Predicting prostate cancer at rebiopsies in patients with high-grade prostatic intraepithelial neoplasia: a study on 546 patients.

The aim of this study was to analyse the factors that predict the diagnosis of prostate cancer (PCa) after high-grade prostatic intraepithelial neoplasia (HGPIN). Data from 546 patients with HGPIN submitted up to a 6-month series of three rebiopsies, according to an institutional protocol, were reviewed. PCa has been found in 174 cases (31.8%), in 116 cases at the first and in 58 cases at a further rebiopsy. The risk of finding PCa at the first rebiopsy was correlated with the PSA value and with an anomalous digital rectal examination (DRE) at the time of the initial biopsy; the risk at a subsequent rebiopsy was correlated to the number of cores with HGPIN, with a cutoff of four, and to the ratio with the total number of cores ('PIN density'), with a cutoff of 50%, at the time of initial biopsy. A tailored protocol of controls can be suggested: (a) higher PSA value and/or anomalous DRE: early extended or saturation rebiopsy; (b) number of cores with HGPIN ≥4 and/or PIN density ≥50%: delayed rebiopsy; and (c) no risk factors: PSA and DRE controls.

[Morbidity of transperineal echo-guided prostatic biopsy, our experience]. / Morbilità da biopsia prostatica ecoguidata transperineale, nostra esperienza.

We present a review of 1245 patients undergone to ultrasound guided transperineal prostatic biopsy. We examined the complications' incidence of this technique to confirm or exclude presence of prostate cancer. Indications to a prostatic biopsy include an abnormal digital rectal examination, TRUS or PSA values increased. Single biopsy or systematic mapping of prostate were performed. For prostate biopsy a "Biopsy Gun" with 18 G. needle was used. Of 1245 patients, only 31 (2.48%) showed complications. Our experience demonstrates that ultrasound guided transperineal prostatic biopsy is a safe and easy technique and it is well accepted by the patient.

Damage to the erectile function following radical pelvic surgery: prevalence of veno-occlusive dysfunction.

A retrospective study was carried out to investigate the prevalence of venoocclusive dysfunction (VOD) in 44 patients who developed impotence following radical cystectomy (24 patients, 55%) and radical prostatectomy (20 patients, 45%) for invasive cancer, performed using a non nerve-sparing technique. Patient evaluation included sexual history, hormone profile, intracavernosal injection test and, in the nonresponders to the test, dynamic infusion cavernosometry and cavernosography (DICC). The follow-up period investigated ranged from 6 months to 9 years and 5 months (average 2.5 years). Our data indicate a 11% prevalence (5 patients) of postsurgical VOD with impotence following radical cystectomy and a 5% prevalence (2 patients) of impotence following radical prostatectomy. In the 7 patients (5 after cystectomy and 2 after prostatectomy) who underwent DICC, cavernosal artery insufficiency was detected. No correlation was found between VOD and the time from surgery (from 6 months to 9 years, average 4.4 years), in both the post-cystectomy and post-prostatectomy groups. Our data indicate that there are not only neurogenic causes of impotence following radical pelvic surgery, VOD and cavernosal artery insufficiency can also be partly responsible. Furthermore, it was shown that erectile inactivity, even in the long-term, does not affect the possible return of drug-induced sexual potency.

[Extra-aponeurotic traditional radical prostatectomy]. / La prostatectomia radicale tradizionale extra-aponeurotica.

Radical extra-aponeurotic prostatectomy is the surgical procedure which guarantees the best chances of total cancer ablation when the lesion is localized. Our incidence of positive specimen margins is low (4.6%). In our experience total incontinence occurs in 3 patients (3.5%). A low rate of post-operative complications makes this operation relatively safe and well accepted by patients. From our data "Nerve Sparing" prostatectomy must be reserved to selected cases in well motivated patients, because with this procedure the risk of oncological failure remains high.

[Retropubic adenectomy (Millin's technique). Our experience]. / Adenomectomia retropubica secondo Millin. Nostra esperienza.

