Developing a five-step training model for transperineal prostate biopsies in a naïve residents' group: a prospective observational randomised study of two different techniques.

PURPOSE: To evaluate a five-step training model for transperineal prostate biopsies (TPPB) and the differences in terms of the detection rate (DR) and the ease of execution when using either the "fan technique" (FT) or the use of a Free Hand technique (FH). METHODS: A prospective observational randomised study was conducted from September 2015 to November 2017. Six naïve residents, who underwent the same five-steps training model, were randomly subdivided into two different groups of three residents based on the selected TPPB technique: A (FT) and B (FH). Patient characteristics (age, PSA, prostatic volume, DRE, MRI), intraoperative (operative time, number of samples) and postoperative parameters (histologic, pain) were evaluated in the 2 groups. The overall and stratified DR for PSA ranges and prostate volume (PV), operative time and complications were compared. RESULTS: The overall detection rate was very high in both groups (FT 58.2% vs FH 59.6%) and not statistically different between the two techniques. There were no differences in terms of complication rates and pain. The FH showed a better detection rate in prostates smaller than 40 cc (p = 0.023) and a faster operative time (p = 0.025) compared to FT. CONCLUSIONS: Within the TPPB, FH is associated with a higher detection rate in patients with prostate < 40 cc compared to an FT when performed by inexperienced trainees. Standardised training organised in consecutive steps seems to contribute to the achievement of overall high detection rates with both methods.

Age is predictive of immediate postoperative urinary continence after radical retropubic prostatectomy.

INTRODUCTION: Immediate continence is a goal to take into consideration for better patient satisfaction after radical prostatectomy. Factors predicting urinary continence at catheter removal were investigated. MATERIALS AND METHODS: We evaluated preoperative, operative, clinical, hormonal and pathological variables in a homogeneous series of radical retropubic prostatectomies (RRPs) following the principles of urinary sphincter restoration technique. RESULTS: The study included 201 patients who underwent RRP. The overall immediate continence rate at catheter removal was 67.7% (136 patients); 28.8% (58 patients) were using one protective pad daily and 3.5% (7 patients) were incontinent. At 6-month follow-up incontinence had reached the lowest level of 2.5% (5 patients) and at 12 months the patients using one pad daily had decreased to 11.9% (24 patients). Multivariate logistic analysis showed that the only two factors independently associated with immediate continence were age <65 years (OR = 2.63, 95% CI 1.13-5.88, p = 0.02) and potency (OR = 3.6, 95% CI 1.2-10.7, p = 0.01) adjusting for D'Amico risk group, surgical margins, extracapsular extension, clinical stage, PSA, testosterone, LH and FSH. No significant association was noted for PSA, hormonal levels, hospital stay, prostate size, clinical stage, risk group, TNM stage, pathological Gleason score or extracapsular extension. CONCLUSIONS: In our series age <65 years was associated with immediate continence after RRP. Moreover, patients who were immediately continent had a 3.6-fold probability to be potent within 12 months.

Recurrence and progression in patients with non-muscle invasive bladder cancer: prognostic models including multicolor fluorescence in situ hybridization molecular grading.

OBJECTIVE: To test the prognostic value of multicolor fluorescence in situ hybridization analyses of tumor cells in urine for prediction of the recurrence and progression of tumor in patients with intermediate risk non-muscle invasive bladder cancer. METHODS: A total of 168 patients with non-muscle invasive bladder cancer were included in the study. Fluorescence in situ hybridization was carried out on the bladder wash urine collected before resection. Tumors were classified as low molecular grading if they had a diploid chromosomal pattern or only a loss of p16 or ch3 aneuploidy, and as high molecular grading if they showed aneuploidy of ch7 or 17. Cox regression models assessed the added prognostic value of fluorescence in situ hybridization for primary tumor recurrence or progression, respectively. RESULTS: Median follow up was 67 months. A total of 57% of tumors were classified as low molecular grading. The 2- and 5-year recurrence-free survival was 68% and 49% for low molecular grading, and 47% and 30% for high molecular grading, respectively. The 2- and 5-year progression-free survival was 95% and 84% for low molecular grading, and 79% and 58% for high molecular grading tumor patients, respectively. Molecular grading (hazard ratio 1.60; P = 0.03) was associated with recurrence, when also accounting for histopathology and a patient's characteristics. Both cancer severity score (hazard ratio 1.51; P < 0.01) and molecular grading (hazard ratio 2.53; P < 0.01) independently and positively predicted progression in multivariable models. The C-index for predicting recurrence increased from 0.58 to 0.61 when molecular grading fluorescence in situ hybridization was included in the model, and from 0.68 to 0.72 when predicting progression. CONCLUSIONS: Fluorescence in situ hybridization-based molecular grading increases the accuracy of a prognostic model, predicting both recurrence and progression in patients with intermediate risk non-muscle invasive bladder cancer.

