Spermatic Cord Sarcoma: A 20-Year Single-Institution Experience.

Introduction: Spermatic cord sarcomas represent a rare genitourinary malignancy with a challenging diagnostic and therapeutic pathway. Different histotypes have been described and prognostic factors remain poorly defined due to the paucity of data presented in literature. Methods: Retrospective chart review of 22 adult patients treated for spermatic cord sarcoma in a single institution in the last 20 years was performed. Clinicopathological characteristics of the tumors were collected with primary and subsequent treatment. Survival analysis was performed in order to identify prognostic factors of disease-specific survival. Results: The median age at diagnosis was 68 years (58-78), the most common histotype was liposarcoma (14/22), and most patients (63.6%) were found to have positive surgical margins after surgery. The 5-year cancer specific survival was 91.3%. Grading (p = 0.480), histotype (p = 0.327), and type of intervention (p = 0.732) were not associated with survival. All patients dead of disease had positive surgical margins (p = 0.172). Conclusion: We report a good prognosis at 5 years. Wide radical resection remains the first and probably the most important step; thus, according also to literature, negative surgical margins should be aimed.

The effects of androgen deprivation therapy on the 18F-Chcoline uptake in prostate cancer patients undergoing neoadjuvant treatment.

BACKGROUND: The aim of the present study was to evaluate how neoadjuvant androgen deprivation therapy (ADT) can impact 18F-choline uptake in primary prostate cancer (PC) and its metastases before radical prostatectomy (RP) or radiation therapy (RT). METHODS: We retrospectively reviewed images of 79 PC patients undergoing 18F-choline PET/CT before RP or RT. Based on concomitant administration of neoadjuvant ADT at the time of 18F-choline PET/CT, patients were subdivided into naïve group (Group 1) and neoadjuvant ADT group (Group 2). PET/CT results, SUVmax and metabolic tumor volume (MTV) for each site were re-assessed by two nuclear medicine physicians with more than 5 years of experience. A chi-square and a U-Mann Whitney test were used to compare the two groups. RESULTS: Sixty-two patients were included in Group 1, while 17 in Group 2. PET/CT was positive in all patients, in particular: 54 had a significant uptake in prostate alone, 12 in prostate plus lymph nodes (LN), 4 in prostate plus LN and bone, 3 in prostate plus bone and 6 in prostate plus other organs (such as lung or thyroid). PET/CT was more frequently positive in a different site, outside the prostate, in Group 1 as compared to Group 2 (P<0.001). Conversely, median SUVmax and MTV in the prostate resulted significantly lower in Group 2 than in Group 1 (5.34 vs. 7.72 and 3.66 vs. 6.86 cm3, respectively; both P<0.05). CONCLUSIONS: PET/CT could have an important role in prostate cancer staging before primary treatment; however, before imaging, hormonal therapy status should be carefully evaluated.

Oligometastatic recurrent prostate cancer detects by fluorine-18-choline positron emission tomography/computed tomography in patients with prostate-specific antigen levels of up to 5 ng/ml.

