A Snapshot from the Department of Urology in Bergamo Evaluating the Timeline of the SARS-CoV-2 Outbreak: Which Patients Are We Missing?

The province of Bergamo in Italy and in particular Papa Giovanni XXIII Hospital was one of the first areas to be hit by the SARS-CoV-2 outbreak and experience firsthand all the different phases of the crisis. We describe the timeline of the changes in overall urological workload during the outbreak period from lockdown to the slow reopening of activities. We sought to compare the 2020 hospital scenario with normality in the same period in 2019, highlighting the rationale behind decision-making when guidelines were not yet available. While we focus on the changes in surgical volumes for both elective (oncological and noncancer) and urgent cases, we have still to confront the risk of untreated and underdiagnosed patients. PATIENT SUMMARY: We present a snapshot of changes in urology during the peak of the COVID-19 outbreak in our hospital in Bergamo, Italy. The effect of medical lockdown on outcomes for untreated or underdiagnosed patients is still unknown.

Difference in Frequency and Distribution of Nodal Metastases Between Intermediate and High Risk Prostate Cancer Patients: Results of a Superextended Pelvic Lymph Node Dissection.

Objectives: To evaluate the frequency and distribution of pelvic nodes metastases, in intermediate-high risk prostate cancer (PCa) patients (pts), who underwent open radical prostatectomy (ORP) and superextended pelvic lymph node dissection (sePLND). Patients and Methods: We retrospectively evaluated 630 consecutive pts with clinically localized, intermediate-high risk PCa, treated with ORP and sePLND from 2009 to 2016 at a single institution. The sePLND always removed all nodal/fibro-fatty tissue of the internal iliac, external iliac, obturator, common iliac, and presacral regions. Results: Positive lymph nodes (LN+) were found in 133 pts (21.1%). The median number of removed nodes and LN+ was 25 and 1, respectively. LN+ were found in 64 (48.1%), 58 (43.6%), 53 (39.8%), 16 (12%), and 20 (15%) pts and were present as a single site in 27 (20.3%), 22 (16.5%), 20 (15%), 0, and 6 (4.5%) cases in the internal iliac, external iliac, obturator, common iliac, and presacral chain, respectively. An ePLND would have correctly staged 127 (95%) pts but removed all LN+ in only 97 (73%) pts. Presacral nodes harbored LN+ in 20 patients. Among them, 18 were high-risk patients. Moreover, all but 1 pts with common iliac LN+ were in high risk group. Conclusions: These results suggest that removal of presacral and common iliac nodes could be omitted in intermediate risk pts. However, a PLND limited to external iliac, obturator, and internal iliac region may be adequate for nodal staging purpose, but not enough accurate if we aim to remove all possible site of LN+ in high risk pts.

The optimal rebiopsy prostatic scheme depends on patient clinical characteristics: results of a recursive partitioning analysis based on a 24-core systematic scheme.

BACKGROUND: The most beneficial number and the location of prostate biopsies remain matters of debate, especially after an initial negative biopsy. OBJECTIVE: To identify the optimal combination of sampling sites (number and location) to detect prostate cancer (PCa) in patients previously submitted to an initial negative prostatic biopsy. DESIGN, SETTING, AND PARTICIPANTS: A transrectal ultrasound-guided systematic 24-core prostate biopsy (24PBx) was performed prospectively in 340 consecutive patients after a first negative biopsy (at least 12 cores). MEASUREMENTS: We relied on a classification and regression tree analysis to identify three clinically different subgroups of patients at dissimilar risk of harboring PCa at second biopsy. Subsequently, we set the cancer-positive rate of the 24PBx at 100% and calculated PCa detection rates for 255 possible combinations of sampling sites. We selected the optimal biopsy scheme (defined as the combination of sampling sites that detected 95% of all the cancers with the minimal number of biopsy cores) for each patient subgroup. RESULTS AND LIMITATIONS: After an initial negative biopsy, cancer was detected at rebiopsy in 95 men (27.9%). At a given number of cores, the cancer detection rates varied significantly according to the different combination of sites considered. Three different PCa risk groups were identified: (1) previous report of atypical small acinar proliferation of the prostate (ASAP), (2) no previous ASAP and ratio of free prostate-specific antigen (fPSA) to total PSA (%fPSA) ≤10%, and (3) no previous ASAP and %fPSA >10%. For patients with previous ASAP or patients with no previous ASAP and %fPSA ≤10%, two schemes with different combinations of 14 cores were most favorable. The optimal sampling in patients with no previous ASAP and %fPSA >10% was a scheme with a combination of 20 cores. CONCLUSIONS: Both the number and the location of biopsy cores taken affect cancer detection rates in a repeated biopsy setting. We developed an internally validated flowchart to identify the most advantageous set of sampling sites according to patient characteristics.