Repositioning of antiarrhythmics for prostate cancer treatment: a novel strategy to reprogram cancer-associated fibroblasts towards a tumor-suppressive phenotype.

BACKGROUND: Cancer-associated fibroblasts (CAFs) play a significant role in fueling prostate cancer (PCa) progression by interacting with tumor cells. A previous gene expression analysis revealed that CAFs up-regulate genes coding for voltage-gated cation channels, as compared to normal prostate fibroblasts (NPFs). In this study, we explored the impact of antiarrhythmic drugs, known cation channel inhibitors, on the activated state of CAFs and their interaction with PCa cells. METHODS: The effect of antiarrhythmic treatment on CAF activated phenotype was assessed in terms of cell morphology and fibroblast activation markers. CAF contractility and migration were evaluated by 3D gel collagen contraction and scratch assays, respectively. The ability of antiarrhythmics to impair CAF-PCa cell interplay was investigated in CAF-PCa cell co-cultures by assessing tumor cell growth and expression of epithelial-to-mesenchymal transition (EMT) markers. The effect on in vivo tumor growth was assessed by subcutaneously injecting PCa cells in SCID mice and intratumorally administering the medium of antiarrhythmic-treated CAFs or in co-injection experiments, where antiarrhythmic-treated CAFs were co-injected with PCa cells. RESULTS: Activated fibroblasts show increased membrane conductance for potassium, sodium and calcium, consistently with the mRNA and protein content analysis. Antiarrhythmics modulate the expression of fibroblast activation markers. Although to a variable extent, these drugs also reduce CAF motility and hinder their ability to remodel the extracellular matrix, for example by reducing MMP-2 release. Furthermore, conditioned medium and co-culture experiments showed that antiarrhythmics can, at least in part, reverse the protumor effects exerted by CAFs on PCa cell growth and plasticity, both in androgen-sensitive and castration-resistant cell lines. Consistently, the transcriptome of antiarrhythmic-treated CAFs resembles that of tumor-suppressive NPFs. In vivo experiments confirmed that the conditioned medium or the direct coinjection of antiarrhythmic-treated CAFs reduced the tumor growth rate of PCa xenografts. CONCLUSIONS: Collectively, such data suggest a new therapeutic strategy for PCa based on the repositioning of antiarrhythmic drugs with the aim of normalizing CAF phenotype and creating a less permissive tumor microenvironment.

The impact of prior TURP on radical prostatectomy surgical margins: a multicenter analysis.

OBJECTIVE: To analyze positive surgical margins (PSM) after radical prostatectomy (RP) in the overall population and in patients previously treated with transurethral resection of the prostate (TURP). MATERIALS AND METHODS: 2,408 patients treated with RP for clinically localized prostate cancer (PCa) were consecutively enrolled in 135 departments. We correlated PSM rates and all preoperative, surgical and pathological features. We stratified the site of PSM as unique or multifocal. Moreover, we analyzed differences between 75 patients who had undergone previous TURP and the remaining 2,333 patients. RESULTS: In the entire study population, we identified 702 patients with PSM (29%). Using univariate analysis, we reported a significant correlation between overall PSM and prostate-specific antigen (PSA), stage cT, biopsy Gleason score, number of biopsy cores, number of positive cores, percentage of positive cores and nerve-sparing approach. PSM proved to be strongly dependent on pT in particular in patients with pT2 PCa. When we compared the data from 75 patients previously treated with TURP and those from 2,333 without previous prostatic surgery, a statistically significant difference in margin localization was found. Moreover, we analyzed the 75 patients mentioned above, stratified in incidental PCa diagnosed at TURP or PCa detected with prostate biopsy for PSA rising during the post-TURP follow-up: no statistical differences were found between the 2 groups regarding margin status, even if PSM were more frequent in incidental PCa with no significance deriving from the stratification for PSM location at the apex or base. CONCLUSION: Men treated with TURP before RP presented an overall incidence of PSM similar to those without previous TURP, but with a higher risk of PSM at the bladder neck and a lower risk of PSM at the prostatic apex.

