Cribriform Pattern of The Prostate Adenocarcinoma: Sensitivity of Multiparametric MRI.

BACKGROUND: The aim of this study was to investigate the diagnostic performance of mpMRI for detecting cribriform pattern prostate cancer. MATERIALS AND METHODS: This study retrospectively enrolled 33 patients who were reported cribriform pattern prostate cancer at final pathology. The localization, grade and volumetric properties of the dominant tumors and areas with cribriform pattern at the final pathological specimens were recorded and the diagnostic value of mpMRI was evaluated on the basis of the cribriform morphology detection rate. It was analyzed using Wilcoxon test, the Chi-square test and Fisher's Exact test. The significance level (P-value) was set at .05 in all statistical analyses. RESULTS: A total of 58 prostate cancer foci were (38 cribriform, 20 non-cribriform foci) identified on the final pathology. mpMRI identified 36 of the 38 cribriform morphology harboring tumor foci with a sensitivity of 94.7% (95% confidence interval 82.7-98.5%). In 17 of the 33 patients mpMRI detected single lesion and for these lesions; mpMRI identified cribriform morphology positive areas precisely in 15 patients with significantly low ADCmean and ADCmin values compared to the non-cribriform cancer areas within the primary index lesion (P < .001). For the remaining 16 patients with multiple lesions; all of the tumor foci that harboring cribriform morphology were identified by mpMRI but in none of them any ADCmean and ADCmin value divergence were detected between the cribriform and non-cribriform pattern tumor foci within the primary index lesion. CONCLUSION: Cribiform pattern should be considered in single lesions with an area of lower ADC value on mpMRI.

One step nucleic acid amplification (OSNA) for detection of lymph node metastasis during robotic radical prostatectomy for prostate cancer: A pilot study.

INTRODUCTION: The OSNA technique is based on reverse transcription loop-mediated DNA amplification for the detection of cytokeratin 19 (CK19) messen-ger RNA (mRNA). The purpose of our paper, which represents the first study in the literature, is to test the accuracy of this method in the detection of lymph node metastases in patients undergoing robotic radical prostatectomy with lymph node dis-section. METHODS: Our cohort consisted of patients that have undergone robotic radical prostatectomy with extended lymph node dissec-tion. Lymph nodes were evaluated with imprint technique and then with frozen section examination. The remaining tissue was evaluated by OSNA method. Lymph nodes were defined as 'neg-ative' or 'positive' according to mRNA copy number. RESULTS: 7 patients and 25 lymph nodes were included in our cohort. Two patients were found negative with all pathology methods. In one patient the standard stains revealed a suspi-cious outcome but it was positive for micrometastasis with OSNA. In another patient the outcome was positive for standard stains and negative for OSNA. Finally, 2 patients were found positive for OSNA and negative for imprint methods. CONCLUSIONS: One Step Nucleic Acid Amplification (OSNA) method using CK19 seems to fail in detection of lymph node metastases in prostate cancer patients undergoing radical prostatectomy and lymph node dissection.

Safe use of intravesical bacillus Calmette-Guérin immunotherapy for bladder cancer during breastfeeding: a case report.

It is unknown whether intravesical bacillus Calmette-Guérin (BCG) is excreted in human breast milk. The US FDA advocates ceasing nursing due to potential adverse reactions. A lactating woman with bladder cancer who elected to receive intravesical immunotherapy with BCG and denied having ceased nursing her newborn is reported. A 42-year-old woman presented with macroscopic hematuria in the 36th week of her pregnancy. Imaging revealed a mass in the bladder. Cystoscopy and resection were performed after childbirth. Pathological examination revealed pT1 urothelial carcinoma. After a thorough discussion of the treatment options, the patient elected intravesical BCG. The infant received intradermal BCG vaccination 2 weeks before the treatment. As a result, the patient could breastfeed without any inadvertent sequela on herself or the baby.

