Biparametric versus Multiparametric MRI with Non-endorectal Coil at 3T in the Detection and Localization of Prostate Cancer.

AIM: To assess the sensitivity of biparametric magnetic resonance imaging (bpMRI) with non-endorectal coil in the detection and localization of index (dominant) and non-index lesions in patients suspected of having prostate cancer. PATIENTS AND METHODS: We carried-out a retrospective analysis of multiparametric MRI (mpMRI) of 41 patients who underwent radical prostatectomy. Results of MRI for detection and localization of index and non-index lesions were correlated with those of histology. RESULTS: No statistically significant difference in size was seen between tumor lesion at histology and index lesion at MRI. In 41 patients, a total of 131 tumors were identified at histology, while bpMRI (T2-weighted and diffusion-weighted MRI) approach detected 181 lesions. bpMRI gave 27.6% false-positives and 3.3% false-negatives. Sensitivity in lesion detection by bpMRI increased with lesion size assuming high values for lesions ≥10 mm. For bpMRI and mpMRI, the sensitivity for detecting index lesions was the same and equal: 100% in the peripheral zone 97.6% and 94.7% in the entire prostate and transitional zone, respectively. CONCLUSION: bpMRI can be used alternatively to mpMRI to detect and localize index prostate cancer.

Robotic Retroperitoneal Lymph Node Dissection in Advanced Stage Disease.

OBJECTIVES: The current report describes the feasibility of robotic retroperitoneal lymph node dissection (RRPLND), including some technical tricks for port placement for both right- and left-sided surgery. METHODS: Patients with advanced stage retroperitoneal disease underwent RRPLND using the 4-arm da Vinci Si Surgical System (Intuitive Surgical, Inc.). In both cases, the field of dissection was an ipsilateral template for lymph node dissection. RESULTS: RRPLND in such configuration was safe and effective in both cases. The illustrated port placement with perpendicular docking of the robot allowed for a wide range of motion with limited external clashing, providing sufficient space for the assistant surgeon. The operative time was 300 min (including docking and console time), with no perioperative complications and short hospital stay. CONCLUSION: The port configuration for right- or left-sided unilateral template RRPLND was feasible, permitting a wide range of motion for the robotic arms and thus facilitating an efficient and safe dissection.

Margin and complication rates in clampless partial nephrectomy: a comparison of open, laparoscopic and robotic surgeries.

In performing partial nephrectomy (PN), surgeons focus on complete removal of tumor, preservation of renal function, the absence of major perioperative complications, expressed by the formula margin, ischemia and complication (MIC). The aim of current study was to perform a single-institution comparison of clampless open (OPN), laparoscopic (LPN) or robot-assisted (RAPN) PN as well as to evaluate pre-, intra- and postoperative factors that may influence achievement of ideal MIC. All consecutive clampless OPN, LPN or RAPN performed by experienced surgeons between 2006 and 2015 were included in the analysis. MIC was defined as negative surgical margin plus zero-ischemia plus absence of any grade ≥3 complications according to Clavien-Dindo classification. Bivariate and multivariate logistic regression models were fitted to predict the MIC. Odds ratios with 95 % confidence intervals were calculated. 80 patients underwent OPN, 66 LPN and 31 RAPN, and both groups had similar characteristics. The MIC rate was 67.5, 86.3 and 83.3 % in the OPN, LPN and RAPN groups, respectively (p = 0.016). At logistic regression analysis, surgical approach (p = 0.03) and operative time (p = 0.008) were independent predictors of the MIC rate. When stratified according to the surgical approach, preoperative aspects and dimensions used for an anatomical classification (PADUA) score, LPN, RAPN and operative time were independent predictors of MIC rate (p = 0.0488, p = 0.0494, p = 0.0479 and p = 0.0108, respectively). Clampless LPN and RAPN have an efficacy and safety profile that is on par with OPN, offering the additional benefits of a reduced operative time, blood loss, on demand ischemia and rate of high-grade complications.

