RESUMEN
AIM: The upgrading or staging in men with prostate cancer (PCA) undergoing active surveillance (AS), defined as Gleason score (GS) ≥ 3+4 or more than 2 area with cancer, was investigated in our experience using the software-based fusion biopsy (FB). METHODS: We selected from our database, composed of 620 biopsies, only men on AS according to criteria of John Hopkins Protocol (T1c, < 3 positive cores, GS = 3+3 = 6). Monitoring consisted of PSA measurement every 3 months, a clinical examination every 6 months, confirmatory FB within 6 months and then annual FB in all men. The suspicious MRI lesions were scored according to the Prostate Imaging Reporting and Data System (PI-RADS) classification version 2. FB were performed with a transrectal elastic free-hand fusion platform. The overall and clinically significant cancer detection rate was reported. Secondary, the diagnostic role of systematic biopsies was evaluated. RESULTS: We selected 56 patients on AS with mean age 67.4 years, mean PSA 6.7 ng/ml and at least one follow-up MRI-US fusion biopsy (10 had 2 or 3 follow-up biopsies). Lesions detected by MRI were: PIRADS-2 in 5, PIRADS-3 in 28, PIRADS-4 in 18 pts and PIRADS-5 in 5 patients. In each MRI lesion, FB with 2.1 ± 1.1 cores were taken with a mean total cores of 13 ± 2.4 including the systematic cores. The overall cancer detection rate was 71% (40/56): 62% (25/40) in target core and 28% (15/40) in systematic core. The overall significant cancer detection rate was 46% (26/56): 69% (18/26) in target vs 31% (8/26) in random cores. CONCLUSIONS: The incidence of clinical significant cancer was 46% in men starting active surveillance, but it was more than doubled using MRI/US Target Biopsy 69% (18/26) rather than random cores (31%, 8/26). However, 1/3 of disease upgrades would have been missed if only the targeted biopsies were performed. Based on our experience, MRI/US fusion target biopsy must be associated to systematic biopsies to improve detection of significant cancer, reducing the risks of misclassification.
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Biopsia Guiada por Imagen , Imagen por Resonancia Magnética , Próstata/patología , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/terapia , Ultrasonografía Intervencional , Espera Vigilante , Anciano , Humanos , Masculino , Persona de Mediana Edad , Imagen Multimodal , Clasificación del Tumor , Estudios RetrospectivosRESUMEN
Tangier disease is an autosomal recessive disorder caused by mutations in the ABCA1 gene and characterized by the accumulation of cholesteryl ester in various tissues and a near absence of high-density lipoprotein. The subject in this investigation was a 36-year-old Italian man with Tangier disease. He and his wife had come to the In Vitro Fertilization Unit, Pesaro Hospital (Azienda Ospedaliera Ospedali Riuniti Marche Nord) seeking help regarding fertility issues. The man was diagnosed with severe oligoasthenoteratozoospermia. Testosterone is the sex hormone necessary for spermatogenesis and cholesterol is its precursor; hence, we hypothesized that the characteristic cholesterol deficiency in Tangier disease patients could compromise their fertility. The aim of the study was to therefore to determine if there is an association between Tangier disease and male infertility. After excluding viral, infectious, genetic and anatomical causes of the subject's oligoasthenoteratozoospermia, we performed a hormonal analysis to verify our hypothesis. The patient was found to be negative for frequent bacteria and viruses. The subject showed a normal male karyotype and tested negative for Yq microdeletions and Cystic Fibrosis Transmembrane Conductance Regulator gene mutations. A complete urological examination was performed, and primary hypogonadism was also excluded. Conversely, hormonal analyses showed that the subject had a high level of follicle stimulating hormone and luteinizing hormone, low total testosterone and a significant decline in inhibin B. We believe that the abnormally low cholesterol levels typically found in subjects with Tangier disease may result in a reduced testosterone production which in turn could affect the hormonal axis responsible for spermatogenesis leading to a defective maturation of spermatozoa.
