cases (24%) vs 241/450 cases (53.5%) were diagnosed by reference vs affiliated radiological centers. The detection rate for cT1c csPCa was equal to 26.7% (35/120 cases) vs 16.6% (40/241 cases) in men with PI-RADS 3 lesions diagnosed in the reference vs the affiliated radiological centers (p < 0.05). Among the 241 PI-RADS score 3 lesions diagnosed by affiliated radiological centers 86/241 (35.7%) and 36/241 (15%) were downgraded (PI-RADS scores < 3) and upgraded (PI-RADS score 4) by the dedicated radiologists of the reference center. CONCLUSIONS: In our series, about 35% and 15% of PI-RADS score 3 lesions diagnosed by affiliated radiological centers were downgraded and upgraded when revised by experencied radiologists, therefore a second opinion is mandatory especially in men enrolled in active surveillance protocols in whom mpMRI is recommended to reduce the number of scheduled repeated prostate biopsies.

Asynchronous Bilateral Ureteric-Arterial Fistula: Diagnosis and Treatment.

A 48-year-old woman submitted to anterior exenteration plus ileal-cutaneous conduit for metastatic cervical cancer during the change of the ureteral stent showed massive bleeding in the left ureter. A selective intra-arterial angiography showed a fistula between the ureter and the left common iliac artery that the interventional radiologist quickly repaired by inserting a vascular endoprosthesis. Six months later, gross hematuria secondary to right ureter-iliac fistula occurred again and a second endoprosthesis was inserted. Asynchronous bilateral ureteric stent-related vascular fistula is an uncommon scenario, but it should be suspected in the presence of hematuria following ureteral stent replacement.

Ischemia of the glans penis following circumcision: case report and revision of the literature.

Ischemic complications of the glans penis are rare and commonly result from trauma, inadvertent administration of vasoconstrictive solutions, diabetes mellitus, circumcision and vasculitis; we refer about a young man with severe ischemia of the glans penis following circumcision. The patient had undergone circumcision 5 days before in a surgery department under local anesthesia (1% mepivacaine hydrochloride). The patient noticed a brownish color and edema of the glans penis at 24 h after he opened the wound dressing, but arrived to our hospital only 5 days after circumcision because these findings had progressed. Physical examination revealed the black color or necrotic appearance of the glans penis, and edema on the dorsal penile skin. The patient underwent antibiotic, antiplatatelet, corticosteroid and iperbaric therapy achieving a complete restitutio ad integrum.

Acute Scrotum Following Traumatic Spermatic Cord Hematoma: A Case Report and Review.

Acute scrotum constitutes the most common urological emergency secondary to spermatic cord torsion, testicular trauma, orchiepididymitis and hernias. We report a very rare case of unique traumatic spermatic cord hematoma following scrotum injury occurred during a football match. Clinical exam showed an increased volume of the left spermatic cord; the color Doppler ultrasound (CDU) demonstrated left testicular ischemia secondary to a large spermatic cord hematoma that needs surgical exploration. Spermatic cord hematoma rarely induces acute scrotum, however it could be treated conservatively surgery is mandatory when pain is persistent or testicular ischemia is confirmed by CDU.

Does prolonged anti-inflammatory therapy reduce number of unnecessary repeat saturation prostate biopsy?

INTRODUCTION: The effect of a prolonged oral anti-inflammatory therapy on PSA values in patients with persistent abnormal PSA values after negative prostate biopsy (PBx) was evaluated. MATERIAL AND METHODS: From September 2011 to September 2012, 70 patients (medi- an age 62 years), with persistent abnormal PSA values after negative extended PBx, were given an herbal extract with anti-inflammatory activity for 3 months (Lenidase®; 1 tablet daily constituted of baicalina, bromelina and escina). All patients were submitted to prostate biopsy for: abnormal DRE; PSA > 10 ng/mL, PSA values between 4.1-10 or 2.6-4 ng/mL with free/total PSA < 25% and < 20%, respectively. Three months after the end of anti-inflammato- ry therapy all patients were revaluated; indication for repeat saturation biopsy (SPBx) and detection rate for PCa were compared with those previously recorded in our Department using the same inclusions criteria for biopsy. RESULTS: Oral administration of Lenidase® was well tolerated and no side effects were observed; PSA values decreased in 54 (77.8%) out 70 patients with a median PSA reduction of 20.5% (from 8.8 to 7 ng/mL) and remained unchanged in 16 patients (22.2%); the repeat SPBx rate resulted significantly lower (22.8% vs 35.5%; p < 0.05) showing a superimposable detection rate for PCa (3 cases) in comparison with our previous data (18.7% vs 22%). CONCLUSIONS: In our preliminary data a prolonged oral anti-inflammatory therapy reduced PSA levels in patients with negative PBx and persistent suspicious for PCa decreasing the indication to perform repeat SPBx (about 30% of the cases).

