[Intrinsic ureteral endometriosis: description of a striking instance]. / Endometriosi intrinseca dell'uretere: descrizione di un caso particolarmente eclatante.

Intrinsic ureteral endometriosis is a very rare condition. A 41 y. o. woman with right hydroureteronephrosis and other aspecific symptoms came to our attention. The CT scan showed an ureteral obstacle causing the hydroureteronephrosis. She underwent ureterorenoscopy with biopsies of the lesion that did not result to be diriment. Suspecting a ureteral neoplasm, the patient then underwent ureteral resection and ureterocystoneostomy, and the extemporary histological examination resulted as endometriosis. The abdominal exploration showed a parametrial and a peritoneal growth - both compatible with the extemporary histological examination - that were also excised. The post-operative course was uneventful. The definitive hystological examination confirmed the perioperatory diagnosis. Intrinsic ureteral endometriosis is confirmed as a rare pathology with an indefinite clinical presentation; its typical presentation, namely cyclic hematuria, seems to be an anecdotal feature. Therefore the diagnostics of intrinsic ureteral endometriosis is still difficult even despite such a striking presentation.

The percentage of core involved by cancer is the best predictor of insignificant prostate cancer, according to an updated definition (tumor volume up to 2.5 cm3): analysis of a cohort of 210 consecutive patients with low-risk disease.

OBJECTIVE: To find out which factors could predict the diagnosis of insignificant prostate cancer (ins-PCa) according to a recently updated definition (overall tumor volume up to 2.5 cm(3); final Gleason score ≤6; organ-confined disease) on a prostatic biopsy specimen. METHODS: This was a retrospective analysis of 210 patients undergoing radical prostatectomy for a cT1c prostate neoplasm with a biopsy specimen Gleason score of ≤6. A logistic regression model was used to assess the differences in the distribution of some possibly predictive factors between the ins-PCa patients, according to the updated definition, and the remaining patients. RESULTS: By applying an updated definition of ins-PCa, the prevalence of this condition increased from 13.3% to 49.5% (104 of 210 patients). The univariate analysis showed a statistically different distribution of the following factors: prostate-specific antigen density, prostate volume, number of cancer-involved cores, and maximum percentage of core involvement by cancer. At the multivariable analysis, the maximum percentage of involvement of the core retained its relevance (27.0% in ins-PCa patients and 43.8% in the remaining patients; hazard ratio, 0.972; P = .046), and a 20% cutoff was detected. CONCLUSION: In a cohort of patients with PCa cT1c and a biopsy specimen Gleason score of ≤6, the ins-PCa rate, according to the updated definition, is close to 50%, and the percentage of cancer involvement of the core is the single factor that best predicts this diagnosis.

[Insignificant prostate cancer: charateristics and predictive factors]. / Carcinoma prostatico insignificante: caratteristiche e fattori predittivi.

INTRODUCTION: The widespread screening for PSA has contributed to the increased incidence of prostate cancer (PCa), mostly identifying disease at earlier stages. Many of these patients will probably not require treatment because of the indolent course of the disease. The European Randomized Study of Screening for Prostate Cancer (ERSPC) has showed that 1410 men needed to be screened and 48 prostatectomies performed to prevent death. The aim of this study was to evaluate predictive factors of insignificant PCa in our experience. MATERIALS AND METHODS: We analyzed various preoperative clinical and biopsy findings of 225 consecutive patients who underwent prostatectomy from October 2007 to June 2010. The indication for biopsy was placed in presence of an abnormal rectal examination and/or suspected transrectal ultrasound and/or PSA >4 ng/ml. We consider insignificant a tumor with a volume ≤5% of the entire gland with a Gleason score ≤ 6, with no grades 4 or 5 and organ confined. RESULTS: The prevalence of potentially insignificant PCa in our experience was 12%. The preoperative findings of patients with insignificant PCa were significantly more favorable than the remaining cases with PCa not insignificant. Multivariate analysis did not reveal any independent predictors. CONCLUSIONS: In our experience, in a population not screened for PCa, we have not identified any factors that can predict with certainty the insignificant nature of a tumor and, therefore, useful to start a patient on an active surveillance program.