Laparoscopic Versus Abdominal Sacrocolpopexy: A Randomized, Controlled Trial.

PURPOSE: Few randomized, controlled trials have compared standard abdominal sacrocolpopexy and the laparoscopic approach. We tested the hypothesis that laparoscopic sacrocolpopexy could compete with abdominal sacrocolpopexy for pelvic organ prolapse repair. MATERIALS AND METHODS: This randomized, controlled trial was done to compare laparoscopic sacrocolpopexy and abdominal sacrocolpopexy for pelvic organ prolapse repair in women referred to our tertiary Department of Urology for symptomatic stage 2 or greater pelvic organ prolapse. The primary outcome was quantitative evaluation by the POP-Q (Pelvic Organ Prolapse Quantification) system. Cure was defined as prolapse stage 1 or less, point C/D -5 or less at the apex and at least 7 cm total vaginal length. Secondary outcomes were the complication rate, operative time, intraoperative blood loss, hospital stay and PGI-I (Patient Global Impression of Improvement) scores. The Kaplan-Meier estimator with the log-rank test was used to estimate pelvic organ prolapse recurrence-free survival rates. RESULTS: A total of 200 patients were eligible for study. We compared 60 and 61 patients treated with abdominal and laparoscopic sacrocolpopexy, respectively. At a mean followup of 41.7 months the cure rate was of 100% for both approaches. Kaplan-Meier curves showed that overall pelvic organ prolapse recurrence-free survival was longer following the open approach. Patients treated with laparoscopic sacrocolpopexy showed significantly earlier recurrence (p = 0.030), mostly in the first 12 months after surgery. When evaluating the different compartments, a statistically significant difference was observed between the laparoscopic and abdominal approaches for anterior compartment descensus (11 vs 1, p = 0.004). Statistical results had high internal validity but may not be applicable to other populations or settings. CONCLUSIONS: Laparoscopic sacrocolpopexy provides outcomes as good as those of abdominal sacrocolpopexy for anatomical correction but not for anterior pelvic organ prolapse.

Laparoscopic Management of Vaginal Vault Prolapse Recurring after Pelvic Organ Prolapse Surgery.

INTRODUCTION: Despite the increasing success of surgery for pelvic organ prolapse, recurrent vaginal vault prolapse is not rare. We present a step-by-step laparoscopic approach with a sacral colpopexy (SC) for treatment of recurrent vault prolapse. MATERIALS AND METHODS: From 2006, 25 women presenting with symptomatic recurrent vault prolapse were prospectively evaluated and treated with laparoscopic SC. This article briefly describes all of the steps that are required to conduct a proper surgery in such cases. RESULTS: After previous abdominal sacropexy, both the dissection of adherences and restoration of normal pelvic anatomy were challenging. As result, the overall operating time was longer in patients who had undergone abdominal sacropexy vs. vaginal route, p = 0.032. No significant peri- or postoperative complications were observed. At a mean follow-up of 41 months, all women presented with less than stage 2 prolapse and high levels of satisfaction. CONCLUSIONS: Despite the need for an intraoperative step-by-step surgical safety checklist, the laparoscopic repair of recurrent vault prolapse is technically feasible, safe and effective.

Influence of hormonal therapy in prostate cancer patients undergoing [18F]fluoromethyl choline PET/CT: a retrospective study.