From January 1983 to December 1993, on 1917 ptz who underwent to operations for BPH, 1532 pts (80%) had transurethral adenomectomy, and 385 pts (20%) had retropubic adenomectomy. The prostatic weight, obtained by ultrasound, is the factor which determines the kind of operations: transurethral adenomectomy if the prostate weight is lower than 50 gr, open surgery if it is more than 50 gr. In our experience about retropubic adenomectomy (Millin) we never had patient's death during operation or in the immediate post-operatively period. The early complications were 13.7%, and the late complications were 3.8%. The retropubic adenomectomy, when performed with right indications, is still valid.

[Role of intraprostatic stents in benign prostatic hypertrophy]. / Il ruolo degli stents endoprostatici nell'ipertrofia prostatica benigna.

We report our indications and experience in the use of intraprostatic endoprosthesis. We report also our preliminary experience in the use of a new intraprostatic endoprosthesis which has been developed at our institute. This prosthesis can be easily positioned, shows little invasiveness and does not require ultrasonic, radiological or endoscopical guidance.

[Sex-dynamic characterization of patients subjected to radical pelvic cavity surgery]. / La caratterizzazione sessodinamica nei pazienti sottoposti a chirurgia radicale dello scavo pelvico.

A retrospective study was carried out using sexual case histories, hormonal profiles, vasoactive drugs test, dynamic cavernosometry and cavernosography on 46 patients who underwent radical cystectomy (26 patients: 57%) and radical prostatectomy (20 patients: 43%) for neoplasia, conducted by means of traditional surgical non-nerve sparing methods, in order to characterize the type of damage affecting the erectile function as a result of surgery. The study was carried out at a minimum of 2 months, a maximum of 9 years and 5 months, an average of 2 years and 6 months, after surgery. One patient (2%) reported intact erectile function and withdrew from the study. 37 patients (80%) showed neurological damage, while the remaining 8 (18%) had prevalently vascular damage.

[Primary ureteral neoplasia]. / Neoplasie ureterali primitive.

From 1983 to 1992, 29 patients with primitive ureteral tumors have been recovered in our department. All the tumors were urothelial. Urography, spontaneous and selective urinary cytology, retrograde ureteropyelography permitted a correct diagnosis in 86% of them. Ureteroscopy is not performed routinely but only when conventional radiology is doubtful or a conservative treatment can be proposed. Controlled trials on endoscopic therapy of ureteral tumours are very few and even if our results are encouraging we believe that this therapeutic option is effective and safe only in selected case and nephroureterectomy is the treatment of choice.

[The ureter in urinary diversion]. / L'uretere derivato.

Ureteral pathology is reviewed in 297 urinary diversions, which were performed consecutively in our Department, in the last 9 years. Either cutaneous or intestinal anastomosis stricture was the most common complication. Our attempts to cure definitely this problem by endourological techniques were unsatisfactory. So the Authors conclude that surgery is usually the best option.

[Controversies on the subject of traumatic lesions of the ureter]. / Controversie in tema di lesioni traumatiche dell'uretere.

The injuries to the ureter, whether from external trauma or iatrogenic, are rare. Some problems are common to this type of pathology, independently from the causes of injuries. It is necessary a prompt diagnosis of the lesion to avoid the urinar leakage, the infection and the fibrosis of the ureteral's stumps. If the diagnosis is not prompt, the clinical pattern may be silent for some days; after, many complications will arise up: sepsis, urinomas and fistulas. When the lesion is incomplete, and there is no devascularization, the urine drainage alone, positioned above the level of the lesion, is indicated for spontaneous repairing. When the ureteral tissue loss is extensive, it is not enough a simple anastomosis between the ureteral's stumps; in these cases is necessary a more complex repair surgery or ureteral substitution.

[Bladder neck cysts: role of transrectal echography]. / Cisti del collo vescicale: ruolo dell'ecografia transrettale.

High frequency probes for transrectal sonography are well tolerated and permit us to study the cervico-urethral unit carefully. We are allowed to single out some rare causes of obstruction, otherwise difficult to diagnose. Bladder neck obstruction secondary to a cyst is one of these. Our case report is about a young patient with complete retention secondary to bladder cyst discovered by transrectal sonography.

[Echography versus nuclear magnetic resonance in the preoperative dynamic evaluation of plastic penile induration]. / Ecografia versus risonanza magnetica nucleare nella valutazione dinamica preoperatoria dell'induratio penis plastica.