PURPOSE: The aim of this study was to assess the ability of fluorine-18-fluorocholine (F-FCH) PET/computed tomography (CT) to detect oligometastatic disease (OMD) in patients with early recurrence of prostate cancer (PC) [prostate-specific antigen (PSA)≤5 ng/ml]. PATIENTS AND METHODS: Between 2010 and 2016, 324 patients with PC and PSA levels of less than or equal to 5 ng/ml were recruited. The mean (SD) age of the patients was 71 (10) years. All patients were treated with a radical prostatectomy±lymphadenectomy. One-hundred and twenty-one patients were under hormonal therapy at the time of PET/CT, whereas 203 were not. The mean (SD) PSA at the time of PET/CT was 1.33 (1.19) ng/ml, the mean (SD) PSA doubling time (PSAdt) was 10 (12) months, and the mean (SD) PSA velocity (PSAvel) was 1.94 (3.31) ng/ml/year. The correlation between continuous and categorical data was assessed using Student's t-test or by analysis of variance and by the χ-test, respectively. Univariate and multivariate analysis was carried out for the identification of clinical variables able to predict the presence of OMD. RESULTS: One-hundred and ninety-three patients had a negative F-FCH PET/CT, whereas 131 (40.4%) had a positive scan. Of these latter patients, 35 had a significant F-FCH uptake in the prostatic fossae, 59 in the lymph nodes, and 37 in bone. PSA levels were significantly different between patients with a positive than those with a negative scan (P<0.001). F-FCH PET/CT was negative in the majority of patients with a PSA of less than or equal to 1 (63.2%) ng/ml. More than 60% of patients with a PSAdt of less than or equal to 6 months had a positive F-FCH PET/CT scan for OMD. PSAvel was higher in patients with a positive scan than those with a negative finding. At univariate analysis, PSA level, PSAdt, and PSAvel were predictors of a positive F-FCH PET/CT for OMD, whereas on multivariate analysis, only PSA level and PSAdt were independent predictors (both P<0.01). Furthermore, PSAdt was the only independent predictor of OMD at the lymph node level. CONCLUSION: In patients with early recurrence of PC, F-FCH PET/CT is able to detect OMD in 40% of cases. This finding has an important impact on the detection of PC recurrent lesions that could be treated by local therapy to achieve long-term survival or cure.

Correlation Between Confocal Laser Endomicroscopy (Cellvizio®) and Histological Grading of Upper Tract Urothelial Carcinoma: A Step Forward for a Better Selection of Patients Suitable for Conservative Management.

BACKGROUND: Despite the recent growing interest in the conservative management of upper tract urothelial carcinoma (UTUC), the diagnostic process is still a challenge for the risk of tumor undergrading. Real-time confocal laser endomicroscopy (CLE) provides in vivo microscopic images of tissues using a low-energy laser light source. OBJECTIVE: To describe our initial experience with CLE for the real-time characterization of UTUC. DESIGN, SETTING, AND PARTICIPANTS: Fourteen flexible ureteroscopies (f-URS) were performed at our center with CLE for UTUC. Lesions were preoperatively identified at computed tomography-intravenous urography. Cellvizio system was used during f-URS to perform CLE on the targeted lesions. Biopsies were then performed. INTERVENTION: f-URS with CLE. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Surgeon's CLE readings (low-grade/high-grade/carcinoma in situ [CIS]) were documented in the operation notes. A dedicated genitourinary pathologist-blinded to the surgeon reading-examined all specimens. A third person collected prospectively the CLE readings and the histopathological reports. Cohen's Kappa analysis was performed to test interobserver agreement. RESULTS AND LIMITATIONS: The mean diameter of tumors at computed tomography scan was 26mm (range, 5-50mm). In eight patients, CLE allowed to obtain images compatible with low-grade UTUC, in five patients with high-grade UTUC, and in one case with CIS. We found correspondence between the CLE images and the final histopathological results in seven out of seven cases of low-grade UTUC (100%), in five out of six cases of high-grade UTUC (83%), and in one out of one case of CIS (100%). Substantial agreement was found at interobserver agreement (k=0.64) between CLE and histological reading. No complications and/or limitations related to the use of CLE were recorded. CONCLUSIONS: CLE is a promising new technology in providing a reliable real-time histological characterization of UTUC lesions. Ideal targets might be UTUC patients potentially candidates for conservative management. PATIENT SUMMARY: We believe that a conservative treatment for low-grade upper tract urothelial carcinoma is an option that must be considered. The diagnostic process is still lacking of accurate tools. In this study, we find that confocal laser endomicroscopy, using the Cellvizio system, seems to help the clinician to have a real-time histological characterization of upper tract urothelial carcinoma lesions. This could better select patients for a conservative treatment.

A Case of Retrograde Treatment of a Ureteral Stone in a Retrocaval Ureter.

