Postoperative outcomes of Fast-Track-enhanced recovery protocol in open radical cystectomy: comparison with standard management in a high-volume center and Trifecta proposal.

BACKGROUND: We aimed at comparing perioperative outcomes in patients submitted to radical cystectomy followed by Fast Track (FT) protocol or standard management, and propose a definition of Trifecta, to improve standardized quality assessment for RC. METHODS: We considered 191 patients submitted to RC between January 2017 and January 2019. Patients followed FT or standard management according to surgeon's preference. Preoperative and intraoperative characteristics, alongside with postoperative outcomes were compared between the two groups. Trifecta was defined as follows: in-hospital stay (HS) ≤ 10 days, time to defecation (TtD) below the overall mean and no major (≥ Clavien-Dindo grade III) complications. Finally, Trifecta achievement rates were assessed in both groups. RESULTS: Seventy-five patients (39%) followed the FT protocol and 116 (61%) standard management. The two groups were homogeneous for preoperative, intraoperative and pathological characteristics. Patients in the FT group had shorter TtD (5 vs. 6 days P=0.006), HS (12 vs. 14 days P=0.008) and lower readmission rate (8% vs. 19% P=0.04). Early complication rates and grades were similar, while less late complications were found in FT group (6.7% vs. 21.6% P=0.006). Trifecta achievement rate was higher for FT group (31% vs. 8% P<0.001). Single-item failure percentages for HS, TtD and major grade complications were respectively 90%, 60% and 19%, with no difference between the two groups. CONCLUSIONS: FT protocol can safely consent faster bowel recovery and earlier discharge after RC, plus reducing readmission rates. Using a Trifecta incorporating essential perioperative outcomes, could improve standardized quality assessment for RC.

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.

Patterns of positive surgical margins after open radical prostatectomy and their association with clinical recurrence.

BACKGROUND: We report long-term oncologic outcomes in patients with positive surgical margins (PSMs) at radical prostatectomy (RP) and the oncologic impact of different scenarios of PSMs presentation. METHODS: We selected 494 men with at least 3 years follow-up after surgery. PSMs patterns were recorded as: burden (focal vs. multifocal), site (apical-anterior vs. posterolateral vs. base-bladder neck vs. multiple) and side (unilateral vs. bilateral). Kaplan-Meier curves depicted the clinical recurrence-free survival (CR-FS) rates at 10-year in the overall population, after biochemical recurrence and according to different PSMs patterns. Multivariate Cox-regression analysis was performed to predict CR. RESULTS: Overall, PSMs sites were apical-anterior, postero-lateral, base-bladder neck and multiple in 19.8%, 23.7%, 3.4% and 43.8%, respectively. Out of 494 patients, 278 (56.3%) had a focal margin, while 216 (43.7%) had a multifocal margin. In 268 (54.3%) and 87 (17.6%) men, PSMs were unilateral and bilateral, respectively. Median follow-up was 93 months. No significant differences were found in CR-FS rates after stratifying according to burden and site of PSMs. Men with unilateral PSMs experienced significant higher CR-FS rates compared to those with bilateral PSMs (87.1% vs. 71.3% at 10 years, P<0.001). At multivariate Cox regression Gleason score 8-10 (HR: 2.53, Confidence Interval [CI]: 1.01-6.33; P=0.04), pathologic stage pT3b-pT4 (HR 3.02, CI: 1.60-7.85; P=0.02) and adjuvant radiotherapy (HR: 0.30, CI: 0.11-0-86; P=0.02) were independent predictors of CR. CONCLUSIONS: Men with bilateral PSMs had higher risk to experience CR, suggesting that the different patterns of PSMs, should be considered during patients counseling to guide postoperative treatments. Retrospective nature of the study and restricted number of patients included consist of main limitations.

Preoperative Staging With 11C-Choline PET/CT Is Adequately Accurate in Patients With Very High-Risk Prostate Cancer.

