Diagnostic pathway of the biopsy-naïve patient suspected for prostate cancer: Real-life scenario when multiparametric Magnetic Resonance Imaging is not centralized.

INTRODUCTION: We aimed to compare the pathway including multi-parametric Magnetic Resonance Imaging (mpMRI) versus the one without mpMRI in detection of prostate cancer (PCa) when mpMRI is not centralized. MATERIALS: January 2019-March 2020: prospective data collection of trans-perineal prostate biopsies. Group A: biopsy-naïve patients who underwent mpMRI (at any institution) versus Group B: patients who did not. Within Group A, patients were stratified into those with negative mpMRI (mpMRI-, PIRADS v2.1=1-3, with PSA density <0.15 if PIRADS 3) who underwent standard biopsy (SB), versus those with positive mpMRI (mpMRI+, when PIRADS 3-5, with PSA density>0.15 if PIRADS 3) who underwent cognitive fusion biopsy. RESULTS: Two hundred and eighty one biopsies were analyzed. 153 patients underwent mpMRI (Group A). 98 mpMRI+ underwent fusion biopsy; 55 mpMRI- underwent SB. 128 Group B patients underwent SB. Overall PCa detection rate was 52.3% vs. 48.4% (Group A vs. B, P=0.5). Non-clinically-significant PCa was detected in 7.8 vs. 13.3% (Group A vs. B, P=0.1). Among the 98 mpMRI+ Group A patients only 2 had non clinically-significant disease. In 55 mpMRI- patients who underwent SB, 10 (18.2%) had clinically-significant PCa. Prostate volume predicted detection of PCa. In Group B, age and PSA predicted PCa. Sensitivity of mpMRI was 75.0% for all PCa, 85.3% for clinically-significant PCa. CONCLUSION: Higher detection of PCa and lower detection of non-clinically-significant PCa favored mpMRI pathway. A consistent number of clinically-significant PCa was diagnosed after a mpMRI-. Thus, in real-life scenario, mpMRI- does not obviate indication to biopsy when mpMRI is not centralized. LEVEL OF EVIDENCE: 3.

The role of preoperative prostatic shape in the recovery of urinary continence after robotic radical prostatectomy: a single cohort analysis.

BACKGROUND: To explore the role of preoperative MRI prostate shape in urinary incontinence after robot-assisted radical prostatectomy (RARP). METHODS: Patients were stratified into four groups based on the mpMRI prostatic apex shape: Group A (prostatic apex overlapping the membranous urethra anteriorly and posteriorly), Group B and C (overlap of the prostatic apex of the anterior or posterior membranous urethra, respectively) and Group D (no overlap). Preoperative variables and intraoperative data were compared. Continence recovery was defined as no pad/day or 1 safety pad/day by an outpatient evaluation performed at 1, 3, 6, and 12 months after RARP. RESULTS: One hundred patients underwent RARP were classified as belonging to Group A (n = 30), Group B (n = 16), Group C (n = 14), and Group D (n = 40). Group D showed a significantly more favorable urinary continence recovery after RARP respect to all the other shapes presenting any forms of overlapping (HR = 1.9, 95% CI 1.2-3.1, p = 0.007). The estimated HR remained substantially unchanged after adjusting by age, body mass index, CCI, prostate volume, and bladder neck sparing (HR = 1.9, 95% CI 1.1-3.2, p = 0.016). The continence recovery median time was 9 months for Group A + B + C (95% CI 5-11) and 4 months for Group D (95% CI 2-6) (p = 0.023). CONCLUSION: Shape D showed a better continence recovery when compared to other shapes presenting any kind of overlapping of the prostatic apex over the membranous urethra.

Is thulium laser vapoenucleation of the prostate equally safe and effective in elderly patients? A propensity score matched analysis of early perioperative and functional outcomes. / Vapoenucleación prostática con láser Tulio. ¿Es igual de segura y efectiva en pacientes ancianos? Análisis por puntuación de propensión de los resultados funcionales y perioperatorios tempranos.