Bacillus Calmette-Guérin (BCG) is tuberculosis vaccine. It contains live but attenuated tubercle bacillus. It is also used for bladder cancer treatment, where it is directly instilled into the bladder. BCG activates the local immune response within the bladder to fight cancer cells. The issue of whether BCG instillations into the bladder cause the bacillus to be excreted in breast milk in a lactating woman remains unknown. The US FDA suggests discontinuing breastfeeding when undergoing treatment with BCG due to potential adverse reactions. The authors report on a breastfeeding woman with bladder cancer who elected to receive BCG immunotherapy. The baby received a precautionary dermal BCG vaccination 2 weeks before the patient's treatment. Ultimately, she was able to complete her treatment while breastfeeding her child without any negative effects on the infant or herself. To the best of the authors' knowledge, this is the first article showing that breastfeeding may be safe during BCG treatment for bladder cancer.

Off-Clamp Robot-Assisted Partial Nephrectomy: Is There Something More to Achieve Optimal Trifecta Outcomes?

Objectives: To report trifecta outcomes of our "off-clamp" partial nephrectomy (PN) patients operated without main renal artery and/or any selective/superselective clamping. Materials and Methods: Between April 2008 and March 2020, 52 patients received "off-clamp" robot-assisted partial nephrectomy. Postoperative sixth month estimated glomerular filtration rate (eGFR) and eGFR decrease were considered for renal function evaluation. Patients with negative surgical margins, <15% postoperative eGFR decrease and absence of grade ≥2 Clavien-Dindo complications were reported to achieve trifecta outcomes. Results: Mean age and body mass index of the patients were 57.51 ± 12.99 years and 27.23 ± 4.35 kg/m2, respectively. Mean preoperative hematocrit, serum creatinine, and eGFR were 42.01 ± 3.86%, 0.92 ± 0.28 mg/dL, and 85.26 ± 21.27 mL/min/1.73 m2, respectively. Mean tumor size was 30.32 ± 13.64 mm. Mean PADUA and RENAL scores were 7.63 ± 1.46 and 6.21 ± 1.63, respectively. One patient had focal surgical margin positivity. Mean console time and estimated blood loss was 82.11 ± 38.51 minutes and 280.76 ± 278.98 mL, respectively. Complications were observed in two (4%) patients (one Clavien I, one Clavien IIIB). At postoperative sixth month, serum creatinine and eGFR were 0.95 ± 0.32 mg/dL and 83.65 ± 22.44 mL/min/1.73 m2, respectively. Eventually seven patients had ≥15% postoperative eGFR decrease, one patient had grade ≥2 complication and one patient had positive surgical margin. Forty-three (83%) patients fulfilled trifecta outcomes. Conclusion: Off-clamp PN is important for optimal renal function preservation. Patient selection and additional operative measures along with experience in robotic procedure can contribute achievement of optimal trifecta outcomes.

Impact of Refractive Errors on Da Vinci SI Robotic System.

OBJECTIVE: To investigate the impact of refractive errors on binocular visual acuity while using the Da Vinci SI robotic system console. METHODS: Eighty volunteers were examined on the Da Vinci SI robotic system console by using a near vision chart. Refractive errors, anisometropia status, and Fly Stereo Acuity Test scores were recorded. Spherical equivalent (SE) were calculated for all volunteers' right and left eyes. Visual acuity was assessed by the logarithm of the minimal angle of resolution (LogMAR) method. Binocular uncorrected and best corrected (with proper contact lens or glasses) LogMAR values of the subjects were recorded. The difference between these values (DiffLogMAR) are affected by different refractive errors. RESULTS: In the myopia and/or astigmatism group, uncorrected SE was found to have significant impact on the DiffLogMAR (p < 0.001) and myopia greater than 1.75 diopter had significantly higher DiffLogMAR values (p < 0.05). Subjects with presbyopia had significantly higher DiffLogMAR values (p < 0.01), and we observed positive correlation between presbyopia and DiffLogMAR values (p = 0.33, p < 0.01). The cut off value of presbyopia that correlated the most with DiffLogMAR differences was found to be 1.25 diopter (p < 0.001). In 13 hypermetropic volunteers, we found significant correlation between hypermetropia value and DiffLogMAR (p > 0.7, p < 0.01). The statistical analysis between Fly test and SE revealed a significant impact of presbyopia and hypermetropia to the stereotactic view of the subject (p = -0.734, p < 0.05). CONCLUSION: Surgeons suffering from myopia greater than 1.75 diopter, presbyopia greater than 1.25 diopter (D), and hypermetropia regardless of grade must always perform robotic surgeries with the proper correction.

Management of prostate cancer patients during COVID-19 pandemic.

