Robotic prostatectomy versus brachytherapy for the treatment of low risk prostate cancer.

INTRODUCTION: To compare oncological and functional results of robot-assisted radical prostatectomy (RARP) and brachytherapy (BT) with a single-center prospective randomized study. MATERIALS AND METHODS: From January 2012 to January 2014, 165 patients with low risk prostate cancer, prostate volume ≤ 50 g, normal urinary (IPSS ≤ 7 and mean flow rate ≥ 15 mL/sec) and erectile functions (IIEF-5 > 17) were enrolled and randomly assigned to the RARP or BT group. Our end points included the comparison of biochemical recurrence-free survival rates, urinary function (IPSS and EPIC scores) and potency rates (IIEF-5 score) at different time points during the first 2 years after surgery between the two groups. RESULTS: The biochemical recurrence-free survival rates were 96.1% and 97.4% for the BT and RARP groups, respectively (p = 0.35). Significantly higher IPSS scores were assessed in the BT than in the RARP group at all the postoperative time points (p < 0.05). Significantly higher continence rates were assessed in the BT than in the RARP group during only the first 6 months of follow up (p < 0.05). Significantly lower potency rates were assessed in the BT than in the RARP group at all the postoperative time points (p < 0.05). CONCLUSIONS: Our data showed similar biochemical recurrence-free survival rates after BT and RARP. BT patients confirmed constantly higher rates of urinary symptoms while only reporting better continence rates for the first 6 months after surgery. RARP patients reported higher potency rates than BT patients during all the follow up period.

A rare case of syncronous solitary para-pharyngeal metastasis of clear cell carcinoma in a patient with small renal mass.

INTRODUCTION: Unusual metastatic sites of renal cell carcinoma (RCC) are not infrequent. We report a rare case of solitary pharyngeal metastasis as first presentation of RCC. CASE DESCRIPTION: A 74 years-old man was referred to our hospital due to rapidly progressive dyspnoea and dysphagia. Physical examination showed a large right para-pharyngeal mass. Imaging findings showed a 5.5 cm mass, suspicious for malignancy, which extended to right para and retro-pharyngeal spaces with compression of the major right cervical vessels, C2-C3 vertebral bodies osteolysis, dural sac compression and dislocation. Futhermore, a small (2.6 × 2 cm) mass located at the upper pole of the right kidney was shown. Patient underwent partial trans-oral removal of the mass. Pathological examination and immunochemistry resulting strongly suggestive for metastatic RCC. Considering the metastatic stage of the tumour and the rapidly progressive clinical worsening with poor performance status, we offered the patient a palliative treatment with tyrosine kinase and cytoreductive radiotherapy on vertebral bodies. The patient developed a rapidly progressive multifocal metastatic disease and died 4 months after the presentation. CONCLUSION: We think that our case is noteworthy for some aspects. Firstly, pharyngeal localizations of RCC are very rare and this is the first case of solitary pharyngeal metastasis. Secondly, this metastatic lesion was really particular because it was synchronous and twice as big than the primary tumour. Thirdly, this case is consistent with previous evidence that synchronous compared with metachronous metastasis RCC is associated with adverse effect on outcome and response to targeted treatment.

The bone anchor suburethral synthetic sling for iatrogenic male incontinence: critical evaluation at a mean 3-year followup.

PURPOSE: We retrospectively report objective and subjective outcomes in 40 male patients who underwent bone anchored suburethral synthetic sling positioning for stress urinary incontinence due to intrinsic sphincter deficiency. MATERIALS AND METHODS: Patients with stress urinary incontinence due to radical retropubic prostatectomy (32), robot assisted laparoscopic prostatectomy (3) and transurethral prostate resection (5) underwent bone anchored suburethral synthetic sling positioning between December 2002 and December 2007. Mean followup was 35.2 months (range 2 to 62). Previous anti-incontinence procedures, radiotherapy and transurethral procedures due to urethral stricture were performed in 5, 11 and 5 patients, respectively. Before and after surgery patients were evaluated by physical examination, urethral cystoscopy, urodynamics, a 1-hour pad test and a quality of life questionnaire. Patients were stratified into 3 groups, including group 1-cured (dry with a pad weight of 0 to 1 gm), group 2-improved (mild to moderate incontinence with a pad weight of 2 to 50 gm) and group 3-failed (patient condition unchanged with a pad weight of greater than 50 gm). RESULTS: At the final followup visit 22 (55%), 5 (12.5%) and 13 patients (32.5%) were cured, improved and failed, respectively. Mean pad weight significantly decreased to 51.3 gm in 54% of cases, while the mean total questionnaire score significantly increased to 72.9 in 65% and abdominal leak point pressure significantly increased to 92.5 cm H(2)O in 52%. Statistical analysis showed a significant association between preoperative radiotherapy and treatment failure (85% of patients). Complications were perineal pain in 73% of cases, detrusor overactivity in 5% and sling infection in 15%. CONCLUSIONS: The bone anchored suburethral synthetic sling is a simple and attractive procedure that can produce immediate good results with low morbidity, especially when strictly selected patients are treated. Radiotherapy remains a strong predictor of failure.