PURPOSE: To evaluate the accuracy of 11C-choline positron emission tomography (PET)/computed tomography (CT) for nodal staging of prostate cancer (PCa) in different populations of high-risk patients. PATIENTS AND METHODS: We evaluated 262 individuals with intermediate- or high-risk PCa submitted to radical prostatectomy and extended pelvic lymph node dissection. Within men with high-risk disease, we identified a subgroup of individuals harboring very high-risk (VHR, n = 28) disease: clinical stage ≥ T2c and more than 5 cores with Gleason score 8-10; primary biopsy Gleason score of 5; 3 high-risk features; or prostate-specific antigen ≥ 30 ng/mL. The diagnostic accuracy of PET/CT and contrast-enhanced CT (CECT) was assessed after stratifying patients according to risk group classification on a patient- and anatomic region-based analysis. RESULTS: On patient-based analysis, considering high-risk patients (n = 155), 11C-choline PET/CT versus CECT had sensitivity and specificity of 50% and 76% versus 21% and 92%, respectively. Considering VHR men as separate subgroups (n = 28), 11C-choline PET/CT versus CECT had sensitivity and specificity of 71% and 93% versus 25% and 79%, respectively. Accordingly, in the VHR category, the area under the curve of 11C-choline PET/CT versus CECT was 0.86 (95% confidence interval, 0.71-1.0) versus 0.69 (95% confidence interval, 0.52-0.86), respectively. On anatomic region-based analysis, considering the VHR group, 11C-choline PET/CT versus CECT had sensitivity and specificity of 70.6% and 95.5% versus 35.3% and 98.5%, respectively. CONCLUSION: Patients with VHR characteristics could represent the ideal candidate to undergo disease staging with PET/CT before surgery with the highest cost efficacy.

The impact of a structured intensive modular training in the learning curve of robot assisted radical prostatectomy.

AIM: The success of Robot Assisted Laparoscopic Prostatectomy (RALP) is mainly due to his relatively short learning curve. Twenty cases are needed to reach a "4 hours-proficiency". However, to achieve optimal functional outcomes such as urinary continence and potency recovery may require more experience. We aim to report the perioperative and early functional outcomes of patients undergoing RALP, after a structured modular training program. METHODS: A surgeon with no previous laparoscopic or robotic experience attained a 3 month modular training including: a) e-learning; b) assistance and training to the operating table; c) dry console training; d) step by step in vivo modular training performing 40 surgical steps in increasing difficulty, under the supervision of an experienced mentor. Demographics, intraoperative and postoperative functional outcomes were recorded after his first 120 procedures, considering four groups of 30 cases. RESULTS: All procedures were completed successfully without conversion to open approach. Overall 19 (15%) post operative complications were observed and 84% were graded as minor (Clavien I-II). Overall operative time and console time gradually decreased during the learning curve, with statistical significance in favour of Group 4. The overall continence rate at 1 and 3 months was 74% and 87% respectively with a significant improvement in continence rate throughout the four groups (p = 0.04). Considering those patients submitted to nerve-sparing procedure we found a significant increase in potency recovery over the four groups (p = 0.04) with the higher potency recovery rate up to 80% in the last 30 cases. CONCLUSIONS: Optimal perioperative and functional outcomes have been attained since early phase of the learning curve after an intensive structured modular training and less than 100 consecutive procedures seem needed in order to achieve optimal urinary continence and erectile function recovery.

MRI Displays the Prostatic Cancer Anatomy and Improves the Bundles Management Before Robot-Assisted Radical Prostatectomy.