Prostate cancer detection at repeat biopsy: can pelvic phased-array multiparametric MRI replace saturation biopsy?

AIM: Magnetic resonance imaging (MRI) accuracy in prostate cancer (PCa) diagnosis in men submitted to saturation prostate biopsy (SPBx) was evaluated. MATERIALS AND METHODS: From June 2011 to December 2012, 78 patients (median 63 years) underwent repeat SPBx (median 28 cores). Multiparametric MRI using a 3 Tesla pelvic phased-array coil was performed before SPBx and lesions suspicious for PCa were submitted to additional targeted biopsies. RESULTS: A T1c PCa was found in 32 (41%) cases. SPBx vs. MRI-suspicious targeted biopsy diagnosed 28 (87.5%) vs. 26 (81.2%) PCa missing four (12.5%) and six (18.8%) cancers localized in the anterior zone and in the lateral margin of the prostate, respectively; moreover, MRI diameter lesions correlated with PCa diagnosis and Gleason score (p<0.05). CONCLUSION: Multiparametric MRI improved SPBx accuracy in diagnosing PCa of the anterior zone; moreover, suspicious areas >10 mm resulted as highly predictive of cancer (about 70% of the cases).

Partial priapism secondary to idiophatic segmental thrombosis of corpora cavernosa.

A 51-year-old man presented at our department 2 days after the onset of a painful mass in the perineum and dysuria. Diagnosis of partial priapism secondary to proximal segmental corpora cavernosa thrombosis was made through colordoppler ultrasound (CDU) and magnetic resonance imaging (MRI). Treatment consisted of administration of systemic anticoagulation drugs (acenocumarol) and local injection of ethylephrine chloridrate. The thrombosis resolved after two months with incomplete restoration of erectile function (loss of rigidity). In conclusion, on the basis of previous reports (23 cases reported in literature) and our experience, in presence of painful mass in the perineum, CDU and MRI evaluation allows to make diagnosis of the rare proximal partial priapism that as first option should be treated conservatively.

Does Ki-67 staining improve quantitative histology in preoperative prostate cancer staging?

To evaluate accuracy of Ki-67 expression on biopsy specimens in comparison with quantitative histology findings for preoperative prostate cancer (PCa) staging. From January 2008 to January 2010, 126 patients (median age 63 years) underwent radical retropubic prostatectomy; median PSA was 9.1 ng/mL; 98 and 28 patients had a clinical stage T1c and T2, respectively. The following variables of quantitative histology were evaluated as predictive of non organ-confined (OC) PCa: Gleason score > 6, TPC > 20%, GPC > 50%, cancer-positive cores > 2, presence of cancer-positive cores in both lateral margins and bilateral PCa. Value of Ki-67% staining in all cancerous cores was calculated. Sixty (47.7%) patients had a non OC-PCa with positive nodes in 12 (20%) cases. The mean Ki-67 score was 4.4%: 3.7% in OC-PCa and 5.6% in non-OC-PCa, respectively. Predictive positive value (PPV) of quantitative histology, Ki-67 (cut-off > 5%) and both parameters to predict a non-OC-PCa vs an OC-PCa was equal to 90%, 40% and 93.4%, vs 36.6%, 78.8% and 78.8%, respectively. Ki-67 staining on biopsy specimens does not improve quantitative histology in predicting non-OC-PCa; moreover, the low expression of Ki-67, even in presence of advanced disease, decreases its prognostic value in predicting an OC-PCa.

