Transrectal Prostate Biopsy Approach in Men Undergoing Kidney Transplant: A Retrospective Cohort Study at Three Referral Academic Centers.

BACKGROUND: Currently, there are no studies evaluating the feasibility of a prostate biopsy approach in men undergoing a kidney transplant (KT). Owing to this evidence, we planned a retrospective population-based study to evaluate our experience of a transrectal prostate biopsy (TR-PB) approach and studied the impact on the complication rate and outcomes in patients undergoing KT with suspected prostate cancer (PCa). METHODS: We collected data from KT patients who underwent PB with a transrectal approach. One week and two weeks after the PB, patients' information was collected regarding possible complications during the post-biopsy period. RESULTS: A total of 121 patients were included in this study. Among them, Group 1 was composed of 59 patients undergoing TR-PB with an ultrasound (US) standard technique, and Group 2 consisted of 62 patients undergoing TR-PB with an MRI-US cognitive technique. We observed a 28.9% Clavien-Dindo grade ≤ 2 of early side effect rates (mostly rectal bleeding and other minor hematuria), with a very low rate of hospital re-admission for acute urinary retention (3.3%); only one man required hospitalization for rectal bleeding, and there were no major complications. CONCLUSIONS: We can affirm that TR-PB can be a safe procedure with a low risk of severe complications when performed by skilled specialists with a standardized procedural pathway.

Scrotal trauma: interest of preoperative ultrasound in the prediction of the rupture of the tunica albuginea.

Aim Scrotal bruises are quite frequent injuries affecting young subjects, with psychological repercussions on body image and fertility. The interest of ultrasound in the context of the emergency remains controversial. The aim of our study was to investigate clinical, ultrasonographic and operative features of scrotal contusions, and to evaluate the contribution of ultrasound in the description of traumatic lesions. Methods In this retrospective and descriptive study 71 scrotal contusions operated from December 2015 to April 2020 were collected. We retrospectively analysed 26 patients (aged between 14 and 79 years) of 71 who sustained a scrotal ultrasound, where the latter was positive. The primary endpoint was albuginea rupture, whose concordance between ultrasound and surgery was assessed using the Kappa method. Positive and negative predictive values, sensitivity and specificity for the presence of albuginea rupture were evaluated for a set of ultrasound data: scrotal haematoma, haematocele, regularity of testicular contours, testicular fracture (specificity (93%), testicular haematoma, and Doppler signal intensity. Results Surgical treatment was necessary in 26 (37%) patients; only six orchiectomy were performed. Surgical exploration should be performed if haematocele is found in the genital examination without any ultrasound complement. Conclusion The ultrasonography is useful, detailed and accurate when the haematocele is not clinically evident.

Safety and efficacy of transperitoneal laparoscopic nephron sparing surgery in patients with previous abdominal surgery.

OBJECTIVE: The aim of this study is to assess the safety and feasibility of the transperitoneal laparoscopic approach during nephron sparing surgery in patients with previous abdominal surgery. PATIENTS AND METHODS: We retrospectively analyzed patients undergoing transperitoneal laparoscopic partial nephrectomy for renal masses. All patients had received a diagnosis of cT1a renal exophytic mass (⩽5 cm). Patients were divided into two groups, those with and without previous abdominal surgery. Patients with solitary kidney or major previous abdominal surgery were excluded in this study. The operative time, estimated blood loss, length of stay, surgical complications, and positive surgical margins were recorded to compare outcomes among two groups. RESULTS: Of the 157 patients who were included in our study, 71 (45.3%) had a history of abdominal surgery (Group 1), while the remaining 86 (54.7%) had not (Group 2). Cholecystectomy was the most common previous surgery performed near the renal fossa. Patients with previous abdominal surgery experienced increased operative time (111.5 vs 83.2 min; p = 0.001). However, no statistically significant difference was found in estimated blood loss (122.1 vs 114.4 mL; p = 0.363), length of stay (4.1 vs 3.8 days; p = 0.465), rate of conversion to open surgery (2.8% vs 2.3%; p = 0.234), and rate of complications (p = 0.121). However, operative time (p = 0.003) and length of stay (p < 0.001) were greater in patients with versus those without previous open cholecystectomy. CONCLUSION: Our results suggest that laparoscopic partial nephrectomy after minor previous abdominal surgery is safe and feasible in selected patients affected by renal masses with low nephrometry score. However, previous cholecystectomy results in an increased risk of conversion to open surgery and longer hospital stay in patients undergoing right laparoscopic partial nephrectomy.