OBJECTIVES: To evaluate the impact of multiparametric magnetic0 resonance imaging (mpMRI) to guide the nerve-sparing (NS) surgical plan in prostate cancer (PCa) patients referred to robot-assisted radical prostatectomy (RARP). METHODS: One hundred thirty-seven consecutive PCa patients were submitted to RARP between September 2016 and February 2017 at two high-volume European centers. Before RARP, each patient was referred to 1.5T or 3T mpMRI. NS was recorded as Grade 1, Grade 2, Grade 3, and Grade 4 according to Tewari and colleagues classification. A preliminary surgical plan to determinate the extent of NS approach was recorded based on clinical data. The final surgical plan was reassessed after mpMRI revision. The appropriateness of surgical plan change was considered based on the presence of extracapsular extension or positive surgical margins (PSMs) at level of neurovascular bundles area at final pathology. Furthermore, we analyzed a control group during the same period of 166 PCa patients referred to RARP in both institutions without preoperative mpMRI to assess the impact of the use of mpMRI on the surgical margins. RESULTS: Considering 137 patients with preoperative mpMRI, the mpMRI revision induced the main surgeon to change the NS surgical plan in 46.7% of cases on patient-based and 56.2% on side-based analysis. The surgical plan change results equally assigned between the direction of more radical and less radical approach both on patient-based (54.7% vs 54.3%) and on side-based levels (50% vs 50%), resulting an overall appropriateness of 75%. Moreover, patients staged with mpMRI revealed significant lower overall PSMs compared with control group with no mpMRI (12.4% vs 24.1%; p ≤ 0.01). CONCLUSIONS: mpMRI induces robotic surgeons to change the surgical plan in almost half of individuals, thus tailoring the NS approach, without compromising the oncologic outcomes. Compared to patients treated without mpMRI, the use of preoperative mpMRI can significantly reduce the overall PSMs.

"In-bore" MRI-guided Prostate Biopsy Using an Endorectal Nonmagnetic Device: A Prospective Study of 70 Consecutive Patients.

INTRODUCTION: We investigated the diagnostic performance of in-bore endorectal magnetic resonance imaging-guided biopsy (MRI-GB) with a 1.5-T MRI scanner using a 32-channel coil in patients with suspected prostate cancer (PCa). PATIENTS AND METHODS: Seventy patients with ≥ 1 suspicious area found on the preliminary multiparametric MRI scan were enrolled. The index lesion was defined as the lesion with the greatest Prostate Imaging Reporting and Data System, version 2 (PIRADS-v2), score. MRI-GBs were performed with a nonmagnetic biopsy device, needle guide, and titanium double-shoot biopsy gun with dedicated software for needle tracking. Clinically significant PCa was defined as the presence of Gleason score ≥ 7 in the biopsy specimen. RESULTS: Seventy index lesions were scheduled for MRI-GB. The median PIRADS-v2 score and the median number of cores per patient was 4 of 5 (interquartile range, 3-5) and 2 (interquartile range, 1-3), respectively. The PCa detection rate was 45.7%. Of the 70 patients, 24 (75%) had clinically significant PCa, with a significant correlation between the PIRADS-v2 score and the Gleason score in the MRI-GB cores (r = 0.839; 95% confidence interval, 0.535-0.951; P = .003). According to the PIRADs-v2 scheme, the proportion of PCa in the central and anterior regions of the gland was greater in the entire population and in the subgroup of patients with a history of negative transrectal ultrasound-guided biopsy findings (P ≤ .01 for all). On multivariate analysis, a PIRADS-v2 score of 5 of 5 correlated significantly with the likelihood of PCa at biopsy (hazard ratio, 4.69; 95% confidence interval, 0.92-23.74; P = .04). No major complications were recorded. CONCLUSION: MRI-GB has a high detection rate for PCa, especially for lesions located in the central and anterior regions of the prostate.

Adverse Features and Competing Risk Mortality in Patients With High-Risk Prostate Cancer.

PURPOSE: To assess survival and competing causes of mortality in prostate cancer (PCa) patients referred to radical prostatectomy through a combination of unfavorable characteristics. PATIENTS AND METHODS: We evaluated 615 PCa patients referred to radical prostatectomy and pelvic lymph node dissection at single tertiary-care center with at least one adverse feature (AF): preoperative prostate-specific antigen ≥ 20 ng/mL, pathologic Gleason score 8 to 10, and no organ-confined disease at final pathology (seminal vesicle involvement, positive surgical margins, and/or lymph node invasion). Kaplan-Meier analyses were used to assess cancer-specific mortality (CSM)-free survival rates by stratifying patients into 3 risk categories according to the number of AFs (namely, 1, 2, and 3 AFs). Multivariable competing risk Cox regression analyses were used to assess CSM and other cause of mortality. RESULTS: Significant differences were found in terms of preoperative and pathologic tumor characteristics, adjuvant therapies, and biochemical recurrence (BCR). Men with 1 AF had higher CSM-free survival estimates compared to those with 2 and 3 AFs (92.8% vs. 84.2% vs. 27.7% at 10 years' follow-up, P < .001). Moreover, the presence of 3 AFs (hazard ratio [HR], 2.96), postoperative adjuvant treatment status (HR, 2.44), and time to BCR (HR, 0.96) were all independent predictors of CSM (P ≤ .04). Age at surgery and time to BCR were the only independent predictors of other causes of mortality (P ≤ .0009). CONCLUSION: The risk group stratification according to the number of AFs could help physicians to accurately predict oncologic outcomes and to select PCa patients for the most appropriate postoperative strategies.