Background: Retrocaval ureter is a rare entity with a reported incidence of ∼1 in 1100 and a 2.8-fold male predominance. The course of the ureter could be classified, using an intravenous urography, as type 1 having S-shaped, fish-hook, or J-shaped retrocaval course or type 2 having sickle-shaped course. No case report describing retrograde endoscopic management of ureteral calculi in the presence of retrocaval ureter could be found in existing literature. We are presenting a case of type I retrocaval ureter with ureteral calculi and nonobstructive drainage, which was effectively managed by flexible ureteroscopy. Case Presentation: A 62-year-old Caucasian man presented with complaints of a renal colic. The patient was positive for a history of noninsulin-dependent diabetes and hypertension. A direct abdomen CT scan showed an 8 mm ureteral stone with suspected retrocaval course of right proximal ureter with no hydronephrosis. After informed consent, ureteroscopy was performed on the patient's right proximal ureter. No complications occurred intraoperatively and postoperatively. On follow-up of up to 3 months, patient was asymptomatic and direct abdomen CT scan showed normal kidney without hydronephrosis. Conclusion: In the presence of retrocaval ureter and associated ureteral calculi with a condition of nonobstructive drainage, retrograde ureteroscopy is a safe and optimal procedure.

Chyluria: the state of the art.

Chyluria is the passage of chyle in the urine. The cause seems to be the rupture of retroperitoneal lymphatics into the pyelocaliceal system, giving urine a milky appearance. This communication is caused by the obstruction of lymphatic drainage proximal to intestinal lacteals, resulting in dilatation of distal lymphatics and the eventual rupture of lymphatic vessels into the urinary collecting system.This condition, if left untreated, leads to significant morbidity because of hematochyluria, recurrent renal colic, nutritional problems due to protein losses and immunosuppression resulting from lymphocyturia.In this review, we summarize the state of the art of this condition and the newest treatments available.

Robotic kidney transplantation: one year after the beginning.

INTRODUCTION: Kidney transplantation (KT) is the preferred treatment for patients with end-stage renal disease (ESRD). To reduce the morbidity of the open surgery, a robotic-assisted approach has been recently introduced. Our aim is to evaluate surgical and functional results on 17 cases of robotic-assisted kidney transplantation (RAKT) performed at the same institution. MATERIALS AND METHODS: From July 2015 to June 2016, we performed 17 cases of RAKT from living donors in pre-emptive patients, who underwent laparoscopic nephrectomy. A prospective pilot study was made at Fundació Puigvert (Barcelona), evaluating functional and surgical outcomes. In this series, we considered the functional results, surgical outcomes and complications rates. RESULTS: Seventeen patients successfully underwent RAKT, in particular surgical console time was 181 min (150-200) with vascular suture time 42 min (32-48), and estimated blood loss <70 ml. Overall ischemia time was 98.9 min (84-140). No patient was converted to open transplantation. No major surgical intra-operative complications were observed. The mean post-operative serum creatinine level 160 µmol/L (81-479). We reported a case of delayed graft function (DGF), one case of graft arterial thrombosis and one case of intraperitoneal hematoma. No anastomosis revision and wounds infections occurred. CONCLUSION: RAKT with regional hypothermia appears to be a safe surgical procedure in a properly selected group of patients. The potential advantages of RAKT are related to the quality of the vascular anastomosis, the possible lower complication rate and the shorter recovery of the recipients.

Non-Parasitic Chyluria: Our Experience With Sclerotherapy With Solution of Povidone-Iodine and Destrose and A Review of the Literature.

Chyluria is the passage of chyle in the urine. The cause seems to be the rupture of retroperitoneal lymphatics into the pyelocaliceal system, giving urine a milky appearance. This condition if left untreated it leads to significant morbidity because of hematochyluria, recurrent renal colic, nutritional problems due to protein losses and immunosuppression resulting from lymphocyturia. We report our experience with the use of povidone iodine with dextrose solution as a sclerosing agent in the management of chyluria in two patients.

Renal colic, where is it headed? An observational study.