Prostate cancer patients' management demands prioritization, adjustments, and a tailored approach during the unprecedented SARS-CoV-2 pandemic. Benefit of care from treatment must be carefully weighed against the potential of infection and morbidity from COVID-19. Furthermore, urologists need to be cognizant of their obligation for wise consumption of restricted healthcare resources and protection of the safety of their coworkers. Nonurgent in-person clinic visits should be postponed or conducted remotely via phone or teleconference. Prostate cancer screening, imaging, and biopsies may be suspended in general. Treatment may be safely deferred in low and intermediate risk patients. Surgery may be delayed in most high-risk patients and neoadjuvant ADT is generally not advocated prior to surgery. Initiation of long-term ADT coupled with EBRT subsequent to the pandemic may be favored as a feasible alternative in high-risk and very high-risk disease. In patients with cN1 disease, treatment within 6 weeks is advocated. Presurgery assessment should include testing for COVID-19 and preferably a chest imaging. In the presence of SARS-CoV-2 infection, surgery should be postponed whenever possible. All protective measurements suggested by national/international authorities must to be diligently followed during perioperative period. Strict precautions specific to laparoscopic/robotic surgery are required, considering the unproven but potential risk of aerosolization of SARS-CoV-2 virus and spillage with pneumoperitoneum. Regarding radiotherapy, shortest safe EBRT regimen should be favored and prophylactic whole pelvic RT and brachytherapy avoided. Chemotherapy should be avoided whenever possible.

Evaluation of Diagnostic Accuracy of Percutaneous Biopsy for Small Renal Masses and First Report of Post-Biopsy Adhesions: A Prospective Study.

PURPOSE: In the present study, we evaluate the biopsy results, complications due to biopsy, and the correlation with the final pathology specimen of 19 patients who had surgery for their small renal masses. MATERIALS AND METHODS: A total of 19 patients (11 male, 8 female) underwent percutaneous biopsy of their renal mass under ultrasound guidance. All patients subsequently underwent extirpative surgery. Preoperative biopsy results were compared with postoperative specimens in terms of tru-cut and fine needle aspiration biopsies' histopathological accuracy and the complications noted. RESULTS: Average age was 56(±10.5) and tumor size was 37(±10.6) mm. Six patients had only fine needle, 4 patients had only tru-cut, and 9 patients had both fine needle and tru-cut biopsies.  Malignancy was reported in 14,  and benign results in 5 patients. Sensitivity, specificity, PPV and NPV's were 64%, 100%, 100%, 33% respectively for FNAB. Sensitivity, specificity, PPV and NPV's were all 100% for tru-cut core biopsy. Two perirenal hematoma was detected which resolved spontaneously under conservative therapy. In 11 patients there were adhesions due to biopsy, which caused difficulty of dissection during the operation. CONCLUSION: In this relatively small serie, percutenous ultrasound guided biopsy to determine the histology of small renal masses achieved a high diagnostic accuracy. FNAB alone has a low diagnostic accuracy with false negative results when compared. However, tru-cut core biopsy has a diagnostic accuracy of %100. Therefore we recommend tru-cut biopsy when histopathological diagnosis is required for small renal masses. Adhesions due to biopsy may cause difficulties during dissection.

Can SUVmax values of Ga-68-PSMA PET/CT scan predict the clinically significant prostate cancer?