Extraperitoneal cystectomy with ureterocutaneostomy derivation in fragile patients - should it be performed more often?

INTRODUCTION AND OBJECTIVES: Radical cystectomy (RC) continues to be standard of care for muscle-invasive bladder cancer and recurrent or refractory nonmuscle invasive bladder cancer. Unfortunately, it has high rates of perioperative morbidity and mortality. One of the most important predictors of postoperative outcomes is frailty, while the majority of complications are diversion related. The aim of our study was to evaluate safety of extraperitoneal cystectomy with ureterocutaneostomy in patients considered as frail. MATERIALS AND METHODS: We retrospectively collected data of frail patients who underwent extraperitoneal cystectomy with ureterocutaneostomy from October 2018 to August 2020 in a single center. We evaluated frailty by assessing patients' age, body mass index (BMI), nutritional status by Malnutrition Universal Screening Tool, overall health by RAI (Risk Analysis Index) and ASA (American Society of Anaesthesiologists) score, and laboratory analyses. We observed intraoperative outcomes and rates of perioperative (within 30 days) and early postoperative (within 90 days) complications (Clavien-Dindo classification). We defined extraperitoneal cystectomy with ureterocutaneostomy as safe if patients did not develop Clavien Dindo IIIb, or worse, complication. RESULTS: A total of 34 patients, 3 female and 31 male, were analyzed. The median age was 77, BMI 26, RAI 28, ASA 3 and the majority had preexisting renal insufficiency. Blood analyses revealed presence of severe preoperative hypoalbuminemia and anemia in half of our cohort. Intraoperative median blood loss was 250 cc, whilst operative time 245 min. During perioperative period 60% of our cohort developed Clavien Dindo II complication and during early postoperative period 32% of patients required readmission. One death occurred during early postoperative period (2.9%). After 12 months of follow-up, we observed stability of the renal function for most patients. CONCLUSIONS: We believe that extraperitoneal cystectomy with ureterocutaneostomy could be considered as a treatment option for elderly and/or frail patients.

Are referral centers for non-muscle-invasive bladder cancer compliant to EAU guidelines? A report from the vesical antiblastic therapy Italian study.

INTRODUCTION: Adherence to international guidelines is viewed as a prerequisite for optimal medical care delivery. Previously reported surveys for non-muscle-invasive bladder cancer (NMIBC) employed mailed questionnaires to urologists or patients resulting in conflicting degrees of agreement with existing guidelines. In the current study, contemporary information on the management of NMIBC was generated from a sample of italian centers. PATIENTS AND METHODS: Eight Italian referral centers for the treatment of NMIBC were asked to collect information relative to all consecutive patients with a histology-proven NMIBC undergoing a transurethral resection from January 1 to March 31, 2009. The primary study objective was to verify the level of adherence of disease management with European guidelines. RESULTS: 344 patients resulted in being evaluable. 49.2% of high-risk patients underwent a repeat transurethral resection. Bacillus Calmette-Guérin was employed in 35% of cases, while chemotherapy was in 22%. An early single regimen was adopted in 136 patients and only in 1 out of 3 low-risk patients. High-risk NMIBC received bacillus Calmette-Guérin and chemotherapy as first-line therapy in 66 and 12.5% respectively. After 3 months, cystoscopy had been reported for 82.5% of patients with a recurrence rate of 13%. CONCLUSION: Adherence of Italian Institutions to EAU guidelines was optimal when reporting baseline variables. Significant degrees of discrepancy emerged in treatment choices.