AIM: In the last thirty years, the treatment for renal and ureteral calculi has undergone profound variations. The objective of this study has been to evaluate the existence of parameters which can affect the spontaneous expulsion of a symptomatic ureteral stone in a reasonably brief period of time and to identify whether certain parameters such as sex, age, the location and dimension of the stone, the presence of dilation in the urinary tract together with the administered therapy, can be used for a correct clinical management of the patient. METHODS: In a period of 9 months, 486 cases of renal colic were registered at emergency department. RESULTS: The cases of renal colic due to ureteral calculus were 188 (38.7%). The patients' charts, complete of all data and therefore, valid for this research, resulted to be 120 (64%). In the presence of a symptomatic ureteral stone, the correct approach must first of all, focalize on the dimension of the calculus itself; less importance instead, is given to the location, as reported in other studies, the presence of hydroureteronephrosis, sex and the side. CONCLUSION: In the cases when the pain symptoms cannot be solved by means of the administration of analgesics, it is then reasonable to take into consideration an immediate endourological treatment. If the pain symptoms are promptly solved, an attentive wait of 4 weeks should be considered reasonable in order to allow spontaneous expulsion of the calculus.

Anesthesiologic effects of transperitoneal versus extraperitoneal approach during robot-assisted radical prostatectomy: results of a prospective randomized study.

OBJECTIVES: To compare the effects of CO(2) insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses. MATERIALS AND METHODS: Sixty-two patients were randomly assigned to TP (32) and EP (30) to RARP. Pre-operation data were collected for all patients. Hemodynamic, respiratory and blood acid-base parameters were measured at the moment of induction of anesthesia (T0), after starting CO(2) insufflation (T1), and at 60 (T2) and 120 minutes (T3) after insufflation. In all cases, the abdominal pressure was set at 15 mmHg. Complications were reported according to the Clavien-Dindo classification. Student's two-t-test, with a significance level set at p<0.05, was used to compare categorical values between groups. The Mann-Whitney U-test was used to compare the median values of two nonparametric continuous variables. RESULTS: The demographic characteristics of the patients in both groups were statistically comparable. Analysis of intra-operative anesthesiologic parameters showed that partial CO(2) pressure during EP was significantly higher than during TP, with a consequent decrease in arterial pH. Other parameters analysed were similar in the two groups. Postoperative complications were comparable between groups. The most important limitations of this study were the small size of the patient groups and the impossibility of maintaining standard abdominal pressure throughout the operational phases, despite attempts to regulate it. CONCLUSIONS: This prospective randomized study demonstrates that, from the anesthesiologic viewpoint, during RARP the TP approach is preferable to EP, because of lower CO(2) reabsorption and risk of acidosis.

Dietary treatment of urinary risk factors for renal stone formation. A review of CLU Working Group.