PURPOSE: The intensity of prostate-specific membrane antigen (PSMA) expression increases as the tumor grade increases and the uptake of Ga-68-PSMA is higher in high-grade tumors. The aim of the present study was to evaluate the correlation of preoperative tracer uptake of primary tumor to Gleason Score in patients who underwent prostatectomy. PATIENTS AND METHODS: We retrospectively evaluated 141 patients who had Ga-68-PSMA positron emission tomography/computed tomography (PET/CT) imaging and who underwent prostatectomy. All patients had a diagnosis of prostate cancer on the basis of 10-24 cores transrectal ultrasound-guided biopsy (TRUS-Bx). Histological assessment was performed according to the New Contemporary Prostate Cancer Grading System. All patients had a prostate-specific antigen (PSA) level measurement within maximum of 28 days before Ga-68-PSMA PET/CT. Region of interests were drawn manually around the prostate gland, avoiding the bladder activity, to calculate the maximum standardized uptake values (SUVmax) values. RESULTS: The median PSA values for all patients were 10.0 ng/ml. PSA values for low-risk patients were significantly lower than those of high-risk patients (P<0.001). There were 41.1% upgrades and 7.8% downgrades following prostatectomy in terms of Grade Groups. According to the final pathology reports, 21% (n=16) of patients moved from a low-risk level (grade groups 1+2) to a high-risk level (grade groups 3+4+5). The median SUVmax value was 8.8, ranging from 2.1 to 62.4. There was a strong correlation between SUVmax values and grade groups (Pearson ρ=0.66) (P<0.001). The mean SUVmax values of high-risk patients were significantly higher than those of low-risk patients (18.9±12.1 vs. 7.16±6.2, respectively) (P<0.001). Receiver operation characteristic curve analysis of SUVmax at the cut-off value of 9.1 showed a high sensitivity (78%) and specificity (81%) for detection of high risk disease. CONCLUSION: SUVmax values correlate significantly with the grade groups of the primary tumor. The intraprostatic accumulation sites may predict clinically significant cancer and potentially serve as a target for biopsy sampling in conjunction with mpMRI in selected patients.

Intra-surgical total and re-constructible pathological prostate examination for safer margins and nerve preservation (Istanbul preserve).

PURPOSE: To demonstrate a novel frozen section analysis technique during robot assisted radical prostatectomy with 2 distinct advantages: evaluation of the entire circumference and easier reconstruction for whole mount evaluation. MATERIAL AND METHODS: Istanbul Preserve was performed on patients who underwent robotic prostatectomy with nerve sparing between 10/2014 and 7/2016. Gland was sectioned at 3-4mm intervals from apex to bladder neck. Entire tissue representing margins (except for the most anterior portion) was circumferentially excised and microscopically analyzed. In margin positivity, approach was individualized based on extent of positive margin and Gleason pattern. A matched cohort was established for comparison. Retrospective analysis of a prospectively maintained database was performed. Impact of FSA on PSM rate was primarily assessed. RESULTS: Data on 170 patients was analyzed. Positive surgical margin was reported in 56(33%) on frozen section. Neurovascular bundle was partially or totally resected in 79% and 18%. Conversion of positive margin to negative was achieved in 85%. Overall positive margin rate decreased from 22.5% to 7.5%. Nerve sparing increased from 87% to 93%. Location of positive margin at frozen was at the neurovascular bundle area in 39%; thus Istanbul Preserve detected 61% additional margin positivity compared to other techniques. Reconstruction for whole mount was easy. CONCLUSION: Istanbul Preserve is a novel technique for intraoperative FSA during RARP allowing for microscopic examination of the entire prostate for margin status and easy re-construction for whole mount examination. It guarantees safer margins together with increased rate of nerve sparing.

Prevention of Urethral Retraction with Stay Sutures (PURS) During Robot-Assisted Radical Prostatectomy Improves Early Urinary Control: A Prospective Cohort Study.

OBJECTIVE: To evaluate early continence rates with a novel modified vesicourethral anastomosis technique based on prevention of urethral retraction using anastomosis sutures as stay sutures (PURS) during robot-assisted radical prostatectomy. MATERIALS AND METHODS: Sixty patients operated by a single surgeon were enrolled and data collected prospectively. This cohort was compared with another consecutive 60 patients operated with standard anastomosis. The new technique is based on preventing urethral retraction of the posterior urethra with two anastomosis sutures being used as stay sutures. The outcomes were prospectively followed and groups compared regarding early continence. International Consultation on Incontinence Questionnaire Short Form was used to assess incontinence and its impact on the quality of life. Pad use (yes or no pads) was evaluated as a more stringent criterion. RESULTS: Preoperative patient characteristics were similar between the two groups. Anastomosis was completed faster in PURS group (15.1 vs 18.5 min, p = 0.05). At postoperative week 1 and month 1, the severity and bother of incontinence were significantly less in the PURS group (12.7 vs 4.1 and 10.1 vs 2.6, p < 0.001). PURS cohort reported significantly superior pad-free rates at both postoperative month 1 (73% vs 35%, p < 0.0001) and month 3 (83% vs 53%, p = 0.0004). On multivariable analysis, younger age and the new anastomosis technique were two independent predictors to improve early continence. Four patients in modified anastomosis group (4/60) and 1 in standard anastomosis group (1/60) necessitated temporary urethral recatheterization because of urinary retention. CONCLUSION: We describe a simple and time-efficient modified urethrovesical anastomosis technique by using anastomosis sutures as stay sutures to prevent perineal retraction of the urethral stump. Our results demonstrated that the technique is an independent factor impacting early recovery of urinary continence. Future randomized controlled studies would be required to further test the reproducibility of this technique.