Age above 70 years and Charlson Comorbidity Index higher than 3 are associated with reduced survival probabilities after radical cystectomy for bladder cancer. Data from a contemporary series of 334 consecutive patients.

OBJECTIVE: To assess the joint effect of age and comorbidities on clinical outcomes of radical cystectomy (RC). METHODS: 334 consecutive patients undergoing open RC for bladder cancer (BC) during the years 2005-2015 were analyzed. Pre-, peri- and post-operative parameters, including age at RC (ARC) and Charlson Comorbidity Index (CCI), were evaluated. Overall and cancer-specific survivals (OS, CSS) were assessed by univariate and multivariate modelling. Furthermore, a three-knot restricted cubic spline (RCS) was fitted to survival data to detect dependency between death-rate ratio (HR) and ARC. RESULTS: Median follow-up time was 3.8 years (IQR = 1.3-7.5) while median OS was 5.9 years (95%CL = 3.8-9.1). Globally, 180 patients died in our cohort (53.8%), 112 of which (62.2%) from BC and 68 patients (37.8%) for unrelated causes. After adjusting for preoperative, pathological and perioperative parameters, patients with CCI > 3 showed significantly higher death rates (HR = 1.61; p = 0.022). The highest death rate was recorded in ARC = 71-76 years (HR = 2.25; p = 0.034). After fitting an RCS to both OS and CSS rates, two overlapping nonlinear trends, with common highest risk values included in ARC = 70-75 years, were observed. CONCLUSIONS: Age over 70 years and CCI > 3 were significant factors limiting the survival of RC and should both be considered when comparing current RC outcomes.

Short-time ureteral catheterization after operative ureteroscopic lithotripsy: an alternative to stent versus no stent evaluated in a retrospective study.

OBJECTIVES: Stent-less procedure following ureterolithotripsy needs a definition for patient selection and procedure criteria. To mediate stenting versus no stenting, a retrospective study was performed to evaluate the insertion of an ureteral open-tip catheter for 24 hours. MATERIAL AND METHOD: From 2002 to 2006 255 ureterolithotripsy were performed (176 male - 79 female, mean age 51.5 y.o.). Stone was in the upper ureter in 101 cases, in the mid in 89 and the lower in 65. Patients were retrospectively separated into 3 groups: in Group A a stent was placed because of complicated lithotripsy and left for 15 days. In Group B an open-tip catheter was placed for 24 hours. In Group C no catheter was left. All patients were evaluated for symptoms as need of antalgic substances. RESULTS: In Group A 134 patients were stented. The mean stone dimensions were 8.7mm. Flank pain was reported in 52 patients (38%) on post-op 15 days, 77 patients (57.4%) referred lower urinary tract symptoms, 2 patients reported hematuria. In Group B 105 patients (41.1%) were stented with open-tip catheter. The mean stone dimension was 6.3 mm. Pain was referred in 43 patient (40.9%) after the catheter removal. In 12 cases (11.4%) hospital readmission was necessary due to pain. Group C was represented by 16 patients (6.27%). Mean stone dimension was 6mm. No postoperative pain was reported. A statistical difference (p < 0.005) is significative comparing the operative time for the stent vs open-tip group. CONCLUSIONS: No rules establish if it is correct to stent or to avoid this procedure, so trying to resolve the dilemma by inserting an open tip catheter for 24 hours seems a good response. The operating time is reduced for no stenting or positioning catheter vs stenting. To reduce immediate post-ureteroscopy complication placing an open-tip catheter for 24 hours seems to be a simple and cheap procedure.

Dermal graft surgery for Peyronie's disease: Long term results at a 15 years follow-up.