Technology Meets Tradition: CO2 Laser Circumcision versus Conventional Surgical Technique.

PURPOSE: We wished to present the clinical applications and to evaluate the benefits of the use of a carbon dioxide (CO2) laser versus the conventional procedure for circumcision in adults, in terms of duration of surgery, surgical techniques, complications, pain and cosmetic appearance. PATIENTS AND METHODS: The medical records of 482 patients who had been circumcised were retrospectively evaluated. The patients were divided into two groups: 168 patients (Group A) were circumcised with traditional techniques; and 314 patients (Group B) were circumcised using a CO2 laser. All the patients were circumcised under local anesthesia. Pain was evaluated using a verbal numerical rating scale for pain assessment. Postoperative wound swelling, bleeding, infection and pain were assessed at 4 hours, 24 hours and 7 days after surgery. RESULTS: There were no significant differences between the two groups in terms of bleeding and infections. The difference in operating times between the groups was significant (p<0.001). Wound disruptions occurred in one patient in Group A at 3 days and two patients in Group B at 1 week. Pain scores were low and there was less pain in Group B than in Group A during the first 4 hours (1.8 vs 3.7; p<0.002). Compared with the conventional method, the CO2 laser technique was associated with much less pain at both 1 day (p<0.002) and 7 days (p<0.001) postoperatively. The cosmetic results were superior in Group B; a linear surgical scar developed in 94.9% of patients in Group B versus 61.3% in Group A (p<0.001). CONCLUSION: Our results show that the use of a CO2 laser was associated with a shorter operative time, less wound irritation and better cosmetic appearance compared with standard surgical techniques for circumcision.

Complications and quality of life of ileal conduit, orthotopic neobladder and ureterocutaneostomy: systematic review of reports using the Clavien-Dindo Classification.

INTRODUCTION: Radical cystectomy (RC) and urinary diversion (UD) are two steps of the same surgical procedure involving likely complications and important impact on quality of life (QoL). The literature was reviewed to identify recent studies reporting UDs complications occurred 90 days after surgery and graded by Clavien-Dindo Classification System (CCS). EVIDENCE ACQUISITION: A comprehensive systematic Medline search was performed in PubMed/Medline, Embase and Scopus databases to identify reports published in English starting from 2013 using key words related to review outcome (i.e. neobladder, ileal conduct, ureterocutaneostomy, cystectomy, QoL). Complications were defined as minor or major whether the CCS grade was ≤2 or ≥3, respectively. Then, manuscripts references were screened to identify unfounded studies. Only studies using CCS to report surgical complications were considered. EVIDENCE SYNTHESIS: Retrieved studies were reported according to two main items of complications and QoL. About UDs complications, fourteen studies were identified incorporating overall 4436 patients. Up to 50% of patients experienced at least one low-grade complications (CCS≤2) requiring pharmacological treatment to be healed. On the other hand, high-grade complications (CCS≥3) occurred in 0.7-42% of cases and required surgical interventions (CCS 3a and 3b) or life support (CCS=4). Finally, mortality (CCS=5) rated between 0.4-7%. Regarding QoL, six studies were analyzed with overall 445 patients. Most of them were retrospective and showed conflicting results whether the external UDs were better than neobladder in term of impact on QoL. CONCLUSIONS: The use of a standardized system such as CCS improves analyses of literature. However, rigorous patient selection for UD type makes unable a randomized comparison between UDs in terms of complications and QoL impact.

Approach for Renal Tumors With Low Nephrometry Score Through Unclamped Sutureless Laparoscopic Enucleation Technique: Functional and Oncologic Outcomes.

