The pathway of isolated seminal vesicle invasion has a different impact on biochemical recurrence after radical prostatectomy and pelvic lymphadenectomy.

OBJECTIVE: Prostate cancer with seminal vesicle invasion (SVI) has been considered an aggressive cancer. To evaluate the prognostic significance of different patterns of isolated SVI in patients undergoing radical prostatectomy (RP) and pelvic lymphadenectomy. METHODS AND MATERIALS: We retrospectively analyzed all patients who underwent RP between 2007 and 2019. Inclusion criteria were localized prostate adenocarcinoma, SVI at RP, at least 24-months follow-up, and no adjuvant treatment. Patterns of SVI were following Ohori's classification: type 1: direct spread along the ejaculatory duct from inside; type 2: seminal vesicle invasion outside the prostate, through the capsule; type 3: the presence of cancer island(s) in the seminal vesicle with no continuity from the primary tumor (discontinuous metastases). Patients with type 3 SVI (isolated or in association) were included in the same group. Biochemical recurrence (BCR) was defined as any postoperative PSA ≥0.2 ng/ml. A logistic regression analysis was performed to assess predictors of BCR. Time to BCR was investigated using the Kaplan-Meier analysis with the log-rank test. RESULTS: Sixty-one out of 1,356 patients were included. Median age was 67(7.2) years. Median PSA was 9.4(8.92) ng/ml. Mean follow-up was 85.28 ± 45.27 months. BCR occurred in 28(45.9%) patients. Logistic regression showed that a positive surgical margin (OR 19.964, 95%CI:1.172-29.322, P = 0.038) was predictor of BCR. Kaplan-Meier analysis demonstrated that patients with pattern 3 had a significantly shorter time to BCR compared to other groups (log-rank, P = 0.016). The estimated time to BCR was 48.7 months in type 3, 60.9 months in pattern 1 + 2, 74.8, and 100.8 months in isolated patterns 1 and 2, respectively. In patients with negative surgical margins, pattern 3 confirmed a shorter time to BCR compared to other types of invasions, with an estimated time to BCR of 30.8 months. CONCLUSIONS: Patients with type 3 SVI demonstrated a shorter time to BCR compared to other patterns.

Is spinal anesthesia a safe alternative for retrograde intrarenal surgery for stone disease in daily practice?

OBJECTIVES: Retrograde intrarenal surgery (RIRS) is commonly performed under general anesthesia (GA) because renal mobility during breathing may affect lithotripsy. However, spinal anesthesia (SA) is adopted in clinical practice due to clinical conditions that contraindicate GA. We aimed to compare results of RIRS for stones performed under GA compared to SA regarding stone-free rate (SFR) status and postoperative complications in a consecutive single-center series. METHODS: We retrospectively reviewed all patients who underwent RIRS for stones between 2017 and 2020. INCLUSION CRITERIA: age ≥ 18 years, renal stone burden deemed suitable for RIRS with a stone diameter ≤ 20 mm. EXCLUSION CRITERIA: stones >20 mm, urinary tract infection, bilateral surgery, second-look procedures, unmodifiable bleeding diathesis, <5mm asymptomatic lower calyx stones. SFR was defined as no residual fragment >3 mm at 6-12 weeks follow-up. The choice of anesthesia was a shared decision between anesthesiologists and patient preference. RESULTS: 230 patients were included in the analysis. Mean age was 57.50±13.73 years. 33% of stones were located in the pelvis. 28.7% of patients had multiple stones. Mean cumulative stone diameter was 16.60±6.54 mm. 63% of patients underwent RIRS under SA. There were no significant differences between the two groups in terms of preoperative characteristics, except for comor-bidity, significantly higher in the GA group. Mean time of operating room occupation was longer in the GA group (81.58±35.37 minutes) than in the SA group (72.85±25.91 minutes,p=0.033). Length of stay was shorter in the SA group (mean 2.2±1.66 days vs 3.46±5.88 in GA,p=0.019). Logistic regression showed that multiple stones in the collecting system were associated with residual fragments (HR 0.386, 95%CI 0.151-0.991,p=0.04). There were no statistically significant differences in overall and high-grade complications, and in SFR between SA (75.9%) and GA groups (70.6%,p=0.317). CONCLUSION: SA does not affect SFR and postoperative complications in patients who underwent RIRS in daily practice.

Is spinal anesthesia a safe alternative for retrograde intrarenal surgery for stone disease in daily practice?

