Prostate cancer testicular metastasis: Are they underestimated? Case report and analysis of the literature.

INTRODUCTION: We aim to present a rare case of a patient who developed a late testicular metastasis of PCa after radical prostatectomy. CASE DESCRIPTION: A 78 years old man presenting for left testicular swelling slowly increasing of size over the last 2 months. He underwent a retropubic radical prostatectomy and extended bilateral lymphadenectomy in 2007 for prostatic adenocarcinoma. At the time of the presentation the last PSA was 0.91 ng/mL. The patient underwent a standard left orchifunicolectomy in April 2019 without intra- or perioperative complications. The pathological analysis showed a testicular metastasis of acinar adenocarcinoma. CONCLUSIONS: In conclusion, testicular metastasis from PCa are uncommon conditions. PSA evaluation and physical examination of all sites of metastasis and accurate evaluation of all signs/symptoms during the clinical visit remains crucial to the diagnosis of recurrence.

ABLATE: a score to predict complications and recurrence rate in percutaneous treatments of renal lesions.

RENAL score has been validated on predicting adverse events and relapses in percutaneous treatments of renal lesions. To better fit interventional issues a modified score (mRENAL) has been introduced, but the only difference from the RENAL score is on the dimensional parameter. However, it remains of surgical derivation while a specific interventional score is missing. This study aims to obtain a specific score (ABLATE) to better quantify the risk of complications and relapses in percutaneous kidney ablation procedures compared to the existing surgical scores. Taking inspiration from previous papers, a score was built to quantify the real difficulties faced in percutaneous treatment of renal lesions. The ABLATE score was used on 71 cryoablations to evaluate its predictivity of complications and relapses. Logistic regression was used to predict complication incidence; Cox-regression was used for relapses; ROC analysis was used to evaluate the accuracy of the different scores. Between January 2014 and November 2019, 71 lesions in 68 patients were treated. Overall, malignant histology was found in 62 lesions (87.3%). Mean and median RENAL, mRENAL, and ABLATE scores were 7.04 and 7, 7.19 and 7, and 5.11 and 4, respectively. Out of 71 treatments, we experienced 3 bleeding with anemia (4.2%), only 2 of which needed further treatment (2.82%). The mean and median RENAL, mRENAL, and ABLATE scores in those with complications were 7.66 and 7.01 (p = 0.69), 8.0 and 7.1 (p = 0.54), and 6.6 and 5.0 (p = 0.38), respectively. Out of 62 malignant lesions, we experienced 2 persistent and 6 recurrent lesions (3.2% and 8.4%, respectively). At Cox-regression analyses, mABLATE score outperformed both RENAL and mRENAL scores in predicting recurrences (HR 1.48; p < 0.001 vs. 1.41; p = 0.1 vs. 1.38: p = 0.07, respectively). The ABLATE score showed to be a better predictor of relapses than RENAL and mRENAL. The small number of complications conditioned a lack of statistic power on complications for all the scores. At the moment to quantify the risks in percutaneous kidney ablation procedures, surgical scores are used. A specific score better performs this task.

Percutaneous Microwave Ablation Versus Cryoablation in the Treatment of T1a Renal Tumors.

PURPOSE: Radiofrequency and cryoablation (Cryo) are the most widely used techniques for the treatment of T1a renal tumors in non-surgical candidates, yet microwave ablation (MWA) has been gaining popularity. In this study, we tested the hypothesis that MWA has comparable safety and efficacy to Cryo in the treatment of selected T1a renal masses. MATERIALS AND METHODS: A retrospective comparative analysis of two patient cohorts was carried out on 83 nodules in 72 consecutive patients treated using image-guided percutaneous ablation with either Cryo or MWA. Patient demographics, tumor histology and characteristics, technical success, procedure time, adverse events and complications, nephrometry score (mRENAL) and renal function were evaluated. Local recurrence was evaluated at 1, 6, 12 and 18-24 months. RESULTS: Fifty-one nodules were treated with Cryo and 32 with MWA (44 and 28 patients, respectively). No statistical differences were observed following Cryo or MWA in median tumor size (p = 0.6), mRENAL (p = 0.1) or technical success (p = 0.8). Median procedure time was significantly lower using microwave ablation (p = 0.003). Median follow-up time was similar in the two groups (22 and 20 months, respectively). Occurrence of complications did not differ (Cryo 5/51, MWA 2/32; p = 0.57), and probability of complications or technical success adjusted for mRENAL did not reach statistical significance (p = 0.6). Renal function was preserved in all patients regardless of techniques. Disease recurrence was observed in 3/47 and in 1/30 treated nodules in the Cryo and MWA groups, respectively, without reaching statistical significance (p = 0.06). CONCLUSION: In the patient population studied, MWA showed comparable safety and efficacy relative to Cryo. LEVEL OF EVIDENCE: Level 3, Non-randomized cohort study.