Anaesthesia in transrectal prostate biopsy: which is the most effective technique?

BACKGROUND: Prostate biopsy (PBx) techniques have changed significantly since the original Hodge's scheme, with an increase in the number and location of cores. These improvements have been realized in part because of the introduction of different local anaesthesia techniques. We critically analysed the literature discussing the role of anaesthesia techniques for use during PBx to find which technique provides the best pain relief for the patient and safety for the urologist. METHODS: We performed a literature review by searching the Medline database for articles published between January 2000 and March 2010. Electronic searches were limited to the keywords 'transrectal prostate biopsy' and 'anaesthesia'. RESULTS: Pain and discomfort perceived during PBx are the result of different anatomic factors: the introduction to and movement of the transrectal ultrasound probe in the rectum and the needle piercing the rectum and the prostate capsule. The anaesthesia techniques currently available can be divided into two groups: local (i.e. intrarectal lubricant agents, periprostatic nerve blocks, caudal blocks, pudendal nerve blocks, and their different combinations) and systemic (i.e. oral/intravenous drug administration and sedoanalgesia). CONCLUSIONS: The most effective anaesthesia technique for transrectal PBx performed in outpatient settings is the periprostatic nerve blocks with 1 or 2% lidocaine 10 ml, which is associated with intrarectal lubricant agents, especially in younger people. Nevertheless, the current choice of the anaesthesia technique still depends both on patient characteristics (age, prostate size, number and location of cores, anxious personality, need for re-biopsy) and, above all, the urologist's experience and habits.

Impact of venous tumour thrombus consistency (solid vs friable) on cancer-specific survival in patients with renal cell carcinoma.

BACKGROUND: To our knowledge, the impact of venous tumour thrombus (VTT) consistency in patients affected by renal cell carcinoma (RCC) has never been addressed. OBJECTIVE: To analyse the effect of VTT consistency on cancer-specific survival (CSS). DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analysed 174 consecutive patients with RCC and renal vein or inferior vena cava (IVC) VTT who underwent surgical treatment between 1989 and 2007 at our institute. INTERVENTION: All patients underwent radical nephrectomy and thrombectomy. MEASUREMENTS: Pathologic specimens were reviewed by a single uropathologist. In addition to traditional pathologic features, the morphologic aspect of the tumour thrombus was evaluated to distinguish solid from friable patterns. The prognostic role of thrombus consistency (solid vs friable) on CSS was assessed by means of Cox regression models. RESULTS AND LIMITATIONS: The VTT was solid in 107 patients (61.5%) and friable in 67 patients (38.5%). The presence of a friable VTT increased the risk of having synchronous nodal or distant metastases, higher tumour grade, higher pathologic stage, and simultaneous perinephric fat invasion (all p < 0.05). The median follow-up was 24 mo. The median CSS was 33 mo; the median CSS was 8 mo in patients with a friable VTT and 55 mo in patients with a solid VTT (p < 0.001). On multivariable analyses, the presence of a friable VTT was an independent predictor of CSS (p = 0.02). The power of our conclusion may be somewhat limited by the relatively small study population and the retrospective nature of the study. CONCLUSIONS: In patients with RCC and VTT, the presence of a friable thrombus is an independent predictor of CSS. If our finding is confirmed by further studies, the consistency of the tumour thrombus should be introduced into routine pathologic reports to provide better patient risk stratification.