OBJECTIVES: To evaluate long-term outcomes of patients subjected to corporoplasty, plaque incision and excision, and autologous dermal grafting, with at least 15 years of follow-up. METHODS: The charts of consecutive patients with a penile curvature and a minimum of 15 years follow up were retrospectively reviewed. The patients underwent corporoplasty and penile straightening with autologous dermal grafting, harvested at the level of the anterior-superior iliac spine. At the time of the follow-up, a postoperative IIEF - 5 questionnaire was administered by telephonic interview, and patients were also asked to complete an 8 items self-evaluation questionnaire. After signing informed consent, the patients were invited to undergo dynamic and basal penile sonography, as well as injection of 10 mcg of PGE1 for dynamic evaluation of the graft. RESULTS: A total of 16 patients were identified. Penile shortening of up to 1.5 cm was reported in about 40% of cases and residual bending was reported by 4 of 16 patients. However, there was no impairment in penetration. On physical examination of the suture site, a small indurated nodule was palpable in two patients. Data regarding the dynamic sonography is available for the 5 patients who accepted to undergo the test. No sign of a fibrotic reaction or calcification was detected in the static phase. After injection of 10 mcg PGE-1, in comparison to the basal measurement, the dermal grafts showed compliant length adaptation. CONCLUSIONS: Dermal graft substitution surgery for Peyronie's disease allows to obtain good functional results with durable satisfaction of the patients on long term follow up.

OBJETIVOS: Evaluar los resultados a largo plazo de los pacientes sometidos a corporoplastia, incisión y escisión de la placa, e injerto dérmico autólogo, con al menos 15 años de seguimiento. MÉTODOS: Revisamos retrospectivamente las historias clínicas de los pacientes con incurvación peneana y un mínimo de 15 años de seguimiento. Los pacientes fueron sometidos consecutivamente a corporoplastia y corrección de la curvatura con injerto dérmico autólogo, obtenido a nivel de la espina iliaca antero-superior. En el seguimiento, se pasó el cuestionario IIEF-5 postoperatorio mediante entrevista telefónica, y también se pidió a los pacientes completar un cuestionario de autoevaluación de 8 preguntas. Después de firmar un consentimiento informado, los pacientes fueron invitados a realizar ecografía peneana dinámica y basal, así como inyección de 10 mcg de PGE1, para la evaluación dinámica del injerto. RESULTADOS: Fueron identificados un total de 16 pacientes. Cerca del 40% de los casos comunicaban un acortamiento del pene de hasta 1,5 cm y 4 de 16 pacientes referían incurvación residual. Sin embargo, no había empeoramiento de la penetración. En la exploración física del sitio de la sutura, en dos pacientes era palpable un pequeño nódulo indurado. Los datos referentes a la ecografía estaban disponibles en los 5 pacientes que aceptaron realizar la prueba. En la fase estática no se detectaron signos de reacción fibrótica o calcificación. Después de la Inyeccion de 10 mcg de PGE-1, los injertos dérmicos mostraron una adaptación longitudinal adecuada en comparación con la medición basal. CONCLUSIONES: En la enfermedad de La Peyronie, la cirugía de substitución con injerto dérmico permite obtener buenos resultados funcionales con satisfacción de los pacientes perdurable en el seguimiento a largo plazo.

Current perioperative management of radical cystectomy with intestinal urinary reconstruction for muscle-invasive bladder cancer and reduction of the incidence of postoperative ileus.