OBJECTIVE: Diet interventions may reduce the risk of urinary stone formation and its recurrence, but there is no conclusive consensus in the literature regarding the effectiveness of dietary interventions and recommendations about specific diets for patients with urinary calculi. The aim of this study was to review the studies reporting the effects of different dietary interventions for the modification of urinary risk factors in patients with urinary stone disease. MATERIALS AND METHODS: A systematic search of the Pubmed database literature up to July 1, 2014 for studies on dietary treatment of urinary risk factors for urinary stone formation was conducted according to a methodology developed a priori. Studies were screened by titles and abstracts for eligibility. Data were extracted using a standardized form and the quality of evidence was assessed. RESULTS: Evidence from the selected studies were used to form evidence-based guideline statements. In the absence of sufficient evidence, additional statements were developed as expert opinions. CONCLUSIONS: General measures: Each patient with nephrolithiasis should undertake appropriate evaluation according to the knowledge of the calculus composition. Regardless of the underlying cause of the stone disease, a mainstay of conservative management is the forced increase in fluid intake to achieve a daily urine output of 2 liters. HYPERCALCIURIA: Dietary calcium restriction is not recommended for stone formers with nephrolithiasis. Diets with a calcium content ≥ 1 g/day (and low protein-low sodium) could be protective against the risk of stone formation in hypercalciuric stone forming adults. Moderate dietary salt restriction is useful in limiting urinary calcium excretion and thus may be helpful for primary and secondary prevention of nephrolithiasis. A low-normal protein intake decrease calciuria and could be useful in stone prevention and preservation of bone mass. Omega-3 fatty acids and bran of different origin decreases calciuria, but their impact on the urinary stone risk profile is uncertain. Sports beverage do not affect the urinary stone risk profile. HYPEROXALURIA: A diet low in oxalate and/or a calcium intake normal to high (800-1200 mg/day for adults) reduce the urinary excretion of oxalate, conversely a diet rich in oxalates and/or a diet low in calcium increase urinary oxalate. A restriction in protein intake may reduce the urinary excretion of oxalate although a vegetarian diet may lead to an increase in urinary oxalate. Adding bran to a diet low in oxalate cancels its effect of reducing urinary oxalate. Conversely, the addition of supplements of fruit and vegetables to a mixed diet does not involve an increased excretion of oxalate in the urine. The intake of pyridoxine reduces the excretion of oxalate. HYPERURICOSURIA: In patients with renal calcium stones the decrease of the urinary excretion of uric acid after restriction of dietary protein and purine is suggested although not clearly demonstrated. HYPOCITRATURIA: The administration of alkaline-citrates salts is recommended for the medical treatment of renal stone-formers with hypocitraturia, although compliance to this treatment is limited by gastrointestinal side effects and costs. Increased intake of fruit and vegetables (excluding those with high oxalate content) increases citrate excretion and involves a significant protection against the risk of stone formation. Citrus (lemons, oranges, grapefruit, and lime) and non citrus fruits (melon) are natural sources of dietary citrate, and several studies have shown the potential of these fruits and/or their juices in raising urine citrate levels. CHILDREN: There are enought basis to advice an adequate fluid intake also in children. Moderate dietary salt restriction and implementation of potassium intake are useful in limiting urinary calcium excretion whereas dietary calcium restriction is not recommended for children with nephrolithiasis. It seems reasonable to advice a balanced consumption of fruit and vegetables and a low consumption of chocolate and cola according to general nutritional guidelines, although no studies have assessed in pediatric stone formers the effect of fruit and vegetables supplementation on urinary citrate and the effects of chocolate and cola restriction on urinary oxalate in pediatric stone formers. Despite the low level of scientific evidence, a low-protein (< 20 g/day) low-salt (< 2 g/day) diet with high hydration (> 3 liters/day) is strongly advised in children with cystinuria. ELDERLY: In older patients dietary counseling for renal stone prevention has to consider some particular aspects of aging. A restriction of sodium intake in association with a higher intake of potassium, magnesium and citrate is advisable in order to reduce urinary risk factors for stone formation but also to prevent the loss of bone mass and the incidence of hypertension, although more hemodynamic sensitivity to sodium intake and decreased renal function of the elderly have to be considered. A diet rich in calcium (1200 mg/day) is useful to maintain skeletal wellness and to prevent kidney stones although an higher supplementation could involve an increase of risk for both the formation of kidney stones and cardiovascular diseases. A lower content of animal protein in association to an higher intake of plant products decrease the acid load and the excretion of uric acid has no particular contraindications in the elderly patients, although overall nutritional status has to be preserved.

The Value of Open Conversion Simulations During Robot-Assisted Radical Prostatectomy: Implications for Robotic Training Curricula.

