Individual risk prediction of high grade prostate cancer based on the combination between total prostate-specific antigen (PSA) and free to total PSA ratio.

OBJECTIVES: Clinical practice guidelines endorse the stratification of prostate cancer (PCa) risk according to individual total prostate-specific antigen (tPSA) values and age to enhance the individual risk-benefit ratio. We defined two nomograms to predict the individual risk of high and low grade PCa by combining the assay of tPSA and %free/tPSA (%f/tPSA) in patients with a pre-biopsy tPSA between 2 and 10 µg/L. METHODS: The study cohort consisted of 662 patients that had fPSA, tPSA, and a biopsy performed (41.3% with a final diagnosis of PCa). Logistic regression including age, tPSA and %f/tPSA was used to model the probability of having high or low grade cancer by defining 3 outcome levels: no PCa, low grade (International Society of Urological Pathology grade, ISUP<3) and high grade PCa (ISUP≥3). RESULTS: The nomogram identifying patients with: (a) high vs. those with low grade PCa and without the disease showed a good discriminating capability (∼80%), but the calibration showed a risk of underestimation for predictive probabilities >30% (a considerable critical threshold of risk), (b) ISUP<3 vs. those without the disease showed a discriminating capability of 63% and overestimates predictive probabilities >50%. In ISUP 5 a possible loss of PSA immunoreactivity has been observed. CONCLUSIONS: The estimated risk of high or low grade PCa by the nomograms may be of aid in the decision-making process, in particular in the case of critical comorbidities and when the digital rectal examinations are inconclusive. The improved characterization of the risk of ISUP≥3 might enhance the use for magnetic resonance imaging in this setting.

Intraoperative ultrasound in robot-assisted partial nephrectomy: State of the art.

INTRODUCTION: Nephron-sparing surgery (NSS) is of one of the most studied fields in urology due to the balancing between renal function preservation and oncological safety of the procedure. Aim of this short review is to report the state of the art of intra-operative ultrasound as an operative tool to improve localization of small renal masses partially or completely endophytic during robotassisted partial nephrectomy (RAPN). MATERIAL AND METHODS: We performed a literature review by electronic database on Pubmed about the use of intra-operative US in RAPN to evaluate the usefulness and the feasibility of this procedure. RESULTS: Several studies analyzed the use of different US probes during RAPN. Among them some focused on using contrastenhanced ultra sonography (CEUS) for improving the dynamic evaluation of microvascular structure allowing the reduction of ischemia time (IT). We reported that nowaday the use of intraoperative US during RAPN could be helpful to improve the preservation of renal tissue without compromising oncological safety. Moreover, during RAPN there is no need for assistant to hand the US probe increasing surgeon autonomy. CONCLUSIONS: The use of a robotic ultrasound probe during partial nephrectomy allows the surgeon to optimize tumor identification with maximal autonomy, and to benefit from the precision and articulation of the robotic instrument during this key step of the partial nephrectomy procedure. Moreover US could be useful to reduce ischemia time (IT). The advantages of nephron-sparing surgery over radical nephrectomy is well established with a pool of data providing strong evidence of oncological and survival equivalency. With the progressive growth of robot-assisted partial nephrectomy (RAPN) techniques, the use of several tools has been progressively developed to help the surgeon in the identification of masses and its vascular net. In this short review we tried to analyze the current use of intra-operative ultrasound as an operative tool to improve localization of small renal masses partially or completely endophytic during RAPN.

Analysis of clinical utility of abdominopelvic computed tomography in the follow-up of Stage I seminoma: a single center evaluation.

BACKGROUND: Abdominopelvic computed tomography (CT) is widely used in the follow-up of seminoma patients after radical orchidectomy. The aim of this study was to evaluate the clinical utility of abdominopelvic computed tomography in the follow-up of patients with Stage I seminoma. METHODS: The pathological reports of all patients that have undergone radical orchidectomy in our tertiary referral center between January 2002 and January 2018 have been retrospectively reviewed. All patients with Stage I seminoma and negative serum tumor markers after radical orchidectomy were included. Patients with follow-up shorter than 12 months were excluded. Surveillance records of every patient were reviewed with regard to abdominopelvic imaging. RESULTS: Of the 133 patients who have undergone radical orchidectomy in our center, 55 had Stage I pure seminoma with normal levels of serum tumor markers after surgery. Two patients were excluded as the follow-up was inadequate. Mean follow-up was 63.2 months (IQR: 30-73). The results of 211 abdominopelvic CTs performed as part of the follow-up were reviewed. Two (3,7%) patients developed recurrence; one consisted of a scrotal lump and was diagnosed with ultrasonography (US) while the second appeared as paraaortic nodal metastasis and was diagnosed with abdominopelvic CT. The recurrence was successfully treated in both patients. A single abdominopelvic CT was useful for the detection of recurrent disease in our entire study population. No cancer specific death has been reported in the study population. CONCLUSIONS: Follow-up schedules for Stage I seminoma expose patients to potential risks of radiation-induced tumors, emotional distress and represent a significant burden for the healthcare system. The current series suggests that a better risk adapted patient-tailored follow-up program is needed in order to avoid unnecessary investigations.