Dosimetry doesn't seem to predict the control of organ-confined prostate cancer after I-125 brachytherapy. Evaluation in 150 patients.

OBJECTIVE: To evaluate the dose-response relationship (D90 >144 Gy: probable absence of biochemical failure) in patients with prostate cancer treated by iodine-125 (I-125) brachytherapy. MATERIAL AND METHODS: From May 1999 to December 2006, 150 patients were treated by I-125 brachytherapy. The median follow-up was 60 months. All patients had clinical stage T1-T2, PSA < or =10 ng/ml, Gleason Scores < or = 3+3=6, IPSS >14 ml/sec. and prostate weight <50 gr. Implantation was ultrasound-guided, using a real-time technique and loose seeds of I-125 (dose 160 Gy). After 30 days, a post-implantation assessment was performed by pelvic CT scan for a definitive evaluation of the D90. All patients were subjected to clinical evaluation, PSA dosage and compilation of IPSS and IEFF questionnaires. In the event of biochemical failure (ASTRO), a prostate biopsy was performed. A D90 >144 Gy was considered the cut-off in order to predict the absence of biochemical failure. RESULTS: Biochemical failure was observed in 9 patients: 5 with positive and 4 with negative prostate biopsies. The D90 >144 Gy cut-off was not achieved in 18 patients at the post-implantation assessment, however only 2 of them (one of whom had a positive biopsy) had biochemical failure (11.1%). On the other hand, only 2 of the 9 patients with biochemical failure had a D90 < 144 Gy while 6 patients had D90 >150 Gy, 5 with positive prostate biopsies. CONCLUSIONS: In our experience, the D90 >144 Gy cut-off does not seem to predict, in a reliable way, the control of prostate cancer following brachytherapy. Limitations of the analysis were the number of the patients, the learning curve, dosimetry processing and the relatively short follow-up.

Advances in stem cell therapy for male stress urinary incontinence.

INTRODUCTION: Among the several options that have been proposed in recent years for the management of male stress urinary incontinence (SUI), stem cell therapy represents a new frontier in treatment. The aim of this paper is to update the current status of stem cell therapy in animal and human studies for the management of iatrogenic male SUI. AREAS COVERED: A literature review was conducted based on MEDLINE/PubMed searches for English articles using a combination of the following keywords: stem cell therapy, urinary incontinence, prostatectomy, regenerative medicine, mesenchymal stem cells. EXPERT OPINION: The few studies reported in the literature have demonstrated short-term safety and promising results of stem cell therapy in treating male SUI. However, many aspects need to be clarified before stem cell therapy can be introduced into daily urologic practice. In fact, important issues such as the limitations of these studies in terms of small sample sizes and short follow-ups, the incomplete knowledge of the mechanism of action of stem cells, the technical details regarding the delivery method and the best sources of stem cells, the safety risks regarding genomic or epigenetic changes and potential immune reactions in the longer term need to be identified in more stringent clinical trials.

[Endoscopic treatment with Wallgraft stenting of complete iatrogenic iliac ureteral injury in a high-risk surgical patient]. / Trattamento endoscopico con Wallgraft stenting di una lesione iatrogena completa dell'uretere iliaco in un paziente ad alto rischio operatorio.

BACKGROUND: Injury of the ureter is a potential complication of any difficult abdominopelvic surgical procedure, with an incidence ranging between 0.5% and 10% in most series. The treatment depends on the severity and the place of the lesion. The severe mid and upper ureteral injuries usually require complex treatment procedures, which can be contraindicated in case of severe comorbidities with high anesthesiologic risk. We report our experience in the endoscopic treatment with Wallgraft stenting of complete iatrogenic iliac ureteral injury in a high-risk surgical patient. METHODS: A 74-year-old female patient was admitted at our department due to a complete lesion of the right iliac ureter following right iliac artery aneurysm repair with iatrogenic ileal injury. The patient was in coma, affected by severe respiratory insufficiency, sepsis and uroperitoneum. These conditions contraindicated a general anesthesia encumbering the positioning of a nephrostomy, and influenced our indication of Wallgraft stent placement. The Wallgraft endoprosthesis (10 x 50 mm) is a self-expanding super-alloy metallic high flexible stent covered by PET, which can be placed at the level of the lesion using fluoroscopy after introducing an angiographic catheter and guidewire. This procedure is usually indicated in the treatment of vascular lesions. RESULTS: After positioning the Wallgraft stent, pyelography showed a complete closure of the lesion. The patient's clinical condition improved quickly and remained stable at a follow-up of 45 months. CONCLUSIONS: Although the Wallgraft stent positioning cannot be considered as a standard treatment for all the complete ureteral lesions, it can be proposed in the management of some patients with severe comorbidities, which do not allow any other approach.