The extent of tumour fat invasion affects survival in patients with renal cell carcinoma and venous tumour thrombosis.

OBJECTIVE: • To investigate the effect of presence and extent of tumour fat invasion (TFI) - perinephric invasion (PFI), renal sinus fat invasion (RSFI) or both PFI and RSFI - on cancer-specific mortality (CSM) in patients with renal cell carcinoma (RCC) and venous tumour thrombus (VTT). METHODS: • We examined 184 consecutive patients with RCC with VTT treated with nephrectomy between 1987 and 2007. Associations with CSM were evaluated by univariable and multivariable Cox proportional hazard models. RESULTS: • Median follow up was 21 months. The 5-year CSM-free survival estimates were 75%, 36% and 20% in patients with VTT without TFI, those with VTT with PFI or RSFI, and those with VTT with both PFI and RSFI, respectively (P < 0.001). In multivariable analyses, presence of either PFI or RSFI was associated with a two-fold increased risk of CSM, whereas presence of both PFI and RSFI was associated with a three-fold increased risk of CSM, relative to VTT-only cases. • The inclusion of the variable describing the presence and extent of TFI in a base model including pT stage, Fuhrman grade and presence of nodal disease and metastatic disease significantly increased the accuracy in predicting CSM (+2.1%; P < 0.001) in patients with VTT. CONCLUSIONS: • Patients affected by RCC with VTT and TFI have a higher risk of CSM relative to cases with VTT only. Patients with both PFI and RSFI showed increased CSM compared with patients with either PFI or RSFI. • Our results suggest TFI should be accurately evaluated and included in routine pathological reports to provide better patient risk stratification.

Is extended and saturation biopsy necessary?

Prostate biopsy (PBx) techniques have significantly changed since the original Hodge's 'sextant scheme', which should now be considered obsolete. The feasibility of carrying out a biopsy scheme with a high number of cores in an outpatient setting is a result of the great improvement and efficacy of local anesthesia. Peri-prostatic nerve block with lidocaine injection should be considered the 'gold standard' because it provides the best pain relief to patients undergoing PBx. The optimal extended protocol should now include the sextant template with an additional 4-6 cores directed laterally (anterior horn) to the base and medially to the apex. Saturation biopsies (i.e. template with > or = 20 cores, including transition zone) should be carried out only when biopsies are repeated in patients where there is a high suspicion of prostate cancer. Complementary imaging methods (such as color- and power-Doppler imaging, with or without contrast enhancement, and elastography) could be used in order to increase the accuracy of biopsy and reduce the number of unnecessary procedures. Nevertheless, the routine use of these methods is still under evaluation.

Biopsy schemes with the fewest cores for detecting 95% of the prostate cancers detected by a 24-core biopsy.