PURPOSE: We report an unclamped sutureless laparoscopic simple enucleation (LSE) technique for renal tumors with low nephrometry score and analyze complication rates as well as functional and oncologic outcomes. PATIENTS AND METHODS: We reviewed the data of 143 consecutive patients who underwent sutureless laparoscopic tumor enucleation with zero ischemia by a single experienced laparoscopic surgeon. The inclusion criteria for LSE with zero ischemia were tumor size ≤ 5 cm and RENAL nephrometry score of 4 to 6. The following data were collected: age, gender, body mass index, tumor side, renal function, tumor characteristics, American Society of Anesthesiologists score, operative time, positive surgical margins, estimated blood loss, and surgical complications. RESULTS: The median RENAL score of patients was 4.7. Median tumor size was 2.7 cm. Conversion to open surgery and hilum vessels clamped were not necessary in any patient. There were no changes in postoperative creatinine values and estimated glomerular filtration rate. The median operation duration time was 78.2 minutes, and median estimated blood loss was 110.2 mL. The median hospital stay was 3.8 days. A total of 2.8% of the patients had positive surgical margins at pathologic examination. Of the 143 patients, 7% developed fever after surgery requiring an adequate antibiotic regimen, 1.4% developed postoperative bleeding requiring blood transfusions, and 0.7% had postoperative urinary leakage from the drainage requiring double-J stent position. CONCLUSION: The unclamped sutureless LSE is a rational and safe approach to renal tumors with a low nephrometry score. This surgical technique does not increase the complication rate despite the reduction in parenchymal mass excised and the absence of hilar control.

Active Surveillance for Low-risk Prostate Cancer: Are All Criteria Similar?

BACKGROUND: Active Surveillance (AS) is a therapeutic strategy for early-stage Prostate Cancer (PCa) conceived to balance early detection of aggressive disease and overtreatment of indolent tumor. Several active surveillance protocols have been published over the years, however the risk of misclassification still exist. In this review, we revised the current criteria of AS and evaluated the characteristics of potential risk factors of misclassification or deferred treatment. METHODS: We did a systematic search of the MEDLINE database, from 1993 to May 2015, according to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement guidelines and limited to the English language. The search terms used included "prostate cancer" and "active surveillance" and "criteria. We have excluded from the study reviews and editorial comments as well as multiple papers from the same data sets. RESULTS: Although the follow-up of reported studies was a quite short compared to the duration of the disease, the data are sufficient to conclude that active surveillance should be offered to men with low-risk disease and to men with intermediate risk and poor life expectancy. The present challenge, in fact, is to differentiate the clinically silent disease from the unfavorable course by identifying the right timing for any deferred treatment. This is made particularly difficult by the absence of randomized controlled trials directly comparing different AS monitoring methods. CONCLUSION: As summarized in this review, it is still difficult to select patients eligible for active surveillance and differentiate them from those that should move to active treatment. From the data, currently available in the literature, however, it is possible to recommend active surveillance to men with low-risk disease and to men with intermediate-risk disease but with short life expectancy.

An update on prostate biopsy in the era of magnetic resonance imaging.