Association Between Prostate Imaging Reporting and Data System (PI-RADS) Score for the Index Lesion and Multifocal, Clinically Significant Prostate Cancer.

BACKGROUND: The ability to identify clinically significant prostate cancer (csPCa) has dramatically improved with the introduction of multiparametric magnetic resonance imaging (mpMRI). Given the growing interest in targeted biopsy and focal therapy, improving our knowledge on the relationship between mpMRI parameters and the ability to predict csPCa multifocality is mandatory. OBJECTIVE: To assess whether the Prostate Imaging Reporting and Data System (PI-RADS) score for the index lesion (IL) may predict multifocal csPCa undetected by mpMRI. DESIGN, SETTING, AND PARTICIPANTS: The study included 343 patients who underwent mpMRI of the prostate with subsequent biopsy between 2014 and 2017 at a single tertiary care referral centre. INTERVENTION: Lesions with a PI-RADS v.2 score ≥2 detected at mpMRI (IL) were targeted with a fusion biopsy (Bx) approach (mpMRI-Bx). Moreover, each patient underwent a random extended transrectal ultrasound-guided biopsy (TRUS-Bx) during the same session. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: csPCa outside the IL was defined as disease detected at TRUS-Bx with a Gleason score (GS)≥3+4 and equal to or greater than the GS for the IL. The extent of csPCa detected in target and random cores was reported and stratified according to the GS and PI-RADS score for the IL. The probability of diagnosing csPCa outside the IL according to the PI-RADS score was also assessed in multivariable logistic regression analyses (MVA) after accounting for confounders. RESULTS AND LIMITATIONS: The detection rate for csPCa outside the IL was 30%. The detection rate for csPCa at TRUS-Bx was 8% for PI-RADS 2, 15% for PI-RADS 3, 36% for PI-RADS 4, and 58% for PI-RADS 5 lesions (p=0.03). Overall, the median length of csPCa found at TRUS-Bx and thus missed at mpMRI was 2.6mm. However, the length significantly increased with PI-RADS score for the IL, and was 1.8, 2.3, 2.8, and 3.8mm for PI-RADS 2, 3, 4, and 5 lesions, respectively (p=0.03). On MVA, PI-RADS 4 (odds ratio [OR] 7.6; p=0.008) and PI-RADS 5 scores (OR 17.3; p<0.001) were independent predictors of the presence of csPCa outside the IL. The study is limited by its retrospective design. CONCLUSIONS: Overall, the accuracy of mpMRI in identifying multifocal csPCa is poor, missing low-volume csPCa in approximately 30% of patients. Moreover, the rate and the extent of csPCa undetected by mpMRI significantly increased with the PI-RADS score for the IL, which can thus be considered a proxy for tumour multifocality. PATIENT SUMMARY: The accuracy of multiparametric magnetic resonance imaging in identifying prostate cancer multifocality is poor. False negative findings were highly related to the PI-RADS score of the index lesion. These findings raise concerns about the indication for targeting the index lesion only when considering prostate biopsy and focal approaches.

Not All Multiparametric Magnetic Resonance Imaging-targeted Biopsies Are Equal: The Impact of the Type of Approach and Operator Expertise on the Detection of Clinically Significant Prostate Cancer.