INTRODUCTION: There is a lack of protocols, formal guidance, and procedural training regarding open conversions from robot-assisted radical prostatectomy (RARP) to open radical prostatectomy (ORP). An open conversion places complex demands on the healthcare team and has recently been shown to be associated with adverse perioperative outcomes. AIMS: To perform a root cause analysis of open conversion simulations from RARP to ORP to identify errors that may contribute to adverse events. METHODS: From May 2013 to December 2013, with a team of two surgeons, an anesthesiologist, and three nurses, we simulated 20 emergencies during RARP that require open conversion. A human simulation model was intubated and prepared in the Trendelenburg position; a robot da Vinci SI was locked to it. All simulations were timed, transcribed, and filmed to identify errors and areas for improvement. An institutional conversion protocol was developed at the end of the conversion training. RESULTS: The average conversion time was 130.9 (interquartile range [IQR] 90-201) seconds. Frequencies of the observed errors were as follows: lack of task sequence (70%), errors in robot movements (50%), loss of sterility (50%), space conflict (40%), communication errors (25%), lack of leadership (25%), and accidental fall of surgical devices (25%). Four main strategies were implemented to reduce errors: improving leadership, clearly defining roles, improving knowledge base, and surgical room reorganization. By the last simulation, conversions were performed without errors and using 55.2% less time compared with initial simulations. CONCLUSIONS: In this preliminary study, repeated simulations, increased leadership, improved role delineation, and surgical room reorganization enabled faster and less flawed conversions. Further studies are needed to identify if such protocols may translate to actual safety improvement during open conversions.

Anesthesiologic Effects of Transperitoneal Versus Extraperitoneal Approach During Robot-Assisted Radical Prostatectomy: Results of a Prospective Randomized Study

To compare the effects of CO₂ insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses.

Comparison between conventional imaging (abdominal-pelvic computed tomography and bone scan) and [(18)F]choline positron emission tomography/computed tomography imaging for the initial staging of patients with intermediate- tohigh-risk prostate cancer: A retrospective analysis.

OBJECTIVE: The aim of this study was to evaluate the efficiency of [(18)F]fluorocholine positron emission tomography/computed tomography (FCH PET/CT) in detecting lymph-node and bone involvement in comparison with conventional imaging, such as abdominal-pelvic CT and bone scan, in the initial staging of prostate cancer (PCa). MATERIALS AND METHODS: The study retrospectively evaluated 48 patients who had FCH PET/CT for the initial staging of PCa. At the same time, 32 of the 48 patients had a bone scan and 26 of the 48 patients had abdominal-pelvic diagnostic CT. Diagnostic performance of FCH PET/CT, i.e. sensitivity, specificity and accuracy, was evaluated on a per-patient basis for the whole population and then separately on a per-risk classification, and later in comparison with conventional imaging. Histological specimens or follow-up data were used as the standard of reference. RESULTS: The overall accuracy of FCH PET/CT for lymph-node involvement was 83.3%. The sensitivity of FCH was higher in the high-risk subset (83.3%) than in the intermediate-risk group (33.3%), whereas FCH specificity was similar. In comparison with dedicated CT scan, FCH PET/CT showed a higher sensitivity and a similar specificity (46.2% vs 69.2% and 92.3% vs 92.3%, respectively). Moreover, the sensitivity and specificity of PET/CT were higher than those of bone scan (100% vs 90% and 86.4% vs 77.2%, respectively). In contrast with conventional imaging, PET/CT changed the staging of the PCa in 33.3% patients. CONCLUSIONS: The efficiency of FCH PET/CT in detecting both bone and lymph-node involvement of PCa at initial staging was found to be higher than that of conventional imaging. Prospective clinical trials are needed to confirm these findings.

¹8F-fluoromethylcholine or ¹8F-fluoroethylcholine pet for prostate cancer imaging: which is better? A literature revision.