Major abdominal surgery, and also radical cystectomy, is followed by a delayed return of bowel function attributable to postoperative ileus (POI), which, in addition, stands out as one of the most frequent complications that causes increased length of stay (LOS). Some variability exists in the definition of POI since time to return of peristalsis and time to first passage of flatus, which are commonly referred to as indicators of bowel activity, have their own weaknesses, observer dependent and time dependent, among other variables. A number of causes have been recognized to induce or maintain the condition of ileus. Some among them are part of the perioperative period. The practices of mechanical bowel preparation (MBP) and of fasting before surgery have been challenged and can be safely abandoned. The perception of pain is an acknowledged promoter of POI; therefore, providing complete pain control constitutes the rationale in favor of administering anesthesia and analgesia combined, both in the form of concurrent general and epidural anesthesia (i.e., at the thoracic level, T9, T11), and represents the mainstay of intraoperative measures. Hypovolemia is also associated with an increased risk of POI. The use of nasogastric tubing (NGT) has been associated with increased pulmonary complications; moreover, bowel resection can be performed safely without postoperative NGT. Early postoperative provision of artificial nutrients has shown beneficial effects, both in the form of total parenteral and enteral nutrition (PEN, EN). We devised a perioperative care regimen, adopting a multimodality approach aimed at minimizing the effects of the above listed factors to ascertain if they could contribute to preventing or reducing POI and the complications associated with radical cystectomy and intestinal urinary diversion. In addition, we investigated the impact of early artificial nutrition, combining PEN and EN via a jejunal nutrition cannula. Time to return of bowel movements, time to reinstitution of a regular diet, presence and duration of POI, and incidence and nature of complications constituted the study end points. Of 143 consecutive patients, 107 who underwent radical cystectomy with intestinal urinary reconstruction were able to be evaluated for results and complications. The male to female ratio was 86:21, the mean age was 74 years, and more than two-third belonged to the American Society of Anesthesiologists categories II and III. Pathologic stages of disease were bladder confined in 48 patients, locally advanced in 33, and extravesical in 26. Urinary diversion with intestine consisted in the configuration of heterotopic reservoirs in 39 patients, orthotopic substitution in 38, and uretero-ileo-cutaneostomy in 30. Bowel movements returned after a median time of 2 days (range, 1-6), and the median time to reinstitution of a regular diet was 4 days (range, 3-9). POI beyond postoperative day 4 was observed in 17.7% of the patients. Overall, a total of 28 patients (26.1%) experienced complications, specifically, medical complications in 19 patients and surgical complications leading to relaparotomy in 11. The mortality rate was 3.7%. No effects were observed on postoperative protein depletion, despite the provision of early artificial nutrition. Our results suggest that a short median time of return of both peristalsis and flatus, and to regular diet resumption with a low incidence of POI, can be obtained in the majority of patients with a perioperative regimen aimed at reducing the effect of some of the causes associated with induction or maintenance of POI. Further studies of multimodality perioperative care plans, similar to that used in the present study, are required.

The UroVysion F.I.S.H. test compared to standard cytology for surveillance of non-muscle invasive bladder cancer.

OBJECTIVE: To evaluate the potential contribution of urinary fluorescent in situ hybridization in the prediction of the risk of recurrence and progression of men undergoing followup for NMIBC. MATERIALS AND METHODS: Patients with a history of NMIBC being followed with urinary cytology and cystoscopy were included in the study. Patients with Carcinoma in situ or tumour stage higher than pT1 were excluded from this analysis. F.I.S.H. Test consisted in the UroVysion kit, able to detect four chromosomal abnormalities, specifically, 9p21, Ch 3, 7 and 17. RESULTS: Of a total of 133 evaluable patients that constitute the subject of the present report 87 patients had a positive urinary F.I.S.H. At a median follow up time of 36 mos 58 patients underwent recurrence (43.6%). In this group 42 (72.6%) and 27 (46.6%) patients had a positive F.I.S.H. and UC, respectively (p = 0.005). A total of 17 patients (12.8%) underwent progression of stage or grade; of those with a positive F.I.S.H. Test and positive UC were 14 (82.4%) and 8 (47.1%), respectively (p = 0.049). CONCLUSION: In patients with history of NMIBC, F.I.S.H. showed a statistically significantly greater capability that UC in identifying patients with recurrence and progression of disease.

The pathologist's role in the detection of rare variants of bladder cancer and analysis of the impact on incidence and type detection.

