PCA3: a new tool to diagnose prostate cancer (PCa) and a guidance in biopsy decisions. Preliminary report of the UrOP study.

OBJECTIVES: PCA3 is a prostate specific non-coding mRNA that is significantly overexpressed in prostate cancer tissue. Urinary PCA3 levels have been associated with prostate cancer grade suggesting a significant role in the diagnosis of prostate cancer. We measured urinary PCA3 score in 925 subjects from several areas of Italy assessing in 114 the association of urinary PCA3 score with the results of prostate biopsy. MATERIAL AND METHODS: First-catch urine samples were collected after digital rectal examination (DRE). PCA3 and PSA mRNA levels were measured using Trascription-mediated PCR amplification. The PCA3 score was calculated as the ratio of PCA3 and PSA mRNA (PCA3 mRNA/PSA mRNA x 1000) and the cut off was set at 35. RESULTS: A total of 925 PCA3 tests were performed from December 2008 to January 2010. The rate of informative PCA3 test was 99%, with 915 subjects showing a valid PCA3 score value: 443 patients (48.42%) presented a PCA3 score >/= 35 (cut-off) whereas the remaining 472 patients (51.58%) presented a PCA3 score lower the cut-off limit (< 35). Of the 443 patients with PCA3 score >/= 35, 105 (23.70%) underwent biopsy or rebiopsy. We found that 27 patients (25.71%) had no tumour at biopsy, 37 (35.24%) had HGPIN or ASAP and 41 (39.05%) had a cancer. Moreover, including the additonal 9 patients with PCA3 < 35, who underwent biopsy post PCA3 results, our data indicate that patients with negative biopsy (n = 31) show lower PCA3 score (mean = 54.9) compared with patients with positive biopsy (n = 45) (mean = 141.6) (p = 0.000183; two-tailed t-student test). The mean PCA3 score (79.6)for the patients diagnosed with HGPIN/ASAP at biopsy (n = 38) was intermediate between patients with negative and positive biopsy. CONCLUSIONS: Our results indicate that the PCA3 score is a valid tool for prostate cancer detection and its role in making better biopsy decisions. This marker consents to discriminate patients who have to undergo biopsy from patients who only need be actively surveilled: Quantitative PCA3 score is correlated with the probability of a positive result at biopsy.

Laparoscopic nephron sparing surgery: a multi-institutional European survey of 592 cases.

Laparoscopic Nephron Sparing Surgery (LNSS) is a technically challenging procedure. Technical aspects and the outcome of LNSS are investigated. A total of 592 LNSS procedures were collected from 12 Centres, either in extraperitoneal or transperitoneal fashion. Mean tumor size was 2.2 cm. Eight centers reported on tumor position for a total of 407 cases with 338 exophytic tumors (83%) and 69 deep lesions (17%). Four centers, accounting for 185 cases, did not report on tumor position. All the centers performed their LNSS by clamping the hilum. The warm ischemia time was < 30 min in all the centers. The positive margin rate was 2% (12/592). Hemostatic agents and/or sealant or tissue glues were used in 86% of cases (511/592). Types of sealants used included: gelatine matrix (Floseal), fibrin gel (Tissucol), bovine serum albumin (BioGlue) and cianacrylate (Glubran). Two Centres never used sealants, one center used only sealants without suturing and 9 centers used a combination of sealants and bolstering-sutures. The intraoperative open conversion rate was 3.5% (21/592). Postoperative complications included bleeding in 15/592 (2.5%) and urine leak in 13/592 (2.1%). No tumor seeding was reported. LNSS has similar results of open partial nephrectomy. The use of hemostatic agents and/or sealants or tissue glues during LNSS is largely diffuse in European centers and may be an effective add on reducing bleeding and urine leakage when used in combination with bolstering-suturing.

Use of haemostatic agents and glues during laparoscopic partial nephrectomy: a multi-institutional survey from the United States and Europe of 1347 cases.

OBJECTIVES: Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure for the management of renal tumours. Major complications of LPN include bleeding and urine leakage. Haemostatic agents (HAs) and/or glues may reduce haemorrhage and urine leakage. We sought to examine the current practice patterns for urologists performing LPN with regard to HA use and its relationship with bleeding and urine leakage. MATERIALS AND METHODS: A survey was sent via e-mail to urologists currently performing LPN in centres in the United States and Europe. We queried the indications for HA/glue usage, type of HAs/glues used, and whether concomitant suturing/bolstering was performed. In addition, the total number of LPNs performed, laparoscopic tools used to resect the tumour, tumour size, and tumour position were queried. RESULTS: Surveys suitable for analysis were received from 18 centres (n=1347 cases). HAs and/or glues were used in 1042 (77.4%) cases. Mean tumour size was 2.8cm, with 79% of the tumours being defined as exophytic and 21% deep. The HAs and glues used included gelatin matrix thrombin (FloSeal), fibrin gel (Tisseel), bovine serum albumin (BioGlue), cyanoacrylate glue (Glubran), oxidized regenerated cellulose (Surgicel), or combinations of these. Sixteen centres performed concomitant suturing/bolstering. The overall postoperative bleeding requiring transfusion and urine leakage rates were 2.7% and 1.9%, respectively. CONCLUSIONS: The use of HAs and/or glues is routine in most centres performing LPN. The overall haemorrhage and urine leakage rates are low following LPN. More studies are needed to assess the potential role of HAs and/or glues in LPN.

Retroperitoneal laparoscopic radical nephrectomy for renal cell carcinoma with infrahepatic vena caval thrombus.

PURPOSE: The retroperitoneal laparoscopic approach is utilized to treat a right renal tumor with vena caval thrombus reaching infrahepatic veins. MATERIALS AND METHODS: The patient is an 87-year-old woman with a tumor measuring 8 x 9 cm and a vena caval thrombus (7 cm), stretching as far as the subhepatic vein. The retroperitoneal laparoscopic approach is used with the patient in the lateral position and the usual 4 laparoscopy trocars. A wide incision is made through Gerota's fascia, the renal artery clipped and severed, and the vena cava is dissected to the level of the infrahepatic veins; a vessel loop is encircled twice upstream of the thrombus. Vessel loop is similarly tied below the thrombus. An 8 cm abdominal wall incision is made joining two trocars on the medial and anterior axillary side. After retrieving the vessel loops and closing the vena cava by pulling gently on the loops, thrombus is extracted through a cavotomy under direct vision, with removal of the surgical specimen, positioning of the Satinsky haemostatic forceps, and closure of the vena cava using uninterrupted Prolene 2/0 sutures. RESULTS: Blood loss was 300 cc. The patient was discharged on day 6, and a CT-scan 4 months later disclosed no signs of recurrence. CONCLUSIONS: This is an original solution that opens the way to further indications for using retroperitoneal laparoscopy to treat tumors extending into the inferior vena cava.