Unusual indications for transrectal pelvic ultrasound.

Transrectal ultrasound (TRUS), routinely performed by urologists to guide prostate biopsy, could be usefully employed in atypical cases. We report our experience in some patients in whom TRUS allowed to obtain a diagnosis in a faster and easier way in comparison to other instrumental procedures usually recommended.

Solitary giant sarcomatoid carcinoma of the bladder. A case report.

A case of sarcomatoid carcinoma of the bladder (SCB) presenting as a giant intravesical mass in a 75-year-old man complaining of lower urinary tract swmptoms (LUTS), abdominal pain and fever is reported. SCB is a rare (0.1% of all primary bladder tumors), aggressive cancer with a complex histology (a biphasic tumor with malignant epithelial and mesenchymal elements) and poor prognosis.

Can Sonovue targeted biopsy replace extended or saturation biopsy in prostate cancer diagnosis? Our experience at primary and repeat biopsy.

OBJECTIVE: To evaluate the detection rate of prostate cancer (PCa) at initial and repeat biopsy in patients submitted to Sonovue targeted biopsy vs extended or saturation prostate biopsy (SPBx). MATERIAL AND METHODS: From November 2007 to April 2008 60 patients aged 64 years (median) underwent extended TRUS-guided transperineal prostate biopsy. Indications to biopsy were: abnormal DRE, PSA > 10 ng/mL; PSA included between 2.6 and 4.0 and 4.1 and 10 ng/mL with %free/total PSA < or = 20% and < or = 25%, respectively. In 45 and 15 men prostate biopsy was performed as primary and repeated procedure respectively; median PSA was 8.3 ng/mL vs 11.8 ng/mL and digital rectal examination was positive in 9 vs 3 patients, respectively. Before performing extended or SPBx scheme in case of primary (19 cores) and repeated (28 cores) procedure, prostate areas characterized by absence of enhancement after Sonovue (2.4 mg) administration on gray scale during continuous harmonic imaging (HI) contrast-enhanced ultrasound (CEUS) were considered suspicious for PCa and submitted to targeted biopsy. RESULTS: 3.5 (median) targeted biopsies were performed in the peripheral zone of 22 men. In patients who underwent primary and repeated biopsy PCa was detected in 20/45 (44.5%) and 3/15 (20%) cases, but Sonovue detected only 6/20 (30%) and 1/3 (33.4%) of cancers, respectively. Sensitivity and specificity of Sonovue in diagnosing PCa was equal to 30.0% and 61.5% (primary biopsy) vs 33.4% and 54.5% (repeated biopsy). CONCLUSIONS: Based on its low diagnostic accuracy, Sonovue CEUS HI targeted biopsy can not replace extended or SPBx in diagnosing PCa.

Is transition zone sampling at repeated saturation prostate biopsy still useful?

OBJECTIVES: To evaluate retrospectively the detection rate of prostate cancer (PCa) located only in the transition zone (TZ) by directed cores at repeated saturation prostate biopsy (SPB). METHODS: From July 2001 to December 2009, 380 and 43 patients (median age: 63 years) underwent second and third SPB because they were persistently suspicious for PCa. Indications for biopsy were: prostate-specific antigen (PSA) of >10 ng/ml, and PSA between 4.1 and 10 ng/ml or 2.6 and 4 ng/ml with free/total PSA of ≤25 and ≤20%, respectively. A median of 23 cores were taken in the posterior zone, including 3 (median) cores in the TZ. The median PSA was 12.8 and 19.5 ng/ml and the digital rectal examination was positive in 36 (9.5%) and in no cases at second and third SPB, respectively. In patients with persistent and/or increasing PSA or abnormal free/total PSA values after negative second and third SPB, a transurethral prostate resection (TURP) was suggested to avoid the risk of missing a cancer localized in the TZ. RESULTS: PCa was detected in the TZ only in 2/82 cases (2.5%), and in details in 1/79 (1.2%) and 1/3 (33.3%) of the men diagnosed at second and third SPB, respectively. After TURP, a PCa was found in 18/95 men (18.9%; 14 stage T1a and 4 stage T1b) and in 3/15 men (20%; 2 stage T1a and 1 stage T1b) previously having had negative second and third SPB. CONCLUSIONS: Sampling from the prostatic TZ by directed needle biopsies at repeated SPB was associated with a very low incidence of PCa (2.5%), especially if compared to TURP (19% detection rate), and could be omitted.