Sex-related penile fracture with complete urethral rupture: A case report and review of the literature.

OBJECTIVE: To present the management of a patient with partial disruption of both cavernosal bodies and complete urethral rupture and to propose a non-systematic review of literature about complete urethral rupture. MATERIAL AND METHOD - CASE REPORT: A 46 years old man presented to our emergency department after a blunt injury of the penis during sexual intercourse. On physical examination there was subcutaneous hematoma extending over the proximal penile shaft with a dorsal-left sided deviation of the penis and urethral bleeding. Ultrasound investigation showed an hematoma in the ventral shaft of the penis with a discontinuity of the tunica albuginea of the right cavernosal corporum. The patient underwent immediate emergency surgery consisted on evacuation of the hematoma, reparation the partial defect of both two cavernosal bodies and end to end suture of the urethra that resulted completely disrupted. RESULTS: The urethral catheter was removed at the 12-th postoperative day without voiding symptoms after a retrograde urethrography. 6 months postoperatively the patients was evaluated with uroflowmetry demonstrating a max flow rate of 22 ml/s and optimal functional outcomes evaluated with validated questionnaires. 8 months after surgery the patients was evaluated by dynamic magnetic resonance (MRI) of the penis showing only a little curvature on the left side of the penile shaft. CONCLUSION: Penile fracture is an extremely uncommon urologic injury with approximately 1331 reported cases in the literature till the years 2001. To best of our knowledge from 2001 up today, 1839 more cases have been reported, only in 159 of them anterior urethral rupture was associated and in only 22 cases a complete urethral rupture was described. In our opinion, in order to prevent long term complications, in case of clinical suspicion of penile fracture, especially if it is associated to urethral disruption, emergency surgery should be the first choice of treatment.

The Prognostic Impact of Tumor Size on Cancer-Specific and Overall Survival Among Patients With Pathologic T3a Renal Cell Carcinoma.

BACKGROUND: We aimed to determine the prognostic role of tumor size in patients with stage pT3a renal cell carcinoma (RCC). PATIENTS AND METHODS: We analyzed our database of patients who underwent radical nephrectomy for RCC between July 2000 and December 2013. Clinical and pathologic data were obtained for each patient. Patients with stage pT3a disease were divided into 2 subgroups according to the most informative threshold for pathologic tumor dimension that was able to predict survival outcomes (group 1, ≤ 8 cm; group 2, > 8 cm). RESULTS: Globally, 185 consecutive patients were evaluated. The median (interquartile range [IQR]) follow-up was 32 months (18-62 months). The median (IQR) pathologic tumor size was 7.5 cm (5.7-10 cm). Seventy (34.3%) patients died of RCC during the follow-up period. Patients in group 2 experienced worse cancer-specific survival (CSS) rates compared with those in group 1, (5- and 10- year CSS, 52% and 40% vs. 67% and 63%, respectively; P = .001). Overall survival (OS) rates were significantly lower for patients included in group 2 compared with patients in group 1 (5- and 10- year OS rates, 46% and 38% vs. 60% and 57%, respectively; P = .01). Subgroup stratification (hazard ratio [HR], 3.65; P < .001), presence of positive surgical margins (HR, 3.86; P = .22), high Fuhrman grade (HR, 4.33; P < .001), and the presence of sarcomatoid cells (HR, 2.61; P = .02) were found to be independent predictors of CSS. CONCLUSION: Worse oncologic outcomes are observed in patients with stage pT3a RCC tumors > 8 cm. The current TNM classification still does not precisely correlate with CSS. Tumor size should be taken into account in a future revision of the TNM staging system.