BACKGROUND: Histology is one of the most important factors determining the prognosis of bladder cancers and rare variants are generally associated with decreased disease specific survival compared to pure transitional cell carcinomas. We believe that rare bladder cancer variants are likely underdiagnosed in the absence of a dedicated uro-pathologist in many centers. The objective of this study is to evaluate the contribution of a dedicated uro-pathologist on the identification of rare bladder cancer variants. METHODS: We retrospectively analyzed the clinical and histological records of all patients which underwent a radical cystectomy and lymph node dissection between January 2000 and September 2015. The sample was divided in two groups: Group A, consists of patients who underwent radical cystectomy in the absence of a dedicated uro-pathologist at our institution, whereas the Group B consists of patients who underwent surgery when a dedicated uro-pathology service was available. We then evaluated the impact of a dedicated uro-pathologist on rare variants detection. RESULTS: One hundred thirty-seven out of 551 (24.9%) of patients who underwent RC had at least one rare variant. In Group A 38/238 (16%) of patients showed a rare variant, while 99/313 (31.6%; P<0.001) in group B. Furthermore, the diagnosis of sarcomatoid variant was statistically significantly less common in group A (P=0.0026). The concordance between final radical cystectomy histology and previous transurethral resection of bladder tumor (TURBT) histology was poor in both groups (overall 50.4%). CONCLUSIONS: The presence of a dedicated urological anatomical pathologist is of paramount importance and significantly increases the detection rate of non-transitional cell carcinoma bladder cancer types, but it does not increase the concordance rate between histological diagnoses in TURBT and radical cystectomy specimens.

Large bladder diverticula: a comparison between laparoscopic excision and endoscopic fulguration.

OBJECTIVE: The treatment of bladder diverticula consists of diverticulectomy, mainly by a laparoscopic approach or transurethral resection of the diverticular neck and fulguration of the mucosa. The endoscopic approach is generally dedicated to small diverticula. The aim of this study was to compare laparoscopic diverticulectomy versus endoscopic fulguration for bladder diverticula larger than 4 cm. MATERIALS AND METHODS: A retrospective review of the medical records of consecutive patients undergoing endoscopic or laparoscopic treatment for bladder diverticula larger than 4 cm at two tertiary hospitals was performed. Therapeutic success was defined as either complete resolution or a decrease of at least 80% in the size of the diverticulum. Complications were recorded and graded according to the Clavien-Dindo classification. RESULTS: All patients were treated with transurethral resection of the prostate in the same operative session. The endoscopic group included a cohort of 20 male patients. The median age, diverticular diameter and operative time were 65 years, 7 cm and 62.5 min, respectively. No early postoperative complications were observed. Therapeutic success was achieved in 15 cases (75%). The laparoscopic group included a cohort of 13 male patients with a median age of 63 years and median diverticular diameter of 7.0 cm. The median operative time was 185 min (p < 0.0001). Two grade III postoperative complications were observed (15.3%). Therapeutic success was achieved in all patients (100%). CONCLUSIONS: Acquired bladder diverticula larger than 4 cm can be effectively managed either by a laparoscopic approach or by endoscopic fulguration.

Pharmacokinetics and toxicity of an early single intravesical instillation of gemcitabine after endoscopic resection of superficial bladder cancer.

BACKGROUND: The tolerability and plasma absorption of gemcitabine administered at 40 mg/ml after small and extensive endoscopic transurethral resection of bladder tumors (TURB) were evaluated. PATIENTS AND METHODS: Nine patients with a history of recurrent superficial bladder cancer were eligible for a single immediate, post TURB, intravesical instillation of gemcitabine. The endoscopic resection was small in 5 patients and extensive in 4. The drug was administered at 40 mg/ml concentration (2000 mg in 50 ml saline) and held in the bladder for 1 hour. Plasma concentrations of gemcitabine and its metabolite (2',2'-difluorodeoxyuridine) were determined with a validated HPLC assay. The blood count and chemistry were performed one day and one week postoperatively. RESULTS: Toxicity was comparable for patients who underwent small or large TURB. The most significant side-effects were grade 2 vomiting and a transient grade 2 leukopenia after small and large TURB respectively. Mean maximum gemcitabine concentrations were 1.47 microg/ml in small TURB and 2.8 microg/ml in large TURB. The highest peak concentration of 4.26 microg/ml was found after extended bladder resection. CONCLUSION: A single, immediate postoperative, intravesical instillation of gemcitabine at high concentration is feasible with acceptable toxicity, and it may be considered as an option taking into account patient performance status, tumor characteristics and TURB extension.

Eleven-year management of prostate cancer patients on active surveillance: what have we learned?

