Holmium laser prostatectomy in a tertiary Italian center: A prospective cost analysis in comparison with bipolar TURP and open prostatectomy.

OBJECTIVE: To assess the economic impact of Holmium laser enucleation of prostate (HoLEP) in comparison with transurethral resection of prostate (TURP) and open prostatectomy (OP). METHODS: Between January 2017 and January 2018, we prospectively enrolled 151 men who underwent HoLEP, TURP or OP at tertiary Italian center, due to bladder outflow obstruction symptoms. Patients with prostate volume ≤ 70 cc and those with prostate volume > 70 cc were scheduled for TURP or HoLEP and OP or HoLEP, respectively. Intraoperative and early post-operative functional outcomes were recorded up to 6 months follow up. Cost analysis was carried out considering direct costs (operating room [OR] utilization costs, nurse, surgeons and anesthesiologists' costs, OR disposable products costs and OR products sterilization costs), indirect costs (hospital stay costs and diagnostics costs) and global costs as sum of both direct and indirect plus general costs related to hospitalization. Cost analysis was performed comparing patients referred to TURP and HoLEP with prostate volume ≤ 70 cc and men underwent OP and HoLEP with prostate volume > 70 cc respectively. RESULTS: Overall, 53 (35.1%), 51 (33.7%) and 47 (31.1%) were scheduled to HoLEP, TURP and OP, respectively. Both TURP, HoLEP and OP proved to effectively improve urinary symptoms related to BPE. Considering patients with prostate volume ≤ 70 cc, median global cost of HoLEP was similar to median global cost of TURP (2151.69 € vs. 2185.61 €, respectively; p = 0.61). Considering patients with prostate volume > 70 cc, median global cost of HoLEP was found to be significantly lower than median global cost of OP (2174.15 € vs. 4064.97 €, respectively; p ≤ 0.001). CONCLUSIONS: Global costs of HoLEP are comparable to those of TURP, offering a cost saving of only 11.4 € in favor of HoLEP. Conversely, HoLEP proved to be a strong competitor of OP because of significant global cost sparing amounting to 1890.82 € in favor of HoLEP.

The pathological and clinical features of anterior lesions of prostate cancer: Evaluation in a single cohort of patients.

INTRODUCTION: The aim of our work is to evaluate the principal differences of the pathological features in prostate cancer (PCa) lesions comparing those in the anterior region of the gland (APCa) to those in the posterior zone (PPCa) among patients who underwent to robotic-assisted radical prostatectomy (RP). MATERIAL AND METHODS: A total of 85 consecutive patients (mean age 66; IQR 62-71) with clinically suspected PCa were studied with multiparametric magnetic resonance of prostate before prostate biopsies. The prostate biopsies were RM-guided (60 inbore biopsy (MR-GB) and 25 Fusion-biopsy (FB). A total of 72 cases were eligible for robotic RP. An experienced genitourinary pathologist reviewed the histopathology of the tissue specimens of the patients after RP. The exclusion criteria were as follows: previous hormonotherapy, radiotherapy and chemotherapy for others cancers. RESULTS: Based on the histological diagnosis, after RP, 68 anterior prostate cancer, and 107 posterior lesions were found. We further subcategorized lesions into peripheral and central zones for each the anterior and posterior lesions. The specific distribution of lesions by pathologic stage was: T2 = 74 (42.3%), T3a = 87 (49.7%), T3b = 12 (6.9%), T4 = 2 (1.1%) cases. Tumor volume of posterior neoplasms ranged from 0.04 to 20.35 cm3, with a median of 3.39 cm3. Anterior tumor volume ranged from 0.17 to 15 cm3, with a median volume of 2.54 cm3: PPCa were larger than APCa but the difference in size was not significant. The prostate cancer grade group (GG) I was distributed as 16.6% and 36% in anterior and posterior lesions cases. GG II and III was 43.8% and 31.5% in anterior and posterior cases, respectively. Comparatively, GG IV-V showed 39.6% and 32.5% for anterior and posterior lesions respectively (p < 0.001). Extraprostatic extention of neoplasm (EPE) was found more frequently in anterior cases (31.4%) than in in posterior cases (25.1%), but without significant difference. Lymphovascular invasion was similar in both the groups: 24% and 28.6% in anterior and posterior group, respectively. Anterior lesions showed a significantly higher rate of lymph node metastasis (9.3%) than posterior lesions (3.4%) (p < 0.005). CONCLUSION: In our study, we have found EPE, often associated with worse prognosis, more frequently (but not significantly) present in anterior lesions among PCa patients. Although posterior lesions are often related to pT3b stage, in our findings, anterior lesions were more often associated with a more aggressive neoplasm with more frequent nodal involvements.