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Colesterol/genética , Infertilidad Masculina/genética , Enfermedad de Tangier/genética , Testosterona/biosíntesis , Transportador 1 de Casete de Unión a ATP/genética , Adulto , Colesterol/deficiencia , Ésteres del Colesterol/genética , Ésteres del Colesterol/metabolismo , Humanos , Infertilidad Masculina/complicaciones , Infertilidad Masculina/fisiopatología , Masculino , Mutación , Oligospermia/complicaciones , Oligospermia/genética , Oligospermia/fisiopatología , Espermatogénesis/genética , Enfermedad de Tangier/complicaciones , Enfermedad de Tangier/fisiopatologíaRESUMEN
AIM: The objective of the present study is to evaluate the diagnostic accuracy of hexylaminolevulinate (HAL) blue light cystoscopy compared with standard white light cystoscopy (WLC) in daily practice. MATERIALS AND METHODS: An observational, comparative, controlled (within patient) study was carried out at our Center. 61 consecutive patients with suspected or confirmed bladder cancer were recruited for the study from January 2008 until January 2015. Patients with suspected bladder cancer (positive cytology with negative WLC) or history of previous high-grade NMIBC or CIS were included in the study. Biopsies/resection of each positive lesion/suspicious areas were always taken after the bladder was inspected under WLC and BLC. Diagnoses of bladder tumor or CIS were considered as positive results, and the presence of normal urothelium in the biopsy specimen as negative result. RESULTS: 61 BLC were performed. 15/61 (24.5%) with suspected initial diagnosis of NMIBC and 46/61 (75.5%) with a history of high-risk non-muscle invasive bladder cancer (NMIBC). We performed a total of 173 biopsies/TURBT of suspicious areas: 129 positive only to the BLC and 44 both positive to WLC and BLC. 84/173 biopsies/TURBT were positive for cancer. All 84 NMIBC were positive to the BLC, while 35/84 were positive to the WLC with a sensitivity of BLC and WLC respectively of 100% and 41.7%. Sensitivity of WLC for highgrade NMIBC and CIS was 34.1% and 39% respectively while sensitivity of BLC for high-grade NMIBC and CIS was 100%. The specificity of the WLC was 79.9% compared to 48.5% of the BLC. The positive predictive value of BLC and WLC were respectively 48% (95% CI: 0.447-0.523) and 79% (95% CI: 0.856-0.734). CONCLUSIONS: Our data confirm those reported in the literature: BLC increases the detection rate of NMIBC particularly in high risk patients (history of CIS or high grade). BLC is a powerful diagnostic tool in the diagnosis of bladder cancer if malignancy is suspected (positive urine cytology) and if conventional WLC is negative.
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Ácido Aminolevulínico/análogos & derivados , Cistoscopía/métodos , Luz , Neoplasias de la Vejiga Urinaria/diagnóstico , Anciano , Ácido Aminolevulínico/química , Biopsia , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Sensibilidad y Especificidad , Neoplasias de la Vejiga Urinaria/patologíaRESUMEN
OBJECTIVE: To evaluate the main factors which influence understaging in patients with T1G3 non-muscle invasive bladder cancer (NMIBC). MATERIALS AND METHODS: 109 patients with T1/G3 underwent transurethral resection of bladder tumor (TURBT) and then radical cystectomy (RC) with pelvic lymph nodes dissection. A number of variables were considered when evaluating the detection of understaging. We considered the patients age and gender, as well as the size, number, location and morphology of their tumor. We also considered coexistence of bladder carcinoma in situ (CIS), microscopic vascular invasion and deep lamina propria invasion. The level of experience of the surgeon was also analyzed. RESULTS: in RC samples muscle invasion, that is understaging, was detected in 74 (67.9%) patients, while 35 (32.1%) patients were appropriately staged. In these cohort of patients with high grade tumors, understaging was associated with deep lamina propria and microscopic vascular invasion, multiple tumors, tumor size > 6 cm, tumor location (trigone and dome), presence of residual tumor; age, gender, tumor morphology, CIS associated, and experience of urological surgeon were not associated with clinical understaging. CONCLUSIONS: in our study, evaluating patients with high grade NMIBC at first TURBT, we identified some risk factors that need to be considered and that are able to increase the risk of understaging: deep lamina propria and microscopic vascular invasion, multiple tumors, tumor size > 6 cm, tumor location (trigone and dome), presence of residual tumor. When these risk factors are present, performing an early cystectomy, and not a re-TURBT, could lower the risk of worse pathological finding due to rapid disease progression of the high grade tumors, and can prolong survival.