PURPOSE: To evaluate the outcomes of active surveillance (AS) on patients with low-risk prostate cancer (PCa) and to identify predictors of disease reclassification. METHODS: In 2005, we defined an institutional AS protocol (Sorveglianza Attiva Istituto Nazionale Tumori [SAINT]), and we joined the Prostate Cancer Research International: Active Surveillance (PRIAS) study in 2007. Eligibility criteria included clinical stage ≤T2a, initial prostate-specific antigen (PSA) <10 ng/mL, and Gleason Pattern Score (GPS) ≤3 + 3 (both protocols); ≤25% positive cores with a maximum core length containing cancer ≤50% (SAINT); and ≤2 positive cores and PSA density <0.2 ng/mL/cm3 (PRIAS). Switching to active treatment was advised for a worsening of GPS, increased positive cores, or PSA doubling time <3 years. Active treatment-free survival (ATFS) was assessed using the Kaplan-Meier method. Factors associated with ATFS were evaluated with a multivariate Cox proportional hazards model. RESULTS: A total of 818 patients were included: 200 in SAINT, 530 in PRIAS, and 88 in personalized AS monitoring. Active treatment-free survival was 50% after a median follow-up of 60 months. A total of 404/818 patients (49.4%) discontinued AS: 274 for biopsy-related reclassification, 121/404 (30%) for off-protocol reasons, 9/404 (2.2%) because of anxiety. Biopsy reclassification was associated with PSA density (hazard ratio [HR] 1.8), maximum percentage of core involvement (HR 1.5), positive cores at diagnostic biopsy (HR 1.6), older age (HR 1.5), and prostate volume (HR 0.6) (all p<0.01). Patients from SAINT were significantly more likely to discontinue AS than were the patients from PRIAS (HR 1.65, p<0.0001). CONCLUSIONS: Five years after diagnosis, 50% of patients with early PCa were spared from active treatment. Wide inclusion criteria are associated with lower ATFS. However, at preliminary analysis, this does not seem to affect the probability of unfavorable pathology.

Some remarks on a re-do urinary diversion by converting the ileal conduit to an Indiana pouch.

Although the ileal conduit is a wide accepted urinary diversion with a low rate of long way postoperative complications, some patients are not satisfied with the change of body image and the need to wear an external bag inherent to the Bricker's diversion. We report on a patient who underwent cystectomy and Bricker's diversion for bladder cancer which afterwards was converted to an Indiana pouch due to patient preference. The use of the proximal portion of the preexisting ileal conduit facilitated the pouch construction, minimizing the bowel requirement and the need for redoing the ureteral anastomoses. The conversion from ileal-conduit to a catheterizable pouch is technically feasible and involves a better perception of the body image, and a less cumbersome management of the diversion. Before any surgical reconstruction, a realistic discussion with the patient, explaining the potential physical and life-style changes, and problems encountered postoperatively, is the crucial issue.

Results and complications with the mini-laparotomic incision in 52 consecutive radical retropubic prostatectomies.

OBJECTIVES: We describe a simple mono-institutional study to prospectively assess the benefits and complications of the mini-laparotomic incision for radical retropubic prostatectomy with the anatomic approach. METHODS: Radical retropubic prostatectomy with the anatomical approach, as described by Walsh, was performed through a 4 to 8 cm incision. Median operative time, body weight, prostate weight, pathologic stage, incidence of positive surgical margins, urinary continence, the need for post-operative analgesics, peri-operative complications, are the parameters we assessed. Blood losses were calculated with the aid of a specific formula instead of simply recording the suction or weighing the sponges. RESULTS: 52 patients were consecutively operated on through a mini-laparotomic incision. Median incisional length was 8 cm (range 4 to 8 cm). Median operating time was 116 minutes (105-141), calculated blood loss was 1108.797ml, incidence of positive margins was 14%, urinary continence was observed in 48/50 patients (98%), and there was a complication rate of 4/52 (7.6%). CONCLUSION: The results we obtained with the mini-laparotomic incision are comparable to previous reports of the standard incision, also by our group, though with a lower need for postoperative analgesia. They also compare with laparoscopic prostatectomy in the length of time of catheterization and post-operative analgetic consumption.