BACKGROUND: The extensive use of multiparametric magnetic resonance imaging (mpMRI) has led to an even more widespread use of different targeted biopsy techniques and approaches. The best way of performing targeted biopsies and the effect of operator expertise have still to be defined. OBJECTIVE: To compare the rate of detection of clinically significant prostate cancer (csPCa) of different mpMRI targeted approaches and to assess the role of operator expertise in the detection of csPCa. DESIGN, SETTING, AND PARTICIPANTS: We included 244 consecutive patients who underwent both 12-core transrectal ultrasound (TRUS) biopsy and mpMRI targeted biopsy with either a cognitive biopsy (CB) or fusion biopsy (FB) approach during the same session between 2013 and 2016 at a single tertiary referral centre. INTERVENTION: All men underwent 1.5-T mpMRI with an endorectal coil. All biopsies were performed by three operators as their first cases of targeted biopsy. Lesions with a Prostate Imaging Recording and Data System (PI-RADS) v.2 score of ≥3 detected at mpMRI were targeted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: csPCa was defined as disease with a Gleason score at biopsy of ≥7. Operator expertise was coded as the progressive number of targeted biopsies performed by each physician. Multivariable logistic regression analyses (MVA) were used to assess the association between the targeted biopsy technique (FB vs CB) and operator expertise for detection of csPCa. Covariates consisted of prostate-specific antigen, prostate volume, PI-RADS v.2 (3 vs >3), number of targeted cores per MRI lesion, and digital rectal examination (negative vs positive). The same analyses were performed for patients undergoing FB only after accounting for the FB approach (transrectal vs transperineal). A lowess smoothing weighted function was used to graphically assess the effect of operator expertise on the probability of detecting csPCa, after accounting for all confounders. RESULTS AND LIMITATIONS: Overall, 157 patients (64%) underwent FB and 87 (36%) underwent CB. The overall csPCa detection rate was 58% for FB and 45% for CB (p=0.07). A significantly higher rate of csPCa detection in targeted samples was observed for FB compared to CB (57% vs 36%; p=0.002). On MVA, FB and operator expertise were significantly associated with a higher probability of csPCa detection in targeted samples (odds ratio [OR] 2.4 and 1.7, respectively; both p≤0.03). When the same analyses were repeated for patients undergoing FB, operator expertise remained an independent predictor of csPCa detection (OR 1.9; p=0.004). An increase in the probability of detecting csPCa with the number of procedures performed was observed after accounting for all confounders. CONCLUSIONS: We demonstrated that FB had higher detection rate than CB for csPCa. Moreover, operator expertise was significantly associated with higher detection rates for csPCa. PATIENT SUMMARY: When different targeted biopsy techniques were compared, fusion biopsy provided a higher detection rate compared to cognitive biopsy for clinically significant prostate cancer (csPCa). Moreover, we found that operator expertise was an important predictor of the detection of csPCa, regardless of the procedure used.

Prostate-specific antigen percentage: An early predictive tool after iodine-125 interstitial brachytherapy for prostate cancer.

BACKGROUND: After interstitial prostate iodine-125 brachytherapy (BT), prostate-specific antigen (PSA) evolution in time could predict overall biochemical relapse, but, considering the single patient, it is influenced by the presentation PSA amount and by the prostatic volume. It is also challenging to differentiate a PSA bounce from a biochemical relapse. PURPOSE: To determine the usefulness of PSA percentage (PP) defined as the rate between PSA presented by a patient at time "t" and the PSA that the same patient had presented at the time of diagnosis (t0) assumed as 100% in predicting biochemical relapse and in differentiating them from PSA Bounces. METHODS AND MATERIALS: We included 721 patients from Milan S. Raffaele Turro (399) and Lucca Campo di Marte (then S. Luca) Hospital (322). The mean age of patients was 66.5 years (range, 50-79). Mean followup was 150 months (range, 24-180). For each patient, PSA was recorded before and after iodine-125 BT, and PPs were calculated. Cox regression model, relative operating characteristic curves, and Kaplan-Meier regression model were elaborated, and a cutoff of 20% was defined. RESULTS: We observed that PP >20% is an independent variable highly associated with relapse risk (p < 0.0001) with a sensitivity of 79.7%, a specificity of 82%, and an hazard ratio of 12.1, since the 6 months of followup. A PSA increase above the nadir should be because of bounce (sensitivity and specificity of 81.4%, p < 0.0001) if patient had experienced at 6 months a PP <20%. CONCLUSIONS: PP might represent an early and useful tool, predictive of clinical outcome in patients after BT for prostate cancer.

Low dose rate brachytherapy (LDR-BT) as monotherapy for early stage prostate cancer in Italy: practice and outcome analysis in a series of 2237 patients from 11 institutions.