INTRODUCTION: The present review was conceived for describing the differences in biodistribution and diagnostic performance of two types of (18)F-radiolabeled choline for positron emission tomography (PET) imaging in prostate cancer (PCa), such as fluoromethylcholine (FCH) and fluoroethylcholine (FEC). MATERIALS AND METHODS: A collection of published data about two radiopharmaceutical agents was made by using PubMed, Web of Knowledge databases and Trip Database, and then a critical revision was discussed. RESULTS: FCH was injected in 338 and 1164 patients, while FEC was injected in 20 and 139 patients, respectively for basal staging and re-staging. The diagnostic performances of FCH and FEC for the detection of lymph node metastasis before the surgical approach are typically around 50% or less and between 0% and 39%, respectively. Conversely, both the tracers appear useful for the detection of recurrent PCa in case of increase in absolute PSA value or in case of high levels of PSA velocity and PSA doubling time (sensitivity ranged between 42.9% and 96% for FCH and between 62% and 85.7% for FEC). CONCLUSIONS: In according with the available information, FCH appears to be a more appropriate radiocompound as compared to FEC, although more comparative data are mandatory. A well designed and prospective trial for the evaluation of biokinetic data and diagnostic performance of both radiopharmaceutical agents seems essential. ADVANCES IN KNOWLEDGE AND IMPLICATION FOR PATIENT CARE: FCH seems to be an appropriate radiopharmaceutical agent as compared to FEC. Anyway both the radiocompounds are useful in the evaluation of recurrent disease in case of a serial increase in PSA value and their performance improves when a correct preparation and acquisition protocol is employed.

Histopathological characteristics of microfocal prostate cancer detected during systematic prostate biopsy.

OBJECTIVE: To evaluate the prevalence of adverse pathological features and the percentage of multifocal and/or bilateral disease in a series of patients who underwent radical prostatectomy (RP) for unique, microfocal prostate cancer (miPCa) detected on prostate biopsy in the pre-active surveillance (AS) era. PATIENTS AND METHODS: In this retrospective, multi-institutional study, we analysed the clinical records of 131 consecutive patients who underwent either retropubic or robot-assisted RP for miPCa at two referral centres from January 2000 to December 2011. miPCa was defined as a neoplastic lesion present in ≤10% of core with biopsy Gleason score not applicable or biopsy Gleason score 6. RESULTS: There were 17 (13%) pT3-4 prostate cancers and a single case (0.8%) of pN+ tumour. Moreover, 31 (24.1%) patients had a Gleason score of >6 in the RP specimen. Therefore, unfavourable pathological features (pT3-4/N+ and/or Gleason score >6) were present in 40 (30.5%) patients. The median (interquartile range) prostate-specific antigen (PSA) density was 0.11 (0.09-0.17) and 0.16 (0.11-0.24) ng/mL/mL in patients with favourable and unfavourable pathological characteristics, respectively (P = 0.003). The receiver operating characteristic curve had an area under the curve value of 0.67 (95% confidence interval 0.56-0.77) for PSA density to predict the risk of unfavourable pathological features. CONCLUSION: Patients with miPCa who are candidates for an AS protocol should be adequately informed that in ≈30% of cases the cancer might be locally advanced and/or with a Gleason score of >6. Those unfavourable pathological characteristics could be predicted by the PSA density value. Further studies should investigate the role of a more extensive biopsy sampling to reduce the risk of under-staging and/or under-grading in patients with an initial diagnosis of miPCa.

The endourological treatment of renal matrix stones.

OBJECTIVE: To report our experience with the endourological treatment of renal matrix stones, an infrequent form of urinary calculi whose diagnosis and treatment are often difficult. METHODS: From 1990 to 2010 we treated 9 female patients with matrix calculi using the endourological approach; 4 presented with renal colics, 3 with symptomatic urinary tract infection and 2 with asymptomatic bacteriuria. Six patients underwent percutaneous lithotripsy and 3 retrograde intrarenal surgery as first-line therapy. Three cases needed a multidisciplinary approach. RESULTS: The six percutaneous procedures were successful after a single session, while the retrograde approach required multiple treatments; a single case needed a shock wave session to complete the fragmentation, in another one a percutaneous lithotripsy was necessary after the first procedure, and a third case needed multidisciplinary treatment. CONCLUSIONS: Percutaneous lithotripsy has been confirmed as the first option for matrix stones. The retrograde approach - by confirming the suspected diagnosis and being minimally invasive - may be employed to treat either lower-size stones or stones at high risk of recurrence.