[Which factors allow to anticipate the diagnosis of prostate cancer in pin patients? A study on 546 patients]. / Quali fattori permettono di prevedere la diagnosi di carcinoma prostatico nei pazienti con PIN? Studio su 546 pazienti.

AIM OF THE STUDY: To analyze which factors allow to assess the risk of finding a prostate cancer (PCa) at repeated biopsies in patients with diagnosis of prostatic intraepithelial neoplasia (PIN). PATIENTS AND METHODS: At our institute all patients with a diagnosis of PIN undergo a 6-monthly control biopsy until the achievement of a benign histology or up to a maximum of 4 consecutive biopsies. For this study a retrospective review of clinical and bioptic data of patients with a diagnosis of isolated PIN (i.e. without associated atypical small acinar proliferation or small cancer foci) was carried out. The correlation between these features and the probability to find PCa at the first re-biopsy or at a further re-biopsy was independently analyzed. RESULTS: The data of 546 patients subjected to a median number of 3 biopsies, (mean: 10.8 and 12.9 cores at initial biopsy and at first re-biopsy, respectively), and with a mean "bioptic" follow-up time of 14.8 months, were analyzed. PCa was found in 174 cases (31.8%): for 116 of them it took place at the first re-biopsy, with a mean latency of 7.8 months from PIN diagnosis, whereas for 58 at a further re-biopsy, with a mean latency of 21.6 months. The risk of diagnosing PCa at the first re-biopsy was statistically correlated with the PSA value--for which a cut-off value of 7 ng/mL was identified--and with an anomalous rectal prostatic examination at the time of the initial biopsy. Differently, the risk of diagnosing PCa after the first re-biopsy correlated with the number of cores positive for PIN at the initial biopsy--for which a cut-off of 4 was identified--and to the ratio between these and the total number of cores, defined as PIN density--for which a cut-off of 50% was determined. DISCUSSION AND CONCLUSIONS. It is possible to suggest a tailored protocol of controls in patients with a diagnosis of PIN on the basis of the data available at the initial biopsy: a) high PSA value and/or an anomalous prostatic rectal examination: the diagnosis of PCa is probably just unacknowledged by the initial sampling and it is advisable to carry out an early re-biopsy; b) number of cores with PIN equal to or higher than 4 and/or PIN density equal to or higher than 50%: a true transition from PIN to PCa is likely to happen with time and it is advisable to carry out a delayed re-biopsy; c) no risk factors: just clinical and PSA monitoring to establish the indication to re-biopsy.

Nomogram predictive of pathological inguinal lymph node involvement in patients with squamous cell carcinoma of the penis.

PURPOSE: In penile cancer the therapeutic benefits of early inguinal lymphadenectomy must be counterbalanced by the high rates of morbidity, postoperative complications and mortality. A relevant aim is optimizing the selection of the patients who could really have the highest survival advantage from inguinal lymphadenectomy, limiting the cases in which this surgery might be considered over treatment with a risk of severe complications. We generated a nomogram estimating the risk of pathological inguinal lymph node involvement according to clinical lymph node stage and pathological findings of the primary tumor. MATERIALS AND METHODS: We retrospectively collected the clinical and pathological data of 175 patients who had undergone surgical therapy for squamous cell carcinoma of the penis from 1980 to 2002 at 11 urological centers in northeastern Italy. A logistic regression model was used to construct the nomogram. RESULTS: The presence of palpable groin lymph nodes and the histological findings of vascular and/or lymphatic embolization were important predictors of metastatic inguinal lymph node involvement. The nomogram predicting the risk of metastatic lymph node involvement showed a good concordance index (0.876) and good calibration. CONCLUSIONS: The clinical stage of groin lymph nodes and pathological findings of penectomy specimens allowed us to generate a nomogram to predict the probability of metastatic lymph node involvement in patients with squamous cell carcinoma of the penis. The statistical model showed an excellent ability to identify the patients with lymph node metastases and good calibration.