BACKGROUND: Patients with suspected recurrence of prostate cancer undergoing [18F]fluoromethyl choline ([18F]FCH) PET/CT were retrospectively evaluated to investigate the influence of hormonal therapy (HT) in [18F]FCH uptake. METHODS: [18F]FCH PET/CT was performed in 102 surgically treated patients with suspected recurrence (PSA increase >0.2 ng/mL) of prostate cancer, divided in two groups: under HT (N.=54) and without HT (N.=48) at the time of PET scanning. PET/CT was carried out by an integrated system (Biograph 6, CTI/Siemens, Knoxville, TN, USA) intravenously by administering 4.1 MBq/kg of [18F]FCH to each patient; images were acquired 60 minutes later. RESULTS: On the total number of patients, 66 were found to be true positives (TP), 9 false positives (FP), 5 false negatives (FN) and 22 true negatives (TN), sensitivity to [18F]FCH PET/CT was 93%, specificity 71%, accuracy 86%, positive predictive value (PPV) 88%, negative predictive value (NPV) 81%. In the 54 patients under HT, 38 were TP, 6 FP, 3 FN and 7 TN, sensitivity was 93%, specificity 54%, accuracy 83%, PPV 86% and NPV was 70%. In the 48 patients receiving no HT, 28 were TP, 3 FP, 2 FN and 15 TN, sensitivity was 93%, specificity 83%, accuracy 90%, PPV 90% and NPV 88%. A χ2 test showed that sensitivity, accuracy and PPV did not differ among patients with and without HT, while specificity and NPV were significantly lower (P<0.001) in HT treated patients. CONCLUSIONS: Sensitivity, accuracy and PPV were similar in patients with and without HT. Specificity and NPV were reduced in patients under HT, but further data are necessary to support if this reduction is casual or related to therapy and it could be confirmed in a larger series of patients.

First and second transurethral resections in intermediate-high risk bladder cancer: impact of the surgeon's volume on the recurrence and progression of primary bladder cancer.

BACKGROUND: We evaluated the impact of surgeon's volume on recurrence and progression in patients with newly diagnosed transitional cell carcinoma of the bladder after first transurethral resection (TUR) and second-TUR. METHODS: Between March 2005 and December 2012, 209 patients with intermediate-high risk primary bladder cancer who received second TUR within 2 to 6 weeks following the initial resection were prospectively included in a database and retrospectively analyzed. Surgeons were stratified into high-volume (>100 TUR) and low-volume (<100 TUR). Tumor recurrence and progression were analyzed respect to first and second-TUR and surgeon-volume. RESULTS: Of the 209 patients who underwent second-TUR, 57 (27.2%) had macroscopic tumors before resection, which correlated to tumors multiplicity. Stage and surgeon category were independent predictors of tumor recurrence, with a 5-year recurrence-free survival rate of 52.7% and 23.1% for high and low-volume surgeon, respectively (P<0.001). Stage and surgeon category at first and second-TUR were independent predictor of tumor progression, with a 5-year progression-free survival rate of 83.8% and 48.0% for high and low-volume surgeon, respectively (P<0.001). CONCLUSIONS: As for other major urological procedures, patients undergoing TUR performed by high volume surgeon may have better outcomes than patients operated by low-volume providers.

Use of the Prostate Health Index for the Detection of Aggressive Prostate Cancer at Radical Prostatectomy.

INTRODUCTION: In current study, we compared the accuracy of the PSA isoform p2PSA and its derivatives, the percentage of p2PSA to free PSA (%p2PSA) and the Prostate Health Index (PHI) in the detection of prostate cancer (PC) characteristics at the xFB01;nal pathology with respect to reference standards. MATERIALS AND METHODS: This was an observational prospective study evaluating 43 consecutive PC patients treated with laparoscopic/robotic radical prostatectomy (RP). Logistic regression models were fitted to test the predictors of pT3 stage, pathologic Gleason score ≥ 8 or Gleason score upgrading, margin status, lymph node invasion, and the presence of high-risk disease (pT3 disease and/or Gleason score ≥ 8 and/or positive lymph node). The comparative base model included tPSA, clinical stage, biopsy Gleason score, and percentage of positive core. RESULTS: Seventeen patients (39.5%) were affected by pT3 disease or had a pathologic Gleason score ≥ 8; positive margins were detected in 12 patients (27.9%), lymph node invasion was found in 2 patients (4.7%), and 15 patients (34.8%) harbored high-risk disease. In the univariate analysis, p2PSA, %p2PSA, and PHI were significant predictors of pT3 disease, pathologic Gleason score, and the presence of high-risk disease (all p < 0.05), whereas only PHI was an independent predictor of pT3 disease, margin status, and presence of high-risk disease, increasing the accuracy of a base multivariable model by 6.3% (p < 0.05) and 4.2% (p < 0.05) for the prediction of pT3 and high-risk disease, respectively. CONCLUSIONS: p2PSA and its derivatives, primarily PHI, were significant predictors of unfavorable PC characteristics as detected at the xFB01;nal pathology, thus improving the clinical performance of standard prognostic factors for aggressive disease.