The accuracy of 68Ga-PSMA PET/CT in primary lymph node staging in high-risk prostate cancer.

PURPOSE: To assess the diagnostic accuracy of 68Ga-PSMA PET in predicting lymph node (LN) metastases in primary N staging in high-risk and very high-risk nonmetastatic prostate cancer in comparison with morphological imaging. METHODS: This was a multicentre trial of the Society of Urologic Oncology in Turkey in conjunction with the Nuclear Medicine Department of Cerrahpasa School of Medicine, Istanbul University. Patients were accrued from eight centres. Patients with high-risk and very high-risk disease scheduled to undergo surgical treatment with extended LN dissection between July 2014 and October 2015 were included. Either MRI or CT was used for morphological imaging. PSMA PET/CT was performed and evaluated at a single centre. Sensitivity, specificity and accuracy were calculated for the detection of lymphatic metastases by PSMA PET/CT and morphological imaging. Kappa values were calculated to evaluate the correlation between the numbers of LN metastases detected by PSMA PET/CT and by histopathology. RESULTS: Data on 51 eligible patients are presented. The sensitivity, specificity and accuracy of PSMA PET in detecting LN metastases in the primary setting were 53%, 86% and 76%, and increased to 67%, 88% and 81% in the subgroup with of patients with ≥15 LN removed. Kappa values for the correlation between imaging and pathology were 0.41 for PSMA PET and 0.18 for morphological imaging. CONCLUSIONS: PSMA PET/CT is superior to morphological imaging for the detection of metastatic LNs in patients with primary prostate cancer. Surgical dissection remains the gold standard for precise lymphatic staging.

Robot-Assisted Partial Nephrectomy for T1b Tumors: Strict Trifecta Outcomes.

BACKGROUND AND OBJECTIVES: "Trifecta" in partial nephrectomy consists of negative surgical margins, minimal renal function decrease and absence of complications. In the present article, our single-center robot-assisted partial nephrectomy (RAPN) experience in T1b renal masses is reported in terms of strict Trifecta outcomes. METHODS: This is a retrospective analysis of patients with a tumor diameter between 4 and 7 cm (stage T1b), who underwent RAPN by a single surgeon. Preoperative, intraoperative, and postoperative data were recorded and analyzed to evaluate short-term functional and oncologic outcomes. Patients with absence of grade ≥ 2 Clavien-Dindo complications, warm ischemia time (WIT) ≤25 minutes, ≤15% postoperative estimated glomerular filtration rate (eGFR) decrease and negative surgical margins were reported to achieve strict Trifecta outcomes. P < .05 was indicated statistically significant. RESULTS: A total of 150 patients underwent RAPN, and 50 patients were identified with tumor size between 4 and 7 cm. Mean WIT was 20.8 ± 6.2 minutes and mean estimated blood loss (EBL) was 269 ± 191 mL. Surgical margins were negative in all patients. Eleven patients (22%) had a >15% eGFR decrease after surgery. Nine patients (18%) had WIT longer than 25 minutes. Four patients (8%) had grade ≥2 Clavien-Dindo complications. Twenty-nine (58%) patients had strict Trifecta outcomes. Mean follow-up was 44.2 ± 27.2 months. Tumor recurrence was not observed in any patient. CONCLUSIONS: Robot-assisted laparoscopic partial nephrectomy for T1b renal masses can be safely performed in experienced hands. Optimal strict Trifecta outcomes and recurrence rates can be achieved.

Can We Accomplish Better Oncological Results with Robot-Assisted Radical Prostatectomy?