Objectives: Retrograde intrarenal surgery (RIRS) is commonly performed under general anesthesia (GA) because renal mobilityduring breathing may affect lithotripsy. However, spinal anesthesia (SA) is adopted in clinical practice due to clinical conditionsthat contraindicate GA. We aimed to compare results of RIRS for stones performed under GA compared to SA regarding stonefree rate (SFR) status and postoperative complications in a consecutive single-center series.Methods: We retrospectively reviewed all patients who underwent RIRS for stones between 2017 and 2020. Inclusion criteria:age ≥ 18 years, renal stone burden deemed suitable for RIRS with a stone diameter ≤ 20 mm. Exclusion criteria: stones >20mm, urinary tract infection, bilateral surgery, second-look procedures, unmodifiable bleeding diathesis, <5mm asymptomaticlower calyx stones. SFR was defined as no residual fragment >3 mm at 6-12 weeks follow-up. The choice of anesthesia was ashared decision between anesthesiologists and patient preference.Results: 230 patients were included in the analysis. Mean age was 57.50±13.73 years. 33% of stones were located in the pelvis.28.7% of patients had multiple stones. Mean cumulative stone diameter was 16.60±6.54 mm. 63% of patients underwent RIRSunder SA. There were no significant differences between the two groups in terms of preoperative characteristics, except for comorbidity, significantly higher in the GA group. Mean time of operating room occupation was longer in the GA group (81.58±35.37minutes) than in the SA group (72.85±25.91 minutes,p=0.033). Length of stay was shorter in the SA group (mean 2.2±1.66 days vs3.46±5.88 in GA,p=0.019). Logistic regression showed that multiple stones in the collecting system were associated with residualfragments (HR 0.386, 95%CI 0.151-0.991,p=0.04). There were no statistically significant differences in overall and high-gradecomplications, and in SFR between SA (75.9%) and GA groups (70.6%,p=0.317)...(AU)

Rupture of the cavernous body diagnosed by contrast-enhanced ultrasound: Presentation of a clinical case.

Penile trauma represents a urological emergency characterized by the breaking of the albuginea tunic. A fast diagnosis and early surgical repair are the best treatments to avoid post-operative sequelae such as curvatures or deformities of the penis. An ultrasound evaluation may not be able to identify the injury in the tunica albuginea due to the edematous swelling of the penis and clots within the tear deteriorate the image contrast and can hide the injury. We here report a case study of successful management via surgical treatment for rupture of the cavernous body diagnosed by contrast-enhanced ultrasound in a young patient with penile trauma.

Blue light cystoscopy with hexylaminolevulinate: Our 7 years experience.

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.

Cognitive zonal fusion biopsy of the prostate: Original technique between target and saturation.

We describe our experience in prostate biopsy using a new standardized cognitive fusion techniques, that we call "cognitive zonal fusion biopsy". This new technique is based on two operative options: the first based on target biopsies, the Cognitive Target Biopsy (CTB) if the same target was detected with transrectal ultrasound (TRUS) and multiparametric magnetic resonance (mpMRI); the second based on saturation biopsies, the Zonal Saturation Biopsy (ZSB) on anatomical zone/s containing the region of interest if the same target was not evident with TRUS and MRI. We evaluated results of our technique compared to standard biopsy in order to identify clinically relevant prostate cancer. METHODS: This is a single-center prospective study conducted in 58 pts: 25 biopsy-naïve, 25 with previous negative biopsy and in 8 with cancer in active surveillance. Based on mpMRI and transrectal ultrasonography (TRUS), all patients were scheduled for standard 12-core TRUS-guided biopsy. If mpMRI was suggestive or positive (PI-RADS 3, 4 or 5): patients underwent additional targeted 2 to 6 cores using cognitive zonal fusion technique. RESULTS: 31/58 (53.4%) patients had a cancer. Our technique detected 80.6% (25 of 31) with clinically significant prostate cancer, leading to detection of insignificant cancer in 20%. Using standard mapping in MR negative areas we found 5 clinically significant cancer and 4 not significant cancers. MRI cancer detection rate was 18/31 (58.1%), and 9/18 (50%) in high grade tumors. Therefore MRI missed 50% of high grade cancers. The mean number of cores taken with cognitive zonal fusion biopsy was 6.1 (2-17), in addition biopsy sampling was done outside the ROI areas. Overall 15.4 cores (12-22) were taken. Cancer amount in Zonal Biopsy was larger than 7.3 mm (1-54.5) in comparison with 5.2 mm (1-23.5) in standard mapping. Largest percentage of cancer involvement with cognitive zonal fusion technique was detected in 19.4% vs 15.9%. CONCLUSIONS: Cognitive Zonal Saturation Biopsies should be used to reduce operator variability of cognitive fusion biopsy in addition to standard biopsy. Cognitive zonal biopsy based on mpMRI findings identifies clinically relevant prostate in 80%, has larger cancer extension in fusion biopsies than in random biopsies, and reduce the number of cores if compared to saturation biopsy.

Improvement of lower urinary tract symptoms and sexual activity after open simple prostatectomy: prospective analysis of 50 cases.