OBJECTIVE: Low-dose-rate brachytherapy (LDR-BT) in localized prostate cancer is available since 15 years in Italy. We realized the first national multicentre and multidisciplinary data collection to evaluate LDR-BT practice, given as monotherapy, and outcome in terms of biochemical failure. METHODS: Between May 1998 and December 2011, 2237 patients with early-stage prostate cancer from 11 Italian community and academic hospitals were treated with iodine-125 ((125)I) or palladium-103 LDR-BT as monotherapy and followed up for at least 2 years. (125)I seeds were implanted in 97.7% of the patients: the mean dose received by 90% of target volume was 145 Gy; the mean target volume receiving 100% of prescribed dose (V100) was 91.1%. Biochemical failure-free survival (BFFS), disease-specific survival (DSS) and overall survival (OS) were estimated using Kaplan-Meier method. Log-rank test and multivariable Cox regression were used to evaluate the relationship of covariates with outcomes. RESULTS: Median follow-up time was 65 months. 5- and 7-year DSS, OS and BFFS were 99 and 98%, 94 and 89%, and 92 and 88%, respectively. At multivariate analysis, the National Comprehensive Cancer Network score (p < 0.0001) and V100 (p = 0.09) were correlated with BFFS, with V100 effect significantly different between patients at low risk and those at intermediate/high risk (p = 0.04). Short follow-up and lack of toxicity data represent the main limitations for a global evaluation of LDR-BT. CONCLUSION: This first multicentre Italian report confirms LDR-BT as an excellent curative modality for low-/intermediate-risk prostate cancer. ADVANCES IN KNOWLEDGE: Multidisciplinary teams may help to select adequately patients to be treated with brachytherapy, with a direct impact on the implant quality and, possibly, on outcome.

Complications and quality of life after template-assisted transperineal prostate biopsy in patients eligible for focal therapy.

OBJECTIVE: To assess the complication rates and quality of life in patients eligible for focal therapy who underwent template-assisted transperineal prostate biopsy (TTPB). MATERIALS AND METHODS: Eighty-seven patients with low-risk prostate cancer (clinical stage T1c-T2a, prostate-specific antigen level ≤10 ng/mL, biopsy Gleason score ≤6), who were candidates for focal therapy, underwent TTPB. The study details are available from http://clinicaltrials.gov (NCT00928603). The primary outcomes were the complication rates, according to the Clavien-Dindo classification, and changes in the quality of life, evaluated using the International Prostate Symptom Score, International Index of Erectile Function, and Functional Assessment of Cancer Therapy-Prostate questionnaires, before and 1 month after TTPB. RESULTS: The median patient age was 63.9 years (range 46-78), with a median Charlson comorbidity index of 2.2 (range 0-4). No statistically significant differences were observed when comparing the general and/or specific domains of the International Prostate Symptom Score, International Index of Erectile Function, and Functional Assessment of Cancer Therapy-Prostate results before and 1 month after TTPB (P >.05 for all). Using the Clavien-Dindo classification, we observed 37 cases of grade 1 complications, including 5 (6.1%) cases of macrohematuria, 13 (16%) of hemospermia, 11 (13.5%) of perineal hematoma, 3 (3.7%) of perineal hematoma and hemospermia, and 5 (6.1%) of macrohematuria and hemospermia. Three patients (3.7%) developed a grade II complication (ie, acute urinary retention). Prostate cancer was detected in 54 patients (62.1%). Of 57 patients, 16 (29.6%) were upgraded from Gleason score 3+3/atypical small acinar proliferation to Gleason score 7. Of the 54 patients with positive TTPB findings, 18 (25.3%) showed an anatomic correspondence between the results of previous biopsies and TTPB. CONCLUSION: TTPB did not appear to have a significant effect on the quality of life of candidates for focal therapy, and the Clavien-Dindo complication rate was negligible.

[Focal therapy and prostate cancer]. / Terapia focale per il carcinoma prostatico: stato dell'arte.

The International Task Force on Prostate Cancer defines focal therapy (FT) for prostate cancer (PCa) as the therapy that "selectively ablates known disease and preserves existing functions, with the overall objective of minimizing lifetime morbidity without compromising life expectancy". FT for the treatment of PCa has been called the "male lumpectomy", an analogue to women's breast lumpectomy for the treatment of breast cancer. Radical prostatectomy continues to be the most frequently performed treatment for localized PCa, as anatomic knowledge and several technical advances, i.e. the introduction of robotic assisted surgery, have led to successful oncological outcome and lower rates of post-treatment morbidity. However, a proportion of patients still experiences a no negligible sexual, urinary, and bowel morbidity. Although the rationale of active surveillance for low-risk PCa (PSA <10 ng/mL, Gleason grade 6 or less, and clinical stage T1c-T2a) is sound, only few of newly diagnosed patients elect this approach. Thus, in the recent years the concept of a "subtotal therapy" gained the interest of some urological schools. The aim of this paper is to review the existing literature in order to provide the status of art on FT for PCa. The manuscript will focus on the characteristics of the target population, on the pre-operative evaluation to localise disease, as well as on perioperative, functional, and disease-control following focal therapy.