PURPOSE: To evaluate if thulium laser vapoenucleation of the prostate (ThuVEP) is equally safe and effective in a selected cohort of elderly patients when compared to "younger" patients. MATERIALS AND METHODS: We performed a retrospective analysis of consecutive patients who underwent ThuVEP between September 2018 and February 2020. After application of the inclusion/exclusion criteria, patients were stratified according to the 75 years-old cut-off point suggested by the WHO. Group A included patients < 75 years-old; Group B included patients > 75 years-old. Preoperative assessment included urological consultation, prostate specific antigen (PSA), International Prostate Symptom Score (IPSS) and quality of life index, transrectal ultrasound to estimate prostate volume (PVol), and uroflowmetry to assess preoperative Qmax, Qave and post-void residual volume (PVR). Perioperative and postoperative data were analyzed during 3-month follow-up. RESULTS: After propensity-score analysis, 51 versus 51 patients were 1:1 matched according to PVol, PSA, Qmax, IPSS and QoL. Patients were comparable at baseline excluding age (65 (IQR 59-70) versus 79 (IQR 77-82) years, Group A versus B, respectively, p-value < 0.001). No differences were found in terms of hemoglobin drop, complications rate, catheterization time and length of hospital stay. Group A (younger) patients had more significant improvement in 30-days absolute Qmax, Qave and ΔQmax. At 90-days follow-up, the differences between the groups disappeared. Within the 90-days follow-up, no significant differences were found in the readmission rate, with no need of reinterventions. CONCLUSIONS: In our hands, even in elderly patients affected by BPH, ThuVEP appears to be a safe and effective treatment option.

Association between background parenchymal enhancement and tumor response in patients with breast cancer receiving neoadjuvant chemotherapy.

PURPOSE: To analyze the relationships between background parenchymal enhancement (BPE) of the contralateral healthy breast and tumor response after neoadjuvant chemotherapy (NAC) in women with breast cancer. MATERIALS AND METHODS: A total of 228 women (mean age, 47.6 years±10 [SD]; range: 24-74 years) with invasive breast cancer who underwent NAC were included. All patients underwent breast magnetic resonance imaging (MRI) before and after NAC and 127 patients underwent MRI before, during (after the 4th cycle of NAC) and after NAC. Quantitative semi-automated analysis of BPE of the contralateral healthy breast was performed. Enhancement level on baseline MRI (baseline BPE) and MRI after chemotherapy (final BPE), change in enhancement rate between baseline MRI and final MRI (total BPE change) and between baseline MRI and midline MRI (early BPE change) were recorded. Associations between BPE and tumor response, menopausal status, tumor phenotype, NAC type and tumor stage at diagnosis were searched for. Pathologic complete response (pCR) was defined as the absence of residual invasive cancer cells in the breast and ipsilateral lymph nodes. RESULTS: No differences were found in baseline BPE, final BPE, early and total BPE changes between pCR and non-pCR groups. Early BPE change was higher in non-pCR group in patients with stages 3 and 4 breast cancers (P=0.019) and in human epidermal growth factor receptor 2 (HER2)-negative patients (P=0.020). CONCLUSION: Early reduction of BPE in the contralateral breast during NAC may be an early predictor of loss of tumor response, showing potential as an imaging biomarker of treatment response, especially in women with stages 3 or 4 breast cancers and in HER2 - negative breast cancers.

Posterior tibial nerve stimulation: is the once-a-week protocol the best option?