Not fatal venous air embolism after holmium laser enucleation of the prostate: Case report and review of literature.

OBJECTIVE: Holmium laser has demonstrated high efficacy in urethral disobstruction. Venous air embolism (VAE) is a rare complication of prostate surgery. Only two cases of venous air embolism (VAE) in patients submitted to HoLEP, have been described. In this paper we show a third case of not fatal VAE after HoLEP. MATERIALS AND METHODS: A case of VAE occurred in holmium laser enucleation (HoLEP) due to obstructive lower urinary tract symptoms (LUTS) in a 70 years old patient. After the procedure, patient's end tidal carbon dioxide (ETCO2) levels dramatically decreased at 17 mmHg, with pressure airway (PAW)16 mmHg; oxygen saturation level was at 75%, without any loss in the ventilation circuit and with arterial blood pressure of 94/54 mmHg. Due to the negativity for other suspicions, the suspect of VAE was postulated. RESULT: The immediate switching from laryngeal mask to Oro Tracheal Intubation increased the oxygen level. A cardiac transthoracic ultrasound was negative for air bubbles inside cardiac cavities, without any alteration in the cardiac kinetics. Arterial blood sample turned negative for any alteration compatible with VAE and catheter continuous vesical irrigation was started to obtain clear washing fluid without blood cloths. The extubated patient showed no neurological defects. CONCLUSIONS: An invasive monitoring system is the key to rapidly and correctly identify any embolic episode during this kind of surgery.

First case of 18F-FACBC PET/CT-guided salvage radiotherapy for local relapse after radical prostatectomy with negative 11C-Choline PET/CT and multiparametric MRI: New imaging techniques may improve patient selection.

We present the first case of salvage radiotherapy based on the results of 18F-FACBC PET/CT performed for a PSA relapse after radical prostatectomy. The patients underwent 11CCholine PET/CT and multiparametric MRI that were negative while 18F-FACBC PET/CT visualized a suspected local relapse confirmed by transrectal ultrasound-guided biopsy. No distant relapse was detected. Thus the patient was submitted to salvage radiotherapy in the prostatic fossa. After 20 months of follow-up, the PSA was undetectable and 18F-FACBC PET/CT was negative. Salvage radiotherapy after surgery, provided that it is administered at the earliest evidence of the biochemical relapse, may improve cancer control and favourably influence the course of disease as well as the adjuvant approach. New imaging techniques may increase the efficacy of the salvage radiotherapy thus helping in the selection of the patients. Preliminary clinical reports showed an improvement in the detection rate of 20-40% of 18F-FACBC in comparison with 11C-Choline for the detection of disease relapse after radical prostatecomy, rendering the 18F-FACBC the potential radiotracer of the future for prostate cancer.

Preservation of the smooth muscular internal (vesical) sphincter and of the proximal urethra during retropubic radical prostatectomy: a technical modification to improve the early recovery of continence.