INTRODUCTION: Prostate cancer (PCa) is a singular disease owing to absence of imaging technique able to detect suspicious glandular area at higher risk of disease. Nowadays, magnetic resonance imaging (MRI) has been used as a way to detect PCa and simplify targeting prostate biopsy (PB). The aim of this study is to review the most recent data regarding standard BP and MRI-guided PB. EVIDENCE ACQUISITION: A comprehensive systematic MEDLINE search was performed in December 2017 for English-language reports by using the following terms: "prostate biopsy," "multiparametric magnetic resonance imaging," "prostate cancer," "transrectal and transperineal ultrasound," "target biopsy." Previous published reviews and recent published original articles were preferred in order to meet our study scope. EVIDENCE SYNTHESIS: Retrieved studies of greater interest were reported in two main sections: standard PB and MRI-guided BP. Thus, the main items regarding PB were analyzed. Briefly, clinical suspicious of PCa is based on prostate specific antigen level and digital rectal examination findings although a PCa risk assessment through a nomogram risk calculator is nowadays advised. Ten-eighteen biopsy cores, depending on prostate volume, and peripheral sampling seem the suitable scheme for initial biopsy while a saturation template (>20 cores including transitional prostate area) is widely used in case of repeat PB. Performing a local anesthesia is now the standard of care with several available techniques. No difference exists in term of PCa detection rate between transperienal and transrectal approaches however the last one is mostly used. The use of MRI-guided biopsy seems to be a promising imaging technique able to identify an index lesion at higher suspicious of PCa. In particular, MRI shows a higher accuracy than standard PB in the detection of clinically significant PCa. No general consensus exists on which MRI-guided biopsy should be used with three different ways currently available to take biopsy core. However, the initial MRI cognitive PB has been replaced by fusion MRI technique to guide biopsy with reproducible results. Absence of standardization founded in initial MRI studies has been recently revised by introduction of common criteria to assess PCa presence on MRI. CONCLUSIONS: PB is the cornerstone in diagnosis and management of PCa. Although ultrasound transrectal and transperineal PB are still considered as the standard, emerging data confirm the role of MRI-guided biopsy, particularly in patients with a previous negative biopsy. However, MRI costs and the moderate inter-reader reproducibility of the exam are still significant concerns requiring further studies to define the right role of MRI in the PCa diagnostic pathway.

Latest Evidence on the Role of Multiparametric Magnetic Resonance Imaging in Active Surveillance for Insignificant Prostate Cancer: A Systematic Review.

OBJECTIVE: Multiparametric Magnetic Resonance Imaging (mpMRI) has become a very useful tool in the management of PCa. Particularly, there is a great interest in using mpMRI for men on Active Surveillance (AS) for low risk PCa. The aim of this systematic review was to critically review the latest literature concerning the role of mpMRI in this clinical setting, underlying current strengths and weakness. EVIDENCE ACQUISITION: A comprehensive literature research for English-language original and review articles was carried out using the National Center for Biotechnology Information PubMed database with the aim to identify studies pertaining to mpMRI for AS in low risk PCa patients. The following search terms were used: active surveillance, prostate cancer and multiparametric magnetic resonance imaging. EVIDENCE SYNTHESIS: Data from 28 recent original studies and reviews were reviewed. We only considered studies on the use of mpMRI in selecting AS patients and during AS follow-up, in order to solve two important questions: -Can mpMRI have a role in improving the detection of clinically significant disease, better selecting AS patients? -Can mpMRI identify the progression of disease and, consequently, be used during AS follow-up? CONCLUSIONS: mpMRI is useful to better select the ideal candidates to AS and to monitor them during follow-up. However, despite many advantages, there are yet important limitations to detect all clinically significant PCa and to better define mpMRI-radiological progression during AS. Further larger prospective studies are needed to definitively solve these important problems.

A larger detrusor wall thickness increases the risk of non muscle invasive bladder cancer recurrence and progression: result from a multicenter observational study.

BACKGROUND: Recent experimental study showed a higher incidence of bladder cancer in presence of bladder detrusor muscle thickening. The aim of this study is to assess whether a higher detrusor muscle thickness (DWT) may be a risk factor of recurrence of non-muscle invasive urothelial bladder cancer (NMIBC). METHODS: Men with histologically-confirmed diagnosis of NMIBC were prospectively enrolled in 4 centers between December 2015 and April 2017. DWT was measured by ultrasound and DWT>2.5 mm was used as threshold for detrusor muscle thickening. Patients underwent to adjuvant local treatment in according to their progression and recurrence risk computed by European Organization Research and Treatment of Cancer (EORTC) Score for NMIBC. Every three months cystoscopy and urinary cytology were used to detect disease recurrence and progression. The main clinic-pathological variables were compared between patients with DWT≤2.5 mm and DWT>2.5 mm. RESULTS: One hundred patients (49.8%) with DWT >2.5 mm were significantly older, had larger and more tumors and experienced more prior NMIBC than 101 (50.2%) patients with a DWT≤2.5 mm. Recurrence and progression disease occurred more often and briefly in patients with a detrusor muscle thickening. At univariate analysis, DWT>2.5 was a predictive risk factors of cancer recurrence and progression, respectively: OR 4.9 (95% CI: 2.5-9.5) P=0.001 and OR 2.21 (95% CI: 1.71-4.73), P=0.001. Enclosing DWT in EORTC risk calculator significantly increased by 3% and 1% recurrence and progression risk assessment, respectively. CONCLUSIONS: Detrusor muscle thickening may have a role in NMIBC course with a higher recurrence rate, however further confirmatory and elucidating studies are required.