Perioperative Antimicrobial Prophylaxis for Preventing Infectious Complications After Transurethral Resection of the Bladder: To Use or Not to Use?

Purpose: Transurethral resection of the bladder (TURB) is a common endoscopic procedure. Perioperative antimicrobial prophylaxis (AMP) is used to reduce the risk of infectious complications. However, there is an absence of knowledge about both incidence of infectious complications after TURB and advantage of AMP in general. The objective of this study is to determinate the prevalence of postoperative infectious complications after routine TURB without AMP. Methods: We retrospectively reviewed clinical data of all patients who underwent TURB in the same Academic Urologic Department between January 2011 and December 2013. We consider as relevant for analysis, patients that underwent TURB without receiving any AMP. Infection was defined as a body temperature >37.5°C sustained for at least 24 hours. Sepsis was defined according to the third international consensus definition for sepsis and septic shock. Results: In the period of the study, 223 TURBs were performed without use of AMP. Mean age was 70.3 years (standard deviation [SD] 11.3). Mean operative time was 25.14 minutes (SD 16). Median length of hospital stay was 3 days (interquartile range [IQR]: 2-4). Six (2.7%) patients developed postoperative infective complications. No case of sepsis was reported. Two (0.9%) patients received an antimicrobial therapy with fluoroquinolones despite absence of any signs of infection. Two hundred fifteen (96.4%) patients of TURBs did not receive any antimicrobial drugs and did not develop any infectious complications. Conclusion: In our series, infectious complications after TURB occurred in <3% of cases. In conclusion AMP should not be routinely used prior TURB.

Needle tract seeding after percutaneous cryoablation of small renal masses; a case series and literature review.

Neoplastic cell seeding due to needle tumor manipulation during renal mass biopsy (RMB) or thermal ablative treatment is a rare but potentially serious event that can turn an organ-confined and curable tumor in a nonorgan-confined and non-curable disease. Despite the widespread use of percutaneous thermal ablative treatment for small renal masses (SRMs), this complication has been described in few case reports and small case series and has never been reported after ablative treatment alone. We report a series of two patients that underwent cryoablation for SRMs and developed recurrence along the needle tract. Available knowledge on the controversial topic of tumor seeding following needle manipulation are poor. So far, reporting cases of tumor cell seeding due to needle manipulation is useful to permit a better understanding of this complication.

Voiceless disability: A worth case of bilateral infrainguinal testicular torsion in a patient with cerebropalsy.

INTRODUCTION: A fast surgical treatment is the gold standard when a testicular torsion is diagnosed.However, an early diagnosis of torsion may not be feasible in case of torsion associated with undescended testis in the patients affected by cerebropalsy. CASE PRESENTATION: A Bolivian 16 year old male with acquired cerebropalsy and spastic neuromuscular disease was admitted to our Institute for a right inguinal swelling observed by the father in the morning. Indeed, the father had reported that the swelling had may be started two days before without pain or any other symptoms apparently. Two episodes of vomiting were only reported. At the general examination the patient, apparently, seemed to laugh repeatedly and a spastic movements increase were observed. The child had an infrainguinal bilateral cryptorchidism. An urgent left infrainguinal orchyectomy had been performed in the past and controlateral cryptorchidism was not corrected. At the right inguinal exploration, a complete twist of the spermatic chord was observed and a right orchyectomy was then performed. DISCUSSION: Testicular torsion in the inguinal canal is a rare reported condition that usually can involve patients with spastic neuromuscular disease. Processing, communication and verbalization of a chronic or acute pain seems to be different in a child with or without intellectual disability. It could be a lot more difficult to correct pain interpretation, with an important repercussion on pain accurate assessment and management. CONCLUSION: In the patients with intellectual disability, a control of the testicles, it should always be done, mostly in case of atypical behaviour.

"Real life use" of troponin in the emergency department: a survey of over 3000 cases.

INTRODUCTION: The aim of this study was to identify clinical variables which may be independently associated with positivity of a cardiac troponin I (cTnI) assay in a large population of patients admitted to the emergency department (ED). MATERIALS AND METHODS: 3166 subjects, with at least two troponin I tests ordered within 6 hours in the ED, were studied. Patient data were statistically analyzed to identify clinical associations with increased values of Troponin I. RESULTS: Although patients with diagnosis of acute coronary syndrome displayed troponin I values significantly higher than those of other groups, positivity to troponin I (>40 ng/L) was also observed in patients with other clinical conditions. In multivariate analysis, age, elevated heart rate and electrocardiographic changes were independently associated with troponin I positivity at admission. In the whole study population troponin I positivity exhibited high sensitivity and negative predictive value, counterbalanced by low specificity and limited positive predictive value. CONCLUSIONS: Troponin I positivity should be combined with history and clinical evaluation and cautiously interpreted in the ED, especially in patients exhibiting factors associated with higher troponin I levels such as older age, elevated heart rate or ECG changes.