State of the art of PET/CT with 11-choline and 18F-fluorocholine in the diagnosis and follow-up of localized and locally advanced prostate cancer.

OBJECTIVE: To provide an updated state of the art about the role of positron emission tomography/computed tomography (PET/CT) with 11C-Choline and 18F-fluorocholine in the localized and locally advanced Prostate Cancer (PCa) in the staging and restaging setting. METHODS: We performed a non-systematic review of the literature based on a free-text search in the National Library of Medicine Database (MEDLINE) to select English-language published papers evaluating PET and PET/CT imaging with radiolabelled choline in initial diagnosis and in post-treatment phase in PCa patients. RESULTS: PET and PET/CT with 11C-choline and 18F-fluorocholine have been largely investigated as non-invasive diagnostic tools in PCa. Actually, the relatively high rate of false negative findings due to the small dimension of neoplastic lesions and the available spatial resolution of PET tracers limits the routine use of choline PET and PET/CT in staging setting; moreover, it cannot reliably replace the lymph node (LN) dissection for detecting LN involvement. On restaging setting, Choline PET/CT showed a higher accuracy than conventional imaging modalities, especially in the detection of LN and systemic metastases, while it is less accurate than magnetic resonance imaging in the detection of local relapse. CONCLUSION: In the Prostate Specific Antigen (PSA) era with a large number of localized disease, the diagnostic performance of choline PET and PET/CT lack of reliability in initial diagnosis of PCa. The major clinical role of choline PET/CT is the re-staging of patients with a biochemical relapse after radical treatment; the promising performance of choline PET/CT scan in patients with low levels of PSA could also lead the clinicians for to perform PET-guided adjuvant curative therapies or palliative treatments in patients already treated radically for PCa.

State of the PET/CT with 11-choline and 18F-fluorocholine in the diagnosis and follow-up of localized and locally advanced prostate / Estado del PET TAC con Colina 11C y Fluorocolina 18F en el diagnóstico y seguimiento del cáncer de próstata localizado y localmente avanzado

OBJECTIVE: To provide an updated state of the art about the role of positron emission tomography/ computed tomography (PET/CT) with 11C-Choline and 18F-fluorocholine in the localized and locally advanced Prostate Cancer (PCa) in the staging and restaging setting. METHODS: We performed a non-systematic review of the literature based on a free-text search in the National Library of Medicine Database (MEDLINE) to select English-language published papers evaluating PET and PET/CT imaging with radiolabelled choline in initial diagnosis and in post-treatment phase in PCa patients. RESULTS: PET and PET/CT with 11C-choline and 18F-fluorocholine have been largely investigated as non-invasive diagnostic tools in PCa. Actually, the relatively high rate of false negative findings due to the small dimension of neoplastic lesions and the available spatial resolution of PET tracers limits the routine use of choline PET and PET/CT in staging setting; moreover, it cannot reliably replace the lymph node (LN) dissection for detecting LN involvement. On restaging setting, Choline PET/CT showed a higher accuracy than conventional imaging modalities, especially in the detection of LN and systemic metastases, while it is less accurate than magnetic resonance imaging in the detection of local relapse. CONCLUSION: In the Prostate Specific Antigen (PSA) era with a large number of localized disease, the diagnostic performance of choline PET and PET/CT lack of reliability in initial diagnosis of PCa. The major clinical role of choline PET/CT is the re-staging of patients with a biochemical relapse after radical treatment; the promising performance of choline PET/CT scan in patients with low levels of PSA could also lead the clinicians for to perform PET-guided adjuvant curative therapies or palliative treatments in patients already treated radically for PCa