Lymphatic and vascular embolizations are independent predictive variables of inguinal lymph node involvement in patients with squamous cell carcinoma of the penis: Gruppo Uro-Oncologico del Nord Est (Northeast Uro-Oncological Group) Penile Cancer data base data.

BACKGROUND: The objective of the current study was to identify independent clinical and pathologic variables that were predictive of lymph node involvement in patients with squamous cell carcinoma of the penis in a multicenter series with the intent to select patients who were suitable to undergo immediate inguinal lymphadenectomy. METHODS: Data were analyzed from 175 patients who underwent surgery for penile carcinoma in 11 urologic centers participating in the Gruppo Uro-Oncologico del Nord-Est (Northeast Uro-Oncological Group) Penile Cancer Data Base. Pathologically positive lymph nodes were defined as the presence of histologically confirmed lymph node metastasis in patients who underwent either immediate or delayed inguinal and/or pelvic lymphadenectomy. Patients who had clinically positive lymph nodes with cytologically positive fine-needle aspiration results and who had not undergone lymphadenectomy were censored. RESULTS: Overall, lymph-node involvement was observed in 71 of 175 patients (40.6%) included in the analyses. After analyzing the whole group of patients, the following variables were identified as independent predictors of pathologic lymph node metastasis: clinical lymph node status, pathologic stage of the primary tumor, venous and lymphatic embolizations, and histologic grade. In the subgroup of patients with clinically negative lymph nodes, tumor thickness, histologic grade, lymphatic and venous embolizations, infiltration of both corpus spongiosum and urethra, and pathologic stage of the primary tumor (according to the 1997 TNM classification system) were predictive of lymph node involvement on univariate analysis. The generated logistic regression model showed that venous and/or lymphatic embolizations and infiltration of the corpus spongiosum and/or urethra were independent predictors of pathologic lymph node metastasis in patients with clinically negative lymph nodes. CONCLUSIONS: Venous and/or lymphatic embolizations played relevant roles as predictors of pathologic lymph node involvement in patients with penile neoplasia and should be considered important parameters in determining which patients with clinically negative lymph nodes should undergo immediate lymphadenectomy.

[Treatment of ureteral lesions during gynecologic surgery]. / Il trattamento delle lesioni ureterali in corso di chirurgia ginecologica.

Surgery of gynecologic area and of pelvic cavity in general is a risk situation for ureteral injury. The incidence of these injuries is about 1% and may be considered as "unavoidable", irrespective of the surgical approach which could be either abdominal, vaginal or laparoscopic. In this study, 37 patients who had undergone a previous gynecological surgery were assessed for 38 ureteral units. Ureteral injury was identified at the surgical table in 2 patients who were treated successfully during the same surgical session with an end-to-end anastomosis. In 8 patients, a double-J ureteral stent was placed and the cure was obtained in 7 patients. The single case of failure was converted to surgery. 22 female patients for 23 ureteral units were subjected to open surgery performing 16 ureterocystoneostomies, 6 of them with a combined psoas-bladder hitching. In 1 patient a termino-terminal anastomosis was performed due to an injury in an upper site. Finally, in 3 patients nephrectomy was carried out due to a nonfunctional kidney; 1 patient refused surgery, whereas in another patient a spontaneous canalization of the excretory tract was obtained after reposition of a percutaneous nephrostomy. The minimum follow-up is of at least 1 year. The diagnostic aspects and therapeutic indications are then described with a special emphasis on the so-called prognostic factors which could influence the outcome of the treatment. Finally, the main surgical correction techniques employed in case of leakage of ureteral substance, are reviewed.