OBJECTIVE: We describe our technique for preservation of the smooth muscular internal (vesical) sphincter and proximal urethra during radical retropubic prostatectomy (RRP) and present our preliminary clinical results. MATERIALS AND METHODS: The first steps of the prostatectomy reflect the standard RRP, while for the final phases the procedure continues in an anterograde manner with incision of the fibers of the detrusor muscle at the insertion of the ventral surface of the base of the prostate. At this level, the inner circular muscle of the bladder neck forms a sphincteric ring of smooth muscle that covers the longitudinally oriented smooth muscle component of the urethral musculature that extends distally to the verumontanum. These two proximal structures represent the internal sphincter that envelopes and locks the proximal urethra. A blunt dissection is continued until the ring shaped vesical sphincter is separated from the prostate and the longitudinally oriented smooth muscle component of the urethral musculature is identified. The base of the prostate is then gently separated from the urethra and from the bladder until the maximal length of the urethral musculature is isolated and preserved. RESULTS: After 30 initial set-up procedures, 40 consecutive patients with organ confined prostate cancer were submitted to radical retropubic prostatectomy with the preservation of muscular internal sphincter and the proximal urethra and compared to 40 patients submitted to standard procedure who served as control group. The group of patients submitted to our technical modification had a faster recovery of early continence than control group at 3 and 7 days. CONCLUSIONS: The described technique is a feasible and safe method for preservation of the internal urethral sphincter and allows improving the early recovery of urinary continence. The technique does not increase the rate of positive margins and the duration of the procedure.

First case of bilateral, synchronous anaplastic variant of spermatocytic seminoma treated with radical orchifunicolectomy as single approach: case report and review of the literature.

Spermatocytic Seminoma (SS) is less common than the Classic variant, as its incidence ranges between 1.3% and 2.3% of all seminomas. Generally SS is diagnosed in men older than 50 years. The Anaplastic variant of Spermatocytic Seminoma is characterized by an earlier onset when compared to SS, but a benign behavior in spite of its histological patterns similar to Classic Seminoma. We reported the first case of bilateral, largest and synchronous Anaplastic Spermatocytic Seminoma, in a patient treated with radical orchifunicolectomy alone and with long-term follow-up. The currently available data show that Anaplastic SS reveals a clinically benign behavior, and no distant metastases have been reported so far. A close surveillance after surgery could be considered a valid option in the management of this rare testicular neoplasm.

Diagnostic accuracy of (11)C-choline PET/CT in preoperative lymph node staging of bladder cancer: a systematic comparison with contrast-enhanced CT and histologic findings.

AIM: The aim of this study was to evaluate the role of C-choline PET/CT in the preoperative evaluation of the nodal involvement of patients with bladder carcinoma (BC) suitable for radical cystectomy and extended pelvic lymph node dissection in comparison with contrast-enhanced CT (CECT) using the pathologic specimen as reference standard. PATIENTS AND METHODS: Twenty-six consecutive patients (69.5 ± 9.3 years; range, 49-84) with histologically proven transitional cell BC were treated with radical cystectomy and pelvic lymph node dissection and were enrolled from April 2011 to January 2013. In all patients, paravesical, internal, eternal, and common iliac nodes as well as obturatory, presacral, preaortic, and precaval lymph nodes (LNs) were dissected up to the origin of the inferior mesentery artery. The areas of the LN dissection were grouped as follow: region A included preaortic and precaval LNs; region B included paravesical, common, internal and external iliac, obturatory, and presacral LNs in the right pelvis; region C included paravesical, common, internal and external iliac, obturatory, and presacral LNs in the left pelvis. C-choline PET/CT and abdominal CECT were used to assess the presence of lymph node metastases on a per patient, region, and lesion analysis using the results of surgical specimens obtained at operation as criterion standard. RESULTS: Seven of 26 patients (26.9%) showed nodal metastases at pathologic analysis. Overall, 844 LNs were evaluated, and 38 of them (4.5%) showed metastatic involvement. On a patient-based analysis, C-choline PET/CT showed a sensitivity of 42% and specificity of 84%, whereas, CECT showed a sensitivity of 14% and specificity of 89%. On a region-based analysis, C-choline PET/CT showed a sensitivity of 11% and specificity of 82%, whereas CECT showed a sensitivity of 5% and specificity of 80%. On a lesion (LN)-based analysis, C-choline PET/CT showed a sensitivity of 10% and specificity of 64%, whereas CECT showed a sensitivity of 2% and specificity of 63%. CONCLUSIONS: C-choline PET/CT could provide additional diagnostic information in preoperative nodal staging of patients with invasive BC in comparison with CECT. A study with a larger population should determine if C-choline PET/CT could be recommended as a routine technique in high-risk patients with BC.