Headache: a unique clinical presentation for renal cell carcinoma (RCC).

Brain metastases of renal cell carcinoma (RCC) are generally seen in advanced stages of disease with a short life-expectancy. A solitary, synchronous brain metastasis of RCC is rare and neurological symptoms may be the presenting sign of cancer. An aggressive surgical approach is justified in patients with favorable prognostic factors (good performance status, age under 65 years, absence of extracraneal lesions) for palliation of symptoms and improvement of cancer-related survival.

Is PSA density still useful in diagnosing prostate cancer?

OBJECTIVE: To evaluate the concordance between the PSAD (PSA density) values calculated using the actual prostate weight and the PSAD values calculated by using the dimensions of the gland given by the pathologist when freshly excised (volume 1) or using TRUS measures (volume 2). Diagnostic accuracy of PSAD in diagnosing PCa (prostate cancer) was evaluated and compared with accuracy obtained using PSA free/total (FIT). MATERIAL AND METHODS: 102 consecutive patients with PSA included between 2 and 10 ng/mL underwent radical prostatectomy. Indications to perform prostate biopsy were: abnormal digital rectal examination, PSA < or = 2.5 ng/mL, PSA between 2.6 and 4 ng/mL and between 4.1 and 10 ng/mL with PSA F/T (free/total) < or = 15%, < or = 20% and < or = 25%, respectively We compared the PSAD values obtained using the actual prostate weight (PSAD1) vs those calculated using volume 1 (PSAD2) and volume 2 (PASD3). RESULTS: The mean weight of prostate specimen was 55.61 grams, while the estimated mean volumes were 50.02 mL (volume 1) and 48.49 mL (volume 2). A statistically significant difference among actual weight vs volume 1 vs. volume 2 (p < 0.0001) was found. In the patients with PSA ranging from 4.1 to 10 ng/mL a cumulative accuracy of 82.6% was found using a cut-off > 0.10 whereas, with a cut-off > 0.15, a diagnostic accuracy of 36.9% (PSAD1), 58.6% (PSAD2) and 60.8% (PSAD3) was reported. CONCLUSIONS: No concordance between the actual prostate weight and the estimated volume was found; moreover PSAD accuracy was of poor value in diagnosing PCa in comparison with PSA F/T.

End-to-end ureteral anastomosis: a simple alternative to cutaneous ureterostomy in selected patients.

UNLABELLED: End-to-end of terminal ureteral segments seems to be a good alternative to terminal cutaneous ureterostomy in very selected cases (patients with short life-expectancy or when it is impossible to utilize the bowel for urinary diversion). BACKGROUND: An end-to-end ureteral anastomosis (UA) drained by a single percutaneous nephrostomy is proposed as an alternative to permanent cutaneous ureterostomy. METHODS: In eight patients who underwent radical cystectomy, an end-to-end UA was realized. All patients had an advanced pelvic neoplasm and/or severe comorbidities with a short life-expectancy. RESULTS: End-to-end UA is a very simple intervention, well tolerated by the patient that requires only the periodic substitution of the nephrostomy. CONCLUSIONS: In very selected cases (patients with short life-expectancy, advanced disease) end-to-end UA is a quick and easy way to divert the urine after bladder removal.

Neuroendocrine tumor in a horseshoe kidney. Case report and updated follow-up of cases reported in the literature.

Renal neuroendocrine tumors (NET) are rare neoplasms of unknown histogenesis. To the best of our knowledge, 40 such cases have been described, 11 of which arising in horseshoe kidneys (HSK). We report an additional case of a NET associated with a HSK occurring in a 45-year-old man. A clinicopathological review of the reported cases together with an updated follow-up of such tumors arising in HSK is provided. The present data show that NET associated with HSK present a better prognosis than those occurring in normal kidneys, even over long-term follow-up periods.