AIM: Aim of our study was to compare the results of posterior tibial nerve stimulation (PTNS) performed weekly with those of PTNS performed 3 times per week in patients with overactive bladder syndrome. METHODS: Thirty-five patients (28 females, 7 males) with overactive bladder syndrome not responding to antimuscarinic therapy were enrolled in a prospective study. A total of 17 out of 35 patients were randomly assigned to group A and treated with a PTNS protocol based on weekly stimulation sessions; 18 out of 35 patients were randomly assigned to group B and treated with a PTNS protocol based on stimulation sessions performed 3 times per week. All subjects were evaluated by means of 24 h bladder diaries, quality of life questionnaires (I-QoL, SF36) and urodynamic evaluation before and after treatment. Patients were asked after each stimulation session to give their opinion on the efficacy of the treatment. We have considered ''success'' those patients who presented a reduction >50% of the micturition episodes/24 h (ME/24) or (if incontinent) of the incontinence episodes/24 h (IE/24). Results before and after treatments in both groups were collected and statistically compared. RESULTS: As a whole, 11/17 patients (63%) in group A and 12/18 patients (67%) in group B were considered ''success''; 4/11 (36%) incontinent patients in group A and 5/11 (45%) incontinent patients in group B were completely cured after treatment. In both groups, patients reported subjective improvement after 6-8 stimulation sessions. CONCLUSIONS: Our findings seem to show that the periodicity of stimulation does not effect the results of PTNS treatment. The advantage of more frequent stimulation sessions is to achieve earlier a clinical improvement.

[Ultrasonography of the upper urinary tract in patients with spinal cord injury]. / Studio ecografico dell'alto tratto urinario in pazienti con trauma vertebro-midollare.

A lesion of the upper urinary tract (UUT) is a possible outcome of the bladder dysfunction following a spinal cord injury (SCI). The most common findings are hydronephrosis, bladder-ureteral reflux and pyelonephritis. Aim of the study was to evaluate the prevalence of UUT abnormalities, evaluable by ultrasound (US), in a population of SCI patients; furthermore we correlated the presence of such abnormalities to clinical findings. We evaluated 115 consecutive patients who underwent US scan of UUT. Mean time between injury and our evaluation was 81.5 +/- 100.2 months. Lesion level was cervical (38/115), dorsal (59/115) and lumbar (18/115). Eight patients emptied their bladder spontaneously, 105 by means of intermittent catheterization, while 2 were wearing indwelling catheter. Seventy-four patients used anticholinergics drugs. It was evaluated the presence of: hydronephrosis, renal stones and chronic pyelonephritis using US. Afterward the presence of such alterations was correlated to sex and age of patients, time between injury and our evaluation, method of bladder emptying and use of anticholinergics drugs. In 25/115 patients (21.7%) were found abnormalities of UUT. A significative correlation was found between presence of UUT lesions and older age. In our series, prevalence of UUT abnormalities observed by means of US in SCI patients is 21.7%. This finding could be due to correct management and strict follow up of the patients.

Vapoenucleación prostática con láser Tulio. ¿Es igual de segura y efectiva en pacientes ancianos? Análisis por puntuación de propensión de los resultados funcionales y perioperatorios tempranos / Is thulium laser vapoenucleation of the prostate equally safe and effective in elderly patients? A propensity score matched analysis of early perioperative and functional outcomes

Objetivo: Evaluar la seguridad y efectividad de la vapoenucleación prostática con laser Tulio (TuLEP) en una cohorte seleccionada de pacientes ancianos en comparación con pacientes «más jóvenes».Material y métodosSe realizó un análisis retrospectivo de los pacientes consecutivos que se sometieron a TuLEP entre septiembre de 2018 y febrero de 2020. Tras aplicar los criterios de inclusión/exclusión, los pacientes se estratificaron según el punto de corte de 75 años sugerido por la OMS: el grupo A incluyó a los pacientes < 75 años; el grupo B incluyó a los pacientes > 75 años.La evaluación preoperatoria incluyó una consulta con el urólogo, el valor del antígeno prostático específico (PSA), el International Prostate Symptom Score (IPSS) y quality of life (QoL), ecografía transrectal para estimar el volumen prostático (PVol) y uroflujometría para evaluar los valores preoperatorios de maximum urinary flow rate (Qmax) y average urinary flow rate (Qave), así como el volumen residual postmiccional (PVR). Se analizaron los datos perioperatorios y postoperatorios con un seguimiento de 3 meses.ResultadosTras el análisis de puntuación de propensión, 51 pacientes fueron emparejados 1:1 frente a otros 51 con base en PVol, PSA, Qmax, IPSS y QoL. Los pacientes eran comparables al inicio excluyendo la edad 65 (IQR 59-70) vs. 79 (IQR 77-82) años, Grupo A vs. grupo B, respectivamente (valor p < 0,001).No se encontraron diferencias en cuanto al descenso de la hemoglobina, la tasa de complicaciones, el tiempo de cateterismo y la duración de la estancia hospitalaria. Los pacientes del grupo A (más jóvenes) experimentaron una mejora significativamente mayor en cuanto al valor absoluto de Qmax, Qave y ΔQmax a los 30 días. A los 90 días de seguimiento, las diferencias entre los grupos desaparecieron.Durante los 90 días de seguimiento, no se encontraron diferencias significativas en la tasa de reingreso ni se requirieron reintervenciones. (AU)