Photodynamic diagnosis for follow-up of carcinoma in situ of the bladder.

INTRODUCTION: A prospective study to evaluate the reliability of cystoscopy was performed with fluorescence (photodynamic diagnosis, PDD) compared with standard white light (WL) cystoscopy in patients with solitary carcinoma in situ (CIS), undergoing BCG treatment. MATERIALS AND METHODS: Between February 2004 and March 2006, 49 patients suffering from CIS were enrolled in the study. Patients age was 68.5 ± 13.5 years (mean ± SD) and all presented CIS alone at inclusion. All suspicious areas were biopsied either under white light or blue light. Urine cytology was peformed on each patient before endoscopy. RESULTS: Out of 49 patients enrolled, 15 (30.6%) presented with positive urinary cytology. Out of 18 patients positive to CIS at biopsy, 14 (77.7%) could be diagnosed exclusively by means of PDD cystoscopy and transurethral bladder resection and 4 (22.3%) during both standard and PDD cystoscopy. No additional CIS could be diagnosed by standard WL cystoscopy alone. The overall false positive rate for PDD accounted for 33.3% compared with 7.1% for WL cytoscopy. A statistical correlation was documented between the number of CIS findings and PDD (r = 0.6976, p = 0.0002) while WL cystoscopy (r = 0.1870, p = 0.3816) and urinary cytology (r = 0.4965, p = 0.0136) correlated only weakly with CIS. The overall side effects related to the drugs were negligible overall. CONCLUSIONS: These data show that PDD cystoscopy is more reliable than WL cytoscopy for the follow-up of CIS patients during BCG treatment. Long-term data and multicenter, prospective data are needed to assess the true impact on tumor recurrence and progression.

Pathological changes of high-grade prostatic intraepithelial neoplasia and prostate cancer after monotherapy with bicalutamide 150 mg.

OBJECTIVES: To evaluate the morphological changes induced by a 3-month course of neoadjuvant bicalutamide 150 mg/day before radical prostatectomy (RP) on prostatic adenocarcinoma and high-grade prostatic intraepithelial neoplasia (HGPIN). PATIENTS AND METHODS: In all, 90 patients with cT1-T2 prostate cancer and HGPIN on prostatic biopsy were randomized to receive bicalutamide (150 mg/day for 3 months) before RP, or to have immediate surgery. Surgical specimens were assessed for the histopathological features of cancer, HGPIN and benign epithelium in a blinded manner. The volumes of prostate cancer and HGPIN were evaluated using a stereological (i.e. grid) method. RESULTS: Compared with the bicalutamide-treated group, the ratio of stroma to epithelium, evaluated by visual microscopic assessment in the normal epithelium of the three prostate zones, was significantly lower in the control group, at 2.27 (sd 1.13), than in the treated group, at 1.87 (sd 0.72) (P = 0.048). The mean (sd) tumour volume was significantly lower in the bicalutamide-treated than in the control group, at 0.914 (0.13) vs 1.47 (0.24) mL (P = 0.044). Similarly, the mean (sd) volume of HGPIN was significantly lower in the bicalutamide-treated than in the control group, at 0.34 (0.06) vs 0.62 (0.07) mL (P = 0.003). At RP, specimen Gleason scores in the bicalutamide-treated group were similar to those in the control group, and were no different from the biopsy Gleason scores. CONCLUSIONS: Involution and epithelial shrinkage of prostate cancer and HGPIN were evident after neoadjuvant treatment with bicalutamide 150 mg. There was no evidence of the emergence of higher-grade cancer after treatment.

Early biochemical outcomes following permanent interstitial brachytherapy as monotherapy in 1050 patients with clinical T1-T2 prostate cancer.