The S.A.C.S. (Satisfaction-Anatomy-Continence-Safety) score for evaluating pelvic organ prolapse surgery: a proposal for an outcome-based scoring system.

INTRODUCTION AND HYPOTHESIS: To date, there is no overall consensus on the definition of cure after surgery for pelvic organ prolapse (POP). The aim of the study was to design and test the scoring system S.A.C.S. (Satisfaction-Anatomy-Continence-Safety) to assess and compare the outcomes of POP repair. METHODS: A total of 233 women underwent open sacrocolpopexy. The S.A.C.S. outcome scoring system was scheduled at 24 months of follow-up, and each component was detected according to: Satisfaction by mean of Patient Global Improvement Inventory scale, Anatomy by mean of POP Quantification system and bulge symptom, Continence by mean of pad use, and Safety by mean of the Clavien-Dindo classification of surgical complications. Each component produced a binary nominal categorical variable (1 or 0), with a total score of 4 representing cure. As a comparative tool, patients answered a simple yes/no question: "If you had to undergo surgery all over again, would you still do it?". The degree of concordance was estimated using Cohen's Kappa test. RESULTS: According to the S.A.C.S. scoring system, only 160 patients (68.6 %) reached the maximum score of cure. Sensitivity of the S.A.C.S. score was 74.1 %, specificity was 90 %, total diagnostic capacity was 75.5 %. The S.A.C.S. score internal consistency was good; the k-coefficient was higher for the satisfaction component of the score (k = 0.560). CONCLUSION: This study proposes an original, simple post-operative scoring system integrating satisfaction, anatomy, continence, and safety reports for patients undergoing surgery for POP, providing a complete, although perfectible, method to accurately report outcomes in all clinical scenarios.

High-intensity focused ultrasound for the treatment of prostate cancer: A prospective trial with long-term follow-up.

OBJECTIVE: High-intensity focused ultrasound (HIFU) is a minimally invasive treatment for prostate cancer. Data from the literature show promising oncological outcomes with a favourable side-effect profile. The aim of this study was to re-evaluate and bring up to date the follow-up of a previously published, prospective trial on HIFU as the primary treatment for prostate cancer. MATERIALS AND METHODS: Between 2004 and 2007, 163 consecutive men with T1-T3N0M0 prostate cancer underwent HIFU with the Sonablate 500. Follow-up included prostate-specific antigen (PSA) tests every 3 months after treatment and a random prostate biopsy at 6 months. Failure was defined according to positive findings at the 6 month biopsy and biochemical failure was defined according to the Phoenix criteria. Biochemical-free survival, metastasis-free survival and cancer-specific survival were calculated by Kaplan-Meier curves. RESULTS: Median follow-up was 72.0 months. Of the 160 evaluable patients, 104 (65%) were biochemically disease free; in low- to intermediate-risk disease, on Kaplan-Meier analysis the 8 year biochemical-non-evidence of disease (bNED), metastasis-free survival and cancer-specific survival rates were 69.6%, 81.3%, 100% and 40.5%, 60.6%, 100%, respectively. A PSA nadir below 0.40 ng/ml and risk stratification have an independent predictive value for bNED and metastasis-free survival. CONCLUSIONS: A long-term favourable outcome of HIFU is associated with careful patient selection, with low- to intermediate-risk disease being the ideal case. A low postoperative PSA nadir is a predictor of long-term bNED.

Ureteroarterial fistula from ureteral stump: a challenging case.