BACKGROUND: The most efficient number and location of prostate biopsies remains a matter of debate. OBJECTIVE: To identify the combination (number and location) of sampling sites that permits the detection of 95% of the prostate cancers (PCa) detected by a 24-core biopsy (24PBx). DESIGN, SETTING, AND PARTICIPANTS: Six hundred and seventeen consecutive patients with a suspicion of PCa were prospectively enrolled. INTERVENTION: A transrectal ultrasound-guided systematic 24PBx was prospectively performed with local anesthesia in an outpatient setting. The 24PBx was obtained by the overlapping of medial sextant, lateral sextant, octant subcapsular, and quadrant transition cores. Before fixation, each single core was individually marked and inked according to the prostatic location sampled. MEASUREMENTS: We relied on a classification and regression tree analysis to identify four subgroups of patients with different PCa detection risk at initial biopsy, according to their clinical characteristics. Subsequently, we set the cancer-positive rate of the 24PBx at 100% and calculated PCa detection rates for 255 possible combinations of sampling sites. We selected the most advantageous biopsy scheme (defined as the combination of sampling sites that detected 95% of all the cancers with the minimal number of biopsy cores) for each patient subgroup. Finally, we internally validated the tumor detection rates by using the 10-fold cross-validation method. RESULTS AND LIMITATIONS: The 24PBx detected PCa in 289 patients (46.8%). The analysis revealed that the most advantageous schemes for patients with a negative digital rectal exam (DRE), prostate volume (PV) < or =60 cm(3), and age < or =65 yr was a combination of a 16-core biopsy. For patients with a negative DRE, PV < or =60 cm(3), and age >65 yr or a negative DRE and PV >60 cm(3), the most advantageous scheme was two different combinations of a 14-core biopsy. Finally, the sampling that permits detection of 95% of cancers in patients with a positive DRE was a combination of a 10-core biopsy. CONCLUSIONS: The most beneficial scheme varied according to the clinical characteristics of the patients. We propose a user-friendly flowchart to identify the most advantageous set of sampling sites according to patients' characteristics.

Diagnosis of high-grade prostatic intraepithelial neoplasia: the impact of the number of biopsy cores at initial sampling on cancer detection after a saturation re-biopsy.

OBJECTIVES: To evaluate factors that may predict prostate cancer (PCa) detection after initial diagnosis of high-grade prostatic intraepithelial neoplasia (HGPIN) on 6-24 cores prostatic biopsies (PBx). MATERIAL AND METHODS: We retrospectively evaluated 193 patients submitted from 1998 to 2007 to prostate re-biopsy after initial HGPIN diagnosis in three urologic departments. HGPIN diagnosis was obtained on initial systematic PBx with 6 to 24 random cores. All patients were re-biopsied with a "saturation" PBx with 18-26 cores with a median time to re-biopsy of 12 months. All slides were reviewed by expert uro-pathologists. RESULTS: Plurifocal HGPIN (pHGPIN) was found in 103 patients and monofocal HGPIN (mHGPIN) in 90. Seventy-two and 121 patients were submitted to > 12-core initial biopsy and < or = 12-core, respectively. Overall PCa detection at re-biopsy was 28.4%. PSA (6.7 vs 8.5 ng/ml; p = 0.029) and age (64 vs 68 years; p = 0.005) were significantly higher in patients with PCa at re-biopsy. PCa detection was significantly higher in patients who underwent a < or = 12-core initial PBx than in those with > 12-core (35.5% vs 16.8%; p = 0.03), and in patients with pHGPIN than in those with mHGPIN (34.9% vs 21%; p = 0.035). At multivariable analysis, PSA value (p = 0.007; HR:1.18), prostate volume (p = 0.01; HR:0.966), age (p < 0.001; HR:1.15), pHGPIN (p = 0.003; HR:2.97) and < or = 12-core initial biopsy (p = 0.012; HR:3.62) were independent predictors of PC detection. We further analysed the 2 groups of patients submitted to < or = 12-core and > 12-core initial PBx. Plurifocal HGPIN and older age at biopsy were independent predictors in patients with < or = 12-core initial PBx. On the contrary, in patients with > 12-core initial biopsy, higher PSA values and lower prostate volume were independent predictors of PC detection. CONCLUSIONS: PCa detection on saturation re-biopsy after initial diagnosis of HGPIN is significantly higher in patients submitted to < or = 12-core than those submitted to > 12-core initial PBx. In patients with < or = 12-core initial biopsy pHGPIN and older age were predictors of PCa detection at re-biopsy. In patients with > 12-core initial biopsy, higher PSA values and lower prostate volume was associated to an increased risk of PCa detection at re-biopsy.