First case of 18F-FACBC PET/CT-guided salvage retroperitoneal lymph node dissection for disease relapse after radical prostatectomy for prostate cancer and negative 11C-choline PET/CT: new imaging techniques may expand pioneering approaches.

We present the first case of salvage retroperitoneal lymph node dissection based on the results of (18)F-FACBC PET/CT performed for a prostate-specific antigen relapse after radical prostatectomy. The patients underwent (11)C-choline PET/CT, which turned out negative, while (18)F-FACBC PET/CT visualized two lymph node metastases confirmed at pathological examination. Preliminary clinical reports showed an improvement in the detection rate of 20-40% for (18)F-FACBC in comparison with (11)C-choline, rendering the (18)F-FACBC the potential radiotracer of the future. Salvage surgery for prostate cancer is a fascinating but controversial approach. New diagnostic tools may improve its potential by increasing the assessment and the selection of the patients.

Preservation of the smooth muscular internal (vesical) sphincter and of the proximal urethra for the early recovery of urinary continence after retropubic radical prostatectomy: a prospective case-control study.

OBJECTIVES: To evaluate the influence of preservation of the muscular internal sphincter and proximal urethra on continence recovery after radical prostatectomy. METHODS: This was a prospective single-center, case-control study. A total of 40 consecutive patients with organ-confined prostate cancer were submitted to radical prostatectomy with the preservation of the muscular internal sphincter and the proximal urethra (group 1), and their outcomes were compared with those of 40 patients submitted to a standard procedure (group 2). Continence rates were assessed using a self-administrated questionnaire at 3, 7 and 30 days, and 3 and 12 months after removal of the catheter. RESULTS: Group 1 had a faster recovery of early continence than group 2 at day 3 (45% vs 22%; P = 0.029) and at day 7 (75% vs 50%; P = 0.018). Considering the number of pads, group 1 had a faster recovery of continence at 3, 7 and 30 days, and also had less incidence of severe incontinence. There was no statistically significant difference in terms of continence at 3 and 12 months among the two groups. Multivariate logistic regression analysis showed that surgical technique and young age were significantly associated with earlier time to continence at 3 and 7 days. The two groups had no significant differences in terms of surgical margins. CONCLUSIONS: Our modified technique of radical retropubic prostatectomy with preservation of the smooth muscular internal sphincter, as well as of the proximal urethra during bladder neck dissection, results in a significantly increased urinary continence at 3, 7 and 30 days after catheter removal, with a minor incidence of severe incontinence. The technique is also oncologically safe, and it does not increase the operative duration of the procedure.

Can testis-sparing surgery for small testicular masses be considered a valid alternative to radical orchiectomy? A prospective single-center study.

BACKGROUND: The aim of this study was to evaluate the incidence of malignancy in small testicular masses (STMs) treated with testis-sparing surgery (TSS) with intraoperative frozen section analysis and to assess the safety of this surgical procedure. PATIENTS AND METHODS: From January 2009 to January 2013, 15 consecutive patients underwent TSS for STMs in a third-referral academic institution. Every patient was preoperatively evaluated with clinical examination and scrotal ultrasonography (US) performed by the same radiologist. Tumor markers were assessed in all cases. All the procedures were performed through inguinal access; the small mass was identified by straight palpation of the testis or with intraoperative ultrasonography (IUS). Frozen-section examination (FSE) was performed in all patients in association with multiple biopsies of the surrounding tissue. Follow-up was carried out in all patients with an ultrasonographic exploration at 6 and 12 months. RESULTS: Preoperative tumor markers were normal in all patients. The mean operative time was 90 ± 31 minutes. The warm ischemia time was 18 ± 3 minutes. The mean size on US was 9.5 ± 4.4 mm. FSE results were confirmed by the final pathologic analysis in 14 patients. At final pathologic analysis, 6 patients (40%) were found not to have tumors, another 7 patients (46.7%) had benign neoplasms, and malignant tumor was found in only 2 patients (13.3%). There was no disease recurrence after a mean follow-up of 19.2 ± 11.5 months. CONCLUSION: Our experience shows that TSS performed for STMs may represent a safe procedure with optimal results in terms of functional and oncologic end points.