Ureteroarterial fistula (UAF) is a relatively rare condition with about 150 cases reported in the literature. Since it is a potentially life-threatening condition, a prompt diagnosis and treatment are crucial. We present here a rare, challenging case of UAF diagnosed after left nephrectomy, thus involving the ureteral stump. The difficult diagnosis and treatment by contemporary use of endovascular stent placement and ureteral occlusion by mean of metallic coils and Onyx injection are discussed.

Urodynamic evaluation after high-intensity focused ultrasound for patients with prostate cancer.

This prospective study assesses the impact of high-intensity focused ultrasound (HIFU) on lower urinary tract by comparing pre- and postoperative symptoms and urodynamic changes. Thirty consecutive patients with clinically organ-confined prostate cancer underwent urodynamic study before HIFU and then at 3-6 months after surgery. Continence status and symptoms were analyzed by means of International Prostate Symptoms Score IPSS and International Index Erectile Function IIEF5. As a result, there were a significant improvement in bladder outlet, maximum flow at uroflowmetry, and reduction in postvoid residual PVR at 6-month follow-up and a concomitant significant reduction of detrusor pressure at opening and at maximum flow. De novo overactive bladder and impaired bladder compliance were detected in 10% of patients at 3 months, with progressive improvement at longer follow-up. Baseline prostate volume and length of the procedure were predictors of 6-month IPSS score and continence status. In conclusion, following HIFU detrusor overactivity, decreased bladder compliance and urge incontinence represent de novo dysfunction due to prostate and bladder neck injury during surgery. However, urodynamic study shows a progressive improvement in all storage and voiding patterns at 6-month follow-up. Patients with high prostate volume and long procedure length suffered from irritative symptoms even at long term.

Evaluation of prostate-specific antigen isoform p2PSA and its derivates, %p2PSA, prostate health index and prostate dimension-adjusted related index in the detection of prostate cancer at first biopsy: an exploratory, prospective study.

OBJECTIVE: To confirm the accuracy of serum proPSA (p2PSA) and its derivatives, percentage of p2PSA to free PSA (%p2PSA) and Prostate Health Index (PHI) and to test the value of prostate dimension-adjusted related index p2PSA density (p2PSAD), %p2PSA density (%p2PSAD) and PHI density (PHID) in discriminating between patients with and without prostate cancer (PCa). PATIENTS AND METHODS: This is a prospective cohort study of 275 patients with a total PSA (tPSA) of 2-10 ng/ml who underwent initial prostate biopsy. Multivariate logistic regression models were complemented by predictive accuracy analysis. RESULTS: PCa was diagnosed in 31.2% of subjects. Median tPSA did not differ between groups, while PSA density (PSAD), percent free PSA (%fPSA), p2PSA, %p2PSA, PHI, p2PSAD, %p2PSAD and PHID (all p < 0.05) were different between men with and without PCa. Univariate accuracy analysis showed p2PSAD (area under the receiver-operating characteristic curve [AUC]: 0.71), %p2PSAD (AUC: 0.76) and PHID (AUC: 0.77) to be the most accurate predictors of PCa at biopsy, significantly outperforming tPSA (AUC: 0.54), PSAD (AUC: 0.68) and %fPSA (AUC: 0.59) (p ≤ 0.001). At multivariate logistic regression models, p2PSAD and PHID significantly increased the accuracy of the basal multivariate model (all p < 0.01). At 90% specificity, sensitivity for p2PSAD, %p2PSAD and PHID were 33.7, 43 and 40.7%, respectively. Spearman's rho coefficient analysis demonstrated a significant relationship between Gleason score, %p2PSA (r = 0.216, p = 0.046), PHI (r = 0.223, p = 0.039) and %p2PSAD (r = 0.205, p = 0.05). CONCLUSIONS: Considering patients suited for initial prostate biopsy by a tPSA range of 2-10 ng/ml, PSA isoforms were confirmed to be strong predictors of PCa. The prostate dimension-adjusted PSA isoforms have been shown to differentiate between patients with or without PCa, with an AUC of 0.71-0.77, p2PSAD offering a gain in accuracy with respect to tPSA, %fPSA and PSAD.