OBJECTIVES: To evaluate the improvement of Lower Urinary Tract Symptoms (LUTS) and Erectile Function (EF) evaluated before and after Open Simple Prostatectomy, focusing on which patients this procedure allows better outcomes in term of sexual activity. MATERIAL AND METHODS: 50 men with large size benign prostatic hyperplasia (BHP) greater than 80 gr were prospectively evaluated before and 6 months after Open Simple Prostatectomy (Freyer procedure) between October 2012 to September 2013. Patients had a pre-operative transrectal ultrasound (TRUS) for volume evaluation and filled pre and post operative questionnaires for International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) score. RESULTS: Mean patients age was 71 years (D.S. 3,5), mean prostate volume results 103 ml (D.S. 23,7); regarding LUTS and EF, mean improvement of IPSS score was 15,3 (D.S. 4) and mean increase of IIEF-5 score was 3,4 (D.S.3). This study highlights a correlation between patients' age and increase of IIEF-5 score; no correlation with prostate size was found. CONCLUSION: According to the EAU Guidelines 2014, large size BPH (over 80-100 mL) with LUTS refractory to medical management continue to have open prostatectomy as the treatment of choice. In our experience we found not only an reduction of LUTS after the procedure but also an improvement of erectile function; this improvement was related with patient's age.

The impact of repeated prostate biopsies on sexual function and urinary symptoms in patients with diagnosis of Atypical Small Acinar Proliferation (ASAP): can ecoDoppler reduce side effects?

OBJECTIVES: To establish whether repeated trans-rectal ultrasound-guided Prostate Needle Biopsies (PNBx) performed in men with diagnosis of Small Acinar Atypical Proliferation (ASAP) predispose these subjects to Erectile Dysfunction (ED) and to evaluate if EcoColorDoppler (ECD) can help to reduce this side effect. MATERIALS AND METHODS: We performed a retrospective study regarding 190 men with diagnosis of ASAP detected between January 2001 and December 2011, who underwent to repeated prostate needle biopsies (PNBx). These patients were investigated about Erectile Function (EF) and Lower Urinary tract Symptoms (LUTS) using International Index of Erectile Function (IIEF-5) and International Prostate Symptom Score (IPSS) questionnaires before the first PNBx and 3 months after each other one. In particular, among the 89 men without ED before first PNBx, we compared IIEF-5 score between 64 patients who underwent to standard PNBx and 25 patients submitted to a PNBx done with in addition ECD ultrasound imaging. RESULTS: Mean patient age was 65 years (SD 7.7); mean follow-up was 3.2 years (SD 1.8) and the mean number of re-biopsies completed was 2 (SD 1.5). Among the 143 men considered, only 89 resulted with a normal EF (IIEF-5 score > 21): in this group incidence of ED (IIEF-5 score < 21) among patients who underwent to standard PNBx was 4/64 (6.25%) while in patients submitted to a PNBx with ECD was 1/25 (4%). A greater decrease of EF was observed in patients undergone to 3 or more biopsies; no relationship between IPSS score and re-PNBx was identified. CONCLUSION: Repeated PNBx done in patients with diagnosis of ASAP appear to get worse EF; number of biopsies seems to increase the risk of ED. Use of ECD in transrectal ultrasound- guided PNBx may have a role to avoid neurovascular bundles (NVBs) and preserve EF; anyway further studies are highly recommended to validate this hypothesis.

Perivascular epithelioid cell tumor (PEC-ome) of the prostate: ultrasound feature in case report.

INTRODUCTION: We describe a rare tumor arising from the prostate gland: Perivascular Epithelioid Cells tumor (PEC-ome). A 54-years old was treated for acute urinary retention with alpha-blockers at presentation due to benign prostate enlargement (65 cc) with asymmetric middle lobe and regular PSA (0.92 ng/ml). After 5 months, patient developed a second acute urinary retention episode and nodules in the left lung; he was treated with transurethral resection of the prostate and left lobectomy. RESULTS: Histological examination of prostate and lung tissue gave the same diagnosis: leiomyosarcoma with atypical morphological features and patient was observed for 4 months. Considering the uncommon diagnosis, pathological review by the uro-pathologist at our Hospital was done. Additional immunohistochemistry was done and both tumors showed similar and typical features of metastatic PEC-ome (T1b N0 M1). Therefore a new staging showed local and distant progression with prostatic mass and small lung metastasis. Three cycles of Gemcitabine and Pazopanib were administered, but 2 months later a new urinary retention occurred, despite chemotherapy. Patient referred to our Hospital for salvage pelvic surgery with lymph node dissection. Final pathological diagnosis was PEC-ome of the prostate stage pT4 pN0 R0 M1. CONCLUSIONS: PEC-ome is a rare but rapidly invasive mesothelial tumor with early metastatic potential. When this tumors originates from the fibromuscular stroma of the prostate it mimics benign prostatic enlargement and causes LUTS. Expert pathology aided by immunoisthochemistry is the cornerstone of diagnosis. There are no pathognomonic imaging on ultrasound or symptoms suggesting the presence of PEC-ome in early stage. A multidisciplinary approach is necessary and radical surgery should be done to treat this aggressive cancer.