OBJETIVOS: Ofrecer una puesta al día de lo último sobre el papel de la tomografía por emisión de positrones/Tomografía axial computarizada (PET/TAC) con colina 11C y fluorocolina 18 F en el cáncer de próstata (CaP) localizado y localmente avanzado. MÉTODOS: Realizamos una revisión no sistemática de la literatura basada en una búsqueda de texto libre en la Base de Datos de la Biblioteca nacional de Medicina (MEDLINE) para seleccionar las publicaciones en lengua inglesa que evaluaban la PET y PET/TAC con colina radiomarcada en el diagnóstico inicial y en la fase posterior al tratamiento en pacientes con CaP. RESULTADOS: El PET y PET/TAC con colina 11C y fluorocolina 18F han sido ampliamente investigados como herramientas diagnósticas no invasivas en el CaP. Realmente, la relativamente alta tasa de hallazgos falsos negativos debido a la pequeña dimensión de las lesiones neoplásicas y la resolución espacial disponible para los marcadores PET limitan la utilización rutinaria de PET y PET/TAC en el estadiaje; además, no puede reemplazar de una forma fiable a la linfadenectomía para detectar la afectación de los ganglios linfáticos. En re-estadiaje, el PET/TAC colina mostró una precisión superior a las modalidades radiológicas convencionales, especialmente en la detección de ganglios linfáticos y metástasis sistémicas, mientras que es menos preciso que la resonancia magnética en la detección de la recidiva local. CONCLUSION: In the Prostate Specific Antigen (PSA) era with a large number of localized disease, the diagnostic performance of choline PET and PET/CT lack of reliability in initial diagnosis of PCa. The major clinical role of choline PET/CT is the re-staging of patients with a biochemical relapse after radical treatment; the promising performance of choline PET/CT scan in patients with low levels of PSA could also lead the clinicians for to perform PET-guided adjuvant curative therapies or palliative treatments in patients already treated radically for PCa

Active surveillance for clinically localized renal tumors: An updated review of current indications and clinical outcomes.

The widespread use of abdominal imaging has led to an increasing detection of small renal masses, and approximately 20-30% of those tumors will prove to be benign, with low metastatic potential if not immediately treated. In elderly or comorbid patients diagnosed with small renal masses, competing cause mortality seems to exceed cancer-specific mortality at short- and intermediate-term follow up. In these cases, surgery might represent an overtreatment, and an expectant management, such as active surveillance, might be proposed. According to the current available evidence, active surveillance is a safe and reasonable option for patients with renal tumors ≤4 cm (cT1a) and short life expectancy. A few studies with short-term follow up reported the preliminary results of active surveillance even in cT1b-cT2 tumors, with acceptable risk of disease progression and mortality, even if this approach should be considered in this setting only for highly-selected and well-informed patients. Furthermore, surveillance protocols can be proposed in selected patients with uncomplicated benign tumors, such as angiomyolipomas, in which active surveillance should be considered the initial standard management. At present, reliable clinical predictors of a tumor's growth rate and aggressiveness are not available. Renal tumor biopsy is useful in the clinical work-up of patients who are candidates for active surveillance, in order to improve patient selection based on tumor histological characterization. Despite the proof of safety offered by expectant management for small renal masses in selected patients, further prospective studies with longer follow up are required in order to confirm the indications and long-term oncological outcomes of active surveillance protocols for renal tumors.

Small renal masses managed with active surveillance: predictors of tumor growth rate after long-term follow-up.

BACKGROUND: The purpose of the study was to evaluate the relationships between the patients' clinical characteristics and the growth pattern of SRMs, and to investigate the predictive factors of tumor growth rates in patients initially managed with AS. MATERIALS AND METHODS: We retrospectively reviewed data from our prospectively collected database of 70 patients diagnosed with 72 SRMs between 1996 and 2013. Clinical and demographic data, and linear and volumetric growth rates were recorded for each patient. A Pearson correlation test was used to evaluate initial tumor size and linear or volumetric growth rate. Logistic regression models were used to evaluate the predictive factors affecting tumor growth kinetics. RESULTS: The mean age was 76 ± 6.8 years, and 47 (67.1%) of patients were male. The mean (± SD) and the median (interquartile range [IQR]) tumor size at presentation were 2.1 ± 1.3 and 2.7 (1.8-3.7) cm, respectively. The mean (± SD) and the median (IQR) linear growth rate were 0.5 ± 0.3 and 0.6 (0.4-1.5) cm per year, respectively. Patients treated with delayed surgery experienced a significantly greater mean linear growth rate (1.4 vs. 0.3 cm per year) than those observed in the AS group (P < .001). Male sex (HR, 1.70; P = .04) and symptomatic presentation (HR, 1.85; P = .02) were found to be significant predictors of tumor growth rates during AS. Conversely, age, Charlson Comorbidity Index, and initial tumor size failed to predict growth kinetics. CONCLUSION: Male sex and symptomatic presentation are associated with faster growth rates in patients managed with AS after long-term follow-up.