Recently Ultrasonography (US) and Magnetic Resonance Imaging (MRI) has been successfully used as painless and non invasive techniques for depicting dense fibrous connective tissue of Peyronie's Disease (PD). The purpose of this study is to demonstrate the extent of disease and to prove the accuracy of US versus MRI. Twenty patients (aged 20-70; mean 43) with clinical diagnosis of PD were studied. All patients were studied with flaccid and erected penis after an intracavernous injection of Papaverine (variable dose). US and MRI examinations were performed independently by 2 groups of observers who knew clinical findings but not the results of the other technique. Both methods gave satisfactory images: they show the capacity to depict and to measure Peyronie's plaques clinically appreciated. US in 4 patients and MRI in 3 patients identified not palpable lesion which infiltrate the septum. Although the most common area of PD involvement is the dorsal surface of tunica albuginea, sometimes fibrous plaques are along the septum between the corpora cavernosa and the corpus spongiosum. In the present study, US and MRI are too able to identify not palpable lesion in the septum. In our opinion US has to be used for its high accuracy and low cost.

[Surgical treatment of caval thrombosis caused by parenchymal renal neoplasms]. / Trattamento chirurgico della trombosi cavale da neoplasia renale parenchimale (N.R.P.).

The incidence of renal cell carcinoma with a vena caval tumour thrombus has been reported in the literature, form 4% to 19%. Vena caval involvement causes serious diagnostic and therapeutic problems. Surgical treatment is usually conditioned by the tumor thrombus cranial extension and the possible invasion of the vena caval wall. Using Diagnostic Imaging (ECHO, CAT, MRI) we are able to establish the real presence, dimension and extension of the tumor thrombus, but we can not evaluate precisely its nature or the infiltration of the vena caval wall. We report our own experience in 27 patients with renal cell carcinoma extending into the vena cava (22 cases with tumor thrombus extending under the diaphragm and 5 cases over the diaphragm) and describe our favourite approach for thrombus extending into the right atrium using extracorporeal circulation, profound hypothermia and cardiac arrest (3 cases). From our data, we believe that the vena cava involvement doesn't make the prognosis any worse, if it isn't associated with the infiltration of the vena caval wall and nodal disease.

Diagnostic value of prostatic acid phosphatase and prostate-specific antigen in patients with prostatic cancer.

To compare the clinical usefulness of the measurement of prostatic acid phosphatase (PAP) and prostate-specific antigen (PSA) in serum of patients with prostatic carcinoma, we studied 128 patients with prostatic pathology, sixty (46.9%) of whom had prostatic cancer. Receiver-operating characteristics (ROC) curves were constructed and the underlying areas were calculated and compared to study clinical efficiency of the two markers regardless of the cutoff level selected. The area for PSA (0.90 +/- 0.30) was significantly higher (p less than 0.001) than that of PAP (0.71 +/- 0.05) showing that PSA was a better discriminator of the patients with or without prostatic cancer. The maximal clinical efficiency of the two tests at selected cutoff levels (0.8 U/L for PAP and 10 micrograms/L for PSA) was 0.787 and 0.883, respectively, confirming the superiority of PSA. However, the associated determination of the two markers improved the clinical specificity with no false-positive cases.

[Comparison of prostatic biopsy guided or not guided by echography]. / Comparaison entre biopsie prostatique aveugle et sous échographie.

We studied 151 patients aged from 49 to 85 years (mean 71) with a clinical suspect of prostatic cancer. 104 underwent a transrectal digitally directed prostatic biopsy, while 47 an ultrasonically perineal guided prostatic biopsy. Transrectal fine needle aspiration was performed in the whole group. Both techniques showed a high cyto-histologic concordance: 83.6% with transrectal digitally directed biopsy, 78.7% with perineal ultrasonically guided biopsy. The ultrasound guided biopsy has been able to downset the rate of cytologic false negatives in comparison to the digitally guided biopsy. In case of pathological rectal examination, digitally directed prostatic biopsy is still available and those who haven't an ultrasound apparatus, can equally perform a traditional biopsy with a limited possibility of mistake.