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Carcinoma de Células Transicionales/patología , Cistectomía/métodos , Neoplasias de la Vejiga Urinaria/patología , Anciano , Anciano de 80 o más Años , Carcinoma de Células Transicionales/cirugía , Bases de Datos Factuales , Progresión de la Enfermedad , Femenino , Humanos , Escisión del Ganglio Linfático , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Factores de Riesgo , Neoplasias de la Vejiga Urinaria/cirugíaRESUMEN
AIM: The objective of this study is to present our initial experience with magnetic resonance imaging/ultrasound (MRI/US) fusion biopsy using the Koelis Trinity device after the first consecutive 59 patients. MATERIALS AND METHODS: 59 consecutive patients with suspected prostate cancer (PCA) underwent prostate biopsy using Trinity Koelis® (Koelis, Grenoble, France). We divided the patients into 2 groups: patients with a previous negative mapping underwent to a MRI/US fusion re-biopsy (Group A); and biopsy-naïve patients who underwent to a first stereotactic 3-D mapping of the prostate (Group B). Group A (22 patients):mean age 64 years (CI 48-73), mean PSA = 7.7 ng/ml (CI 4.2- 9.9); mean prostate volume 55 ml(CI 45-82), Digital Rectal Examination (DRE) positive in 2/22, number of lesions detected by MRI 1.4, mean cores from each MRI target lesion 3 (CI 2-5), mean total cores 15 ( CI 12-19). Group B (37 patients): mean age 66 years (CI 49-77), mean PSA= 4.7 (3.2- 7.9); mean prostate volume 45 ml (33-67), DRE positive in 5/37, mean total cores 14 ( CI 10-16) Results: In Group A 10/22 patients were positive for PCA (overall detection rate of 45.5%): 6 PCA were detected by target biopsy and 4 cancer by random biopsy. Significant prostate cancer (defined as the presence of Gleason pattern 4) was detected in 4/10 patients (Significant PCA detection rate of 40%) and all significant PCA were detected by MRI target biopsy. All PCA detected by random biopsy had Gleason score 3 + 3 = 6. In Group B (biopsy naïve patients) 14/37 patients were positive for PCA (overall detection rate of 37.8%), Significant prostate cancer was detected in 5/14 patients (Significant PCA detection rate of 35,7%). No significant side effects were recorded. CONCLUSIONS: Our overall detection rate was 45.5% and 37.8% in Group A (patients with previous negative biopsy and persistent suspicion of PCA) and in Group B (biopsy naïve patients) respectively; clinical significant PCA detection rate was respectively 40% and 35.7%. These results are similar to current literature and promising for the future. We believe that using platforms of co-registered MRI/US fusion biopsy can potentially improve risk stratification and reduces understaging, undergrading and the need for repeat biopsies in biopsy naïve patients (using a stereotactic first mapping) and in patients with previous negative biopsy and persistent suspicion of PCA ( using a second MRI/US fusion biopsy).
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Imagen por Resonancia Magnética , Próstata/patología , Ultrasonografía , Anciano , Humanos , Biopsia Guiada por Imagen , Masculino , Persona de Mediana Edad , Imagen Multimodal , Neoplasias de la Próstata/patologíaRESUMEN
INTRODUCTION: The purpose of this report was to analyze the management of a large prostatic abscess in a patient with urethral stenosis and recurrence of penile cancer, who had presented with acute urinary retention. METHODS: The clinical diagnosis was based on the end-fire transrectal ultrasound (TRUS) findings and later confirmed by CT. The patient had several surgical scars and radiation-induced effects in the lower abdomen, therefore the placement of a percutaneous sovrapubic catheter was considered hazardous. The placement of a transurethral catheter was impossible because of firm meatal stenosis due to previous penile partial amputation and growing tissue that suggested local recurrence of penile cancer. RESULTS: Transurethral placement of a 8 Fr catheter was possible under radiologic/ultrasound control using a hydrophilic glidewire. The definitive treatment also included percutaneous transperineal drainage and placement of a 8 Fr pig-tail drain under TRUS. Subsequent surgical treatment of the penis showed low grade superficial squamous cell carcinoma. Management and follow-up of prostatic abscess is based on TRUS imaging. After 4 years of follow-up, abscess recurrence was observed and treated with a urethral catheter and antibiotics. CONCLUSION: Urethral stenosis due to penile cancer is a predisposing factor in the development of prostatic abscesses. Placement of a bladder catheter and percutaneous drainage of the abscess are the mainstays of treatment. In malignant urethral stenosis, the conservative management of a prostatic abscess is safe and efficacious in a long-term follow-up. Transrectal US is a key instrument to guide intervention and to check results.