Small renal masses initially managed using active surveillance: results from a retrospective study with long-term follow-up.

BACKGROUND: The purpose of this study was to provide outcomes of patients managed using active surveillance (AS) for small renal masses (SRMs). PATIENTS AND METHODS: We retrospectively reviewed data of 62 patients diagnosed with 64 contrast enhancing SRMs suspicious for renal cell carcinoma. We evaluated the differences between patients who remained on AS and those who underwent delayed surgical intervention. RESULTS: The mean age of patients was 75 years and the mean follow-up was 91.5 months. The median tumor size and the median estimated tumor volume were 2.6 cm and 8.7 cm(3), respectively. The median linear growth rate and the median volumetric growth rate were 0.7 cm/y and 8.8 cm(3)/y, respectively. The mean linear and volumetric growth rates of the group of patients who underwent surgery was higher than in those who remained on surveillance (1.9 vs. 0.4 cm/y and 16.1 vs. 4.6 cm(3)/y, respectively; P < .001). CONCLUSION: Most SRMs show an indolent course, with low metastatic potential. Faster linear and volumetric growth rates could be the expression of malignant disease, thus suggesting the need for a delayed surgical intervention. AS is a reasonable option for the management of SRMs in properly selected patients with low life expectancy.

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.

Molecular diagnostic tools for the detection of nodal micrometastases in prostate cancer patients undergoing radical prostatectomy with extended pelvic lymph node dissection: a prospective study.

BACKGROUND: Routine pathological examination can miss micro-metastatic tumor foci in the lymph nodes (LN) of patients with prostate cancer (PCa) that undergo radical prostatectomy and pelvic lymph node dissection (PLND). The aim of the present prospective study was to evaluate the impact of micrometastases assessed by serial section (SS), immunohistochemistry (IHC), and Real-time Polymerase Chain Reaction (RT-PCR) in patients undergoing radical prostatectomy with extended PLND. MATERIALS AND METHODS: 32 consecutive patients who underwent radical prostatectomy with extended PLND (obturator, internal/external and distal 2 cm common iliac lymph-nodes (LN)) for intermediate (clinical T1c-T2 and PSA:10-20 ng/mL and clinical Gleason Score = 7) or high (clinical stage T3 or PSA>20 or clinical Gleason Score = 8-10) PCa were enrolled. The nodes were processed by the one uropathologist, both according to the routine pathological examination (analysis of the central section for 4 mm nodes or every 2 mm for LN>4 mm), which served as comparative method, both according to SS, IHC with antibodies against PSA and broad-spectrum Cytokeratins (BSCK), and quantitative RT-PCR targeting PSA, PSMA (PS Membrane Antigen), and Glucuronidase-S-Beta (GUSB) mRNA, that are over-expressed in prostatic cancer cells. RESULTS: A total of 628 LN were analyzed, with a mean number of LN removed of 19.6 (SD = 7.2). Applying the routine pathological examination, 10 (31.2%) patients and 23 (3.9%) LN resulted positive for nodal involvement, with mean positive LN of 2.2 (SD = 1.4). After applying the SS and the molecular method of analysis (IHC and RT-PCR), micrometastases were found in 7 LN (SS showed micrometastases in 3 of them, IHC in 6 of them and RT-PCR in 7 of them); a total of 3 (9.3%) node-negative patients showed micrometastases at routine pathological examination (in 2 patients with RT-PCR and in 1 with IHC). CONCLUSIONS: The significance of micrometastases in PCa and the potential therapeutic role of PLND is not yet clarified, but the molecular analysis of the LN can detect a significant percentage of patients who harbor micro-metastatic PCa missed at routine pathological examination, and can enhance the accuracy of lymphadenectomy as a staging method.