BACKGROUND AND PURPOSE: Five European centres (France, Finland, Italy, Spain and the UK) have pooled data to generate a large patient series involving 1175 patients treated with prostate brachytherapy. This paper reports preliminary data on PSA outcome up to 4 years. PATIENTS AND METHODS: Out of 1175 in the database, 1050 patients with localised prostate cancer who had received transperineal seed implantation as monotherapy between May 1998 and August 2003 were stage T1-T2. A total of 668 (63.6%) patients met the low-risk group definition, 297 (28.3%) as intermediate-risk definition and 66 (6.3%) the high-risk group definition. The majority of patients were Gleason score 6 or less (n=951) and disease stage was T1c in 557 patients. RESULTS: Of the 1050 patients, PSA data up to 4 years were available for 210 patients, while 364 patients with PSA values up to 36 months were evaluable by the Kaplan-Meier method for freedom from biochemical failure. The biochemical progression-free rate at 3 years was estimated to be 91%, with a 93% and 88% rate for low- and intermediate-risk groups, respectively, versus 80% for the high-risk group. PSA kinetics provide encouraging evidence of treatment efficacy. CONCLUSION: These data on 4-year PSA follow-up on patients treated with prostate brachytherapy reflect those previously reported in the literature. This patient series will be followed to provide long-term outcome in the future.

Salvage brachytherapy for local recurrence after radical prostatectomy and subsequent external beam radiotherapy.

OBJECTIVES: To evaluate the technical feasibility, safety, and efficacy of seed implantation for local recurrence after radical prostatectomy and external beam radiotherapy. METHODS: Between October 1999 and March 2002, 10 patients with targeted, histologically proven local relapse after surgery and subsequent external beam radiotherapy (only in 8 patients), underwent permanent brachytherapy with palladium-103 and iodine-125 after complete restaging. In all patients, an intraoperative morphovolumetric ultrasound study of the target was performed, with a planning target volume ranging from 5 to 26.7 cm(3). The preimplant prostate-specific antigen values ranged from 1.1 to 6.31 ng/mL. RESULTS: Postplan dosimetry was performed to determine the percentage of the target volume that received a dose equal to, or greater than, the prescribed dose (range 84.5% to 95.9%) and the dose that was delivered to the 90% of the target volume (range 85.08% to 129.43%). The urinary scores, measured using the International Prostate Symptom Score, had normalized at 3 months. Only 1 patient had worsened incontinence during the first 2 months, with subsequent restoration of the previous situation. The other patients did not have any changes in their previous clinical condition. One patient experienced occasional gross hematuria that had been present after external beam radiotherapy. No rectal complications were reported. After a median follow-up of 20.6 months, 7 patients showed a decreasing or stable prostate-specific antigen level. CONCLUSIONS: This preliminary experience has demonstrated that seed implantation of a neoplastic local recurrence is technically feasible and safe and allows for accurate dosimetry when the area to be treated can be defined by ultrasonography. Longer follow-up, accurate patient selection, and larger series of patients could help to better define the oncologic outcome.

Laparoscopic nerve- and seminal-sparing cystectomy with orthotopic ileal neobladder: the first three cases.

INTRODUCTION AND OBJECTIVES: Seminal and prostate sparing cystectomy represents an alternative in young patients where preservation of urinary continence and sexual potency are fundamental. We present our preliminary experience with this procedure performed laparoscopically. METHODS: Three men-53, 58 and 49 years old-suffering from recurrent superficial transitional cell carcinoma of the bladder, resistant to intravesical therapy, underwent laparoscopic nerve, prostate and seminal vesical sparing cystectomy. One week before surgery, TURP was performed to create an adequate prostate capsule. After pneumoperitoneum induction and the positioning of five/six trocars, the ureters were clipped and transected, the vas deferens and seminal vescicles were identified and prepared for the conservative procedure. Cystectomy was performed with vascular pedicles transection by EndoGia. The reconstruction of the bladder was obtained through a 7 cm longitudinal periumbilical incision using 60 cm of ileus and an orthotopic neobladder realized outside the abdomen. The ileocapsular anastomosis was performed laparoscopically after the re-induction of pneumoperitoneum. RESULTS: No major complications were recorded. The surgical time was respectively 480, 450 and 410 min. Blood loss was 150, 220 and 300 ml respectively. Drains were removed after 4 days (two patients) and 6 days (one patient) and the patients were discharged after 8 days (two patients) and 9 days. The patients were fully continent after catheter removal with normal uroflowmetry. At the three month follow-up they had a normal sexual function, equivalent to the preoperative assessment. The patients reported adequate erections for intercourse. CONCLUSIONS: Laparoscopic prostate and seminal cystectomy with orthotopic ileal neobladder is a safe, feasible, reproducible surgical technique. In patients who desire to preserve sexual functioning and obtain complete continence it represents a valid alternative to classic radical cystectomy.