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Absceso/diagnóstico , Absceso/terapia , Enfermedades de la Próstata/diagnóstico , Enfermedades de la Próstata/terapia , Absceso/etiología , Carcinoma de Células Escamosas/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/complicaciones , Neoplasias del Pene/complicaciones , Enfermedades de la Próstata/etiología , Estrechez Uretral/complicacionesRESUMEN
OBJECTIVES: To evaluate the efficacy of a training program with uroflowmetry biofeedback and pelvic floor relaxation biofeedback on urodynamic and voiding parameters in women with dysfunctional voiding. METHODS: Eighty-six women with recurrent urinary tract infections (UTIs) and dysfunctional voiding were randomly assigned to receive a treatment schedule as follows: uroflowmetry biofeedback (group 1), biofeedback training of the pelvic floor muscles (group 2), uroflowmetry biofeedback combined to biofeedback training of the pelvic floor muscles (group 3), no treatment (group 4). Patients were regularly evaluated by American Urological Association Symptom Index and urodynamics during the study period. All the patients were followed up for 1 year with monthly urine cultures. A further evaluation was done at month 24 by American Urological Association Symptom Index and free uroflowmetry with measurement of residual urine. RESULTS: The prevalence of storage and emptying symptoms decreased significantly at 3, 6, and 12 months in the groups 1, 2, and 3, and remained stable during the study period. Mean flow rate, flow time, voiding volume increased significantly, whereas postvoid residual urine decreased. The prevalence of UTI decreased significantly in groups 1, 2, and 3. At month 24, storage and emptying symptoms and voiding patterns were similar to the baseline values in all the patients. The incidence of UTIs was similar to baseline values in groups 1, 2, and 3. CONCLUSIONS: Training the voluntary control of the pelvic floor seems essential in obtaining control over the bladder function. These results reinforce the importance of pelvic floor therapy in the resolution of UTIs.
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Biorretroalimentación Psicológica , Terapia por Ejercicio/métodos , Calidad de Vida , Terapia por Relajación/métodos , Infecciones Urinarias/rehabilitación , Trastornos Urinarios/rehabilitación , Adolescente , Adulto , Factores de Edad , Análisis de Varianza , Enfermedad Crónica , Femenino , Estudios de Seguimiento , Humanos , Contracción Muscular/fisiología , Relajación Muscular/fisiología , Diafragma Pélvico , Probabilidad , Estudios Prospectivos , Recurrencia , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Infecciones Urinarias/diagnóstico , Trastornos Urinarios/diagnóstico , Urodinámica , Adulto JovenRESUMEN
PURPOSE: We used urodynamics and perineal ultrasound to assess the function and morphology of the urethral sphincter and detrusor muscle in the evaluation of dysfunctional voiding in female patients with recurrent urinary tract infections. MATERIALS AND METHODS: Patients selected for study purposes completed the American Urological Association Symptom Index and underwent multichannel video urodynamics and perineal ultrasound to evaluate urethral sphincter volume and detrusor thickness. RESULTS: Of the 337 patients referred to our institution for recurrent urinary tract infections 166 were finally evaluated, including group 1-65 women with recurrent urinary tract infections and dysfunctional voiding, group 2-77 with recurrent urinary tract infections without dysfunctional voiding and group 3-24 healthy controls. Storage and emptying symptoms were recorded in 87.6% and 84.6% of group 1 patients, respectively. Opening and maximum flow detrusor pressure significantly correlated with urethral sphincter volume, and mean and maximum urethral closure pressure and detrusor thickness correlated with urethral sphincter volume. Dysfunctional voiding could be diagnosed by ultrasound when an increase in detrusor thickness and striated sphincter volume were observed. A threshold sphincter volume of 1.96 cm3 had 100% sensitivity and 63.2% specificity, and a threshold detrusor thickness of 4.95 mm had 100% sensitivity and 85.4% specificity for identifying patients with dysfunctional voiding. CONCLUSIONS: We think that perineal ultrasound is useful in the evaluation of dysfunctional voiding in women with recurrent urinary tract infections.
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Perineo/diagnóstico por imagen , Infecciones Urinarias/complicaciones , Trastornos Urinarios/diagnóstico por imagen , Adolescente , Adulto , Femenino , Humanos , Estudios Prospectivos , Recurrencia , Ultrasonografía , Uretra/diagnóstico por imagen , Vejiga Urinaria/diagnóstico por imagen , Trastornos Urinarios/complicaciones , UrodinámicaRESUMEN
We investigated the efficacy of Tachyplesin III alone or combined with piperacillin-tazobactam (TZP) to prevent biofilm formation in vitro and in a rat model of Pseudomonas aeruginosa ureteral stent infection. We have observed that in vitro TZP, in presence of Tachyplesin III, showed minimal inhibitory concentrations (MIC)s twofold and minimal bactericidal concentrations (MBC)s eightfold lower. The in vivo study showed that rats that received intraperitoneal TZP showed the lowest bacterial numbers. Tachyplesin III combined with TZP showed efficacies higher than that of each single compound. Coating ureteral stents with Tachyplesin III is able to inhibit bacterial growth up to 1,000 times.