Purpose: To evaluate if thulium laser vapoenucleation of the prostate (ThuVEP) is equally safe and effective in a selected cohort of elderly patients when compared to “younger” patients.Materials and MethodsWe performed a retrospective analysis of consecutive patients who underwent ThuVEP between September 2018 and February 2020. After application of the inclusion/exclusion criteria, patients were stratified according to the 75 years-old cut-off point suggested by the WHO. Group A included patients < 75 years-old; Group B included patients > 75 years-old.Preoperative assessment included urological consultation, prostate specific antigen (PSA), International Prostate Symptom Score (IPSS) and quality of life index, transrectal ultrasound to estimate prostate volume (PVol), and uroflowmetry to assess preoperative Qmax, Qave and post-void residual volume (PVR). Perioperative and postoperative data were analyzed during 3-month follow-up.ResultsAfter propensity-score analysis, 51 versus 51 patients were 1:1 matched according to PVol, PSA, Qmax, IPSS and QoL. Patients were comparable at baseline excluding age (65 (IQR 59-70) versus 79 (IQR 77-82) years, Group A versus B, respectively, p-value < 0.001).No differences were found in terms of hemoglobin drop, complications rate, catheterization time and length of hospital stay. Group A (younger) patients had more significant improvement in 30-days absolute Qmax, Qave and ΔQmax. At 90-days follow-up, the differences between the groups disappeared.Within the 90-days follow-up, no significant differences were found in the readmission rate, with no need of reinterventions. (AU)

Acute vs chronic effects of l-dopa on bladder function in patients with mild Parkinson disease.

OBJECTIVE: To compare acute and chronic effects of l-dopa on bladder function in levodopa-naive Parkinson disease (PD) patients who had urinary urgency. METHODS: We evaluated 26 l-dopa-naive PD patients at a university-based PD center with a first urodynamic session with a double examination: in the off treatment condition and 1 hour after acute challenge with carbidopa/l-dopa 50/200 mg; then, a chronic l-dopa monotherapy was administered (mean dose 300 +/- 150 mg). Two months later, patients underwent a second urodynamic session with a single evaluation 1 hour after the acute carbidopa/l-dopa challenge. RESULTS: The first acute l-dopa challenge significantly worsened bladder overactivity (neurogenic overactive detrusor contractions threshold [NDOC-t; 32% of worsening] and bladder capacity [BC; 22% of worsening]); on the contrary, l-dopa challenge during chronic administration ameliorated the first sensation of bladder filling (FS; 120% of improvement), NDOCT-t (93% improvement), and BC (33% of improvement) vs the values obtained with acute administration. An 86% significant improvement of FS in comparison with the basal value was observed. CONCLUSIONS: The acute and chronic l-dopa effects may be due to the different synaptic concentrations or to the activation of postsynaptic mechanisms obtained by chronic administration.

Effects of motor cortex rTMS on lower urinary tract dysfunction in multiple sclerosis.

We tested the effects of 5-Hz rTMS over the motor cortex in multiple sclerosis (MS) subjects complaining of lower urinary tract symptoms either in the filling or voiding phase. Our data show that motor cortex stimulation for five consecutive days over two weeks ameliorates the voiding phase of the micturition cycle, suggesting that enhancing corticospinal tract excitability might be useful to ameliorate detrusor contraction and/or urethral sphincter relaxation in MS patients with bladder dysfunction.