Surgical removal with radical prostatectomy has been a cornerstone for the treatment of prostate cancer and is associated with level 1 evidence for survival advantage compared with watchful waiting. Since the first structured robotic program was launched in 2000, robot-assisted radical prostatectomy (RARP) has had a rapid diffusion and surpassed its open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP) counterparts in the United States and is progressively expanding in other countries. Interestingly, this common acceptance of RARP was initially driven in the paucity of robust clinical evidence. There is still lack of level 1 evidence with prospective randomized trials on the oncologic outcomes of RARP. In that scenario, the clinician has to rely on retrospective data and systemic and meta-analyses. In comparison with ORP and LRP, RARP has proven to reach at least equivalent oncological outcomes. Lower rate of positive surgical margins may probably be achieved with RARP in pT2 patients. Although urologists were initially reluctant to embrace RARP in high-risk patients and lymph node yield was low, contemporary series have revealed that RARP and extended lymphadenectomy may be safely performed with obtaining similar (or better) nodal yields compared with ORP. Surgeon experience is universally of utmost importance in obtaining good outcomes. We will need to wait for long-term results of contemporary series to comprehend the impact of RARP on cancer-specific survival and overall survival. Using novel imaging before surgery and frozen section analysis during surgery may allow for superior oncological outcomes.

Procedural sedation and analgesia as an adjunct to periprostatic nerve block for prostate biopsy: A prospective randomized trial.

BACKGROUND: To assess whether patient comfort could be increased by adding procedural sedation and analgesia (PSAA) to periprostatic nerve block (PNB) in patients undergoing transrectal ultrasound-guided prostatic biopsy (TRUS-PB). METHODS: This was a prospective, randomized (1:2) trial comparing PNB with the combination of PSAA+PNB in patients undergoing TRUS-PB. PNB was achieved by using lidocaine gel and lidocaine and bipuvacaine infiltration. PSAA-treated patients received midazolam and remifentanil. All biopsies were standardized and performed in a fully equipped endourology suite. PSAA was delivered by an anesthesiology nurse in the presence and availability of an anesthesiologist. An orally administered numeric scale of 0-10 was used to assess the patient's pain, and a visual scale of 0-4 was used to quantify their satisfaction. Pain and satisfaction scores were compared between the groups. RESULTS: Data on 331 patients were analyzed: 235 received PNB, and 96 received PSAA+PNB. Distribution within the groups by age, prostate-specific antigen serum levels, prostate volume, and number of cores obtained was similar. Airway insertion was required in 4 of 96 patients in PSAA+PNB arm (4%), with no other complications related to sedation. The average pain level was significantly lower in the PSAA+PNB group than it was in the PNB group (0.88 versus 1.31; p = 0.008). The satisfaction level was high (3.5) and alike in the two groups; however, significantly more patients reported a perfect score of 4 in the PSAA+PNB arm (p = 0.03). CONCLUSIONS: PSAA with midazolam and remifentanil used as an adjunct to the standard PNB is safe and effective during TRUS-PB. Patients undergoing PSAA in addition to PNB experienced significantly less pain and higher satisfaction scores than did those given PNB alone.

Core length in prostate biopsy: size matters.

PURPOSE: The diagnostic yield of prostate biopsy is limited. Increasing the number of cores enhances the cancer detection rate by sampling additional sites and obtaining more tissue. An alternative way to inspect more tissue would be to obtain longer cores. However, the impact of biopsy core length on cancer detection rate is an undervalued topic. We assessed the role of biopsy core length in prostate biopsy and determined the minimal tissue length to serve as quality assurance. MATERIALS AND METHODS: We retrospectively analyzed the records of 331 patients who underwent transrectal ultrasound guided initial prostate biopsy with 12 to 18 cores. The biopsy procedure and pathological evaluation were standardized. Core length was compared in patients with vs without cancer. Statistical analysis was done to determine a minimally acceptable cutoff for biopsy length. RESULTS: We analyzed data on 245 patients. The overall cancer detection rate was 30.2%. Mean core length in patients with vs without cancer was 12.3±2.6 vs 11.4±2.4 mm (p=0.015). Thus, core length was significantly longer in patients with cancer. Core length greater than 11.9 mm was associated with an increased prostate cancer detection rate (OR 2.57, 95% 1.46-4.52). The cancer detection rate for cores less vs greater than 11.9 mm was 23% vs 39%. CONCLUSIONS: Needle core length is an important morphometric parameter of transrectal prostate biopsy that directly influences the cancer detection rate. Results suggest a core length of greater than 11.9 mm as a cutoff for quality assurance.