Bladder stone management: an update.

INTRODUCTION: Bladder stone (BS) is a rare disease curable with several options. Herein, we reviewed the specific literature in order to update the current BS management. EVIDENCE ACQUISITION: A comprehensive systematic MEDLINE search was performed for English language reports published before April 2017 using the BS related terms, i.e. bladder-vesical calculi, lithotripsy. Then manuscripts references were screened to identify unfounded studies. Studies regarding BS in children were excluded. EVIDENCE SYNTHESIS: Retrieved studies were classified according to their main item as: etiology, diagnosis, treatment, treatment in specific illnesses and advances in BS management. Treatment option was mainly related to stone size and number as well as concomitant causative disease. However, stone nature was not analyzed in all the retrieved studies. Both trans-urethral and percutaneous lithotripsy were efficacy for stone fragmentation although the last one was suggested to avoid urethral injuries. Holmiun:Yag laser lithotripsy has made stone fragmentation feasible by using local anesthesia however in selected patients only. The urological dogma to perform concomitant prostate surgery in men with BS has been recently questioned by some observational case-series studies however, the lack of randomization and long follow up preserve that knowledge. CONCLUSIONS: Bladder stone is a rare and ancient disease. Nowadays new technologies have been developed in the effort to make less invasive stone treatment. The retrieved studies show that stone fragmentation can be archived by using several surgical approaches and devices whereas comparative randomized studies are still unavailable to identify the best option.

Metabolic syndrome diagnosis and widespread high grade prostatic intraepithelial neoplasia significantly increase prostate cancer risk: results from a multicenter biopsy study.

BACKGROUND: To test in multicenter setting if patients affected of metabolic syndrome (MetS) and initial widespread high grade prostatic intraepithelial neoplasia (wHGPIN) diagnosis are at higher risk of prostate cancer (PCa) on repeat biopsy. METHODS: Patients clinical charts from three European Academic Hospital were reviewed in order to identify patients with initial diagnosis of HGPIN undergone to repeat biopsy. Inclusion and exclusion criteria were adopted to minimize patient heterogeneity. MetS was defined according to Word Heart Organization criteria while initial wHGPIN when ≥ 4 cores biopsy were involved. A multivariate logistic model was computed to assess the association between PCa and clinical-pathological variables. RESULTS: Overall 283 patients were scheduled. Median age was 67 years (IQR 62-72). MetS was diagnosed in 116/283 (41%) patients and PCa was detected in 84/283 (29.7%) patients. In particular, PCa was more frequently diagnosed in patients affected of wHGPIN and MetS (45/86, 52.3%) than in patients with wHGPIN and normal metabolic profile (28/95, 29.5%), p = 0.002. The multivariate logistic model confirmed that wHGPIN and MetS are independent risk factors for following PCa diagnosis, respectively OR 2.4 (95% CI 1.01-5.71, p = 0.04), OR 2.79 (95% CI 1.49-5.22, p = 0.01) while total PSA and DRE findings are not able to predict PCa at repeat biopsy, OR 1.05 (95% CI 0.98-1.03 p = 0.69) and OR 1.01 (95% CI 0.55-1.84, p = 0.96) respectively. CONCLUSIONS: wHGPIN is positively associated to PCa; assessing metabolic profile and repeat prostate biopsy is advisable in patients with initial diagnosis of wHGPIN.